JRSM >
Volume 95, Number 10 >
Pp. 503-505
Department of Medicine for the Elderly, Dewsbury & District Hospital, Dewsbury, W Yorkshire WF13 4HS, UK
Correspondence to: Dr MK Harkness E-mail: mharkness{at}doctors.org.uk
Swellings of the neck can present a difficult diagnostic challenge, especially when bilateral.
CASE HISTORY
A domiciliary visit was requested on an 81-year-old male smoker because of weight loss, shortness of breath and general weakness. He had lately been in hospital elsewhere with pneumonia. The most striking feature on physical examination was the massive swelling on either side of his neck (Figure 1). For 25 years he had had swelling of the right cheek and for 9 years swelling of the left cheek. These caused little discomfort; both had become progressively larger over the past year. The swellings were cystic, with a little tenderness to pressure on the right. A core biopsy was attempted on both lesions, but only purulent fluid was obtained. Cultures were negative. Cytology showed no malignant cells; otherwise the samples were poorly cellular.
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Ultrasound of the neck showed that the swellings were predominantly cystic, and uniformly low-level echoes suggested proteinaceous content. On a CT scan, well-defined cystic masses on each side of the neck were seen to arise from behind the angle of the mandible to the level of the hyoid (Figure 2). There was no cervical adenopathy. The neck swellings were thought to be longstanding branchial cysts. Unfortunately, radiological imaging showed metastatic disease within the liver from a primary bronchogenic carcinoma. Also, ultrasound suggested a lesion in one kidney. The patient's condition deteriorated rapidly and he died peacefully in hospital. At necropsy two primary tumours were found—a poorly differentiated non-small-cell bronchogenic carcinoma with hepatic metastases, and a small renal cell carcinoma. The neck cysts were confirmed as branchial, measuring 13x9x5 cm on the left and 17x10x8 cm on the right. On histological examination the walls of the cysts contained abundant lymphoid tissue with an attenuated lining of squamous epithelium; there were many cholesterol clefts.
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COMMENT
There are reports of branchial cysts up to the age of 60 years1, but we have found no record of bilateral branchial cysts in older patients. These cysts emerge in the anterior triangle of the neck under the anterior border of sternocleidomastoid where the upper third meets the middle third. They present most commonly in males, usually on the left side, after the age of 10 years and peaking in the third decade of life. The cyst fluid contains cholesterol crystals.
There are several theories about the origin of branchial cysts. They may represent remnants of pharyngeal pouches or branchial clefts or they could be due to the non-disappearance of the cervical sinus (where the second branchial arch grows down over the third and fourth). Most are lined by squamous epithelium and have lymphoid tissue in the wall—hence the notion that cyst epithelium arises from lymph node squamous epithelium2.
A thorough history and examination will provide clues to the diagnosis but radiological imaging, fine-needle aspiration and core biopsy may be required3. The differential diagnosis of swelling in the neck lies between a parotid tumour, lymphadenopathy, thyroid disease, cystic hygroma, branchial cyst and a carotid body tumour. Ultrasound of a branchial cyst shows a uniformly low echogenicity4 that distinguishes these lesions from other tumours and allows prompt surgical treatment. If a parotid mass is suspected a CT scan is advisable, to define the extent of the mass and whether there is involvement of the deep lobe or the parapharyngeal space5. MRI provides the best information because of greater tissue contrast resolution and multiplanar images1. Fine-needle aspiration and examination of the aspirate may be used to differentiate conditions that clinically mimic each other—for example, cystic nodal metastasis6. If an aspirate sample is insufficient or non-diagnostic, a core biopsy will be required. Treatment is by excision.
Acknowledgments
We acknowledge the help of Dr BA Cadman, Department of Histopathology, Dewsbury and District Hospital; the Department of Medical Illustration, Huddersfield Royal Infirmary; and Mrs L Prescot.
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