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Clinical Problem Solving: Radiology
February 2004

Radiology Quiz Case 2—Diagnosis

Author Affiliations


Arch Otolaryngol Head Neck Surg. 2004;130(2):246-247. doi:10.1001/archotol.130.2.246

The CT scan revealed a left prestyloid parapharyngeal space mass, extending to the left EAC area, findings that were consistent with a first branchial cleft cyst. Indeed, the official report noted a "tubular cystic appearing lesion," measuring approximately 8 mm in diameter and 2.5 to 3.0 cm in length. The patient was taken to the operating room for planned excision of a first branchial cleft cyst via a cervicofacial approach. A standard superficial parotid incision was used in conjunction with facial nerve monitoring. The main trunk of the left facial nerve was easily identified, and all branches were stimulated without difficulty. During the course of the dissection, multiple enlarged level 2 lymph nodes were removed and sent to the pathology laboratory for evaluation. The cystic lesion, which was seen filling the left EAC, produced thick, brown fluid. It was excised with tenotomy scissors, and an apparent sinus tract appeared to course near the main trunk of the facial nerve, diving deep into the parotid gland toward the parapharyngeal space. Dissection around the tract revealed thick, fibrotic tissue, with the tract itself appearing to consist of firm, dark material. The tract was opened to reveal 2 plastic foreign bodies, which were removed with hemostats under direct visualization. One additional piece was then identified and removed from the left infratemporal fossa, for a total of 3 interlocking plastic toy pieces (LEGOs), each 1 cm long. The final pathology report revealed benign reactive lymph nodes and skull base samples consistent with granulation tissue and acute/chronic inflammation. One week after the operation, the patient was doing extremely well. His left facial nerve was noted to be completely intact, and the left EAC cyst had fully resolved.

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