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

More documents

Recommendations

Info

ANL-1153; No of Pages 4 2 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
Page 1: ANL-1153; No of Pages 4 Abstract Se

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

Create successful ePaper yourself

Delete template?

Save as template?