INTRODUCTION
Second branchial cysts (SBCs) are the most common second branchial arch anomalies (SBAAs) in adults whereas sinuses, fistulas and cartilaginous remnants are in children (1–3). The branchial arches consist of clefts and pouches and are the embryological precursors of the face, neck and pharynx. In total, six pairs of branchial arches form on either side of the pharyngeal foregut. Incomplete obliteration of these arches can lead to formation of branchial anomalies, of which the SBAA represent up to 95% of the cases (2). The second branchial arch forms part of the hyoid and surrounding structures of the head and neck, while the second branchial pouch shapes the palatine tonsil and the supratonsillair fossa (1). Therefore SBAAs can occur anywhere along the course of the second branchial arch tract that extends from the skin overlying the supraclavicular fossa up to the pharynx at the level of the tonsillar fossa (2).
In adults, when encountering an unilateral swelling of the neck, a cystic metastasis of head and neck cancer should always be excluded before SBC diagnosis can be confirmed (4,5). Since SBCs are prone to recurrent infections and do not dissolve spontaneously, early and complete surgical excision is the recommended treatment (1,6). Different surgical techniques for SBC removal have been proposed. Traditionally, conventional surgery using a large cervical incision was used to ensure complete removal (7). However, the large cervical incision results in a prominent scar. In an attempt to reduce visible scars, newer techniques have been developed, such as endoscopic surgery (6,8–10) and the use of a retro-auricular hairline incision (RAHI) (11–13). RAHI can be performed either as an open procedure using a ‘facelift’ incision or as an endoscopic technique. To provide insight in the optimal surgical management of patients presenting with a SBC, this systematic review evaluates which surgical technique (conventional, endoscopic or RAHI) for SBC removal results in the lowest recurrence and complication rates with the highest scar satisfaction.