Branchial cleft cyst encircling the hypoglossal nerve
A 10-year-old African boy presented with complaints of left-sided anterior neck swelling for 1year. The swelling was non-tender, not associated with any prior trauma and had no drainage or sinus tract. The patient reported occasional shortness of breath and a history of snoring, but was otherwise in good health. He had no prior medical or surgical history, no allergies and took no medications. He was the fifth born in a family of seven children. On physical examination, the patient was alert and in no distress. He had a prominent non-tender swelling in the left anterior neck, measuring 8 cm by 5 cm. The remainder of his physical examination was unremarkable, as were vital signs and basic laboratory values.\nAfter obtaining informed consent from the parents, the patient was taken to the operating room with a diagnosis of a branchial cleft cyst. After incision, a large cystic mass was easily identified. During dissection of the cyst, it was noted that a structure appeared to pass through the cyst (Fig. A). This was identified as the hypoglossal nerve. The cyst was found to completely encircle the hypoglossal nerve. With careful dissection and eventual transection of the cyst anterior to the nerve, the cyst was removed and the hypoglossal nerve remained intact (Fig. B). Rupture of the cyst was necessary to release the nerve at the time of excision. The completion of the procedure was uneventful and the patient recovered from general anesthetic without incident. On postoperative day 1, he was noted to have mild left-sided tongue deviation, suggesting hypoglossal nerve palsy. No hypoglossal nerve palsy was present preoperatively. He remained otherwise asymptomatic and was discharged home in stable condition.