Branchial Cleft Remnant (Branchial Cyst)
What is a Branchial Cleft Remnant?
Branchial clefts are the grooves that transiently appear on the side of your baby’s head and neck just 3 to 4 weeks after conception. The clefts are under branchial arches, that are arranged in rows that look like the gills of a fish. One by one these arches and grooves change and vanish and create specific parts of the face, head and neck. Most of the time, the arches and grooves completely vanish.
Very rarely, a part of the cleft can persist, and it’s location and features depend on which arch has failed to regress.
Branchial arches each have some primitive cell lineages called ectoderm, mesoderm and endoderm. Ectoderm makes skin and nerves, mesoderm makes muscles and cartilage, and endoderm lines the body cavities (called mucosa) and makes glands such as the thyroid and parathyroid glands. Branchial clefts remnants can have components of skin, nerves, cartilage, and muscle. They can be arranged as a cyst which is under the skin, a sinus which is a tract that opens on to the skin, or a fistula, which is a tunnel between the skin on the outside and the inside lining of the body such as the pharynx (throat).
The most common branchial cleft remnant is from the second cleft. The second arch that makes some of the bones of the inner ear, part of the hyoid bone in the neck, and muscles that give facial expression. The remnant is usually found along the edge of the sternocleidomastoid muscle, which is the neck muscle that helps to turn the head. It may feel like a hard lump of cartilage, or have an opening in the skin. If there is a long fistula tract, it can travel up inside the neck and move in between the carotid arteries and join to the tonsils in the throat.
Branchial cleft remnants can get infected, and discharge pus. This is common and not usually a life threatening emergency.
Third and fourth cleft remnants are the next most common, and are incredibly rare. The third cleft remnants may connect to the thyroid gland and predispose a patient to thyroiditis.
Dr ROB’S APPROACH
Dr Rob will recommend that the remnant is surgically removed under a general anaesthetic. If there is a history or physical signs that are not typical of second cleft remnants, then Dr Rob will arrange for your child to have a MRI scan to help clarify the anatomy.
If it is in a classic location for a second cleft remnants then no further investigation is required and an operation can be arranged.
If the remnant is actively infected, then your child will have a 2 week course of antibiotics and ideally wait at least 6 weeks before having an operation.
The operation is performed as a day case, so you will arrive in the morning and take your child home in the afternoon. The surgical incision will be closed with dissolving sutures, glue and sometimes a sticky white plaster called Hypafix® for extra reinforcement. If there is a long fistula, your child may need more than one incision on their neck to safely remove the entire tract.
POST OPERATIVE RECOVERY AND CARE
After a couple of days of paracetamol and ibuprofen, your child should be feeling much better and can return to daycare, kindy or school.
DR ROB McCUSKER
Gold Coast Children’s Surgeon
Dr Rob is dedicated to the highest quality of care and technical excellence for his patients.