Managing a solitary cystic lateral neck mass, specifically differentiating between a simple second branchial cyst and a metastatic cyst poses a challenge. Often the diagnosis only becomes apparent on the final histology. This paper analysed 28 adults that presented to the authors’ department with a presumed branchial cyst over an eight-year period. Patients with risk factors for a head and neck malignancy and/or subsequent malignant cytology were excluded. Following surgical excision, the histology of two patients revealed cancer, one had papillary thyroid cancer and the other a HPV+ squamous cell carcinoma. Statistical analysis showed that a purely cystic mass on imaging was the only significant predictor of a true second branchial cyst. The authors reviewed the literature in this area, and with the help of their data formulated a proposed management algorithm. The core message was to recommend managing a cystic lateral neck lump as an unknown primary if there was evidence of malignant cytology, age over 40, or a suspicious mass (i.e. not purely cystic on imaging). Having recently applied the principles of their algorithm, I did find it useful in risk stratifying a patient with a presumed branchial cyst.

The incidence of malignancy in clinically benign cystic lesions of the lateral neck: our experience and proposed diagnostic algorithm.
Yehuda M, Schechter M, Abu-Ghamnem N, et al.
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Sidhartha Nagala

Royal Hallamshire Hospital, Sheffield, UK.

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