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Figure 13.3b. The fistula was removed with a rim of the cartilage from the ear canal and a superficial parotidectomy carried out to remove the branchial cyst (arrow).

Figures 13.3c and 13.3d. The parotidectomy specimen shows the cyst deep in the parotid, but it was lying superficial to the facial nerve.

Figure 13.3e. Following superficial parotidectomy (the ear lobe is sutured up for surgical retraction).

3-5% (Stulner et al. 2001), this may increase in patients with previous infection or inadequate surgery. Branchial cysts will usually appear as parotid masses and are usually clinically diagnosed as cystic parotid tumors (Figure 13.4).

The first branchial lesions are usually superficial to the nerve, and Triglia, Nichollas, and Ducroz et al. (1998) reviewed 73 cases including their 39 and found that 63% were superficial, 29% deep, and 8% between the nerve. In the Solares, Chan, and Koltal (2003) small series, however, 7

of 10 lesions were deep to the nerve and 1 lay between the branches. Larger cysts deep to the nerve may be difficult to remove, as the nerve may be adherent to them (Figure 13.5), and dissection can be slow and tedious.

It is very important to recognize the first arch abnormality, as its complexity and anatomical variety necessitates wide exposure through a parotidectomy incision and dissection of the facial nerve to minimize the chances of subsequent facial nerve damage.

Figures 13.4c and 13.4d. Histology of the branchial (lymphoepithelial cyst). The proteinaceous cyst contents are superior and the arrow points to the squamous epithelial lining and its associated lymphoid follicles.

Figure 13.5a. A 27-year-old man with a large cystic lesion in his right parotid. The FNAB showed benign disease.

Figure 13.5d. Parotidectomy specimen with deep lobe branchial cyst.

Figure 13.5b. Initial superficial parotidectomy (superficial lobe retracted by an Allis clamp) reveals the cyst lying deep to the cervico-mandibular branch of the facial nerve (arrow).

Figure 13.5e. The cervico-mandibular trunk (arrow) is stretched over the defect that the deep lobe branchial cyst occupied.

Figure 13.5c. The cervico-mandibular branch is carefully dissected off the cyst capsule and retracted toward the ear.

CYSTIC FIBROSIS

The composition of saliva is changed in cystic fibrosis and the formation of viscous mucus may lead to cystic dilations of the ducts and acini, especially in the sublingual gland. The calcium concentration in saliva is also raised and microliths of calcium complexes with the viscous mucus can be seen.

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