Definitive surgical management for second branchial cleft fistula: A case series

Abstract

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.

Early presentation of complete branchial fistula with review of literature

“…This obviates the need for ipsilateral tonsillectomy and also lowers the recurrence rate. 26,27 Histology often reveals turbid yellow fluid containing cholesterol crystals and stratified squamous epithelium linig. 3 Complications of surgery include, recurrence, mostly due to incomplete surgical excision, which could be 3% in fresh cases and up to 20% in second surgical attempts.…”

Branchial Cleft Anomalies: Embryogenesis, Clinical Features, Diagnosis, and Management

“…Several recent studies have found that performing a tonsillectomy confers no additional clinical benefit and should be avoided. 48,54,55 Endoscopically-assisted dissection techniques obviate the need for additional incisions and reduce the morbidity of surgery. 56 Guerrissi 57 was the first to describe this technique and demonstrated excellent visualization of a second BCA fistulous tract through a minimal skin incision.…”

“…Several recent studies have found that performing a tonsillectomy confers no additional clinical benefit and should be avoided. 48,54,55…”

A Rare Presentation of Second Branchial Cleft Cysts in Adult Patient: Case Report with Literature Review

“…To prevent any risk recurrence the surgeon must make sur the excision is complete. An ipsilateral tonsillectomy ensures removal of the fistulous tract [10]. But it is not required, as some studies have shown, to avoid recurrences [11].…”