Parotid Branchial Cleft With Facial Paralysis Report of Andrew W.

a

Case

Miglets,

MD

\s=b\ Cysts of branchiogenic origin are an extremely unusual source of parotid swelling. I describe the clinical course of a patient with a branchiogenic cyst that initially developed as a rapidly enlarging parotid mass associated with a partial facial paralysis. (Arch Otolaryngol 101:637-638, 1975)

branchiogenic origin Cystsextremely swelling. Only patients of

are an

unusual

cause

of pa¬ with

rotid 25 this anomaly have been previously re¬ ported in the literature.1 I describe a patient with a branchiogenic cyst that developed as a rapidly enlarging parotid mass. A partial facial paraly¬ sis was also present, adding to the difficulty in the management of this

patient.

REPORT OF A CASE A

64-year-old man had a two-month his¬ a gradually enlarging mass ante¬

tory of

rior to his left ear. One week prior to ad¬ mission, the mass became painful and the patient noted weakness in the upper left part of his face.

publication May 26, 1975. Department of Otolaryngology, Ohio State University College of Medicine, Columbus. Reprint requests to 456 Clinic Dr, Room 4118, Columbus, OH 43210 (Dr Miglets). Accepted

From the

for

Cyst

On initial examination,

canal. Since the posterior surface of gland was separated from the carti¬ laginous ear canal, the facial nerve was found to be displaced inferiorly by the mass. The superior branch of the facial

firm,

ear

slightly painful mass was present in the superior portion of his left parotid gland. Complete paralysis of the temporal and zy¬ gomatic branches of the facial nerve was present, while the lower portion of his face

the

a

3x3 cm-,

exhibited a substantial weakness. A pa¬ rotid sialogram revealed the presence of a mass lesion in the upper portion of the su¬ perficial lobe. Several areas where the con¬ trast material was collected were reported as a probable "necrotic area" within the gland. Results of a needle biopsy revealed that the lesion was cystic. A milky fluid was aspirated. Cytologie examination re¬ vealed no malignant cells. A coagulasenegative Staphylococcus was cultured from the fluid, while anaerobic cultures later also showed the presence of a diphtheroid. Results of a Vim-Silverman needle biopsy of the cyst wall revealed only chronic inflammatory cells. The patient was treated preoperatively with tetracycline, and the next day explor¬ atory surgery was performed on the pa¬ rotid gland. Because of the combination of an en¬ larging parotid mass with facial nerve in¬ volvement, the patient was informed that the lesion probably represented a carci¬ noma, and that the facial nerve might have to be sacrificed with its excision. The parotid gland was exposed through a "S" incision, with care taken to include the previous needle biopsy site with the specimen. The mass was in the superior portion of the superficial lobe, close to the

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nerve was close to the tumor, which could then be palpated within the gland. At this stage, the option was present to sacrifice the facial nerve with the speci¬ men, or attempt to make a definitive diag¬ nosis by frozen section. We chose the latter course, and cut a deep wedge section through the portion of the parotid gland that had already been exteriorized. The dissection in this area was complete, and if cancer was present, the biopsy site could be sutured closed, and a total parotid¬ ectomy could be done without compromis¬ ing the tumor margins. The frozen sections showed a squamous epithelium that was surrounded by dense lymphoid tissue—the classic picture of a branchiogenic cyst. It was believed that a representative speci¬ men had been taken, and that the lesion was indeed benign. Accordingly, a super¬ ficial parotidectomy was done, with care taken to preserve of the facial nerve. As the dissection progressed, a medial prolon¬ gation or stalk was discovered projecting from the cyst. This tissue extended deep to the facial nerve and ended near the bony ear canal. Permanent histologie sections showed a unilocular cyst that was lined with both squamous and respiratory epithelium that were surrounded by a sea of lymphoid tis¬ sue. Between the cyst and the parenchyma

parotid was a fibrous capsule that infiltrated with inflammatory cells. The final diagnosis was branchial cleft cyst within the parotid gland. The patient did well postoperatively, and

of the was

year later was asymptomatic with full return of facial function. one

COMMENT The vast majority of branchial anomalies are secondary to maldevelopment within the second and third branchial grooves. They usually de¬ velop as cysts, fistulas, or sinuses within the neck. Anomalies of the first branchial groove are quite rare, comprising less than 1% of the total branchial anomalies.2 These first branchial groove lesions may occur behind the angle of the jaw, behind the ear, or, occasionally, anterior to the ear. They may be confused with

preauricular cysts, lymph nodes,

or

cysts.3 The presence of a branchiogenic cyst within the sub¬ stance of the parotid gland is an ex¬ tremely uncommon finding, with only sebaceous

having been previously re¬ in the world literature.1 Be¬ cause of the rarity of parotid bran¬ chiogenic cysts, these patients are

25

cases

ported

frequently misdiagnosed prior to sur-

gical removal. The lesion is usually thought to represent a parotid gland tumor or cyst. Parotid branchiogenic cysts are usually unilocular, and may be lined with either squamous

or respiratory epithelia, depending on their origin. Those arising from incorrect fusion

of the ectodermal-covered branchial grooves will be lined with squamous epithelia, while branchial pouch anomalies will be lined with res¬ piratory epithelia.4 Characteristical¬ ly, branchiogenic cysts are surrounded by abundant lymphoid tissue. Rarely, cartilage, muscle, or blood vessels are present close to the cysts, and if so, indicate the participation of the mesodermal branchial arch in the for¬ mation of the cyst.3·5 An accurate preoperative diagnosis can be quite helpful in planning the surgical approach since branchiogenic cysts will often have a medial exten¬ sion or stalk extending toward the ear canal or pharynx. This should alert the surgeon to the possibility of the various relationships that this medial extension may have with the facial nerve. This "stalk" of tissue may pass over or under the facial nerve, and in rare instances may even

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bifurcate the nerve.5 The primary diagnosis in my pa¬ tient was clouded by the facial paral¬ ysis, which made a malignant neo¬ plasm of the parotid gland the most likely probability. The definitive diag¬ nosis, made by open biopsy during the operation, would not have compro¬ mised the surgical margins if cancer had been present, yet it enabled selec¬ tion of the proper conservative proce¬ dure. The facial nerve paralysis was probably due to inflammation that surrounded the cyst, which was close to the nerve, especially the upper two branches.

References 1. Sisson GA, Summers GW: Branchiogenic cysts within the parotid gland. Arch Otolaryngol 96:165-167, 1972.

2. Whitson TC: Anomaly of the first branchial cleft. Plast Reconstr Surg 42:595, 1968. 3. Randall P, Royster HP: First branchial cleft anomalies: A not so rare and a potentially dangerous condition. Plast Reconstr Surg 31:497, 1963. 4. Karlan MS, Pierce MK, Smolin A: Branchiogenic cysts in the parotid salivary gland. Calif Med 99:21-24, 1963. 5. Purcelli FM: First branchial cleft anomalies. Am Surg 33:785-790, 1967.

Parotid branchial cleft cyst with facial paralysis. Report of a case.

Cysts of branchlogenic origin are an extremely unusual source of parotid swelling. I describe the clinical course of a patient with a branchiogenic cy...
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