Superficial Parotidectomy for a First Branchial Cleft Cyst

This video demonstrates a superficial parotidectomy approach for the excision of a first branchial cleft cyst in a pediatric patient. This particular patient was a 4-year-old girl who presented with intermittent swelling in the region of the left parotid. On MRI, she was found to have a lobular mass consistent with a first branchial cleft cyst. Here we outline the steps of the recommended surgical procedure.

Authors: Sarah Maurrasse, MD1,2; Monica Herron, MPAS, PA-C1; John Maddalozzo MD, FAAP, FACS1,2
Editors: Sarah Maurrasse1,2; Jesse Arseneau1
Voiceover: Vidal Maurrasse

1Ann & Robert H. Lurie Children’s Hospital of Chicago
2Northwestern University Feinberg School of Medicine

Superficial parotidectomy for excision of a left first branchial cleft cyst
First branchial cleft cysts are congenital masses that form due to a developmental anomaly of the branchial apparatus. Although they are benign, branchial cleft cysts can cause problems due to superinfection and mass effect. First branchial cleft cysts are divided into two types--Type I and Type II. Type I are purely ectodermal, typically present posterior to the pinna, and are usually superior to the main trunk of the facial nerve. Type II lesions, which are more common, include ectodermal and mesodermal structures and represent a duplication of the external auditory canal (EAC). These are often associated with the parotid gland and can be mistaken for a parotid tumor. These cysts can be associated with fistulae to the concha, EAC, or neck. Surgical excision is the definitive treatment for branchial cleft cysts. Surgical excision is indicated for branchial cleft cysts when there are associated complications such as recurrent infections, recurrent swelling, a cosmetic deformity, or in the case of first branchial cleft cysts, persistent otorrhea.
-Active infection -Bleeding disorder (relative)
-Endotracheal intubation -Avoid long acting paralytic -Facial nerve monitoring -Sterile prep and drape with face visible
CT/MRI is often used to determine if there is parotid involvement and/or if there is a connection to the external auditory canal. Suspicious lesions on imaging may warrant preoperative biopsy.
-Greater auricular nerve -Anterior border of the sternocleidomastoid muscle -Internal jugular vein -Parotid -Posterior border of the digastric -Tragal cartilage The tragal pointer, the posterior belly of the digastric muscle, and the tympanomastoid suture-line are used as landmarks to identify the main trunk of the facial nerve. The nerve exits the skull base at the stylomastoid foramen, which is bracketed by the posterior belly of the digastric and stylohyoid muscle.
Advantages include prevention of future infections and further scarring, cure for persistent otorrhea, and removal of a mass causing cosmetic concern. Disadvantages include surgical scar and possible need for additional surgery.
-Bleeding -Scarring -Surgical wound infection -Injury to the facial nerve -Tympanic membrane perforation -Recurrence
The authors would like to thank Vidal Maurrasse for his voiceover work.
Adams A, Mankad K, Offiah C, Childs L. Branchial cleft anomalies: a pictorial review of embryological development and spectrum of imaging findings. Insights Imaging. 2016 Feb. 7 (1):69-76. Baader WM, Lewis JM. First branchial cleft cysts presenting as parotid tumors. Ann Plast Surg. 1994;33:72-74. Finn DG, Buchalter IH, Sarti E, Romo T, Chodosh P. First branchial cleft cysts: clinical update. Laryngoscope. 1987 Feb;97(2):136-40. Krishnamurthy A, Ramshanker V. A Type I first branchial cleft cyst masquerading as a parotid tumor. Natl J Maxillofac Surg. 2014 Jan. 5 (1):84-5.

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