Hydatid disease may affect humans especially in endemic areas where sheep, dogs and man live in close contact such as Mediterranean countries, the Middle East, South America, New Zealand, Australia, and Southeast Asia and many parts of china [9,12,13]. Unavailability of clean potable water supplies and close association of people with sheep and dogs makes Pakistan a region endemic to the disease [12]. Therefore, a detailed history regarding patient’s occupation, patient’s residence and family history may include diagnosis of hydatid disease in the differential diagnosis. In contrast to the common belief, the incidence of hydatid disease has not decreased significantly during the past decade.

Patients having echinococcosis in any part of the body must undergo thorough systemic investigation as most of the larvae become adult cysts in liver and lung. Multiorgan involvement is seen in 20% to 30% of the cases with involvement of liver in all cases [14]. Our patient did not have any evidence of hydatid disease elsewhere in the body, neither at the time of presentation nor on postoperative diagnostic imaging. Other authors have also confirmed the solitary occurrence of hydatid cysts [9,15]. Interesting aspect of solitary hydatid cysts in the absence of disease in lung and liver is to explain how these larvae produces solitary cysts after passing through the two filter sites. Although no route other than portal has been proven in humans, systemic dissemination through lymphatic route is a strong possibility in case of unusual presentation sites. The majority of hydatid cysts are asymptomatic. Echinococcus in liver produces similar symptoms seen in liver cancer patients like mass, abdominal pain and jaundice. Gal −3, soluble E and N cadherin can be used as marker for differentiation between the two [16]. The values of Gal-3, soluble E cadherin was not estimation in our case. Clinical sign and symptoms depend on the anatomic localization, size and pressure of the enlarged cyst. Therefore signs and symptoms are variable and never pathognomic of hydatid cyst [7]. Hydatid cysts are usually slow-growing, fluctuant, painless masses. These symptoms are characteristic of any slow growing benign tumour in the body. The diameter of the cyst grows at a highly variable rate and ranges from 1 to 5 cm a year [17]. Typically hydatid cyst consists of a single, unilocular cyst, however multiloculated cyst in the same or multiple organ are seen in 20 to 30% of the cases [18].

In non endemic areas because of clinician’s lack of experience and rarity of the disease, it is at times difficult to diagnose a hydatid cyst located in the head and neck region. The diagnosis of Echinococcus infection mainly depends on the clinical history of the patient, diagnostic radiological findings and serologic tests. ELISA, Casoni skin tests, latex agglutination, immunoelectrophoresis and direct hemagglutination are serological methods, used for the diagnosis of hydatid disease. Sensitivity of serology is high (80-100%) for liver cysts, but low for lung (50-56%) and other organs (25-56%). Importance of these tests lies mainly in the follow up of treated patients. An increase in titer indicates recurrence of disease and a decrease in titer indicates resolution [9,14,17]. Imaging modalities like US, CT and MRI remain more sensitive than serodiagnosis. These techniques help to determine the cystic avascular nature of the lesion. Daughter cysts, vesicles and internal septa can also be demonstrated [7,19].

No serological test was done in our case because hydatid cyst was not in the clinical differentials. MRI done was not able to do exact characterization and the report was suggestive of benign cyst. The differential diagnosis therefore includes branchial cleft cyst, bronchogenic, thymic, parathyroid, thoracic duct, and foregut-derived (esophageal duplication) cysts, pseudocysts or benign tumor that is congenital and acquired cystic lesions of the neck [2].

For the evaluation of mass lesions in the cervical region, fine-needle aspiration cytology (FNAC) is beneficial however due to possibility of an anaphylactic reaction, dissemination of disease and recurrence as result of spillage of cyst contents, it is not recommended in the routine evaluation of suspected hydatid cysts [15,20,21]. FNAC was not performed in our case due to possibility of benign cystic disease; the case was subjected to surgical excision.

Surgical removal is the most effective treatment of hydatid cyst [9,20]. Surgeon must be careful to avoid spillage of cyst contents to avoid fatal anaphylaxis, recurrence and multiple hydatidosis [7,21]. If presurgical diagnosis is hydatid cyst, preliminary aspiration and instillation of hypertonic saline (20%), silver nitrate (0.5%), formalin, and other chemicals could be used to prevent seeding of the cyst contents and to inactivate the protoscolices [9,17]. Therapy with nontoxic scolocidal agents or combination chemotherapy with mebendazole is of therapeutic value in the treatment of patients with recurrence or a high risk of contamination [15]. There was complete cyst removal with no rupture and spillage of cyst contents in the present case. Albendazole is suggested to be given post operatively for 1–3 months [22]. We treated the present case with albendazole for six weeks post operatively.

The diagnosis of hydatid cyst is confirmed by histology [23]. Histopathological evaluation shows three layers of hydatid cyst. The inner most germinal layer which is thin and translucent on gross. The embryonic tape worm, scolices, develops from an out pouching of the germinal layer and form hydatid sand, settling into the dependent parts of cyst .The cyst fluid is crystal clear, as it is transudate of serum containing proteins and is therefore antigenic. The middle laminated membrane is white 2mm thick and is easily ruptured. It is selectively permeable to nutrients but not to bacteria. The outer layer or pericyst is a rigid protective layer with a few millimeters thickness, representing response of the host to the parasite [21].