HEAD AND NECK

Cystic swellings of the neck Key aspects of history-taking from patients with neck
lumps
William AE Parker
Andrew J Parker History of presenting complaint
Duration
Onset e sudden, gradual, congenital
Changes in size and exacerbating factors e.g. increasing in size
Abstract
when eating
Cystic neck swellings in the neck arise from a diverse range of tissues and
pathological disorder. The approach to diagnosis relies on a thorough Associated symptoms
history and an appropriate examination including the internal ENT to Pain
exclude an occult primary malignancy. The typical feature of fluctuance is Dysphagia
often not elicited because the contents of the cyst can be under tension Dysphonia
and transillumination is seldom performed these days. Aspiration and ultra- Hypo/hyperthyroid symptoms
sonography are usual but other imaging such as CTand MRI scanning can be Weight loss
indicated. Definitive treatment is usually surgical excision but with benign Night sweats
disease repeat aspiration can be considered. No intervention can be an Any other swellings
option if there is significant co-morbidity, absence of functional or cosmetic
Past medical/surgical/family history
impairment or there is reluctance by the patient to undergo surgery.
Endocrine disorders
Congenital abnormality
Keywords cyst; fine needle biopsy; neck lump; salivary gland; thyroid
Malignancy
Trauma/neck surgery

Introduction
Cystic swellings of the neck comprise an important group of head
and neck pathologies. They are relatively common and often cause
alarm in patients presenting with them. Cysts can arise from any
component of the neck and hence thorough knowledge of the
embryology, anatomy and pathology is vital for correct diagnosis
and management. Here we consider the main groups of cystic
swellings, discussing their origin, clinical features and treatment.
Some neck cysts are thought to have a congenital origin. The
neck develops in utero from fusion of ectodermal, mesodermal and
endodermal elements. There are five branchial arches containing
cartilaginous, muscular, neural and blood vessel elements and
corresponding clefts on each side which become fused. Ecto-
dermal tissue from the second arch then grows down caudally to
form the external neck covering and this arrangement is a throw-
back to the pattern found in vertebrates with a primitive gill
apparatus. In the midline where the upper arches meet is a small
elevation known as the tuberculum impar containing a median
depression known as the foramen caecum which gives rise to the
primordial thyroid tissue, which then descends in the neck taking
with it a thyroglossal tract which then becomes obliterated.
Diagnosis and general considerations
The management of a patient with a neck lump poses several
challenges to the clinician. A cyst implies the presence of fluid
Drug history
Social history
Smoking status
Occupation
Box 1
within an epithelialized cavity. A pseudocyst is defined as the
presence of fluid within a tissue or tissue space, but without an
epithelial boundary. When considered together, cystic lesions of
the neck form a diverse collection of pathological disorders.
To evaluate the situation further, the clinician needs to
undertake history-taking and examination along conventional
lines, the latter dividing into inspection, palpation and auscul-
tation. Investigations may then be needed and are discussed
below.
History
The history should include ascertaining the nature of the pre-
senting complaint, namely duration, speed of onset, changes in
size since onset, any exacerbating factors (for example when
eating), presence or absence of pain, dysphagia, dysphonia,
hypo/hyperthyroid symptoms, weight loss, night sweats, other
swellings, as well as the usual past medical, surgical, drug, social
and family histories, looking particularly at endocrine disorders,
congenital abnormality, malignancy, trauma and smoking status
(see Box 1).

William AE Parker BA (Hons) is a Clinical Medical Student, Magdalene Examination

College and Addenbrooke’s Hospital, University of Cambridge. Conflicts
of interest: none.
Andrew J Parker LLM ChM DLO FRCS is a Consultant ENT and Head & Neck
Surgeon, Senior Lecturer in ENT Surgery, Royal Hallamshire Hospital
and Sheffield University. Conflicts of interest: none.
There are various ways of classifying neck cysts. From the point
of obtaining a diagnosis, probably the best method is as set out
below and in Figure 1.
1. Is the lesion fixed to the skin or within subcutaneous tissue?
This implies that the lump can be picked up with the skin and
moves with it and is not fixed to underlying structures. The

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 HEAD AND NECK

Algorithm for diagnosis of cystic neck swellings on examination

Cystic swelling in the neck

Fixed to
the skin In/fixed to the Deep
skin or deep?

Epidermal cyst lipoma

Lateral Midline or
lateral?

Midline
No
No
Branchial cyst
Moves on Moves on Cystic
Salivary gland cyst
swallowing? swallowing? hygroma
Cystic hygroma

Yes Yes

No
Moves on tongue Thyroid
Thyroid cyst
protrustion? cyst

Yes

No
Above Thyroglossal
the hyoid? cyst

Yes

Sublingual dermoid

Figure 1

classic example is an epidermal cyst. It is important to remember Other ways of determining a differential diagnosis include
that at body temperature fat can feel fluid and a lipoma can have trying to ascertain the tissue of origin by clinical and anatomical
a cystic quality, although it is not a cyst. Note that these are characteristics, for example a cystic swelling present in the
generalized disorders and can occur anywhere there is skin or parotid area, and some clinicians may find the traditional
fat. ‘surgical sieve’ approach to diagnosis useful, as shown in Box 2.
2. What is the anatomical location? Is it midline or lateral?
Midline neck cysts are generally either thyroid, thyroglossal or
The ‘surgical sieve’ applied to cystic neck swellings
sublingual dermoid. These can however sometimes be lateral.
3. Does it move on swallowing? Congenital Acquired
Any lesion attached to the laryngopharyngeal structures, including Cystic hygroma Traumatic e pseudocyst
the hyoid, would do this including the three examples given in (2). Thyroglossal cysts Inflammatory e branchial cyst, some
4. What is its relation to the hyoid bone? Branchial cysts thyroid and salivary gland cysts
Midline cysts at the level of or below the hyoid that move on Neoplastic e some thyroid and salivary
swallowing are thyroglossal or thyroid in nature and those above gland cysts
represent sublingual dermoids. Degenerative e pseudocyst
5. Does it move on tongue protrusion? Other
This suggests a thyroglossal cyst or, uncommonly, something
attached to the hyoid bone such as a sublingual dermoid. Box 2

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 HEAD AND NECK
During examination the patient should be seated, be fully
exposed from the clavicles upwards and be seen in good light. An
internal ENT examination is similarly essential and this should
include at least examination of the oral cavity, oro-pharynx and
indirect laryngoscopy or flexible fibreoptic endoscopy in outpatients
under local anaesthesia. This is necessary to ascertain whether or
not the lesion is related to the internal ENT structures and particu-
larly applies to an occult malignancy, which cannot be excluded
otherwise. This is an omission that is potentially negligent.
Clinical characteristics of a cystic swelling are those of fluc-
tuancy where the examiner’s fingers on either side of the lesion
are displaced outwards when pressure is applied to the centre of
the cyst and also translucency, although the latter is rarely per-
formed outside the examination hall!
Investigations
It is often reasonable practice to aspirate the lesion in clinic with
a needle and syringe as it confirms the cystic nature of the lump
and enables cytological, biochemical and microbiological anal-
ysis to be undertaken, but this is often performed in association
with an ultrasound scan.
It is usual to undertake some form of imaging as further
investigation. Ultrasonography is a very useful technique and
needle aspiration can be performed at the same time. An elegant
review of this mode of imaging and its application to cystic neck
swellings is provided by El-Simily and Corney, 1993.1
Other techniques include magnetic resonance imaging (MRI) and
computed tomography (CT) scanning. There is no place for plain
neck X-rays and barium swallow contrast examinations are of limited
value in the investigation of a patient thought to have a neck cyst.
This review deals with the clinical presentation, diagnosis and
management of various common cystic lesions specific to the neck.
Specific lesions
Epidermal cysts and sebaceous cysts
The clinical characteristic of an epidermal (sebaceous) cyst is one
of a tense swelling within the skin, usually with absence of
fluctuance. Since these arise from the adenexae of hair follicles,
there is usually an obvious relation or a small punctum although
this is not inevitable. The usual treatment is surgical excision,
which can often be undertaken under local anaesthesia.
Lipoma
Although not a cystic lesion, these can often assume the clinical
characteristics thereof. They usually move with the skin, but do
not have a punctum. Since they arise from subcutaneous tissue,
as with the epidermoid cyst, they are not exclusive to the neck.
Treatment is usually excision.
Cystic hygroma
This is a curious swelling usually present at birth, but occasionally
presents later on. It is thought to result from abnormal fusion of the
lymphoid elements of the neck.2 It usually consists of multiple
grape-like swellings which often interconnect and is obviously
cystic on examination. It can affect any part of the neck, but is
usually seen laterally. This disorder can be extensive and involve
other structures such as the mediastinum, and can be associated
with other congenital abnormalities. It can progressively increase
in size, often dramatically so, and can be associated with infection
SURGERY 27:12
with profound consequences. Differential diagnosis should
include haemangiomata and it is useful that any surgeon
attempting excision should have this diagnosis excluded first.
Aspiration may temporarily relieve the problem, but never in
the long term and surgical excision is the treatment of choice. This
is potentially difficult because of important anatomical relations,
such as the great vessels and lower cranial nerves. Recurrent
lesions are often seen and it is not uncommon to require multiple
operations throughout the course of a patient’s life.
Sclerosant agents have been used to good effect including in
utero. These include OK-432 (a lyophilized incubation mixture of
group A Streptococcus pyogenes of human origin), also known as
Picibanil3 and the antineoplastic agent bleomycin.4 However,
these drugs are not licensed for this use.
Branchial cysts
An understanding of the embryology of the neck is essential in
the appreciation of branchial fistulae and sinuses because of the
important anatomical relationships which can make excisional
surgery fraught with difficulty. The aetiology of the branchial
cyst is controversial and most authorities consider that is not in
fact a congenital disorder, but rather a cystic degeneration within
a lymph node.5 The branchial cyst is seen in young adults, rather
than at birth, and typically lies at the junction of the upper and
lower two-thirds of the sternomastoid muscle, either anterior or
deep to it. They occur more frequently in males, in their thirties
and in the anterior triangle of the neck.
Occasionally, because of the tension within the cyst, the lesion
feels solid. Again, it can dramatically increase in size and become
infected. A detailed internal ENT examination is essential. Aspira-
tion shows straw-coloured fluid, typically showing degenerate
keratinocytes and cholesterol crystals. The diagnosis of a branchial
cyst in those over 40 years of age should be made with trepidation as
it can be cystic degeneration in a lymph node containing metastatic
squamous carcinoma from an internal ENT occult primary.6
Treatment is usually by surgical excision unless the patient
prefers recurrent aspiration, for example during pregnancy or
simply pursuing an expectant course. When patients are asked to
give consent for surgery, it is appropriate to warn about the possi-
bility of cranial nerve deficit. This is predominately to the
mandibular division of the facial nerve, especially if the incision is
inadvertently placed too high. In addition, one should warn the
patient about the potential for accessory nerve damage since this
can occur and can be particularly disabling, leading to destabiliza-
tion of the ipsilateral shoulder joint with weakness and pain. Divi-
sion of the greater auricular nerve is often necessary, particularly
with the larger cysts, and will result in numbness of the ipsilateral
ear which can be permanent but surprisingly very often recovers.
The accessory nerve, which enters the neck through the internal
jugular foramen, can be intimately applied to the posterior aspect
of the cyst and so inadvertently divided or traumatized. This is
a particular risk if surgery is undertaken after incision and drainage
of an infected branchial cyst when scar tissue can obliterate tissue
planes and make dissection difficult. As a good guide, the surface
anatomy of this vulnerable nerve is determined by drawing a line
between the junction of the upper third and lower two-thirds of the
sternomastoid muscle and the junction of the upper two-thirds and
lower one-third of the anterior border of the trapezius muscle in the
posterior triangle of the neck.
532 Ó 2009 Published by Elsevier Ltd.
 HEAD AND NECK

Case study
A 35-year-old male who works as a pie factory operative pre-
sented to the general ENT clinic with a 12-week history of a left-
sided swelling in the neck. On further questioning, there was no
dysphagia, no changes in the voice and there was no significant
past medical history. He was a non-smoker, but drank approxi-
mately 6 units of alcohol per night.
On examination, the internal ENT was normal. External
examination demonstrated a 5 cm swelling just anterior to the
sternomastoid muscle on the left side at the junction of the upper
one-third and lower two-thirds and deep to the subcutaneous
tissues. Periodic aspiration had been performed at the patient’s
request but with recurrence shortly after and was clearly not
a long-term solution. Repeated cytological analysis showed
degenerate keratinocytes and cholesterol crystals. Microbiolog-
ical analysis revealed no detectable infection. An ultrasound scan
showed cystic appearances.
Figure 2 Marking landmarks. The upper line indicates the lower limit of the
The situation was entirely typical for a benign branchial cyst. mandible. The lower line indicates the anterior border of the sternomastoid
The patient was advised to undergo excision to resolve the muscle. The middle line represents the site of the incision, taking care to
problem and obtain precise histology. Informed consent was place it at least two finger-breadths below the mandible to avoid trauma to
obtained and the patient warned pre-operatively about the small the mandibular branch of the facial nerve. Ideally it should be placed in
risks of bleeding, infection, unsightly scarring, recurrence, a natural skin crease but some surgeons prefer an incision running anterior
to and parallel with the upper sternomastoid muscle. The arrow below the
numbness and associated cranial nerve deficit.
lowest line was drawn on whilst the patient was on the ward and indicates
The operation was undertaken and the sequence for excision the side to be operated upon. It forms part of the pre-operative checks
of the cyst are as detailed in Figures 2e6. before the patient leaves for theatre, once again in the anaesthetic room
and then when on the operating table just before commencing excision.
Thyroid cysts
This article is not intended to provide an exhaustive discussion of enlargement or a sinus tract may be present.7 MRI may be useful in
thyroid disorder, which can be obtained elsewhere. Thyroid cysts recurrent disease as it can help to define the residual fistulous tract
can form part of more generalized thyroid disorder, but pre-operatively, thus aiding accurate excision, although in our
a common presentation is of a solitary and unilateral thyroid experience this investigation is usually not necessary.8
enlargement. Fluctuance is not usually demonstrated. The Small cysts can be left alone, but often patients presenting
swelling moves on swallowing, but not on tongue protrusion. with larger lesions request removal. Recurrence is relatively
The patient usually becomes aware of a painless lump and common following simple cyst excision and it is usual practice to
a history of rapid enlargement may indicate haemorrhage or less remove the body of the hyoid bone in continuity (Sistrunk’s
commonly malignancy. It is important to determine the nature of operation).
a lesion in this situation. Thyroid cysts are usually best investi-
gated with an ultrasound scan and aspiration. Benign cytology
and no further recurrence after aspiration requires no further
attention but a recurrent or progressively enlarging lesion usually
requires surgery, for example hemithyroidectomy.

Thyroglossal duct cysts

The thyroglossal cyst provides an example of how an under-
standing of the embryology of this area can aid diagnosis and
management. The thyroid gland arises from the region of the
base of tongue and then descends through the neck taking with it
a thyroglossal tract. This usually disappears, but occasionally can
either persist or an isolated segment can remain and undergo
cystic change. It is usually seen at the level of or below the hyoid
bone and in the midline, but not exclusively so. It is a relatively
easy clinical diagnosis to make and is a favourite for clinical
examinations. Occasionally it can be confused with an anterior
lymph node or rarely a sublingual dermoid.
On ultrasound, if uncomplicated, a thyroglossal cyst may appear Figure 3 Exposure of the branchial cyst. Once the incision has been made
through skin, the subcutaneous tissue, platysma and deep cervical
dark and well circumscribed or pseudosolid if it contains cholesterol
investing fascia needs to be divided. The sternomastoid muscle can be
or keratinocytes. If complicated by infection or haemorrhage, the divided to assist in the delivery of the larger cyst, but this increases the
cyst may show internal echoes of a complex nature and hetero- risk of haemorrhage and is a more major undertaking leading to a longer
genicity. In the surrounding tissues, oedema, reactive lymph node recovery phase. The lesion is then usually easily identified.

SURGERY 27:12 533 Ó 2009 Published by Elsevier Ltd.

 HEAD AND NECK
Figure 4 Dissection. Further dissection around the cyst is then undertaken
bearing in mind that on its posterior aspect lies the internal jugular vein,
common carotid artery and bifurcation, and the accessory nerve. Dissection
can be difficult if there has been previous infection and sometimes the
internal jugular vein has to be sacrificed if the lesion is strongly adherent.
This produces no adverse functional problem but is not usually necessary.
Salivary gland cysts
Cysts can occur in salivary tissue and those presenting as
external swelling usually arise from either the parotid or
submandibular glands. Occasionally cystic degeneration can
arise in the sublingual area within the mouth, which then
herniates through or around the mylohyoid muscle when it
becomes known as a ‘plunging’ ranula. This latter swelling is
always accompanied by a swelling in the floor of mouth.
Diagnosis is usually obtained on the clinical characteristics
and on the anatomical location. A true cyst of the parotid gland
usually occurs in the region overlying the angle of the mandible
and may in fact represent a branchial arch abnormality. As with
other lesions, aspiration and cytology can be undertaken. Often
Figure 5 Delivering the specimen. Atraumatic tissue-holding forceps, such
as those of the Babcock or Allis design, are useful during this phase of the
procedure. As dissection proceeds, often the lesion seems to originate
from a pedicle arising superiorly and this can be ligated and divided. In
some instances a branchial fistula can continue up to the tonsil region
and represents a true first arch abnormality.
SURGERY 27:12
Figure 6 Preparation for pathological analysis. After delivery the lesion is
then examined and placed in formalin for histological analysis. If there is
a strong suspicion of an infectious cause e.g. tuberculosis, part of the cyst
can be removed with a scalpel and sent for microbiology. If lymphoma is
suspected, some laboratories require fresh material for examination and
this should be ascertained beforehand. Often the lesion is associated with
a small cluster of lymph nodes which are typically reactive in nature and
can be removed in continuity. A pre-vacuumed neck drain is inserted
through a separate stab incision and the wound closed in two layers with
appropriate sutures.
surgery is required, firstly to resolve the problem and secondly to
determine the precise histological characteristic because cystic
change can be an accompaniment of salivary gland neoplasia.
Salivary gland surgery often involves meticulous localization and
preservation of various cranial nerves, for example the facial in
relation to the parotid and can be complex and time consuming.
Salivary gland outlet obstruction can be seen as a result of
stone formation or inflammation and this most often affects the
submandibular gland although this is not necessarily a true cyst.
Removal of the gland is indicated if the obstructive element
cannot be resolved. A
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534 Ó 2009 Published by Elsevier Ltd.