First Branchial Cleft Sinus

Khalid Al Aboud, MD, Khalid Al Hawsawi, MD, V. Ramesh, MD, Daifullah Al Aboud, MD, Ahmed Al Githami, MD


Skinmed. 2003;2(1) 

In This Article


Branchial cysts represent swellings of the neck due to a remnant of the branchial cleft. When there is an opening in the skin it is called a branchial cleft sinus. They can arise from remnants of the first, second, or third branchial arches. Most of the branchial cysts are of 2nd cleft origin and occur in the neck on the anterior border of the sternocleidomastoid muscle in the carotid triangle.[1] Branchial cysts are said to be the second major cause of head and neck pathology in childhood, related to the embryonic remnants of the thyroid and branchial structures. In the experience of a surgeon, of the congenital masses related to embryonic remnants, approximately 70% would be thyroglossal duct sinuses and cysts, 25% would be branchial cysts and sinuses, and 5% would be cystic hygromas.[2] Branchial cysts are invariably lined by squamous epithelium, immediately outside which lies abundant lymphoid tissue corresponding to the tonsils and other lymphatic tissues in the pharynx. The etiology of branchial cysts is not clear. The majority of opinion points to its origin from either the branchial apparatus or from lymphoid tissues. A retrospective review of the clinical and histopathologic features strongly supports the theory of lymphoid origin for the majority of such cysts.[3] Taking into account the anatomic location and the radiologic appearance, the precise embryologic origin can be predicted.[4]

The location of the sinus in the present case corresponds to the first branchial arch, which represents a semicircular area drawn from the lower third of the retroauricular aspect across the inferior part of the ear to the anterior aspect. These defects occur in the region of the parotid gland and occasionally communicate with the external auditory canal; however, true first cleft sinuses that communicate with the external ear canal are rare.[5] An unusual cause of parotid tumors is the embryologic remnant of first branchial cleft cysts.[6] Fistulae arising in the first branchial cleft are rare.[7] Radiologic studies in our patient revealed a normal parotid gland and ruled out a fistula. The scanty discharge resulting from secondary infection had caused maceration and erosion around the sinus, and had later dried to form thick crusts. Complete excision is the treatment of choice as was done in this patient before reporting to us. The problem had recurred when the patient presented to our clinic. Review of the histopathology had revealed evidence of both acute and chronic inflammation. In one localized area giant cell reaction of the foreign body type was seen which might have resulted from external manipulation. Apart from secondary bacterial infection, chronic conditions like tuberculosis were excluded.

Recurrences are known to occur following complete surgical excision of branchial cyst sinuses, as seen in a large retrospective study where the overall recurrence rate was noted to be 4.9% after a 2-year follow-up period.[8] In the differential diagnosis it is important to note that branchial cysts should not be confused with bronchogenic cysts. The main points of difference are their anatomic locations and histopathology, which have been outlined.[9] Bronchogenic cysts occur mainly around the sternal, scapular, and supraclavicular areas, and histopathologically ciliated respiratory epithelium is almost always found in them, as their origin is from the embryonic foregut that divides into the esophagus and trachea. Though all these anomalies fall in the domain of the surgeon, the presentation may be cutaneous and the dermatologist should be aware of them.