Second branchial cyst in the parapharyngealspace - Université de ...

ANL-1153; No of Pages 4
Abstract
Second branchial cyst in the parapharyngealspace: A case report
S. Saussez a,b, *, T. De Maesschalk a , V. Mahillon a , O. Filleul b , S. Louryan c
a Department of Otorhinolaryngology, Head and Neck Surgery, CHU Saint-Pierre, 322 Rue Haute, 1000 Brussels, Belgium
b Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons-Hainaut, 7000 Mons, Belgium
c Laboratory of Anatomy and Embryology, Faculty of Medicine, Université Libre de Bruxelles, 808 route de Lennik, 1070 Brussels, Belgium
Received 15 January 2008; accepted 10 June 2008
Objective: We report the clinical findings and management of a large retro- and parapharyngeal branchial cyst in a 54-year-old man whose
only complaint was a 12-month history of snoring.
Method: Case report and a review of the world literature concerning parapharyngeal cysts are presented.
Results: On computed tomography (CT) images, a well-marginated cystic mass was observed in the left retro- and parapharyngeal spaces,
with displacement of the left internal and common carotid arteries. The cyst contained thick, sterile, yellowish pus, without malignant cells.
We performed a transoral resection without any surgical complications. No recurrence was observed 2 years later.
Conclusion: Parapharyngeal branchial cysts are rare and often paucisymptomatic. The transoral approach can provide good exposure
allowing complete resection without significant post-operative complications or cervical scarring.
# 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Branchial cyst; Parapharyngeal space; Transoral approach
1. Introduction
Auris Nasus Larynx xxx (2008) xxx–xxx
Branchial cysts are common neck masses in adults but
very rarely develop in the parapharyngeal space. The
parapharyngeal space lies adjacent to the naso- and
oropharynx between the base of the skull and the hyoid.
The most common symptoms are hearing loss due to middle
ear effusion, dysphagia, dysarthria and dyspnea. According
to Bailey and Proctor, second branchial cysts can be divided
into four subtypes: (i) type 1 cysts are located superficially
along the anterior edge of the sternocleidomastoid muscle
beneath the cervical fascia, (ii) type 2 cysts lie on the great
vessels beneath the enveloping fascia of the neck, (iii) type 3
cysts pass between the great neck vessels to reach the
pharyngeal wall and (iv) type 4 cysts are situated under the
pharyngeal wall medial to the great neck vessels [1,2]. Total
excision of the cystic mass is the only way to prevent
* Corresponding author at: University of Mons-Hainaut, Faculty of
Medicine, Department of Anatomy, Pentagone 1B, Avenue du Champ de
Mars, 6, 7000 Mons, Belgium. Tel.: +32 65 37 35 62; fax: +32 65 37 35 57.
E-mail address: sven.saussez@umh.ac.be (S. Saussez).
0385-8146/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.anl.2008.06.005
recurrence. Here, we describe a case of large retro- and
parapharyngeal branchial cyst (type 4) revealed only by
snoring and that was successfully resected transorally. We
discuss the embryological origin of this parapharyngeal cyst
and the therapeutic options described in the literature,
especially the transoral approach.
2. Case report
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A 54-year-old man presented at the otolaryngological
consultation with a 12-month history of snoring. The patient
did not describe any dysphagia but exhibited weight loss of
6 kg during the previous 3 months. He did not report alcohol
abuse and had stopped smoking 18 months earlier.
The clinical examination revealed a large submucosal
tumefaction of the left postero-lateral wall of the
oropharynx, extending from the nasopharynx to the
hypopharynx (Fig. 1a). This lesion was not palpable in
the neck or in the parotid region. The remainder of the
examination was normal, with normal larynx mobility and
no cervical adenopathies. Head and neck computed
Please cite this article in press as: Saussez S, et al. Second branchial cyst in the parapharyngealspace: A case report. Auris Nasus Larynx
(2008), doi:10.1016/j.anl.2008.06.005

ANL-1153; No of Pages 4
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tomography (CT) revealed a 10-cm diameter cyst situated
medially to the internal and common carotid arteries,
enlarging the left para- and retropharyngeal spaces (Fig. 1b
and c). An intraoral fine-needle aspiration of the cyst
revealed thick, sterile, yellowish pus, without malignant
cells.
After aspiration and drainage of the parapharyngeal cyst,
we performed a complete transoral resection under general
anesthesia. In fact, we placed the patient in supine decubitus
position with forced cervical extension and used an
amygdalectomy autostatic retractor to realize this transoral
S. Saussez et al. / Auris Nasus Larynx xxx (2008) xxx–xxx
Fig. 1. The para- and retropharyngeal cyst was observed directly when the patient opened his mouth (A). Axial (B) and coronal (C) head and neck CT-scans
show the branchial cyst before the resection. The cyst filled the retropharyngeal and parapharyngeal spaces and displaced the left common -black arrow- and
internal carotid arteries laterally.
resection. First of all, we performed a very superficial
incision – 7–8 cm length – of the lateral oropharyngeal wall.
We prolonged this incision in the lateral part of the soft
palate which allowed one to dissect the superior –
nasopharyngeal – part of the cyst. The wall cyst was very
thin and located just below the pharyngeal wall. After that,
we visualized the cyst wall and aspired this content – not
completely – decreasing significantly the cyst size but
avoiding complete collapsus. Then, using the electrothermal
bipolar vessel sealer, we dissected very carefully the space
between the lateral cyst wall and the middle, inferior
Please cite this article in press as: Saussez S, et al. Second branchial cyst in the parapharyngealspace: A case report. Auris Nasus Larynx
(2008), doi:10.1016/j.anl.2008.06.005

ANL-1153; No of Pages 4
pharyngeal constrictor muscles. We have teared the wall of
the cyst in two places but the resection was even complete.
The inferior part of the cyst was logically the more difficult
to dissect. Finally, the resting pharyngeal mucosa was
sutured to these pharyngeal constrictor muscles. We sutured
also the incision of the soft palate. The patient did not
experience any surgical complications and was able to eat
normally on the eighth day. Histopathological examination
of the resected cyst was consistent with a branchial cyst.
Subsequent head and neck CT, at 2 and 12 months of followup,
showed no recurrence of the cyst (Fig. 2B). The ENT
examination 2 years after surgery confirmed this lack of
recurrence (Fig. 2).
3. Discussion
Parapharyngeal tumors are rare, accounting for about 0.5
percent of all head and neck tumors. The main three groups
of parapharyngeal tumors are salivary (most frequently,
deep-lobe parotid tumors) and neurogenic tumors, followed
by paragangliomas [3]. The differential diagnoses of a
parapharyngeal cystic mass include cystic schwannomas,
minor salivary gland tumors and branchial cysts. In this
report, we discuss the difficult and challenging operative
management of this lesion (branchial cysts), which in our
view must be managed differently from other solid
parapharyngeal tumors.
Parapharyngeal branchial cysts usually cause the
enlargement of the pharynx, resulting in dysphagia,
dysarthria and, rarely, dyspnea. Depending on the location
of the cyst, it may compress the Eustachian tube,
determining hearing loss [4], or cranial nerves IX, X and
XII [5]. More often, symptoms referable to masses in the
parapharyngeal space are minimal: our patient’s only
symptom of this large cyst was snoring without any
S. Saussez et al. / Auris Nasus Larynx xxx (2008) xxx–xxx 3
dysphagia. Such a clinical presentation has never been
described in the literature.
Branchial clefts, fistula and cysts correspond to remnants
of branchial grooves and/or pouches. The second, third and
fourth grooves fuse to constitute the cervical sinus, closed by
an expansion of the second arch. Branchial ectodermal cysts
anterior to the sternomastoid muscle derive from a remnant
of the cervical sinus. They can also develop between this
muscle and the internal jugular vein, between the internal
jugular vein and the internal carotid artery, or finally
medially to the carotid, as in our case [6,7]. The origin of
parapharyngeal cysts is controversial. It could correspond to
a remnant of the cervical sinus, as explained above. But this
kind of cyst can also arise from endodermal pharyngeal
tissue. The second branchial pouch gives rise to the palatal
tonsil. Thus, it could be possible that the present cyst
corresponds to a vestige of this pouch [6,7]. Considering the
presence of subepithelial lymphocytes, Wild and co-authors
proposed a second hypothesis, where parapharyngeal cysts
derived from ectopic epithelial cells in regional lymph nodes
[8].
From our point of view, the decision to opt for either a
transcervical or a transoral approach is the real challenge
with this pathology. We decided to resect this large
parapharyngeal cyst transorally, for several reasons that
we describe hereafter.
First, the cyst was located medially to the internal carotid
artery, requiring the dissection of carotid and jugular vessels
and cranial nerves (lingual, hypoglossal and superior
laryngeal nerves) if a transcervical approach was chosen,
potentially increasing the risk of post-operative complications.
Such complications have never been reported when a
transoral approach was used [4,10,11,14]. In our review of
the literature, 36 cases have been reported until now and
several approaches used: repeated aspiration and sclerosant
injection (5/36 cases), transcervical approach (20/36 cases),
Fig. 2. Photograph (A) shows the patient’s oropharynx after the complete resection. (B) Axial head and neck CT confirmed the absence of recurrence 12 months
after surgery.
Please cite this article in press as: Saussez S, et al. Second branchial cyst in the parapharyngealspace: A case report. Auris Nasus Larynx
(2008), doi:10.1016/j.anl.2008.06.005

ANL-1153; No of Pages 4
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transcervical–transparotid approach (mandibular luxation
vs. mandibular swing, 4/36 cases) transoral approach with
total excision (5/36 cases) and marsupialisation (2/36 cases)
[5,9–15]. Simple incision, puncture-aspiration of the cyst, or
injection of sclerosant substances presents a high risk of
recurrence. Complete resection using the transcervical
approach seems to be the technique of choice but several
neurovascular complications (palsies of cranial nerves IX, X
and XII) are described [9,12]. In our experience, the key
point of the transoral approach was to aspirate the cyst –
decreasing very significantly the cyst size – before
performing the lateral dissection with a long-electrothermal
bipolar vessel sealer. For a very large cyst, even using a
transcervical approach, the reduction of the cyst size thanks
to an aspiration could be an interesting solution. Moreover,
we realized usually such aspiration for huge cervical cyst
(type 2) which allowed to decrease the incision size.
Second, the transoral approach provides the best
esthetic results. Diaz-Manzano recently described a
transoral approach allowing marsupialization with postoperative
obliteration of the tract [15]. No visible scar was
created using this transoral approach; this cosmetic
consideration could be particularly significant for our
young patients. The transparotid and transmandibular
approaches presented the poorest aesthetic results. Finally,
the transcervical approach could be preferred when the
tumor has a palpable neck component, which in practice
means that the cyst has to present a lateral cervical
extension (type 3 cyst) [3,5].
In short, parapharyngeal branchial cysts are rare and
often paucisymptomatic. The transoral approach can
provide good exposure allowing complete resection
without significant post-operative complications or cervical
scarring.
S. Saussez et al. / Auris Nasus Larynx xxx (2008) xxx–xxx
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Please cite this article in press as: Saussez S, et al. Second branchial cyst in the parapharyngealspace: A case report. Auris Nasus Larynx
(2008), doi:10.1016/j.anl.2008.06.005