Second branchial cyst: a rare presentation.
CASE REPORT: 60 years old female presented to ENT OPD with complains of swelling over the right side of the neck for the past 3 years. It was insidious in onset, gradually progressive in size. On examination there was a swelling in the right side of the neck which was approximately 5.5x4cm in size, oval in shape, not moving with deglutition. No visible pulsations were seen over the swelling. On palpation there was a single, soft, cystic swelling over the right side of the neck, which was non-tender, not moving vertically as well as horizontally, no other clinically palpable nodes. Trachea deviated to left side.
Ultrasonography of the neck showed 6.8x5.2x4.6cm well defined cyst with internal echoes in the right side of neck. The lesion was deep to sternocleidomastoid muscle and right lobe of thyroid. It was medial to common carotid artery. It was displacing the trachea to left side. Neck vessels appeared normal on Color Doppler. MRI showed large well defined mass in the right side of neck with fluid intensity, deep to sternocleidomastoid and posterior to thyroid lobe. The mass was displacing the trachea to left side.
Excision of the cyst in to was done under general anesthesia. Intra operatively cyst was approximately 6x4cm in size. The cyst wall was very thin. Cyst was located medial to Sterno-mastoid muscle & Common carotid artery and posterior to right lobe of thyroid. Specimen was sent for histopathological examination. It was suggestive of Branchial Cyst with the cyst wall being lined by squamous epithelium.
DISCUSSION: Branchial cleft cysts are the most common cystic swellings of the neck. The term branchial cyst was first coined by Ascherson in 1832. 
Second branchial cleft anomalies are the most common branchial apparatus anomalies, representing approximately 95% of cases. [1, 2] Several theories are proposed its origin.  Most accepted theory is the evolution of incomplete branchial apparatus. 
Second branchial cleft cysts are also known as lateral cervical cysts. These are usually seen deep to the anterior border of sternocleidomastoid. These are commonly seen at the junction of upper 1/3rd & lower 2/3rd of the sternocleidomastoid.
According to Bailey Second Branchial Cleft Anomalies are divided into:
* Type I: Localized between the platysma & anterolateral surface of SCM.
* Type II: Along the anterior surface of SCM, lateral to carotid space & posterior to submandibular gland.
* Type III: Located between internal carotid and external carotid artery. The presence of tail of the cyst between internal & external carotid pathognomonic of type IH. [7. 8]
* Type IV: Originates from pharyngeal mucosa, deep as compared to the palatine tonsils and often it can reach to base of the skull. 
The peak age incidence of branchial cysts is in the third decade.  Sixty percent are in males & sixty percent are on the left side. In patients over the age of 40yrs a cystic metastatic node from a primary neoplasm has to be excluded.  Other differential diagnosis are Lymphoma, Tuberculosis, carotid body tumor. Ultrasonography is the primary investigation of choice for these types of cystic lesions. The advantage of USG is that it is noninvasive technique which fairly distinguishes various type of cystic neck lesions.
In these types of late presentations, CT/MRI is useful to distinguish between other cystic neck lesions and to avoid complications like injury to carotids, spinal accessory nerve, hypoglossal nerve.
CONCLUSION: Branchial cleft cyst is common in young adults. In elderly it is important to exclude metastatic cystic lymphadenopathy with correct radiological diagnosis like CT/MRI. A proper preoperative assessment of cystic lesion is important to prevent complications while excision.
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[4.] Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al, editors Scot-Brown's Otorhinolaryngology, Head & Neck Surgery, 7th edition Great Britain: Hodder Arnold; 2008.
[5.] Mihaela Mitroi, Management of second branchial cleft anomalies, Romanian Journal of Morphology and Embryology, 2008; 49 (1): 69-74.
[6.] Cho SS Zal Zal GH (MGJ) Branchial anomalies: a review of 52 cases. Laryngoscope 105: 909-913.
[7.] Lev S, Lev MH (2000) Imaging of Cystic lesions: Radiol Clin North Am 38: 1013-1027.
[8.] Koeller KK, Alamo L, Adair CF (1999) congenital cystic masses of the neck: Radiologic--pathologic correlation. Radiographics 19: 121.
[9.] M.J. McClure, C S Mc Kinstry, R Stewart, M Madden later presentation of branchial cyst. The Ulster Medical Journal, Volume 67, No. 2, PP. 129-131, Nov 1998.
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G. Vinod Kumar , B. Ranganatha Reddy , Supriya Mohan Bhat , Rakesh Vuppala 
[1.] G. Vinod Kumar
[2.] B. Ranganatha Reddy
[3.] Supriya Mohan Bhat
[4.] Rakesh Vuppala
PARTICULARS OF CONTRIBUTORS:
[1.] Assistant Professor, Department of ENT, Apollo Institute of Medical Sciences & Research.
[2.] HOD, Department of ENT, Apollo Institute of Medical Sciences & Research.
[3.] Assistant Professor, Department of ENT, Apollo Institute of Medical Sciences & Research.
[4.] Assistant Professor, Department of ENT, Apollo Institute of Medical Sciences & Research.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. G. Vinod Kumar, Plot. No. 136, Sardar Patel Colony, Trimulgherry, Secunderabad-15, Telangana.
Date of Submission: 31/08/2015.
Date of Peer Review: 01/09/2015.
Date of Acceptance: 05/09/2015.
Date of Publishing: 10/09/2015.
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|Title Annotation:||CASE REPORT|
|Author:||Kumar, G. Vinod; Reddy, B. Ranganatha; Bhat, Supriya Mohan; Vuppala, Rakesh|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Sep 10, 2015|
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