Type II first branchial cyst and sinus excision with preservation of facial nerve and parotid gland

An extremely rare case of adult with first branchial cleft fistula: Case report

Atypical first branchial cleft fistula: A case report

A Very Rare Case of First Branchial Cleft Sinus Outside Triangle of Triglia

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Objective: To provide the experience of diagnosis and treatment of second branchial cleft fistula in children. Methods: The clinical data of 76 children with second branchial cleft fistulas admitted to Beijing Children's Hospital affiliated with Capital Medical University from January 2016 to December 2020 were retrospectively analyzed. All patients underwent cervical ultrasonography and resection of the second branchial cleft fistula, and their clinical manifestations, surgical methods, complications, recurrence condition, and lesion appearance of the patients were analyzed. Results: Among the 76 cases, the lesions of 43 cases were on the right side, 20 were on the left side, and 13 were bilateral, for a total of 89 lesions. There were 49 type I lesions, 28 type II lesions, 8 type III lesions, and 4 type IV lesions. Type I and type II cases underwent complete excision of the fistula through a small incision in the neck; 2 cases of type III branchial cleft fistulas were treated with trapezoidal incision; 2 cases of type III branchial cleft fistulas underwent single transverse incisions; single small incision-assisted endoscopic resection was adopted in 4 cases of type III and 4 cases of type IV branchial cleft fistulas. During the follow-up period of 6 to 60 months, only 3 cases developed postoperative infection, the others had no postoperative complications, and no cases had recurrence during postoperative follow-up. Conclusion: The incision of the second branchial fistula should be selected according to imaging examination to achieve removal of the fistula while maintaining esthetics.

The objective of the study was to evaluate the effectiveness of make-inside-exposed method by tract incision to remove the first branchial cleft fistula, while avoiding injury to the facial nerve and completely excising the fistula. Fifteen patients who underwent the make-inside-exposed method by tract incision for excision of the first branchial cleft anomalies were reviewed. Pre-auricular fistulas or sinuses occurred in nine of them, and post-auricular fistulas occurred in six cases. The symptoms of these patients, post-operative complications including facial nerve paralysis and recurrence of the lesion, were observed. Of the 15 patients, 6 had undergone previous incision and drainage of abscess for the infected fistulas. All patients had swelling or suppuration in the pre-auricular or post-auricular region. Post-auricular fistulas had intimate relationship with facial nerves in most of the cases (5/6). The fistulas or sinuses tracts were all removed completely without any complications, such as facial palsy, but severe scar formation occurred in one case. No remnant of fistula or sinus was observed during the follow-up period from 2 to 12 years postoperatively. Make-inside-exposed method by tract incision is an effective and safe technique for the excision of the first branchial cleft fistula. The two main advantages of this method are that it can preserve the facial nerve safely and excise the fistulas completely. However, skillful microsurgery manipulation is necessary.

First branchial cleft anomalies (FBCAs) are uncommon congenital malformations that develop due to incomplete closure of the first branchial cleft during embryonic development. They represent a small proportion of all branchial cleft anomalies. These lesions, which may present as cysts, sinuses, or fistulas, pose significant diagnostic and therapeutic challenges due to their nonspecific clinical manifestations and complex anatomical relationships, particularly with the facial nerve and parotid gland. This case report describes a 47-year-old male patient presenting with recurrent infections and purulent discharge in the right preauricular and submandibular regions, later diagnosed as a Work Type II first branchial cleft fistula extending from the external auditory canal (EAC) through the parotid gland to the submandibular skin. Diagnostic evaluation included high-resolution magnetic resonance imaging (MRI) and computed tomography (CT) fistulography, which confirmed the fistula’s course and its intimate relation to the facial nerve. Surgical management involved complete excision via a modified Blair incision, retrograde facial nerve dissection, and superficial parotidectomy, with intraoperative neuromonitoring to minimize nerve injury risk. Histopathology revealed a cutaneous fistulous tract lined with stratified squamous epithelium and sparse chronic inflammatory infiltrates. Postoperative recovery was uneventful, with transient House-Brackmann grade II facial nerve palsy resolving within four weeks and no recurrence at the 12-month follow-up. This case is notable for the patient’s unusually late presentation in adulthood, contrasting with the typical diagnosis in childhood. A comprehensive literature review highlights the embryological basis, clinical variability, and diagnostic challenges of FBCAs, emphasizing the critical role of preoperative imaging for delineating the fistula’s anatomy and planning surgery. Complete surgical excision with facial nerve preservation remains the gold standard, though the procedure is complicated by the lesion’s proximity to critical neurovascular structures. Intraoperative neuromonitoring and patient-specific surgical approaches are essential to minimize complications such as facial nerve palsy and recurrence. This case underscores the importance of timely diagnosis, meticulous preoperative planning, and specialized surgical expertise in achieving favorable outcomes for FBCAs, particularly in atypical adult presentations.

The goal of this case report is to describe an unusual case of recurrent first branchial cleft fistula with cysts and the effective surgical approach of complete removal with preservation of the facial nerve. A 27-year-old woman presented to our clinic after unsuccessful removal twice during the last 20 years. We have achieved satisfactory outcomes by using an approach to identify the facial nerve at the stylomastoid foramen with canal wall up mastoidectomy under a microscope. No sign of facial palsy, hearing loss, or recurrence were noted in postoperative follow-up. This approach might facilitate the complete dissection of scar and lesions of recurrent first branchial cleft anomalies around the main trunk of the facial nerve in the parotid gland.

<p class="abstract">First branchial cleft anomalies (BCA) are a rare finding in head and neck with incidence nearly- incidence of nearly 1 million per year which are distributed below external auditory canal, above the hyoid bone, anterior to sternocleidomastoid and posterior to submandibular triangle. First branchial cleft cysts are frequently misdiagnosed as they are rare and pose unfamiliar clinical signs and symptoms. Here we are reporting a case of surgical management of 1st branchial cleft fistula in a 5 years old male child from AIIMS, Raipur, Chhattisgarh, India as it’s a rare entity. Child presented with discharge from right upper part of neck. There was a swelling in right upper lateral part of neck with an opening also in floor of right external auditory canal (EAC). Contrast enhanced computed tomography of neck showed a 4.8 cm long obliquely oriented fistulous tract opening at junction of middle and upper one third of sternocleidomastoid with opening in right EAC. Surgical excision of the fistulous tract was done with preservation of facial nerve. Histopathology examination confirmed the presence of fistula. Common clinical presentation of BCAs is pre-auricular swelling (24%), parotid swelling (36%) or cervical region swelling (41%). In our case, it was a fistulous opening that presented as discharging tract in upper neck. Management include early diagnosis, control of infection and complete excision with facial nerve preservation Surgical approach should be based on the clinical examination, imaging and clinical course; and there is a need to safely identify and preserve facial nerve in almost all cases.</p>

Multidetector computerized tomographic fistulography in the evaluation of congenital branchial cleft fistulae and sinuses

<p>Branchial cleft anomalies comprise approximately 30% of congenital neck mass and present as cyst, sinus or fistula. They occur due to disturbance in the maturation of the branchial apparatus during fetal development. They are congenital lesions usually present in childhood, but they are usually diagnosed in later childhood or early adulthood because of enlargement or infection. Branchial cleft fistulae are usually diagnosed earlier than cysts. Correct diagnosis leads to proper management. Complete surgical excision is the treatment of choice. Second branchial cleft and pouch anomalies are commonest amongst all branchial cleft lesions, but complete second branchial cleft anomalies with external and internal opening is rare. Branchial anomalies with family history are also very rare. Here we present a case report of complete branchial fistula with family history which was managed by complete excision of fistula through transcervical and transoral approaches. 3 members of one family in 2 generations presented with branchial apparatus anomalies (father and his two children, elder son and younger daughter). All of them were having branchial fistula on right side of neck since birth.</p>

A rare case of second branchial fistula with heterotopic salivary gland tissue in the lower neck is described. The patient was a 12-year-old girl with a fistula which appeared to be clinically a second branchial cleft anomaly. It was removed from her neck. Histological examination revealed that the lesion was a branchial cleft fistula with elements of salivary gland tissue.

Branchial abnormalities occur when there is disturbance in the maturation of the branchial apparatus during fetal development. Branchial anomalies are congenital lesions usually present in childhood, even if they can be diagnosed later for enlargement or infection. A correct diagnosis will lead to proper management: complete surgical excision is the treatment of choice. The purpose of this article is to present clinical features, diagnostic methods and surgical treatment of branchial anomalies in childhood, based on a series of 50 patients. We conducted a retrospective analysis of a total of 50 pediatric patients operated from June 2005 to June 2014 for the presence of branchial cleft anomalies. 27 cases (54 %) presented a second branchial cleft fistula and 11 cases (22 %) a second branchial cleft cyst and one case (2 %) presented both cyst and sinus of the second branchial cleft; four cases (8 %) presented first branchial cleft cyst whereas four cases (8 %) a first branchial cleft sinus and two cases (4 %) a first branchial cleft fistula; one case (2 %) presented a piriform sinus fistula (third branchial cleft). None of our patients presented anomalies of the fourth branchial cleft. All patients underwent surgical treatment and lesions have been removed by excision or fistulectomy. No post-surgical complication occurred. The rate of recurrence was 4 %. Pre-operative diagnosis supplies important information to the surgeon for a proper therapy: a complete excision of the lesion without inflammatory signs is essential to avoid re-intervention and to achieve a good outcome.

Two patients (a 58-year-old man and a 58-year-old woman) had branchial cysts in the parotid gland, and the other patients had one in the submandibular gland. Branchial cysts usually occur in the lateral cervical area and are rare in salivary glands. Branchial cysts in salivary glands are classified as first branchial cleft cyst and second branchial cleft cyst depending on the site of origin.First branchial cleft cysts are rarer than second branchial cleft cysts and usually appear in the preauricular area. The cysts are lined with stratified squamous epithelium, and scant lymphoid tissue is seen in the subepithelial area. Second branchial cleft cysts usually occur in the lower portion or superficial lobe of a parotid gland. They are lined with stratified squamous epithelium plus columnar or cuboidal epithelium. Beneath which is abundant lymphoid tissue with clear lymphoid follicles. Clinical and pathological examinations showed that the two parotid gland cysts were probably second branchial cleft cysts and the one in the submandibular gland was probably a first branchial cleft cyst.

Nonsyndromic bilateral second branchial cleft fistulae: A case report