with an MRI or CT The potential risk to the airway and neurovascular structures, coupled with the possibilities of hemorrhage or lymphangitis, dictates the need for early intervention Consultation with an otolaryngologist is indicated Treatment options include percutaneous drainage, surgery, sclerotherapy, radiofrequency ablation, and medical therapy FIGURE 120.13 Lateral abdominal wall cystic hygroma (lymphangioma) Branchial cleft anomalies consist of a group of congenital malformations, including subcutaneous cysts, sinus tracts, and cartilaginous remnants They are caused by persistence of structures derived from the embryonic branchial arches Of these anomalies, 90% arise from the second branchial arch and are found along the anterior border of the sternocleidomastoid muscle Sinus tracts of second branchial arch remnants may end in an internal ostium located near the tonsillar fossa Less commonly, first branchial arch anomalies may be noted as masses or sinus tracts near the mandibular ramus Some first branchial arch remnants end in an internal ostium located in the external auditory canal Branchial cleft anomalies may be noted shortly after birth either as a firm, mobile mass with or without an overlying pore, or simply as an external ostium or pore without an underlying mass ( Fig 120.14 ) More commonly, branchial cleft cysts are detected later in childhood when they may present as an asymptomatic mass or with acute painful enlargement as a result of secondary inflammation or infection All branchial cleft anomalies should be referred for surgical excision for cosmetic purposes and to avoid potential morbidity, which includes infection and the development of carcinoma in situ When patients present with infection, initial therapy includes antimicrobial therapy and incision and drainage (if needed) Definitive excision should be deferred until antibiotics have quelled all signs of inflammation