Lateral cyst of neck

The congenital lateral cyst of the neck is considered a benign neoplasm, which is very rarely diagnosed - only 2-3 cases per 100 diagnoses pertaining to the neck tumors. The etiology of development of the cyst of the neck is not yet specified, although its pathogenesis has been studied for two centuries. To date, all existing versions concern the violation of the process of embryogenesis, that is, congenital malformations, fetal development abnormalities. Formation of neoplasm begins in the early stages of pregnancy, the development of cysts is 90% asymptomatic, which greatly complicates the timely diagnosis and differentiation of a lateral benign tumor from similar neck diseases.

The lateral cyst in most cases is not dangerous, but it is assumed that with latent, latent form, inflammation and suppuration, the tumor can develop into a malignant tumor.

In the international classification of diseases (ICD-10), the cyst and fistula of the gill slit belong to the block Q10-Q18 - congenital anomalies (malformations) of the face and neck.

[1], [2], [3], [4], [5], [6]

Causes of the lateral cyst of the neck

The lateral cyst of the neck is not accidentally received a more accurate name - branhiogenic, closely related to the most reliable version, explaining the appearance of such neoplasms. Vranchia are gills, indeed, starting from the fourth week of gestation, the embryo forms the so-called gill apparatus. It includes five pairs of specific cavities (gill pockets), gill slits and arc arches (arcus branchialis) connecting them. Moving along the ventrolateral plane, the cells of the tissues of the gill apparatus form the basis for the formation of the CHO-maxillofacial region of the infant. If malfunctions occur in this process, the gill arches are not completely obliterated, leaving cavities and holes, in these zones a cyst and the accompanying fistula (fistula) may develop. The cyst consists of ectodermal tissue, and the fistula consists of an endoderm corresponding to the tissue of the pharyngeal pocket.

Types of embryonic branhyogenic disorders: 

• Cyst.
• Full fistula, open from both sides.
• Incomplete fistula with one exit.
• Combination of the lateral cyst and fistula.

Most often, the causes of the lateral cyst of the neck are associated with the rudimentary remains of the second pocket, which should form the tonsils. Such a cyst in 60-65% is accompanied by a fistula, the outer opening of which can leave in any zone along the edge of the nipple muscle, and the fistula is located along the carotid artery, sometimes crossing it. Branhyogenic cyst due to its origin is located deep enough, in contrast to atheroma or hygroma, and in most cases is detected in children older than 10 years and adult patients. Lateral fistula is defined earlier - in newborns and children up to 5-7 years, especially if it is characterized as complete, having two holes, one of which goes into the side of the pharynx, and the second - in the zone of Musculus sternocleidomastoideus - the sternocleidomastoid muscle. In addition, the causes of the lateral cyst cause its structure, from the inside the neoplasm consists of multilayered planar epithelium or cylindrical cells, as well as lymphatic tissue, which is the primary source for the formation of branchial arches and pockets.

[7], [8], [9], [10], [11], [12], [13]

Symptoms of a lateral cyst of the neck

The clinical signs of the branhyogenic cyst are not specific and are similar to the manifestations of the median benign neoplasm on the neck. However, unlike the thyroglossal cyst, the symptoms of the lateral cyst of the neck manifest themselves more intensively, in addition, the gill tumor is always localized laterally, between the 2nd and 3rd fascia, adjacent to the anterior zone of the sternocleidomastoid muscle.

Symptoms of the lateral cyst of the neck most often debut as a result of a common infectious inflammatory process or after trauma and can be such: 

• The cyst can appear as a small, almost unnoticeable swelling in the zone of the carotid artery ("sleepy triangle").
• At palpation the lateral cyst is felt as an elastic, mobile and painless neoplasm.
• The lateral cyst of the neck often increases during an acute or prolonged, chronic inflammatory process in the body (SARS, acute respiratory infections, influenza).
• An increase in the tumor, it becomes visible with the naked eye, sticking out and reaching at times 10 centimeters in diameter 10 centimeters.
• When the lateral cyst is inflamed, the nearby lymph node of the neck can grow.
• An enlarged cyst provokes a displacement of the larynx.
• The cyst can exert pressure on the neurovascular bundle and cause periodic painful sensations.
• Infection of the cyst is accompanied by suppuration and the formation of an abscess.
• The acute form of inflammation of the branhyogenic cyst can be accompanied by phlegmon and the corresponding symptoms - general intoxication, increased body temperature, lesion of the sternocleidomastoid muscle and the immobility of the neck.
• Purulent inflammation of the cyst can provoke an independent breakthrough of the walls and the release of exudate through the fistula.
• The lateral cyst may disrupt the ingestion of food, cause a feeling of heaviness in the esophagus (dysphagia).
• Cyst of large size provokes violations of diction, makes breathing difficult.
• Gill cyst, located in the larynx, can provoke a characteristic whistling sound when breathing - stridor.

It should be noted that the clinical manifestations of the branhyogenic cyst depend on its location and size and are often not detected for a long period of time until the effect of a provoking factor - inflammation or trauma. Lean symptomatology, slow development of the cyst creates certain difficulties in its diagnosis, especially in differentiation.

Lateral cyst of a neck at the child

Gill neck cyst is most often diagnosed in children older than 7 years, on the whole, congenital anomalies in this anatomical zone are extremely rare and appear closer to the pubertal period. The lateral cyst of the neck in a child of younger age, especially in newborns, usually has a latent form and does not show clinical signs until the impact of a provoking factor - a trauma, a respiratory infection or a general inflammatory process in the body. Some experts associate the debut of the symptom of the gill cysts with typical age periods, when hormonal changes occur in the body. The statistical data on this disease is extremely scarce and can not claim the title of objective, clinically confirmed information, however, practicing surgeons note the predominance of boys among patients with bronchial cysts.

Development of the cervical cyst in a child is almost always preceded by acute respiratory diseases, less often influenza. The close connection of the neoplasm with the lymphatic pathways facilitates the unhindered penetration of pathogenic microbes into the cavity of the cyst, inflammation of which in 75% is accompanied by suppuration.

The potential danger is represented by the increased cyst itself and its complications, abscess, phlegmon of the neck. It should be noted that in a quarter of the sick children, the primary detection of the gill cyst was associated with the referral to the doctor for the abscess of the neck. There is also the risk of malignization of the branhyogenic cyst, although in childhood, branhyogenic cancer does not occur, it is diagnosed in male patients after the age of 55 years. Nevertheless, given the ability of the lateral cyst to develop asymptomatically for decades, the importance of timely detection of the tumor is undeniable.

In the clinical sense, the lateral cyst of the neck in a child does not show any specific symptoms and may not bother him for a long time. Only inflammation and enlargement of the neoplasm causes problems with eating, pain in the area of the tumor, and difficulty breathing. A large cyst, abscess or phlegmon provokes symptoms of general intoxication of the body, the child's body temperature rises, a wheezing sound (stridor breathing), lymph nodes increase, nausea and vomiting are possible.

Treat side cysts in children and adults only in an operative way outside the stage of exacerbation. The purulent cyst is subject to puncture and anti-inflammatory treatment, then after the signs of acute inflammation subsided, it is removed. Surgery is performed for children older than 3 years, but the removal of the cyst can be shown at an earlier age in case of serious complications and a threat to the life of the baby.

The lateral cyst of the neck is considered more complicated in the sense of carrying out the operation than the middle one, since the walls of the tumor are in close contact with the neurovascular bundle and are anatomically connected with the carotid artery. Nevertheless, the removal of the lateral tumor in the presence of high-precision surgical equipment and instruments does not pose a danger to the health of the child. The operation is performed both under general and under local anesthesia, it all depends on the age of the patient, the size of the cyst and the presence of a fistula (fistula). Restoration period, scarring of the wound takes no more than 2 weeks. Since the incision is small, cosmetic, a few months later the seam on the neck is almost imperceptible, and as the child grows, it disappears altogether.

Diagnosis of the lateral cyst of the neck

Before, differential diagnosis of the cyst of the neck, determine its localization. Branhyogenic tumor is always located at the side, hence its name - lateral cyst. Diagnosis of the lateral cyst of the neck is most often performed already at the time of complication, when the cyst has increased in size, and is accompanied by an abscess or phlegmon. On the one hand, the clinical manifestations are obvious, on the other - they are similar to the signs of other neck diseases, which can make difficulties in the diagnosis process. In addition, the branhyogenic cyst is anatomically closely connected with the edge of Musculus sternocleidomastoideus - sternocleidomastoid muscle, carotid artery and other large vessels, with part of the hyoid bone, which provokes simultaneous increase in the inflammation of both cysts and lymph nodes. Therefore, the lateral cyst is often mistaken for lymphadenitis, its suppuration is often defined as an abscess, respectively, the treatment is not entirely adequate.

It should be noted that differential diagnosis of the lateral cyst of the neck from other types of congenital cysts is not of principle, since all of them, one way or another, are subject to prompt removal. Much more significant is the timely statement of the presence of the cyst as a benign tumor, the specification of its size, shape and presence of the fistula.

How is the cyst of the neck revealed? 

• Collection of anamnesis, including hereditary, since gill anomalies can be transmitted genetically by a recessive type.
• Examination and palpation of the neck, lymph nodes.
• Ultrasound of the neck.
• Computed tomography of the neck in the mode of contrasting according to the indications - clarification of tumor location, dimensions, consistency of the contents of the cavity, type of fistula (complete or incomplete).
• Puncture of cyst under indications.
• Fistulogram (staining fistula).

The lateral cyst is differentiated with such neck diseases: 

• Lymphadenitis, including non-specific tuberculosis form.
• Dermoid of submandibular salivary glands.
• Lymphangioma.
• Metastases in thyroid cancer.
• Chemodectomy (tumor of the glomus or vagus nerve).
• Lymphosarcoma.
• Abscess.
• Lipoma of the neck.
• Teratoma of the neck.
• Branhyogenic carcinoma.
• Vascular aneurysm.

[14], [15], [16], [17]

Treatment of the lateral cyst of the neck

The only common method that involves the treatment of the lateral cyst of the neck is surgery. Operative treatment is carried out both in a stationary and outpatient setting, everything depends on such factors:

• The diagnosis period, the definition of the lateral cyst. It is believed that the earlier it is detected, the more successful and effective its treatment is considered.
• Age of the patient. The most difficult to operate are small children under the age of 3 years. Such operations are indicated for large cysts that threaten the breathing process and cause a general intoxication of the body.
• The size of the tumor. The cyst is shown to operate when its dimensions exceed 1 centimeter in diameter.
• Localization of the lateral cyst. The closer it is to large vessels, nerves, the more complex and extensive the surgical intervention.
• The form of the cyst is inflamed, with suppuration.
• Complications that accompany the development of cysts. Concomitant abscess or phlegmon require additional anti-inflammatory treatment.
• The type of fistula, which in most cases is detected when the operative removal of the cyst. An incomplete or complete fistula is complicated in treatment, since it has moves closely in contact with the pharynx, the main vessels, the hyoid bone.

When removing the branhyogenic cyst, a thorough dissection of all fistulous passages, cords, up to the part of the hyoid bone, is carried out. In some cases, the tonsillectomy is performed in parallel. Careful and complete removal of all parts of the cyst leads to a hasty result, relapses are possible only in the case of incomplete excision of the fistulous course or during proliferation of the cyst epithelium into nearby tissues.

Inflamed, festering cysts do not operate, they are preliminarily treated with conservative methods, including with the help of antibiotic therapy. After the inflammatory symptoms subsided, the cyst can be removed to achieve the remission stage.

Removal of the cyst of the lateral neck

Removal of the cyst, including the lateral cysts of the neck - this is the most common method of treating benign cystic tumors. It is necessary to operate the branhyogenic cyst as early as possible, without waiting for its inflammation, suppuration and related complications. Even with the condition of spontaneous breakout of pus in the form of an open external abscess, earlier removal of the cyst helps to avoid the risk of malignancy. In addition, the scars that remain after the opening of the abscess significantly complicate the inevitable surgical intervention in the long term, since it will be more difficult to technically excise such a tumor.

The removal of the lateral cyst of the neck suggests its radical excision, which includes fistula. The more carefully removed all parts of the epithelial tissue of the tumor, the less the risk of recurrence of the cyst, the frequency of which is 10 cases for every 100 operations. The process of removal of the gill neoplasms is rather complicated, which is explained by the anatomical connection of the cyst with such important parts of the neck and body as a whole: 

• arteria carotis externa - carotid artery.
• nervous nodes.
• venae jugulares - jugular veins.
• hyoid bone.
• musculus sternocleidomastoideus - sternocleidomastoid muscle.
• processus styloideus - styloid process.

During the procedure, it is often necessary to remove part of the os hyoideum - the hyoid bone, and tonsils and even resect a part of the jugular vein that is in contact with the fistulous course. All this speaks for the complexity and seriousness of surgical intervention, although such procedures are classified as "small" surgery. It should be noted that modern equipment, instruments and new surgical techniques allow the removal of lateral cysts even in small children, if earlier, only 15 years ago, a cystectomy was performed only after 5 years of age, now the cyst is excised even in three-year-olds. Maximum anesthesia - local or general anesthesia, minimal traumatism during the operation allows patients to recover in the shortest time, the cosmetic incision is almost invisible, and the scar quickly resolves, leaving virtually no trace.

Operation with a lateral cyst of the neck

The operation to remove the branhyogenic cyst is performed in patients starting from the age of 3 years. The scope of surgical intervention, its duration is determined by the clinical picture of the disease and the results of the diagnostic examination.

The operation with the lateral cyst of the neck is not currently considered difficult, but requires care, since any part of the epithelium of the tumor that is behind can subsequently provoke a relapse, hence, a re-surgical treatment.

The general scheme of the operation is as follows: 

• After the preparation of the patient, anesthesia is performed, most often intubation of the trachea (endotracheal anesthesia).
• In the fistula, a coloring substance is used to clarify and visualize its course. More rarely a fistula is inserted into the fistula, this is shown with full fistulas with wide ducts.
• The incision is made along the conditional lines on the skin of the neck, showing the location of the collagen connecting bundles (Langer's lines). This ensures minimal traumatization of the skin - a cosmetic incision.
• If a fistula is identified, its outgoing external opening is cut, and the retention suture (ligature) is applied to the fistula itself.
• The tissues of the neck are dissected layer by layer until the fistula is reached, which is determined by palpation.
• The fistula is mobilized, isolated in the cranial direction (up, to the skull, to the auditory canal), continuing the process through the bifurcation of the carotid artery towards the fossa tonsillaris - amygdala fossa. In this zone, the fistula is ligated (bandaged) and cut off.
• Quite often, during the removal of the lateral cyst, two incisions are required, which after the procedure are sutured with subepidermal small sutures.
• Very rarely during the operation, bipolar electrocoagulation is used, it is not recommended for use in removing cysts in small children due to the close anatomical connection of the tumor and the vascular system.
• In complicated cases, with a lateral cyst and fistula, localized close to the palatine tonsils, parallel tonsillectomy is shown.

Operation with a lateral cyst of the neck lasts from half an hour to an hour, depending on the age of the patient and the complexity of the procedure. After removal of the cyst, antibacterial anti-inflammatory treatment is usually performed, physiotherapeutic procedures are prescribed-microcurrents, UHF. Surgical sutures are removed after 5-7 days, follow-up is carried out throughout the year to avoid recurrence of the process.

Prophylaxis of the lateral cyst of the neck

Warn the development of the gill cyst is almost impossible, it is due to the reasons for its inception, that is, with abnormalities of intrauterine development. Therefore, prevention of the lateral cyst is obviously a task for geneticists and those specialists who deal with the etiology and pathogenesis of congenital malformations of the embryo. If the cyst is detected in a small child and has no propensity for inflammation, an increase, doctors recommend a dynamic observation (examination every three months) until reaching the age of 3 years. Regular visits to the ENT doctor, otolaryngologist is the only way to control the development of the tumor, which at the first opportunity should be removed, thereby eliminating the risk of suppuration and various complications in the form of abscess or phlegmon. Adult patients should remember that the prevention of the lateral cyst of the neck also lies in its early diagnosis and radical excision, since the gill cysts are prone to overgrowth into branhyogenic cancer.

The main way to help in time to stop the increase and inflammation of the lateral cyst, can be regular medical examination of children and their thorough examination by otolaryngol. Timely detected benign tumor is successfully operated, which almost 100% guarantees the neutralization of the risk of malignant process in the neck.

Prognosis of the lateral cyst of the neck

In general, the prognosis of the lateral cyst of the neck can be classified as favorable, the risk of developing branhyogenic cancer exists, but in percentage terms it is very small. In addition, to date, there is no clear statistical information that could confirm the truth of the development of a cyst in a malignant tumor, rather, its alleged malignancy is associated with untimely diagnosed primary thyroid cancer and other oncology of the neck.

The prognosis of treatment of the lateral cyst of the neck is more specific, this gill anomaly is considered recurrent, and the success of the radical surgery is 90%, the remaining 10% are due to repeated removal of parts of the cyst or fistula. It should be noted that it is the fistulous passages that are most difficult for excision even with preliminary staining, this is due to the complex anatomical structure of the neck and the close connection of the tumor with large vessels, lymph nodes, the hyoid bone, the neurovascular bundle, the tonsils and the facial nerve.

The prognosis of the lateral cyst of the neck may depend on such factors: 

• Age of the patient.
• The duration of the development of the cyst.
• The size of the cyst, its location, proximity to important organs, nerve connections and large vessels.
• Presence of a fistula and its type (complete or incomplete fistula).
• The shape of the lateral cyst is inflammation, suppuration.
• The contents of the cyst cavity are exudate or pus.
• The presence or absence of a common inflammatory process, chronic diseases of the body.
• General health of the patient.

The lateral cyst of the neck or branhyogenic benign tumor is a rare congenital anomaly, which requires further study both in terms of etiology, pathogenesis, and in the field of new techniques for its treatment. Currently, the only available and common method by which the side cyst is curated is a radical operation. Perhaps in the near future there will be new methods of tumor neutralization, including those related to the category of conservative treatment.