Branchial cleft anomaly


  • During 4th week of embryonic development, five branchial arches grow into distinct parts of head and neck
  • All consist of arteries, nerves, muscle, skeletal tissue
  • If arches fail to fuse--> soft tissue anomaly on lateral neck may form, called branchial cleft anomaly
  • Anomalies include cysts (most common), fistulas, sinus tracts
  • 2nd branchial cleft anomalies most common

Clinical Features

  • Lateral neck soft tissue anatomy
  • 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 mucus 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)


  • Thyroid nodules or cancer
  • Goiters
    • Graves' disease
    • Hashimoto thyroiditis
    • Iodine deficiency
    • Lithium use
    • Toxic multinodular
  • 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



  • 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


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