Background
Second branchial cleft fistulae are rare pediatric anomalies managed with surgical excision and, in certain cases, ipsilateral tonsillectomy to prevent postoperative recurrence or wound infection. Limited information is available in the published literature regarding surgical techniques to maximize patient outcomes and minimize recurrence. Our objective was to describe outcomes for the largest series of branchial cleft fistulae excised using a uniform technique based on embryologic principles.
Methods
We conducted a retrospective analysis of pediatric patients who underwent surgery for second branchial cleft fistula using a uniform technique developed by the senior surgeon between 2006 and 2018 at a tertiary care pediatric hospital. The technique involves dissection to the level of the greater cornu of the hyoid bone as the point of transection, which is the landmark for the base of the tonsillar fossa. Data collected included age at surgery, initial presentation, laterality of fistula tract, final pathology, and follow up data. Measured outcomes included fistula recurrence, wound infection, and other complications.
Results
Of 67 patients, 28 (42%) were male and 10 (15%) had bilateral fistulae, for a total of 77 tracts excised. After a median follow up of 31 months, there were no recurrences and one wound infection that was treated successfully with oral antibiotic therapy. No patients underwent tonsillectomy.
Conclusion
Effective management of second branchial cleft fistulae can be challenging. We present the largest cohort of results using a uniform surgical technique performed at a single center that obviates the need for tonsillectomy, and thus represents a less morbid and effective approach with no evidence of recurrence.
Background: Mometasone-eluting stents (MES) have demonstrated improvement in short-term endoscopic outcomes and reduce short-to medium-term rescue interventions. Their effect on the local inflammatory environment, longerterm patient-reported outcomes, and radiographic severity have not been studied.Methods: Middle meatal mucus and validated measures of disease severity were collected before and 6 to 12 months after endoscopic surgery in 52 patients with chronic rhinosinusitis with nasal polyps (CRSwNPs). Operative findings, type 2 mediator concentrations, intraoperative variables, and disease severity measures were compared between those who did and those who did not receive intraoperative frontal MES. Results: A total of 52 patients with CRSwNPs were studied; 33 received frontal MES and were compared with 19 who did not. Pre-endoscopic sinus surgery (ESS) middle meatus (MM) interleukin (IL) 13 and eosinophil cationic protein (ECP) were higher in the stented group (p < 0.05), but pre-ESS clinical measures of disease severity were similar as were surgical extent and post-ESS medical management. Intraoperative eosinophilic mucin was more frequent in the stented group (58% vs 11%, p = 0.001). IL-5 (p < 0.05) and IL-13 (p < 0.001) decreased post-ESS in the stented group, but this was not observed in the nonstented group. Post-ESS IL-4 and IL-13 were higher in the nonstented vs stented group (p < 0.05 for both).
The 22-item Sino-Nasal Outcome Test (SNOT-22) and 12-item Patient Reported Outcomes in Chronic Rhinosinusitis (CRS-PRO) instrument are validated patient-reported outcomes measures in CRS. In this study we assess the correlation of these with type 2 (T2) biomarkers before and after endoscopic sinus surgery (ESS). Methods: Middle meatal mucus data were collected and the SNOT-22 and CRS-PRO were administered to 123 patients (71 CRS without nasal polyps [CRSsNP], 52 CRS with nasal polyps [CRSwNP]) with CRS before and 6 to 12 months after undergoing ESS. Interleukin (IL)-4, IL-5, IL-13, and eosinophilic cationic protein (ECP) were measured using a multiplexed bead assay and enzyme-linked immunoassay. Pre-and post-ESS SNOT-22 and CRS-PRO were compared with T2 biomarkers. Results: Before ESS neither PROM correlated with any biomarker. After ESS, CRS-PRO showed a correlation with 2 mediators (IL-5 and IL-13: p = 0.012 and 0.003, respectively) compared with none for the SNOT-22. For CRSwNP patients, pre-ESS CRS-PRO and SNOT-22 correlated with IL-4 (p = 0.04 for both). However, after ESS, CRS-PRO correlated with 3 biomarkers (IL-5, IL-13, and ECP: p = 0.02, 0.024, and 0.04, respectively) and SNOT-22 with 2 biomarkers (IL-5 and IL-13: p = 0.038 and 0.02, respectively). There were no significant relationships between any of the T2 biomarkers pre-or post-ESS among patients with CRSsNP. Exploratory analyses of the subdomains showed the SNOT-22
Background
Patients with chronic rhinosinusitis (CRS) may have persistence of polyps, discharge, or edema after endoscopic sinus surgery (ESS). Inflammation in CRS can be classified into three endotypes, with the presence of polyps associated with the type 2 endotype. Here, we evaluate the endotypic underpinnings of discharge or edema without polyps after ESS.
Methods
At a visit 6–12 months post ESS, patients underwent endoscopy and completed the CRS‐PRO and SNOT‐22. Luminex analysis of middle meatal mucus obtained at that visit was performed for IFN‐γ, ECP, and IL‐17a. Type 1, 2, and 3 endotypes were defined as greater than the 90th percentile expression of each marker, respectively, in controls. Wilcoxon rank‐sum and chi‐squared tests were used to compare cytokine levels and endotype prevalence between those with and without endoscopic findings.
Results
A total of 122 CRS patients completed a clinical exam (median: 8.2 months post ESS). Of the 122 patients, 107 did not have polyps on endoscopy. Of these 107 patients, 48 had discharge, 44 had edema, and 46 had neither discharge nor edema. Compared with those patients without any findings, patients with discharge or edema reported significantly worse severity as measured by CRS‐PRO (10.5 vs. 7.0, p = 0.009; 12.0 vs. 7.0, p < 0.001; respectively), and had higher post‐ESS IFN‐γ, ECP, and IL‐17a. Patients with discharge had higher prevalence of only T1 and T3 endotypes, while patients with edema had higher prevalence of only the T3 endotype.
Conclusions
Post‐ESS discharge or edema in the absence of polyps was associated with higher patient‐reported outcome severity and was more strongly associated with type 1 or 3 inflammation.
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