MANAGEMENT OF CYST

TUMOR IN NECK
BOB ANDINATA
DHARMAIS NATIONAL CANCER CENTER HOSPITAL
PAEDIATRIC NECK LUMP

• The majority are benign

• Commonly located anterior to the SCM (anterior triangle)
• Divide into midline and lateral
• The most common congenital lesions are medial (thyroglossal) and lateral
(branchial) cysts and fistulae. In addition, haemangiomas, lymphangiomas and
dermoid cysts can occur.
• Congenital malformations of the neck are comparatively rare and present as
neck masses that typically present in the two first decades of life.
MIDLINE NECK LUMPS
THYROGLOSSAL CYST

• The commonest midline mass

• Fistulae and cysts of thyroglossal origin are also known as thyroglossal duct/tract
remnants, and median neck cysts/fistulae.
• Median neck cysts/fistulae are infrahyoidal remnants of the thyroglossal duct
apparatus, which normally obliterates by the end of 8 embryonic week and
become completely reabsorbed.
• Its site of origin persists as the foramen caecum at the base of the tongue.
EMBRYOLOGICALLY, THE CYST CAN ARISE AT ANY SITE ALONG THE ROUTE OF
THYROGLOSSAL DUCT, EXTENDING FROM THE TONGUE (FORAMEN CAECUM) TO
THE THYROID GLAND. COMMONLY LOCATED BELOW HYOID BONE
• The most common presentation of the thyroglossal duct
cyst is an upper midline (fluctuating) cervical mass that
occurs during the first decade of life.
• Roughly 75% of cases present during the first 5 years of
life, with equal distribution between sexes.
• Fistulae – if occurring – manifest early in infancy as
draining dimples, which will retract during swallowing.
• Histopathologically, the majority of specimens
demonstrate squamous or respiratory columnar
epithelium. Up to 20% of the lesions have been reported
to contain thyroid tissue.
• Moves both on swallowing and tounge protrusion
• Most cysts are asymptomatic, beside presence of a lump
• Approximately 10–15% demonstrate infection (reddening, pain)
• Fistula formation (pus drainage) is only present after infection of the cyst and
maceration of the skin
• Abscess formation, large cysts at the base of the tongue may cause dyspnoea,
dysphagia or even sore throat symptoms.
INFECTED THYROGLOSSAL CYST LOCATED IN THE MIDLINE.
OVERLYING SKIN IS MACERATED, AND THERE IS A RISK FOR SPONTANEOUS
RUPTURE OF THE ABSCESS. (PHOTO COURTESY OF PROF. W. ARNOLD, TECHNICAL UNIVERSITY OF MUNICH, GERMANY)
THYROGLOSSAL CYST. (A) ULTRASOUND SHOWS A MIDLINE
HYPOECHOIC, AVASCULAR MASS (ARROW).
THYROGLOSSAL CYST.
(B) AXIAL SHORT INVERSION RECOVERY MRI CONFIRMS A HIGH SIGNAL,
WELL DEFINED CYST (ARROW).
TREATMENT

• The definitive therapy for branchial anomalies is complete surgical excision.

• excision, which should include the central portion of the body of the hyoid
bone to prevent recurrence (Sistrunk Operation)
• Tips : It is important to follow the epithelial trunk up to the hyoid bone.
• At least the central part of the hyoid bone must be removed.
• If the epithelial trunk continues cranially, it must be followed up to the tongue
base.
PROGNOSIS

• If completely removed, the patient is considered cured.

• If the middle portion of the hyoid bone in not resected, recurrence will usually
happen.
• All cysts and tracts must be examined histopathologically
• It is rare instances of concomitant neoplastic disease, especially if the patient
has received prior neck irradiation.
LATERAL NECK LUMP
• Chemodectoma
carotid body, chemoreceptor, or glomus jugulare tumor; nonchro
maffin paraganglioma; relatively rare, usually benign neoplasm ori
ginating in the chemoreceptor tissue of the carotid body, glomus j
ugulare,
and aortic bodies; consisting histologically of rounded or ovoid hyp
erchromatic cells.

• Cystic Higroma : A cystic lymphangioma and macrocystic

lymphatic malformation, is an
often congenital multiloculated lymphatic lesion that can arise
anywhere, but is classically found in the left posterior triangle of
the neck and armpits.
BRACHIAL CYST

• Rare cyst
• Located anterior to tragus
• The aetiology is cystic degeneration in a lymph node
• Most are lined by lymphoid tissue
• Pain and swelling may be experienced with upper
respiratory infections
• Present a tract may extend to the pharynx
• The branchial apparatus develops during the 2nd - 6th weeks of life.
• It is lined by ectoderm externally and endoderm internally;
• meso-derm and neural crest cells migrate into the branchial arches to evolve
into musculo-skeletal, vascular and cranial nerves
• The endoderm that lines the branchial pouches evolves into the middle ear,
tonsil, thymus and parathyroid
• The 1st branchial cleft evolves into the external auditory meatus
• Because clefts 2 - 4 embryologically have a common external opening, one
cannot determine the cleft of origin by the position of the external sinus.
• A fistula results from a communication between a branchial cleft and pouch.
 STRUCTURES THAT EVOLVE
FROM BRANCHIAL CLEFTS AND
POUCHES; CLEFTS 2-4 FORM
CERVICAL SINUS THAT IS
SUBSEQUENTLY OBLITERATED
• Branchial cleft cysts and fistulae are classified as first, second, third and
fourth branchial cleft abnormalities.
• the second branchial cleft cyst/fistula is the most common
• The second branchial cleft cyst or its opening is found along the anterior
border of the sternocleidomastoid muscle.
• Branchial anomalies may be diagnosed at any age but present most
commonly in infancy and childhood as a cutaneous sinus, a cyst or an abscess.
• There is no gender or laterality predominance. Bilateral presentation is rare.
• Histopathologically, branchial cysts characteristically appear as stratified
squamous and/or a mixture of squamous and respiratory epithelium with
lymphoid follicles.
• The existence of branchiogenic carcinoma is controversial.
• Cystic metastases to cervical lymph nodes originating from oropharyngeal
squamous cell carcinoma occur far more commonly and should be suspected
particularly in adult patients presenting with cystic masses in Levels 2 or 3 of
the neck.
 BRANCHIAL CYST FROM THE SECOND CLEFT.
(PHOTO COURTESY OF PROF. W. ARNOLD, TECHNICAL UNIVERSITYOF MUNICH, GERMANY)
ULTRASOUND OF AN UNCOMPLICATED BRANCHIAL CYST.
NOTE THE ABSENCE OF SEPTATIONS AND THE THROUGH ENHANCEMENT.
GENERAL CLINICAL PRESENTATION A CYST MAY PRESENT AS AN EXTERNAL SWELLING, OR CAUSE
DYSPHAGIA OR AIRWAY OBSTRUCTION DUE TO ITS MASS EFFECT, OR BECOME INFECTED AND
PRESENT AS AN ABSCESS
AXIAL CONTRAST ENHANCED CT SHOWING A RIGHT SIDED LOW
ATTENUATION BRANCHIAL CYST.
TREATMENT

• Should be removed at initial diagnosis, since repeated infections make later

surgery more difficult
• The epithelial tract passes superiorly and laterally to the common carotid
artery,
• The cyst and the entire fistula must be resected up to the tonsillar region to
avoid recurrences.
RESECTION OF CYST BY SUPER-FICIAL PAROTIDECTOMY, EXPOSING
VIIN AND ITS BRANCHES
PROGNOSIS
• Surgical removal usually cures the patient.
• If surgery is not radical with complete removal of the cyst or fistula, there is a
high incidence of recurrence.
• With increasing age, one has to consider malignancy (cystic metastases) as an
increasingly important differential diagnosis of a lump in the neck; this makes
the surgical excision even more relevant.
• In some international reports, up to 25% or all “branchial cysts” have been
reported to be histopathologically malignant in individuals older than 40 years
of age.
• A malignant transformation of a lateral branchial cyst itself is extremely
unusual, and only a few cases have been reported in the international
literature.
KESIMPULAN
 TERIMA KASIH

• R.S. Dillon, C. A East, Ear, nose and throat and head and neck surgery, 2nd Edition, Churchill livingstone, 1999
• W. Arnold U. Ganzer Series Editors M. Anniko M. Bernal-Sprekelsen V. Bonkowsky P. Bradley S. Iurato Otorhinolaryngology,Head and
Neck Surgery European Manual of Medicine, Springer Heidelberg Dordrecht London New York ý Springer-Verlag Berlin Heidelberg
2010
• J R A TURKINGTON, FRCR, A PATERSON, FRCR, L E SWEENEY, FRCR and G D THORNBURY, FRCR Department of Radiology, Royal Belfast
Hospital for Sick Children, The British Journal of Radiology, 78 (2005), 75–85 E 2005 The British Institute of Radiology