European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 321–322
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Letter to the Editor Nasopharyngeal branchial cyst Kyste nasopharyngé branchial (origine) A 70 year-old male without previous medical history was referred for right nasal obstruction associated with a sensation of fullness of the right ear. Nasal endoscopy found a well-delineated smooth-surfaced cystic-like mass in the right superolateral nasopharynx, obstructing the right choana and projecting into the contralateral choana (Fig. 1A). MRI found a high-intensity 22.4 × 23.7 × 32 mm cystic mass with a thickened wall showing slight gadolinium uptake, obliterating the Rosenmüller fossa in the right nasopharynx, without parapharyngeal extension (Fig. 1B). Marsupialization was performed under general anesthesia by an endonasal approach, followed by regularization of the marsupialization site edges, without bleeding or neurovascular damage (Fig. 1C and D). Histopathology diagnosed branchial cyst (Fig. 2). At 3 years’ follow-up, the patient was asymptomatic, without recurrence.
Nasopharyngeal locations are extremely rare in branchial cyst, which is usually located on either the anterior edge or the deep side of the sternocleidomastoid muscle, and generally originates in the 2nd branchial cleft [1]. Nasopharyngeal locations are possible, if unusual, and are classified as type IV according to Proctor [2]; there are only a few dozen reports in the literature, mainly in Asian populations [3,4]. Clinical presentation is polymorphic, associating rhinorrhea, nasal obstruction, ear fullness or seromucous otitis; location is lateral [1]. Nasal endoscopy shows a well-delineated smooth-surfaced cystic-like mass attached to the lateral wall of the nasopharynx. Radiological diagnosis is mainly founded on MRI, which usually shows a low-intensity signal on T1 and a high-intensity on T2-weighted sequences, without peripheral contrast uptake; signals may, however, be high-intensity on both sequences in protein-rich cysts [4]. Differential diagnosis mainly involves nasopharyngeal carcinoma, which is very frequent in Mediterranean lands, or Thornwaldt’s cyst, although this diagnosis is confirmed by a medial location and the absence of lymphoid tissue on histology [4]. Treatment consists in complete surgical
Fig. 1. A. Cyst-like formation originating in the superolateral nasopharynx and obstructing the right choana. B. High-intensity 22.4 × 23.7 × 32 mm cystic mass, with thickened wall showing slight gadolinium uptake, obliterating Rosenmüller’s fossa in the right nasopharynx, without parapharyngeal extension. C. Cyst marsupialization. D. Regularization of marsupialization site edges. http://dx.doi.org/10.1016/j.anorl.2014.01.007 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
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Letter to the Editor / European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 321–322
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Marom T, Russo E, Ben Salem D, et al. Int J Pediatr Otorhinolaryngol 2009;73:1063–70. [2] Proctor B. Lateral vestigial cysts and fistulas of the neck. Laryngoscope 1955;65:355–61. [3] Chen P-S, Lin Y-C, Lin Y-S. Nasopharyngeal branchial cleft cyst. J Chin Med Assoc 2012;75:660–2. [4] Chen YA, Su JL, Hao SP. Nasopharyngeal branchial cleft cyst. Otolaryngol Head Neck Surg 2007;136:144–6. [5] Kim YW, Baek MJ, Jung KH, et al. Two cases of nasopharyngeal branchial cleft cyst treated by powered instrument assisted marsupialisation. J Laryngol Otol 2013;127:614–8.
Fig. 2. The cyst wall was bordered by cylindrical epithelium surrounding abundant lymphoid tissue compatible with branchial cyst.
resection. Various approaches are feasible: endonasal, transpalatine, transoral or transmandibular [1,3]; but an endonasal approach is to be preferred, being easier and showing less associated morbidity, the only restriction being in case of parapharyngeal extension; the alternative approaches incur a risk of severe complications such as hemorrhage or velopharyngeal insufficiency. Kim reported 2 cases of nasopharyngeal branchial cyst, managed in 1 case on a transoral approach and in the other endonasally by the microdebrider; there was no recurrence in either case. Given the small number of cases, however, and the rare implementation of this technique, a larger long-term study would be useful to assess this attitude [5].
B. Hemmaoui ∗ M. Sahli A. Jahidi F. Benariba Service d’ORL et chirurgie cervico-faciale, hôpital d’instruction militaire Mohamed V, BP 1018, Hay Riad, Rabat, Morocco ∗ Corresponding
author. Tel.: +212 66 10 69 73 4. E-mail address: [email protected] (B. Hemmaoui)
Available online at
ScienceDirect www.sciencedirect.com
Letter to the Editor Nasopharyngeal branchial cyst Kyste nasopharyngé branchial (origine) A 70 year-old male without previous medical history was referred for right nasal obstruction associated with a sensation of fullness of the right ear. Nasal endoscopy found a well-delineated smooth-surfaced cystic-like mass in the right superolateral nasopharynx, obstructing the right choana and projecting into the contralateral choana (Fig. 1A). MRI found a high-intensity 22.4 × 23.7 × 32 mm cystic mass with a thickened wall showing slight gadolinium uptake, obliterating the Rosenmüller fossa in the right nasopharynx, without parapharyngeal extension (Fig. 1B). Marsupialization was performed under general anesthesia by an endonasal approach, followed by regularization of the marsupialization site edges, without bleeding or neurovascular damage (Fig. 1C and D). Histopathology diagnosed branchial cyst (Fig. 2). At 3 years’ follow-up, the patient was asymptomatic, without recurrence.
Nasopharyngeal locations are extremely rare in branchial cyst, which is usually located on either the anterior edge or the deep side of the sternocleidomastoid muscle, and generally originates in the 2nd branchial cleft [1]. Nasopharyngeal locations are possible, if unusual, and are classified as type IV according to Proctor [2]; there are only a few dozen reports in the literature, mainly in Asian populations [3,4]. Clinical presentation is polymorphic, associating rhinorrhea, nasal obstruction, ear fullness or seromucous otitis; location is lateral [1]. Nasal endoscopy shows a well-delineated smooth-surfaced cystic-like mass attached to the lateral wall of the nasopharynx. Radiological diagnosis is mainly founded on MRI, which usually shows a low-intensity signal on T1 and a high-intensity on T2-weighted sequences, without peripheral contrast uptake; signals may, however, be high-intensity on both sequences in protein-rich cysts [4]. Differential diagnosis mainly involves nasopharyngeal carcinoma, which is very frequent in Mediterranean lands, or Thornwaldt’s cyst, although this diagnosis is confirmed by a medial location and the absence of lymphoid tissue on histology [4]. Treatment consists in complete surgical
Fig. 1. A. Cyst-like formation originating in the superolateral nasopharynx and obstructing the right choana. B. High-intensity 22.4 × 23.7 × 32 mm cystic mass, with thickened wall showing slight gadolinium uptake, obliterating Rosenmüller’s fossa in the right nasopharynx, without parapharyngeal extension. C. Cyst marsupialization. D. Regularization of marsupialization site edges. http://dx.doi.org/10.1016/j.anorl.2014.01.007 1879-7296/© 2014 Elsevier Masson SAS. All rights reserved.
322
Letter to the Editor / European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 321–322
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Marom T, Russo E, Ben Salem D, et al. Int J Pediatr Otorhinolaryngol 2009;73:1063–70. [2] Proctor B. Lateral vestigial cysts and fistulas of the neck. Laryngoscope 1955;65:355–61. [3] Chen P-S, Lin Y-C, Lin Y-S. Nasopharyngeal branchial cleft cyst. J Chin Med Assoc 2012;75:660–2. [4] Chen YA, Su JL, Hao SP. Nasopharyngeal branchial cleft cyst. Otolaryngol Head Neck Surg 2007;136:144–6. [5] Kim YW, Baek MJ, Jung KH, et al. Two cases of nasopharyngeal branchial cleft cyst treated by powered instrument assisted marsupialisation. J Laryngol Otol 2013;127:614–8.
Fig. 2. The cyst wall was bordered by cylindrical epithelium surrounding abundant lymphoid tissue compatible with branchial cyst.
resection. Various approaches are feasible: endonasal, transpalatine, transoral or transmandibular [1,3]; but an endonasal approach is to be preferred, being easier and showing less associated morbidity, the only restriction being in case of parapharyngeal extension; the alternative approaches incur a risk of severe complications such as hemorrhage or velopharyngeal insufficiency. Kim reported 2 cases of nasopharyngeal branchial cyst, managed in 1 case on a transoral approach and in the other endonasally by the microdebrider; there was no recurrence in either case. Given the small number of cases, however, and the rare implementation of this technique, a larger long-term study would be useful to assess this attitude [5].
B. Hemmaoui ∗ M. Sahli A. Jahidi F. Benariba Service d’ORL et chirurgie cervico-faciale, hôpital d’instruction militaire Mohamed V, BP 1018, Hay Riad, Rabat, Morocco ∗ Corresponding
author. Tel.: +212 66 10 69 73 4. E-mail address: [email protected] (B. Hemmaoui)
