What is a branchial cleft cyst?
A branchial cleft cyst is a lump that develops in front of or below a child’s ear, along the side of their neck, or directly below their collarbone. Doctors may also refer to it as a pharyngeal cleft cyst.
These cysts usually form during embryonic development, when the tissues in a baby’s neck and collarbone region fail to develop normally. The cysts are small, fluid-filled sacks that look like lumps underneath the skin.
In all, there are three different types of brachial cleft anomalies:
- Branchial cleft cysts
- Sinus tracts
- Branchial fistulas
branchial cleft cyst
With a branchial cleft cyst, there is no external opening on the skin, which means that liquid cannot drain out of the neck. As a result, fluid builds up in that region. A branchial cyst can occur on its own during development or it can accompany a branchial cleft sinus tract or fistula.
A branchial cleft sinus tract is an open space that appears on one or both sides of the child’s neck. These openings in the skin are called sinus tracts, and fluid can drain from them. In time, the cyst or sinus can become infected.
Branchial fistulas occur when there’s an opening that forms between the child’s skin and throat lining, called their pharynx. Mucus can drain from the neck out of this opening.
Types of Branchial Cleft Cysts
There are four different types of branchial cleft cysts:
There are two types of first branchial cleft cysts. Together, these make up between 5% and 25% of all branchial cleft anomalies.
In Type 1, children have an external opening above their jawline. In Type 2, the opening to the sinus track is lower, located on the upper neck, right above the hyoid bone.
This is a U-shaped bone located between the lower jaw and voice box. Children with a type 2 first branchial cleft cyst may also have an internal opening to their sinus tract, located in their ear canal.
Second branchial cleft cysts are the most common of the four. They normally do not develop until a child is at least 10 years old and may look like skin tags on the child’s neck. With these, children will have external openings to their sinus tract, located on the upper sides of their neck. They may also have internal openings at the back of their throat, near their tonsils.
Third branchial cleft cysts tend to appear on the left side of a child’s neck, near their thyroid gland. This is a gland shaped like a butterfly, located on the front of the throat. These cysts are usually located inside of the muscle attached to the child’s collarbone. They are less common than the first and second types of branchial cleft cysts.
Most often occurring on the lower left side of a child’s neck, these are the rarest type of branchial cleft cysts. In both the third and fourth branchial clefts, sinus tracts may be absent. This means there is no external opening to allow fluids to exit the child’s body. This can cause the cysts to become infected, which leads to skin irritation in the area around the thyroid gland.
Symptoms of Branchial Cleft Cysts
Sometimes, branchial cleft cysts are noticeable at birth. Other times, they can go undiagnosed until a child develops an upper respiratory infection, such as the common cold.
While infected cysts can be painful, others are not. Some of the most common symptoms include:
- Lump or skin tags on the neck or upper shoulder
- Bumps that become painful with swallowing
- Bumps that grow bigger over time
- Neck swelling and tenderness, sometimes following an upper respiratory infection
- Fluid exiting the neck from a small hole or dimple in the skin (called a punctum)
- A tightness in the chest when the child inhales
Lumps that appear at the onset of an upper respiratory infection may be large and swollen at the beginning and gradually get smaller as the infection clears.
Signs that a cyst has become infected include:
- Difficulty swallowing
- Painful lump in the neck
- Skin irritation and itching
Who gets a branchial cleft cyst?
Branchial cleft cysts are congenital conditions. This means they are present at birth. Doctors have confirmed that they are linked to unexpected changes that occur during pregnancy.
Around the fifth week of pregnancy, gill-like structures begin to form around the child’s neck and are not reabsorbed back into their skin. During this same time, there are bands of tissue forming that will develop into the child’s head and neck. Called pharyngeal arches, these bands will eventually become bone, muscles, cartilage, and blood vessels.
If they fail to form correctly, empty spaces can develop within them. These spaces can fill up with fluids and turn into cysts. In most children, these cysts are unilateral, which means that they occur on only one side of the neck. If they form on both sides, they are called bilateral cysts. Children with bilateral cysts are more likely to experience other types of congenital abnormalities.
How is a branchial cleft cyst diagnosed?
Most of the time, doctors can perform a simple physical exam to determine the presence of a branchial cleft cyst. If they cannot determine the exact location of the cyst, they can perform a Computed tomography (CT) scan or a Magnetic Resonance Imaging (MRI) test.
If a doctor suspects that a branchial fistula might be present, they can perform an ultrasound to determine if there is one connected to the child’s throat or ear canal. An ultrasound uses high-frequency sound waves to create real-time images and videos of internal tissues and organs.
They can also perform a hearing test if they suspect a first branchial cleft cyst, as these can include an internal opening to the sinus tract in the ear canal.
When is surgery needed?
Once your child’s doctor diagnoses them with a branchial cleft cyst, they will refer you to a pediatric surgeon. Even if the child isn’t experiencing any adverse symptoms, removal is usually necessary. Not only will it remove the cyst, but it will also eliminate the chance that it could cause more health issues in the future.
The surgeon can remove the cyst to prevent any infection that might occur if fluid within the cyst becomes stuck or infected. If an infection does occur in the cyst or sinus tract, they may prescribe antibiotics.
Currently, there is no medication that can effectively remove a brachial cleft cyst. This condition will not go away without an operation. Once they are successfully removed, the cysts typically do not return.
What can I expect from surgery?
To perform the surgery, most surgeons will remove the sinus tracts and cysts by making a small incision in the child’s neck. Your child will be under general anesthesia to ease their pain and any anxiety they may be experiencing.
They may make two separate incisions instead of one long one, as sinus tracts can span across the full length of the neck. They may also place small tubes during surgery to allow fluid to drain out of the skin. In some cases, the surgeon may be able to
close off internal openings without making any type of incision, although this isn’t common.
Surgeons will use dissolvable sutures or stitches to close up the incisions they make. These will dissolve on their own, and most children do not have to return to the hospital to have their stitches removed.
To keep your child comfortable after the procedure, you are encouraged to bring their favorite soft things, including blankets, stuffed animals, and small toys. While they will wear a hospital gown during surgery, you can bring soft clothes or pajamas
for them to change into once they are feeling better.
Most children are able to go home between 24 and 48 hours after the surgery. The surgeon may require a longer stay if they are concerned that the swelling on your child’s neck may affect their breathing.
To be released from the hospital, they must have a normal temperature and be able to eat and drink on their own. They must also be able to take pain medication orally.
At-Home After Care
Before you leave the hospital, your medical team will discuss ways to care for your child at home in the days following their surgery.
This may include the following steps:
- Removing or changing the dressing at the site of the incision
- Administering medication to control the pain and soreness
- Limiting your child’s activity level until approved by your doctor
The incisions should not be submerged under water for at least one week after the surgery. Your child may take a shower or a bath after five days, though sponge baths are permissible beforehand. They may return to their normal diet as soon as they get home, though they may feel nauseous. Small sips of clear liquids can help prevent dehydration.
With intervention and surgery, branchial cleft cysts can be successfully removed, allowing your child to reclaim their confidence and quality of life.