Endoscopic removal of a cystic neck mass via an axillo‐breast approach

摘要

Benign cystic neck masses can be found in any portion of the neck area, especially in the young age group.1 Benign cystic neck masses such as branchial cleft cyst, epidermal cyst, and lymphangioma are commonly found beneath the sternocleidomastoid (SCM) muscle, perithyroidal area.1 The treatment of choice for these benign cystic neck lesions is surgical excision. Conventional excision is performed through an incision placed over the entire protruding area.2 This approach produces an incision on the neck, resulting in a final scar that is evident and aesthetically undesirable. By means of an alternative approach, several authors previously reported the surgical excision of cervical branchiogenic cysts via transcervical endoscopic approach.2, 3 However, even though the scar is small, these techniques still leave a visible one on the neck. Considering that one of the most important goals of endoscopic surgery is to minimize a visible scar in a natural position, incisions on the body part that is easily seen should be avoided.4 In recent years, we have been performing endoscopic thyroidectomy via a unilateral axillo-breast approach without gas insufflation for the purpose of minimizing the visible scar in a natural position, and we have already reported the feasibility and safety in thyroid surgery.4, 5 At this point, we applied this approach to benign cystic neck lesions, and we herein report our successful outcomes. We reviewed two cases of perithyroidal cystic lesions of the head and neck treated by endoscopic removal via a unilateral axillo-breast approach without gas insufflation. A 29-year-old female patient visited our institution because of palpable neck mass for several months. Neck computed tomography (CT) scan revealed a 3.5-cm thin-walled cystic lesion in the lateral aspect of carotid space, posterior to the SCM muscle (Fig. 1A). Fine-needle aspiration biopsy (FNAB) showed many bland-looking keratinized squamous cells and necrotic ghost materials. Findings were suggestive of a benign cystic lesion with lining of squamous epithelium. Under the impression of a third branchial cleft cyst, endoscopic excision via a unilateral axillo-breast approach was performed. The final pathologic result was reported as branchial cleft cyst. Preoperative computed tomography scan. (A) A 3.5-cm thin-walled cystic lesion in the lateral aspect of carotid space, posterior to the sternocleidomastoid muscle. (B) A 3.3-cm well-defined cystic mass with thin peripheral enhancement in the left neck level IV. A 23-year-old woman presented with a left neck mass she had for one month. A 3.3-cm well-defined cystic mass with thin peripheral enhancement in the left neck level IV was found on the neck CT scan (Fig. 1B). FNAB showed mature squamous cells admixed with acute inflammatory cells and squames, consistent with epidermal cyst. We excised the cystic mass via the same endoscopic approach. The mass was pathologically diagnosed as an epidermal cyst. We successfully finished both operations without any complications. The patients were discharged on postoperative day seven and five, respectively. At a follow-up visit after discharge, both patients were completely satisfied with the cosmetic outcome of the surgery (Fig. 2A). (A) Postoperative photograph after endoscopic excision. The small axillary scar, which was completely covered by the patient's arm in a natural position. There was no visible scar on the neck. (B) Axillo-breast approach. An external retractor was inserted through the skin incision in the axilla and raised the skin flap using a lifting device to create a working space. A 12-mm trocar is directed to the midline of the sternal notch through the periareolar skin incision. The surgical instruments (endoscopic dissector or suction irrigator and the Harmonic Scalpel) are inserted through the 45° angled direction of the axillary and periareolar ports. In both cases, before the operation, we first aspirated about 10 cc of cystic fluid for de