CASE REPORT
A 10-year old girl presented with a palpable right neck lump. This was described as a slow-growing lesion which would intermittently resolve. On examination a 3 x 2 cm solid, mobile, non-painful lesion was palpated deep to the anterior border of the sternocleidomastoid muscle. The rest of the clinical examination was unremarkable. An ultrasound scan (USS) reported a cystic mass 4.2 x 4.0 x 3.8 cm in diameter with mobile internal echoes and a diagnosis of a branchial cleft cyst was made (Figure 1A). An excision via a transverse incision was attempted under general anaesthesia by a general paediatric surgeon: due to unclear diagnosis and dense adhesion to neck neurovascular structures, the procedure was abandoned; an incisional biopsy was therefore obtained, and histology documented xanthogranulomatous inflammatory change and fibrosis. A post-operative magnetic resonance imaging (MRI) scan documented a soft tissue lesion with cystic/fluid components at the right parapharyngeal space extending to the retropharyngeal space (Figure 1B); it also confirmed the presence of normal mediastinal thymus. The patient returned to theatre for formal excision one month later as a joint procedure by the general paediatric surgeon and an ear nose and throat (ENT) surgeon. A mixed cystic/solid mass was found posterior to the sternocleidomastoid muscle, adherent to the carotid artery and internal jugular vein (IJV) and adjacent to the trachea. The ansa cervicalis which was densely adherent to the lesion, was identified with a nerve stimulator and preserved. The lesion was then completely excised with no significant complications. Histological analysis revealed an ECT (Figure 1C). The patient remains well at 18 months follow-up with no evidence of recurrence.