Complete Congenital Third Branchial Fistula on Right Side

Surgical treatment of fourth branchial apparatus anomalies: a case series study

Background

Fourth branchial apparatus anomalies, are rare clinical entities, and present as complex cysts, sinuses and fistulae in the neck that can be difficult to manage.

Methods

This is a retrospective review of a series of consecutive patients with fourth branchial apparatus anomalies treated at Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from Apr 2014 to Nov 2019.

Results

Ten patients with fourth branchial apparatus anomalies were identified, including 8 patients with fourth branchial fistula, and 2 patients with fourth branchial pouch sinus. There were 6 female patients and 4 male patients. Their age was from 6 years old to 39 years old (average age 20.4 years old, median age was 21 years old). All 8 fistulae were on the left side, while 2 pouch sinuses were both on the right side. Pre-operative examination with fiberoptic laryngoscope, barium swallow X-ray, CT or MRI identified internal orifice at pyriform fossa apex in 8 (80%) patients. All patients underwent challenging surgical resection by the senior author. Intra-operative direct laryngoscope confirmed or identified internal orifice in 9 (90%) patients. The tracts were all followed to the vicinity of inferior cornu of the thyroid cartilage and the cricothyroid space. Complete resection of cervical lesions and their attachment to hypopharynx were achieved in 9 cases. No complication occurred. One recurrence was detected, in the only patient whose internal orifice could not be located pre- or intra-operatively, and the hypopharyngeal attachment could not be removed.

Conclusions

Direct laryngoscopy under general anesthesia is a reliable method of diagnosis for the fourth branchial apparatus anomalies. Complete surgical removal of fourth branchial apparatus anomalies, including their hypopharyngeal attachment, is the treatment of choice, and the key to prevent recurrence.

Right-Sided Complete Third Branchial Cleft Fistula

Branchial cleft anomalies occur due to insufficient closure of cavities during embryogenesis. These anomalies consist of cysts, sinuses, and fistulas, with the rarest type being fistulas. A 29-year-old male presented at the authors' clinic with a right-sided complete third branchial cleft fistula. Fistula track excision surgery was successfully performed and no recurrence was observed in the 12-month follow-up after the surgery. While second branchial cleft fistula is the most common, third and fourth brancial cleft fistulas are extremely rare. In addition, they are usually incomplete and almost always on the left side.

Second branchial cleft anomalies in children: a literature review

Branchial cleft anomalies are the second most common head and neck congenital lesions in children. It may sometimes be a part of branchio-oto-renal (BOR) syndrome, so in patients with branchial cleft anomalies associated with a complaint of auricular deformity or a similar history and findings in other family members, we should take an additional examination to find the possibility of BOR syndrome. Complete excision is essential for good prognosis. For the management of branchial cleft anomalies, various methods have been reported. Endoscopically assisted dissection technique and transoral robot-assisted surgery were used in the management of fistula and allowed excellent visualization of the pharyngeal component of the lesion and a minimally invasive approach. It is essential for the surgeon to fully comprehend the congenital lesions to attain the correct preoperative diagnosis and plan for an appropriate surgical approach to prevent the most common complication and recurrence in these lesions. The following sections discuss the anatomy, common presentation, auxiliary examination, differential diagnosis, the current principles of surgical treatment and prognosis for second branchial cleft anomalies in children, and discussed the branchio-oto-renal syndrome.

A novel surgical management of hypopharyngeal branchial anomalies

OBJECTIVE

To review our experience treating hypopharyngeal branchial anomalies utilizing an open transcervical approach that: (1) includes recurrent laryngeal nerve (RLN) monitoring and identification if needed; (2) resection of tract if present; and (3) a superiorly based sternothyroid muscle flap for closure.

METHODS

A retrospective chart review was performed to identify all patients at a tertiary level children's hospital with branchial anomalies from 2005 to 2014. The clinical presentation, evaluation, treatment and outcome were analyzed for those patients with hypopharyngeal branchial anomalies.

RESULTS

Forty-seven patients who underwent excision of branchial anomalies with a known origin were identified. Thirteen patients had hypopharyngeal branchial anomalies. Six of these patients were treated by the authors of this study and are the focus of this analysis. All six underwent an open transcervical procedure with a sternothyroid muscle flap closure of a piriform sinus opening over a nine year period. Definitive surgery included a microlaryngoscopy and an open transcervical approach to close a fistula between the piriform sinus and neck with recurrent laryngeal nerve monitoring or dissection. A superiorly based sternothyroid muscle flap was used to close the sinus opening. There were no recurrences, recurrent laryngeal nerve injuries or other complications from these procedures.

CONCLUSIONS

This study supports complete surgical extirpation of the fistula tract using an open cervical approach, recurrent laryngeal nerve monitoring or identification, and rotational muscle flap closure to treat patients with hypopharyngeal branchial anomalies.

Coexistence of bilateral first and second branchial arch anomalies

Branchial arch anomalies are one of the most common congenital anomalies that are usually unilateral and bilateral presentation is rare. The simultaneous presence of bilateral second branchial arch anomalies along with bilateral first arch anomalies is extremely rare, with only three such cases reported in the literature. We present two non-syndromic cases of coexisting bilateral first and second arch anomalies. Developmental anomalies of the branchial apparatus account for 17% of all paediatric cervical masses and are the most common type of congenital cervical mass. They usually present in the paediatric age group. About 96-97% of these anomalies are unilateral. Bilateral presentation is seen in 2-3% having a strong familial association. Congenital syndromes also have been associated with first and second branchial arch anomalies. Thorough clinical examination and investigations should be done to rule out these syndromes.

[Swelling of the neck following tonsillectomy. Lateral cervical fistula]

A 16-year-old patient presented with recurrent cervical swelling to the right side of the neck on coughing and sneezing. Although present since childhood, the symptoms had progressed over the preceding year. Immediately prior to this period a bilateral tonsillectomy had been performed for recurrent tonsillitis. Magnetic resonance imaging revealed a complete lateral cervical fistula extending between the thyroid and submandibular glands on the right side of the neck. Successful surgical resection accomplished complete removal of the fistula.

Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis

OBJECTIVE

We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy.

METHOD

A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented.

RESULTS

A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence.

CONCLUSION

To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Cervical infection secondary to pyriform sinus fistula of branchial origin

Complete third branchial arch anomalies are rare and have been described only in case reports, affecting mainly children and typically presenting as a cervical inflammatory process. Anomalies of the third and fourth branchial apparatus, though rare, usually present as sinuses/incomplete fistulas of pyriform sinus or recurrent suppurative thyroiditis. A 6-year-old girl presented with a small opening on the left side of her anterior neck, which had been present since birth and was associated with recurrent infection. She had no history of incision and drainage of swelling. Computed tomography with contrast injection into the cervical opening revealed a fistulous tract extending from the cervical neck skin to the pyriform fossa. Complete excision of the fistulous tract and left hemithyroidectomy were performed. There was no recurrence at 22 months of follow-up.

Magnetic resonance imaging of branchial cleft abnormalities: illustrated cases and literature review

Objective:

We report two cases of branchial cleft abnormalities investigated using magnetic resonance imaging.

Background:

There appears to be no clear imaging technique that is universally recommended for imaging branchial cleft abnormalities. Options include fistulography, computed tomography, magnetic resonance imaging and ultrasonography.

Method:

Case reports and literature review.

Case reports:

Two cases, although not unusual in themselves, are described to illustrate the use of magnetic resonance imaging to define the anatomy and to assist surgical planning.

Conclusion:

Magnetic resonance imaging is able to accurately depict the extent and course of branchial cleft abnormalities, and in the current cases could have been relied upon to determine the necessary surgical procedure. Branchial cleft abnormalities are sufficiently rare for magnetic resonance imaging to be recommended as the first-line imaging modality.

Bilateral First and Second Branchial Cleft Fistulas: A Case Report

Branchial cleft anomalies—which include branchial cysts, sinuses, and fistulas—are uncommon developmental defects of the neck. Approximately 2 to 3% of cases are bilateral; bilateral presentations appear to have a familial component. Only 5 cases of bilateral branchial cleft fistulas have been reported in the English-language literature, and only 1 case of simultaneous first and second branchial cleft fistulas has been previously reported. We report what to the best of our knowledge is the second case of bilateral first and second branchial cleft fistulas.