Bronchogenic Cysts: Symptoms, Types, Causes and Treatment

Bronchogenic cysts are rare, congenital anomalies that arise from abnormal development of the respiratory tract. While often overlooked due to their subtle or absent symptoms, these cysts can lead to significant health issues when they do manifest or become complicated. This article provides a comprehensive overview of the symptoms, types, causes, and treatment options for bronchogenic cysts, synthesizing current research and clinical insights.

Symptoms of Bronchogenic Cysts

Bronchogenic cysts can be elusive, with many individuals experiencing no symptoms at all. However, when symptoms do occur, they can range from mild discomfort to life-threatening complications, depending on the cyst’s size, location, and whether complications have developed. Understanding these symptoms is crucial for timely diagnosis and management.

Symptom	Frequency	Complications	Source
Cough	Common	Airway compression, infection	1 3 5 8
Chest Pain	Common	Fistula, hemorrhage	1 5 8
Dyspnea	Possible	Respiratory distress	2 3 5 14
Asymptomatic	Frequent	May develop symptoms later	3 4 5 15
Hoarseness	Rare	Nerve involvement	5
Dysphagia	Occasional	Esophageal compression	5 13
Infection	Occasional	Abscess, fistulization	1 5 13

Table 1: Key Symptoms

Common and Uncommon Symptoms

Bronchogenic cysts frequently go unnoticed, especially in adults, with up to 56% of cases initially presenting without symptoms. When present, the most common symptoms are cough and chest pain, while shortness of breath (dyspnea) may occur if the cyst compresses the airway or lung tissue. In some cases, particularly in children, symptoms can be more severe due to the smaller size of the airway, leading to potentially life-threatening airway obstruction2 3 5 8.

Other symptoms may include:

• Hoarseness, if the recurrent laryngeal nerve is affected.
• Difficulty swallowing (dysphagia), especially with cysts located near the esophagus.
• Recurrent respiratory infections due to impaired airway clearance or cyst infection.
• Rarely, hemoptysis (coughing up blood) or paralysis if there is nerve involvement5 13 14.

Complications

While many bronchogenic cysts remain uncomplicated, complications can develop, especially in symptomatic patients:

• Infection: The cyst can become infected, forming an abscess or fistula (an abnormal connection to the airway).
• Fistulization: The cyst may develop abnormal passages to the airway or pleural space, causing chronic drainage or respiratory issues1 13.
• Hemorrhage: Bleeding into the cyst can cause sudden pain or even shock.
• Compression Syndromes: Large cysts may compress adjacent structures, such as the trachea, esophagus, or superior vena cava, leading to severe symptoms like superior vena cava syndrome or tracheal obstruction1 2 14.
• Malignant Transformation: Rarely, cancer can develop within a bronchogenic cyst, especially in long-standing, untreated cases13.

When to Suspect a Bronchogenic Cyst

Because bronchogenic cysts can mimic other diseases or remain silent for years, they should be considered in the differential diagnosis of:

• Persistent, unexplained cough or chest pain.
• Recurrent respiratory infections with no clear cause.
• Mediastinal or pulmonary masses seen on imaging, especially if cystic1 5 6 8.

Types of Bronchogenic Cysts

Bronchogenic cysts are a diverse group, primarily classified by their location, which correlates with their embryological origin. Recognizing these types is key to understanding their clinical presentations and management.

Type	Typical Location	Frequency	Source
Mediastinal	Middle/posterior mediastinum	Most common	1 2 6 8
Intrapulmonary	Lung parenchyma	Less common	1 5 8
Hilar	Pulmonary hilum	Rare	5
Subcutaneous/Cervical	Suprasternal/neck	Very rare	9 10 11
Diaphragmatic	Diaphragm	Extremely rare	12
Other ectopic	Adrenal, retroperitoneum	Exceptionally rare	5 12

Table 2: Types of Bronchogenic Cysts

Mediastinal Bronchogenic Cysts

Mediastinal cysts are the most common, typically found in the middle or posterior mediastinum. They can cause symptoms by compressing the trachea, bronchi, or esophagus, particularly in children or if the cyst grows large1 2 6 8.

Intrapulmonary Bronchogenic Cysts

These are located within the lung tissue and may present as solitary, well-circumscribed cystic masses. They are more likely to become infected or communicate with the bronchial tree, leading to recurrent infections or hemoptysis1 5 8.

Hilar and Other Thoracic Cysts

Rarely, cysts may be found at the pulmonary hilum, visceral pleura, or other thoracic locations. Their presentation depends on their relationship to surrounding structures5.

Subcutaneous and Cervical Cysts

Ectopic bronchogenic cysts can occur in the skin or soft tissues, most commonly in the suprasternal notch or neck. These often present as painless swellings in infants or children but can be mistaken for other lesions9 10 11.

Diaphragmatic and Other Ectopic Cysts

Exceptionally rare, bronchogenic cysts have been reported in the diaphragm, retroperitoneum, adrenal glands, and even the dura mater. Their symptoms depend on their location and size5 12.

Causes of Bronchogenic Cysts

The cause of bronchogenic cysts is rooted in developmental abnormalities during early embryogenesis. Understanding their origin helps explain their varied presentation and locations.

Cause	Mechanism	Timing	Source
Abnormal foregut budding	Maldevelopment of tracheobronchial tree	3rd-7th week gestation	1 4 11 12
Sequestration of tissue	Isolation of embryonic airway cells	Embryonic period	9 10 11
Ectopic migration	Misplacement of bronchial tissue	Early fetal development	9 10

Table 3: Etiological Mechanisms

Embryologic Development

Bronchogenic cysts are congenital lesions that arise from abnormal budding or branching of the primitive foregut, which eventually forms the tracheobronchial tree. If a segment of the foregut becomes isolated during the 3rd to 7th week of gestation, it can develop into a fluid-filled cyst, lined with respiratory epithelium and sometimes containing cartilage or smooth muscle1 4 11 12.

Ectopic and Subcutaneous Cysts

Rarely, these isolated embryonic tissues can migrate or become sequestered in unusual locations, such as the neck, diaphragm, or even skin and subcutaneous tissues. This is believed to result from misplaced or "pinched off" cells during sternal or tracheobronchial development9 10.

Are Bronchogenic Cysts Hereditary?

There is no strong evidence of genetic inheritance; most cases are sporadic and not associated with family history or known environmental exposures1 4.

Treatment of Bronchogenic Cysts

Treatment decisions for bronchogenic cysts are influenced by the patient’s symptoms, cyst location, risk of complications, and patient comorbidities. While some debate exists regarding the management of asymptomatic cysts, evidence overwhelmingly supports surgical excision in most cases.

Treatment	Indication	Outcome/Prognosis	Source
Complete resection	Symptomatic/complicated cysts, most asymptomatic cysts	Excellent, low recurrence	1 5 8 13 14
Thoracoscopic surgery	Select mediastinal cysts	Shorter recovery	5 16
Open surgery	Large/complex cysts	Excellent	1 5 8
Observation	Small, asymptomatic cysts in adults	Risk of later symptoms	3 15
Needle aspiration/biopsy	Diagnostic uncertainty, high-risk surgical candidates	Risk of recurrence/infection	15

Table 4: Treatment Approaches

Surgical Resection

Complete surgical removal is the gold standard for bronchogenic cysts, providing:

• Definitive diagnosis (histological confirmation).
• Symptom relief.
• Prevention of future complications, including infection, hemorrhage, or rare malignancy1 5 8 13 14.

Most mediastinal cysts can be excised without removing lung tissue, while intrapulmonary cysts may require lobectomy or wedge resection, especially if they are complicated or infected1 5 8.

Minimally Invasive Techniques

Video-assisted thoracic surgery (VATS) or thoracoscopic excision is increasingly used for mediastinal cysts. This approach offers:

• Shorter hospital stays
• Less postoperative pain
• Faster recovery in selected patients5 16

Conversion to open surgery may be needed if there are adhesions, bleeding, or involvement of vital structures16.

Observation and Conservative Management

For small, classic, asymptomatic cysts in adults, observation may be considered, particularly in high-risk surgical candidates. However, studies show that many asymptomatic cysts eventually become symptomatic or complicated, prompting delayed surgery with potentially higher risk3 15.

Aspiration or biopsy may be used for diagnostic purposes in selected cases, but incomplete removal risks recurrence, infection, or persistent symptoms15.

Postoperative Outcomes

• Recurrence: Rare after complete excision.
• Complications: Low, but higher in those operated when symptomatic or with complicated cysts1 3 5 8 13.
• Long-term prognosis: Excellent, with most patients remaining symptom-free and no evidence of late complications or malignancy after complete removal5 8 16.

Conclusion

Bronchogenic cysts are uncommon but important congenital anomalies that can present at any age with a wide spectrum of symptoms, types, and potential complications. Early recognition and management are essential to avoid significant morbidity. Here’s a summary of the key points:

• Symptoms: Most cysts are asymptomatic, but when symptoms occur, cough, chest pain, and dyspnea are most common. Serious complications can develop if left untreated.
• Types: The majority are mediastinal or intrapulmonary, but they can occur in many other locations, including the neck, subcutaneous tissue, and even the diaphragm.
• Causes: Bronchogenic cysts result from abnormal development of the primitive foregut during embryogenesis, occasionally leading to ectopic locations.
• Treatment: Complete surgical excision is recommended for most cysts due to the risks of complications and diagnostic uncertainty. Minimally invasive approaches are increasingly used for suitable cases.

A multidisciplinary approach—combining imaging, pathology, and surgical expertise—remains the cornerstone of effective management for bronchogenic cysts.