Work Type II First Branchial Cleft Cyst with External Auditory Canal Duplication

A 25 year-old male presented with a tender, fixed 3-cm right parotid mass persisting over 2 years with recent interval enlargement. CT scan demonstrated a cystic mass that did not invade adjacent soft tissue or bone. Fine needle aspiration (FNA) yielded cyst fluid. Total parotidectomy with facial nerve dissection for a presumed parotid tumor demonstrated a mass tracking deep to the facial nerve, coursing medially and superiorly to terminate adjacent to the cartilaginous external auditory canal (EAC). Pathology revealed an epithelial-lined cyst with hair matrix surrounded by elastic cartilage in focal areas consistent with a Work type II first branchial cleft cyst with EAC duplication. This case supports the literature in demonstrating that 1. misdiagnosis occurs commonly and frequently necessitates revision; 2. full facial nerve dissection reduces incidence of its injury; and 3. increased familiarity with its clinical symptoms, inclusion on the differential for parotid masses, preoperative imaging, and identification of a tract in the specimen can reduce recurrence rates. Work type II first branchial cleft anomalies must be included in the differential diagnosis for head and neck masses above the level of the hyoid bone. Preoperative imaging, more so than FNA, can confirm the diagnosis. Improved diagnosis can ensure the appropriate surgical approach, and decrease the risk of post-operative complications. Mal-development of First Branchial Cleft Leads to External Auditory Canal Malformations 2 References 1. D’Souza AR, Uppal HS, De R, Zeitoun H. Updating concepts of first branchial cleft defects: a literature review. Int J Pediatr Otorhinolaryngol. 2002;62(2):103-9. 2. Benson MT, Dalen K, Mancuso AA, Kerr HH, Cacciarelli AA, Mafee MF. Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. Radiographics 1992; 12(5):943-60. 3. Blevins, NH et al. External auditory canal duplication anomalies associated with congenital aural atresia. J Laryngology & Otology 2003;117: 32–38. 4. Triglia JM, Nicollas R, Ducroz V, Koltai PJ, Garabedian EN. First branchial cleft anomalies: a study of 39 cases and review of the literature. Arch Otolaryngol Head Neck Surg. 1998;124(3):291-5. 5. Acierno SP, Waldhausen JH. Congenital cervical cysts, sinuses and fistulae. Otolaryngol Clin North Am. 2007;40(1):161-76, vii-viii 6. Martinez Del Pero M, Malumdar S, Bateman N, Bull PD. Presentation of first branchial cleft anomalies: the Sheffield experience. Laryngol Otol. 2007;121(5):455-9. 7. Schroeder JW Jr, Mohvuddin N, Maddalozzo J. Branchial anomalies in the pediatric population. Otolaryngol Head Neck Surg. 2007;137(2):289-95. 8. Solares CA, Chan J, Koltai PJ. Anatomical variations of the facial nerve in first branchial cleft anomalies. Arch Otolaryngol Head Neck Surg. 2003;129(3):351-5. 9. Jakubikova J, Stanik R, Stanikova A. Malformations of the first branchial cleft: duplication of the external auditory canal. Int J Pediatr Otorhinolaryngol 2005;69(2):255-61 10. Sichel JY, Halperin D, Dano I, Dangoor E. Clinical Update on type II first branchial cleft cysts. Laryngoscope. 1998;108(10):1524-7. Discussion