Surgical Approaches to First Branchial Cleft Anomaly Excision: A Case Series

Abstract

Objectives. First branchial cleft anomalies (BCAs) constitute a rare entity with variable clinical presentations and anatomic findings. Given the high rate of recurrence with incomplete excision, identification of the entire tract during surgical treatment is of paramount importance. The objectives of this paper were to present five anatomic variations of first BCAs and describe the presentation, evaluation, and surgical approach to each one. Methods. A retrospective case review and literature review were performed. We describe patient characteristics, presentation, evaluation, and surgical approach of five patients with first BCAs. Results. Age at definitive surgical treatment ranged from 8 months to 7 years. Various clinical presentations were encountered, some of which were atypical for first BCAs. All had preoperative imaging demonstrating the tract. Four surgical approaches required a superficial parotidectomy with identification of the facial nerve, one of which revealed an aberrant facial nerve. In one case the tract was found to travel into the angle of the mandible, terminating as a mandibular cyst. This required en bloc excision that included the lateral cortex of the mandible. Conclusions. First BCAs have variable presentations. Complete surgical excision can be challenging. Therefore, careful preoperative planning and the recognition of atypical variants during surgery are essential.

Branchial Cleft Anomalies: Our clinical experience and literature review

“…The branchial anomaly can be found in the surface or deep of the facial nerve. The relationship of the facial anomaly with facial nerve should be evaluated with preoperative tests and an operation plan should be performed (16). In our study, in 20 patients 1.…”

“…Surgery can be performed 4-6 weeks after the treatment (4). For complete surgical excision, cyst, fistula, and tract should be kept intact, and a lacrimal probe can be placed in the trauma during surgery (16). In patients, staining with methylene blue intra-operatively is also a method used for complete surgical excision (4).…”

A two-year-old with a duplicated external auditory canal; a first branchial cleft anomaly

“…Surgical excision with facial nerve monitoring is the definitive treatment for first branchial cleft anomalies [3,6]. Work et al propose surgical excision, consisting of parotid gland and facial nerve dissections.…”

“…Second branchial arch anomalies are the most common and account for approximately 95% of the cases [1]. First branchial cleft anomalies (FBCA) are less common: they account for <8% of all branchial anomalies [4][5][6]. The annual incidence is largely unknown and has been cited as 1 per 1,000,000 [7].…”

“…Because first branchial cleft anomalies are uncommon, recognizing them can be difficult and they are often misdiagnosed [8]. They may present as cysts, sinuses or fistulae and can occur anywhere along the course of the first branchial arch tract, distributed in the lateral neck below the external auditory canal, above the hyoid bone, anterior to the sternocleidomastoid muscle, and posterior to the submandibular angle [4,6]. In 1972 Work proposed a classification system for first branchial cleft anomalies based on histological and clinical features [9].…”