A 23-year-old male was referred to the outpatient unit of the surgery department, with a left side neck swelling of 1-month duration [Figure 1]. There was no history of trauma, tuberculosis, pain, discharge, and no limitation in mouth opening. Examination revealed a soft, partially mobile, nontender swelling, 5.5 cm x 4.5 cm in size, on the left side of submandibular area with normal overlying skin. No cervical lymphadenopathy was found.
Fine-needle aspiration cytology (FNAC) revealed pus-like fluid mixed with blood showed numerous anucleated squamous cells along with scattered giant cells and few inflammatory cells indicating a benign cystic lesion. Computed tomography (CT) scan showed a well-circumscribed rounded cystic lesion, measuring about 3.2 cm x 2.6 cm x 3.1 cm with peripherally enhancing thin wall in the left submandibular region posterior to the submandibular gland and anterior to the sternocleidomastoid muscle. There was no sign of infiltration into the nearby structures. Both lobes of thyroid gland, carotid, and jugular vessels appeared normal. There was no significant enlarged cervical lymph node and no obvious mass lesions in the oral cavity, oropharynx, and larynx. Differential diagnosis included branchial cleft cyst, tuberculosis, salivary gland neoplasm, neurogenic neoplasm, and metastatic lymph node enlargement.
The imaging features and location were suggestive of 2nd branchial cleft cyst [Figure 2].
Complete surgical excision was done under general anaesthesia using the left transverse cervical approach. Incision was followed by exposure of platysma with careful dissection and the lesion was found separate from the left submandibular gland and removed in toto [Figure 3].
The lesion was sent for histopathological examination. Macroscopically, specimen was a round unilocular cyst measuring about 4.8 cm x 4.2 cm x 3.0 cm. The cut surface showed a cystic mass filled with purulent material and multiple grayish-yellow nodules were present. Microscopy showed cyst wall with a stroma of lymphoid type, having germinal center in a few areas, covered by stratified squamous epithelium with reactive changes. Cystic lining revealed granulomatous features with foamy histiocytes, giant cells (Touton type) and lymphocytic infiltrate [Figure 4]. Our diagnosis was consistent with a branchial cleft cyst with XGI.
Postoperative course was uneventful and the patient was discharged from the hospital on 4th postoperative day and has been in regular follow-up for 9 months and doing well.