A new case of a branchial cyst of the parapharyngeal space.

Abstract

Branchial cysts in the parapharyngeal space are rare. Until now, only 23 such cases have been reported in the literature. In this article, we report a new case in a 65-year-old man. Information gained from the clinical examination, fiberoscopy, and computed tomography revealed that the cyst was obstructing the oropharynx and filling the parapharyngeal and retropharyngeal spaces on the right. The mass was excised via a transcervical approach without any complications. We also review the literature on this condition.

Introduction

Cystic lesions in the parapharyngeal space are rare. When they do occur, they typically arise from the parotid gland and the first and second pharyngeal pouches. Generally, these lesions manifest as neck masses; sometimes they are asymptomatic, but more often they are accompanied by an abscess formation.

To the best of our knowledge, only 23 cases of a branchial cyst in the parapharyngeal space have been heretofore described in the literature (table). [1-16] In this article, we report an additional case, and we discuss the diagnosis and treatment of this lesion.

Case report

A 65-year-old man reported that he had been experiencing dysphagia and sore throat for the previous 20 days. He had been treated with antibiotics and anti-inflammatory drugs at another medical center, but when these treatments failed to relieve his condition, he came to our facility.

On physical examination, we observed in the oropharynx a fluctuating mass that was covered with normal mucosa. On fiberoscopy, we noted that the mass had extended to the right torus tubarius in the nasopharynx and to the level of the epiglottic tip on the lateral wall of the hypopharynx. The lesion was estimated to be 3 x 2 cm based on palpation of the neck between the angle of the mandible and the anterior border of the right sternocleidomastoid muscle. Findings on otoscopic examination were normal bilaterally. Computed tomography (CT) revealed that a 3.8 x 7.0-cm cystic mass was obstructing the oropharynx and filling the parapharyngeal and retropharyngeal spaces on the right (figure).

The patient was administered general anesthesia and underwent surgery via a transcervical approach. After decompression, the cyst wall was excised. The aspirate consisted of clear fluid. Histopathologic examination was consistent with a branchial cleft cyst. The patient experienced no postoperative complications, and no recurrence had been detected at 2 years' followup.

Discussion

A number of reports on cysts in the lateral pharyngeal area suggest that they have a branchial origin. These lesions expand through the cervical planes and manifest as submucosal lateral pharyngeal masses; they generally have a cervical component. The most common symptoms are sore throat, dysphagia, dysarthria, and dyspnea. In most cases, an accompanying infection leads to an abscess formation, which adds pain, fever, and cervical stiffness to the list of symptoms. In rare instances, paresis of the cranial nerves that pass through the parapharyngeal space has been observed. [11,13]

Imaging techniques establish the site of origin of these lesions with a 96% accuracy. [17] In order to ascertain the best surgical approach, it is necessary to distinguish deeplobe parotid lesions from extraparotid lesions. [18] CT with contrast is valuable in accurately identifying the location and extent of the tumor and is occasionally helpful in determining the nature of the lesion. [18-20] Magnetic resonance imaging (MRI) is the best radiologic technique for evaluating parapharyngeal space lesions. With its high-resolution capacity, MRI can establish the precise limits of the lesion and its relation to the neighboring skull base, carotid artery, and especially the parotid gland. [16] Radiologically, branchial cysts have a characteristic appearance and can be distinguished from other lesions by their solitary, ovoid, sharply outlined, fluid-containing features.

Different conservative methods have been used in the treatment of branchial cysts: repeated aspiration of the cystic fluid, incision and drainage, marsupialization, and injection of sclerosing agents. [21] These methods often provide only a temporary resolution of symptoms, however, as these cysts often recur and eventually require surgery. [22] Therefore, total excision is the definitive treatment and the only way to prevent recurrence. [13]

The transoral route is primarily used to remove anteriorly placed tumors that are not palpable in the neck. [19,23] The transcervical approach is the choice for lesions that are inferiorly located and have a palpable neck component. This route enables the surgeon to dissect the intact thin cyst wall from surrounding tissues and to completely resect it, which is the method we used on our patient. The transcervical-transparotid approach is an effective way to expose superiorly located lesions and to preserve the facial nerve. The transmandibular approach provides the most complete exposure, but it is a morbid procedure and is associated with the risk of complications. [23,24]

Histopathologically, the cyst walls are lined with columnar epithelium. However, in cases of metaplasia, respiratory epithelium can be found. The cyst wall generally contains lymphoid follicles. [25]

There are two theories regarding the etiology of internal branchial cysts. The first suggests that they are derived from the branchial apparatus. [26] The second theory considers the presence of subepithelial lymphocytes and suggests that the cysts are derived from ectopic epithelial cells in the regional lymph nodes. [27] In our case, the cystic wall was lined with columnar epithelium without lymphocyte infiltration. Furthermore, the site of the pharyngeal attachment and the lack of deformity in derivatives of the first branchial apparatus support the view that this cyst originated in the second branchial apparatus.

From the Department of Otolaryngology-Head and Neck Surgery, Ege University. Izmir, Turkey.

References

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(5.) Mills CP. A branchiogenic cyst of the nasopharynx. J Lar Otol, Lond 1959;73:191-2.

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(7.) Boysen ME, de Besche A, Djupesland G, Thorud E. Internal cysts and fistulae of branchial origin. J Laryngol Otol 1979;93:533-9.

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(11.) Gatot A, Tovi F, Fliss DM, Yanai-Inbar I. Branchial cleft cyst manifesting as hypoglossal nerve palsy. Head Neck 1991;13:249-50.

(12.) Shidara K, Uruma T, Yasuoka Y, Kamei T. Two cases of nasopharyngeal branchial cyst. J Laryngol Otol 1993;107:453-5.

(13.) Durrant TJ, Sevick RJ, Lauryssen C, MacRae ME. Parapharyngeal branchial cleft cyst presenting with cranial nerve palsies. Can AsSoc Radiol J 1994;45:134-6.

(14.) Guneri A, Gunbay MU, Guneri EA, et al. Management of parapharyngeal space cysts. J Laryngol Otol 1994;108:795-7.

(15.) Papay FA, Kalucis C, Eliachar I, Tucker HM. Nasopharyngeal presentation of second branchial cleft cyst. Otolaryngol Head Neck Surg 1994;110:232-4.

(16.) Chabot M, Fradet G, Theriault R, Morrissette YP. [The excision of branchial parapharyngeal cysts by transbuccal or cervical approach]. J Otolaryngol 1996:25:108-12.

(17.) Carrau RL, Myers EN, Johnson JT. Management of tumors arising in the parapharyngeal space. Laryngoscope 1990;100:583-9.

(18.) Som PM, Sacher M, Stollman AL, et al. Common tumors of the parapharyngeal space: Refined imaging diagnosis. Radiology 1988;169:81-5.

(19.) Som PM, Biller HF, Lawson W. Tumors of the parapharyngeal space: Preoperative evaluation, diagnosis and surgical approaches. Ann Otol Rhinol Laryngol Suppl 1981;90:3-15.

(20.) Som PM, Braun IF, Shapiro MD, et al. Tumors of the parapharyngeal space and upper neck: MR imaging characteristics. Radiology 1987; 164:823-9.

(21.) Cross RR, Shapiro MD, Som PM. MRI of the parapharyngeal space. Radiol Clin North Am 1989;27:353-78.

(22.) Nicolai P, Luzzago F, Maroldi R. Nasopharyngeal cysts. Report of seven cases with review of the literature. Arch Otolaryngol Head Neck Surg 1989; 115:860-4.

(23.) Goodwin WJ Jr., Chandler JR. Transoral excision of lateral parapharyngeal space tumors presenting intraorally. Laryngoscope 1988;98:266-9.

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Table. Characteristics of reported cases of branchial cyst in the
parapharyngeal space
Author                      Age  Sex  Treatment
Magnotti, 1927 1             8    F   Excision
Guissani, 1928 2            25    M   Excision
Hoogland, 1951 3            69    M   Aspiration
Taylor and Burwell, 1954 4  53    M   Aspiration and
                                       sclerosant injection
                            49    M   Aspiration
                            54    M   Aspiration and
                                       sclerosant injection
Mills, 1959 5               52    F   Excision
Shaheen, 1961 6             18    M   Aspiration
                            59    M   Excision
Boysen et al, 1979 7        45    F   Excision
Yoshimura et al, 1986 8     48    F   Excision
                            58    M   Excision
Takimoto et al, 1989 9      12    M   Excision
Dilkes et al, 1990 10       42    M   Excision
Gatot et al, 1991 11        27    M   Excision
Shidara et al, 1993 12       2    F   Marsupialization
                             6    M   Excision
Durrant et al, 1994 13      20    F   Excision
Guneri et al, 1994 14       30    F   Drainage and excision
                            53    M   Drainage and excision
Papay et al, 1994 15        29    M   Drainage and excision
Chabot et al, 1996 16       22    F   Excision
                            17    F   Excision
Bilgen et al, 2001 *        65    M   Excision
(*)Present study.