Branchial cleft anomaly

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During the 4th week of embryonic development, there are five branchial arches that grow into distinct parts of the head and neck, all of which consist of arteries, nerves, muscles, and skeletal tissue. If the branchial arches fail to fuse, a soft tissue anomaly on the lateral aspect of the neck may form, which is called a branchial cleft anomaly. The range of anomalies include cysts (most common), fistulas, and sinus tracts. The second branchial cleft anomalies are the most common.

Clinical Features

  • Typically asymptomatic unless superinfected causing cellulitis or abscess formation
  • First branchial cleft cyst
    • Lump in parotid/auricular region
    • Facial nerve palsy
    • May drain through neck and external auditory canal
  • Second branchial cleft cyst
    • Most common
    • Present in late childhood or early adulthood
    • Swelling below angle of mandible and anterior to sternocleidomastoid
    • Sinus tracts travel into the deep neck structures and drain into tonsillar fossa
    • Fistulae cause mucous drainage from cutaneous opening at lateral neck
    • Very rarely become squamous cell carcinoma
  • Third and fourth branchial cleft cyst
    • Difficult to differentiate between the two
    • Located lower in neck, anterior or posterior to sternocleidomastoid
    • Preference for left side

Differential Diagnosis


Subacute (weeks to months)

  • Cancer
    • HPV-related squamous cell carcinoma
    • Upper aerodigestive tract squamous cell carcinoma
    • Metastatic disease
    • Lymphoma
    • Parotid tumors
  • Systemic diseases


  • Thyroid nodules or cancer
  • Goiters
  • Congenital cysts
    • Thyroglossal duct cyst- 2nd most common benign neck mass
    • Dermoid cyst
  • Carotid body tumor
  • Glomus jugulare or vagale tumor
  • Laryngocele
  • Lipoma/liposarcoma
  • Parathyroid cysts or cancer


  • Ultrasound
  • CT
  • MRI


  • Surgical excision is definitive treatment (high risk of recurrence if not completely excised)
  • Antibiotics if superinfection present


  • Discharge with outpatient surgical referral (if no systemic signs of infection present)
  • Admit for sepsis

See Also

External Links



Michael Holtz