Artículo Científico

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Clinical-cytohistological correlation of cervicofacial congenital cysts
Correlación clínico-citohistológica de los quistes congénitos cervicales

 

L.D. Medina Vega¹, E. Márquez Rancaño², J. Concepción Guzmán³, R. Rodríguez Jiménez⁴, J. Martín Pino⁵

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Abstract: Objective: To determine the effectiveness of clinical and cytological diagnosis in congenital cysts located in head and neck. Method: We were carried out a retrospective study of patients with clinical, cytological or histological diagnosis of thyroglossal, branchial and dermoid cyst, assisted in the University Hospital Arnaldo Milián Castro", during five years. It was calculated the sensibility, specificity and security of the clinical diagnosis and the Fine Needle Aspiration Biopsy for each cyst. Result: The security of the clinical diagnosis it was respectively of 94,1%, 92,2% and 98% for the thyroglossal, branchial and dermoid cysts. We find bigger tendency to the clinical error in branchial cysts, where the most frequent confusions are presented with inflammatory linfoadenopathy. The security of the Fine Needle Aspiration Biopsy was of 96,1% and 94,1% for the thyroglossal and branchial cysts respectively.  Conclusions: Clinical diagnosis is not enough in occasions, for what is necessary to appeal to means complementary diagnoses, as the Fine Needle Aspiration Biopsy; however this test is not 100% sure. Key words: Thyroglossal cyst; Branchioma; Dermoid cyst; Biopsy with needle.

Resumen: Objetivo: Determinar la efectividad de los diagnósticos clínico y citológico en los quistes congénitos cervicofaciales. Método: Se realizó un estudio retrospectivo de los pacientes con diagnóstico clínico, citológico y/o histológico de quiste tirogloso, branquial y dermoide, atendidos en el Hospital Universitario «Arnaldo Milián Castro», durante cinco años. Se calculó la sensibilidad, especificidad y seguridad del diagnóstico clínico y la biopsia por aspiración con aguja fina (FNAC) para cada quiste. Resultado: La seguridad del diagnóstico clínico fue de 94,1%, 92,2% y 98% para los quistes tirogloso branquial y dermoide respectivamente. Encontramos mayor tendencia al error clínico en los quistes branquiales, donde las confusiones más frecuentes se presentan con linfoadenopatías inflamatorias. La seguridad de la biopsia por aspiración con aguja fina fue de 96,1% y 94,1% para los quistes tirogloso y branquial respectivamente. Conclusiones: El diagnóstico clínico no es suficiente en ocasiones, por lo que es preciso recurrir a medios diagnósticos complementarios, como la biopsia por aspiración con aguja fina; sin embargo esta prueba no es 100% segura. Palabras clave: Quiste tirogloso; Branquioma; Quiste dermoide; Biopsia con aguja.

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1 Especialista de Primer Grado en Cirugía Maxilofacial. Villa Clara, Cuba.
2 Especialista de Primer Grado en Cirugía Maxilofacial. Profesor Instructor del Hospital
 Universitario Arnaldo Milián Castro y del Instituto Superior de Ciencias Médicas de Villa Clara, Cuba.
3 Especialista de Primer Grado en Cirugía Maxilofacial. Profesor Asistente del Hospital 
Universitario Arnaldo Milián Castro y del Instituto Superior de Ciencias Médicas de Villa Clara, Cuba.
4 Especialista de Segundo Grado en Cirugía Maxilofacial. Profesor Asistente del Hospital 
Universitario Arnaldo Milián Castro y del Instituto Superior de Ciencias Médicas de Villa Clara, Cuba.
5 Estudiante de 5º año de Estomatología. Instructora no Graduada de Cirugía Maxilofacial. 
Facultad de Estomatología. Instituto Superior de Ciencias Médicas de Villa Clara. Cuba.

 

Introduction

Cysts constitute a pathological cavity lined by a wall of defined connective tissue with epithelial lining. They show a liquid content inside that is semiliquid or gaseous. Their growth is centrifugal and expansive.¹

The Robinson and Thoma modified classification for cervicofacial area cysts include thyroglossal, branchial and dermoid cysts, within the congenital ones.² At present, they include other cysts such as: laryngoceles, thymic cysts, lymphangiomas, other teratomas and bronchogenic cysts.^3-4

The thyroglossal duct cyst is a congenital formation located in the middle line of the neck or near it, between the base of the tongue and the hyoid bone. A pathognomonic sign is the vertical movement of the mass to deglutition and to the lingual protraction. It is considered to be the most frequent congenital swelling of the neck and constitutes the second cause of cervical tumor after benign lymphadenopathies.^5-6

The branchial cyst is a soft, smooth and lobulated malformation having a very debatable etiology, however, the theory of the branchial reminents is very accepted and is based on the imperfect closure of the first, second, third or fourth branchial cleft.

Between 92% and 90% are related with the second one.^7-8 The diagnosis should be performed in the first place by the suggestive symptoms, such as that of laterocervical swelling in front of the sternocleidomastoid muscle in a young adult.⁹

The dermoid cyst is a development abnormality and constitutes a cavity full of serous material with evidence of derivatives of specialized skin full of serous material and with evidence of derivatives of specialized skin.^10-11

The cervicofacial congenital cysts, due to their site, form of appearance and due to the clinical examination data offer little doubt in regards to the differential diagnosis. This became clear some time ago when clinical support was practically the only requirement to propose the surgical act. In recent years, the advance of the modern imaging diagnostic techniques and the increase of the reliability and harmlessness of the FNAB, make this study battery an essential requirement to carry out surgery with surgical suspicion that mostly coincides with the definitive histopathological results.¹²

Material and method

A retrospective study was performed with 51 patients with a clinical, cytological and/or histological diagnosis of thyroglossal, branchial or dermoid cyst seen in the University Hospital: Arnaldo Milán Castro, between January 1996 and December 2000; with the objective of determining the effectiveness of clinical and cytological diagnosis of these cysts.

The following variables were recorded: age, gender, diagnostic impression in the request for FNAB and cytological and histological diagnoses. To do so, a review was made of the biopsy and FNAB files of the Pathology Department of the hospital institution.

The patients were classified in:

• True positives (TP): Those whose clinical and cytological diagnosis coincided with the histology.

• False positives (FP): The clinical or cytological diagnosis is that of a congenital cyst that was not corroborated histologically.

• True negatives (TN): The presence of the cyst being analyzed is not seen either clinically or cytohistologically.

• False negatives (FN): The clinical or cytological diagnosis does not show the presence of the cyst being analyzed, but the histological study does. 
The sensitivity, specificity and safety of the clinical diagnosis and the FNAB for each type of cyst were calculated with the following formula:

• Sensitivity = TP/(TP + FN)*100 It is the probability that a test presents of being positive in an individual who is really ill.

• Specificity =TN /(TN + FP)*100 It is the probability that a diagnostic test presents of being negative and a healthy individual.

• Safety = (TP +TN)/total It groups the two previous categories.

The report of the histological diagnosis was considered as that having the greatest diagnostic accuracy.

The data are recorded on a data file for this purpose. The information was processed manually and with the use of a calculator, obtaining absolute frequencies and percentages. The data listed were placed in tables and the most important ones were graphically represented.

Results

Figure 1 shows the behavior of the congenital cysts according to the modified Robinson and Thoma classification. The thyroglossal cyst was the most frequent, it being 52,9% of all the poorly formed cysts studied. The branchial cyst is next in frequency, with 29,4% and the dermoid one with 17,7%.

The value of the clinical diagnosis for the cervicofacial congenital cysts is shown in tables 1, 2 and 3.

 

The safety of the clinical diagnosis for the thyroglossal cyst was 94,1%.

A total of 88,9% of the patients who presented a thyroglossal cyst were diagnosed correctly in the medical visit.

The rest were distributed into:

• False negatives:1 thyroid nodule.

- 1 sublingual cyst.

- 1 chronic inflammatory lymph node.

• False positives:

- 1 reactive adenitis.

For the branchial cyst, we see that only 73,3% had a correct clinical diagnosis and the rest: 

• False negatives:

- 3 chronic inflammatory lymph nodes.

- 1 mixed tumor of the submaxillary gland.

• False positives:

- 3 reactive adenitis.

- 2 pleomorphic adenomas of submaxillary gland.

- 1 low grade adenocarcinoma in submaxillary gland.

- 1 ganglionar metastasis of epidermoid carcinoma.

For the dermoid cyst, 95,5% were clinically diagnosed correctly and as:

• False negative:

- 1 verruca vulgar.

• False positive:

- 1 lymphoma.

- 1 cyst of epidermal inclusion.

Tables 4 and 5 show the diagnostic value of FNAB in the congenital cysts of the face and neck. For the thyroglossal one, it was defined that 92,6% of the patients were correctly diagnosed with this test and 96% of those who did not present this disease were identified as such, the safety of the cytology diagnosis being 94,23% in this case. They were presented as:

• False negatives:

- 2 thyroid nodules.

• False positive:

- 1 submucous epidermoid carcinoma.

For the branchial cyst, the FNAB safety was 90,6%; 80% (sensitivity) were correctly diagnosed by the FNAB and the rest were:

• False negative:

- 2 chronic inflammatory lymphomegalias.

• False positive:

- 2 reactive ganglionar hyperplasias.

 

 

 

 

Discussion

On several occasions, it was difficult to establish an accurate presumption diagnosis in cases of cervical cystic tumors even after following a total series of steps and complementary studies. 

Entrada Sarmientos,⁶ and Santana Garay,⁹ recognized thyroglossal cyst as the cervicofacial malformative cyst having the greatest prevalence, which supports our results.

In spite of being considered a disease characteristic of patients under 10 years of age, it was still predominant in our sample, made up of patients over 15 years of age.

Basically, the differential diagnosis must be established when there is a cervical tumor with three possible etiologies: congenital, infectious and neoplastic¹³.

When a patient with cervical swelling is examined, the first observation should be the their age group: pediatric (until 15 years), young adult (16-40 years) and older adult (+ than 40 years). In the first and second group, the inflammatory swellings are more frequent than the congenital ones and are followed by the neoplastic ones. However, in more advanced ages, the first consideration should be that of the neoplastic origin. After age, the site of the cervical mass should be considered; the congenital ones generally appear in constant sites. Those having a ganglionary origin generally follow the vessel and lymph node pathway. In addition, emphasis should be placed on family and personal disease background, the latter being considered the most important step of the diagnosis, since it helps us determine the site, size, relationship with neighboring structures, consistency, presence of thrills or pulsations.

The evolution time is another element to consider, since a swelling having a few days of evolution is generally inflammatory, that of months is surely neoplastic and of years is generally congenital.¹⁴

We find a greater tendency for clinical error in the branchial cysts. This could be due to the fact that they present a location common to a large number of diseases such as: cervical masses having a benign or malignant tumor origin, metastatic, inflammatory or congenital origin. The most frequent confusions are presented as lymphadenopathies, perhaps due to the elevated frequency of superinfections that become manifest and painful. The authors,^8-15 attribute this susceptibility to the infection of the upper airways.

For the dermoid cyst, there was less clinical error, probably because the clinical characteristics are pathognomonic and lead to confusion less frequently since an increase in soft volume, not fixed to the skin, that undermines the underlying bone and that is frequently located in the tail of the eyebrow and frontal region leads us to first think in a dermoid cyst.

The anamnesis and physical examination are often not enough and it is necessary to turn to complementary diagnostic means. FNAB is a diagnostic test which, in our experience, shows mildly lower sensitivity than the world mean that ranges between 97% with a variation among different cytologists of 8%.¹³ Other studies,¹⁶ show a sensitivity and specificity of 100% and 99% respectively for the cervical masses.

We consider the FNAB to be very useful for the diagnosis of the cervicofacial congenital cysts. Some authors^16,17 prefer this method as it is simple, rapid and economical, although other investigators¹⁷ consider the imaging tests such as computed tomography and magnetic nuclear resonance to be of first choice.

Conclusions

The clinical diagnosis is not totally effective. It is necessary to turn to auxilliary diagnostic means, such as fine needle aspiration biopsy. This constitutes a technique having greater safety. It is necessary to improve the pre-surgical diagnosis of the cervicofacial congenital cysts for the treatment to be adequate and to develop with a minimum of complications.

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