Branchial Anomalies

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CHAPTER 4 Branchial Anomalies

Tory A. Meyer

Step 1: Surgical Anatomy

♦ The course of branchial cysts, sinuses, and fistulas depend on the branchial arch from which they are derived (first, second, third, or fourth).
♦ The extent of branchial anomalies varies considerably, from small sinuses or cysts limited to the subcutaneous tissue (Figs. 4-1 and 4-2) to large inflammatory masses extending to the pharynx.
♦ First branchial anomalies appear in the preauricular or submandibular area and may course through the parotid gland, insinuate around the facial nerve trunk or branches, and connect to the external auditory canal.
♦ Second branchial anomalies are seen along the anterior border of the sternocleidomastoid muscle and may ascend through the deep tissues of the neck above the hyoid, between the internal and external carotid arteries, adjacent to the hypoglossal and glossopharyngeal nerves, and terminate in the tonsillar fossa or other nasopharyngeal areas.
♦ Although the theoretical course of third and fourth branchial anomalies has been described as descending into the mediastinum, this course has not been noted in vivo. These rare lesions have more recently been described by their pharyngeal terminus as pyriform fossa sinuses. Externally they may be evident along the anterior border of the sternocleidomastoid, usually on the left side of the neck, and pass through the thyroid, posterior to the internal carotid, adjacent to the recurrent laryngeal nerve, through the inferior constrictor muscle, and connecting to the pyriform fossa.
♦ Branchial anomalies may contain keratinizing or nonkeratinizing squamous epithelium or pseudostratified columnar respiratory epithelium.
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Figure 4-1

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Figure 4-2

Step 2: Preoperative Considerations

♦ Most common initial signs of branchial anomalies are an asymptomatic cystic mass, chronically draining sinus, or recurrently infected lesion of the neck.
♦ Occasionally it may manifest in infants with respiratory distress or stridor resulting from the swelling of cyst, impinging on the airway.
♦ Sinuses of the pyriform fossa may manifest as recurrent neck abscesses or acute thyroiditis.
♦ Preoperative imaging may help distinguish a branchial anomaly from other lesions, such as a cystic hygroma, lymphoma, neurofibromatosis, lymphadenopathy, carotid body tumor, tuberculous adenitis, lipoma, hemangioma, thyroglossal duct cyst, ectopic thyroid, thymic cyst, or a dermoid.
♦ Ultrasound or computed tomography scan with intravenous contrast may demonstrate gas in a cystic structure and may be useful to delineate the course of the lesion and possible thyroid involvement.
♦ Barium swallow may show the origination and extent of fistula or sinus.
♦ Antibiotics (with drainage, if necessary) should be administered until clinical signs of infection have resolved and before removal to minimize risks of complications and recurrence.
♦ Removal of a branchial anomaly before repeat infections will aid dissection in clean surgical planes.
♦ Goal of surgery is complete excision to prevent recurrence.
♦ Laryngoscopy or telescopic pharyngoscopy is useful for identification or cannulation of a pharyngeal fistula.
♦ Recent studies suggest that chemical or thermal cauterization of the internal opening may be adequate treatment for pyriform fossa sinus anomalies.
♦ Resection of all but the simplest anomalies limited to the subcutaneous tissue should be done with the patient under general anesthesia with an endotracheal tube rather than a laryngeal mask airway.

Step 3: Operative Steps

First Branchial Anomalies

♦ Intraoperative facial nerve monitoring should be considered.
♦ Injection of the tract through the external auditory canal with methylene blue or instrumentation with a small probe facilitates tract identification.
♦ A preauricular cervicomastoid incision is made and may be extended as necessary.
♦ The superficial lobe of the parotid is mobilized with clear identification of the facial nerve as it emerges from the stylomastoid foramen and enters the parotid.
♦ Lateral parotidectomy may be necessary to see the nerve and branchial anomaly adequately.
♦ The cyst is dissected free from surrounding tissues and the tract followed along its course, which may be posterior to the parotid (type I), or intraparotid (type II) (Fig. 4-3). The tract may ultimately connect with the external auditory canal.
♦ A segment of the external auditory canal, including skin and cartilage, is taken with the cyst. The external auditory canal wound may be packed open.
♦ The wound is closed in layers with a subcuticular skin closure and appropriate dressing applied.
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Figure 4-3

Second Branchial Anomalies

Large Cysts

♦ With the neck extended, large cysts are approached through an oblique neck incision following Langer lines along the superior portion of the swelling (see Fig. 4-5).
♦ The cyst is freed up circumferentially, paying careful attention to the jugular and carotid vessels and the hypoglossal nerve (XII) posteriorly.
♦ The facial vein and branches of the jugular vein may be ligated as necessary.
♦ If a tract is present, it should be freed up from attachments as it courses over the hypoglossal nerve (XII), between the internal and external carotid arteries, beneath the posterior belly of the digastric muscle, and over the glossopharyngeal nerve (IX) to enter the pharynx in the tonsillar fossa.
♦ The tract is suture ligated at the level of the pharynx with absorbable suture.
♦ The wound is closed in layers, and a drain is not usually necessary.
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Figure 4-5

Fistulas and Small Cysts

♦ With the neck extended, a small transverse elliptical incision is made around the skin opening in the lower neck.
♦ A small probe or Prolene suture may be passed along the course of the tract and into the pharynx to help with identification of the tract. The suture can be tied to a wad of gauze and used for traction on the tract.
♦ As the tract ascends in the neck, it is dissected free from surrounding tissues as far superiorly as possible, at which time an additional transverse incision is made (stair-step incision) and the fistulous remnant is delivered through this more superior wound (Fig. 4-4).
♦ This process is repeated until the tract turns into the deep tissues, at which point the incision may need to be extended to allow deeper dissection.
♦ Similar to large second branchial cysts, dissection continues around the fistulous tract, paying careful attention to preservation of the hypoglossal and glossopharyngeal nerves at the lower margin and the branches of the carotid arteries medially and laterally (Fig. 4-5).
♦ The fistulous tract is ligated at the level of the pharynx with absorbable suture, and the wounds are closed and dressed.
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Figure 4-4

Third and Fourth Branchial Anomalies (Pyriform Fossa Sinus Tracts)

♦ The traditional approach is open excision of the entire fistulous tract; however, recent studies have shown that cauterization of the pyriform sinus opening alone can be effective.

Open Operation

♦ With the neck extended, direct laryngoscopy is performed to identify the sinus tract opening in the pyriform sinus.
♦ A Fogarty catheter is inserted into the sinus and secured to aid with identification of the tract (Fig. 4-6).
♦ If an external opening is present, it may be injected with methylene blue or instrumented with a lacrimal duct probe to facilitate identification during dissection.
♦ A generous oblique neck incision is made at the level of the thyroid cartilage.
♦ The strap muscles are retracted, and the cyst or tract is dissected circumferentially to the thyroid gland, through which it passes.
♦ Resection of the lateral portion of the thyroid or a thyroid lobectomy is performed to include the fistulous tract.
♦ The recurrent laryngeal nerve is clearly identified and preserved because the course of the fistula may be parallel to the recurrent laryngeal nerve.
♦ The superior parathyroid gland is identified and preserved.
♦ The most commonly seen tract courses superiorly into the pyriform sinus.
♦ Alternatively, the tract is followed superior to the hypoglossal nerve and posterior to the carotid. It will pass superior or inferior to the superior laryngeal nerve, depending on its cause as a third or fourth branchial anomaly, respectively.
♦ The tract is then dissected as it courses inferiorly, anterior, or lateral to the recurrent laryngeal nerve, then piercing the inferior constrictor muscle at the level of the base or apex of the pyriform sinus.
♦ A portion of the thyroid cartilage may be removed, or the inferior constrictor may be opened to adequately view this portion of the tract.
♦ Using absorbable suture, the tract is closed where it enters the pyriform sinus.
♦ The wound is closed in layers, and a drain is not generally necessary.
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Figure 4-6

Endoscopic Sinus Cauterization

♦ Cauterization may be performed at the time of drainage of neck abscess or subsequently when acute infection has resolved.
♦ Laryngoscopy is used to visualize the pyriform sinus (Fig. 4-7).
♦ A small Fogarty catheter is passed into the opening of the sinus, and the tract is dilated enough to allow passage of a coagulating instrument into the opening.
♦ An insulated probe or ball coagulating tip is passed into the sinus opening and activated on low power till tissue blanching occurs.
♦ The superficial portion of the opening is coagulated again to ensure closure of the tract.
♦ To prevent perforation of the hypopharynx, avoid overcoagulation.
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Figure 4-7

Step 4: Postoperative Care

♦ Recurrence is much more likely if the pathology specimen does not contain an epithelium-lined tract.
♦ Long-term follow-up is necessary to monitor for recurrence.

Step 5: Pearls and Pitfalls

♦ Infection should be treated before surgical intervention for removal of branchial anomalies.
♦ Mastery of the anatomy of the neck and possible courses of these anomalies are essential for successful resection.
♦ Complete surgical extirpation is the traditional approach for preventing recurrence.
♦ Complications include injury to the hypoglossal, glossopharyngeal, vagus, superior laryngeal, and recurrent laryngeal nerves. In addition, injury to the carotid or jugular vessels and formation of a pharyngocutaneous fistula may occur.
♦ Although the long-term recurrence rate is not well established, endoscopic sinus cauterization may be adequate treatment for pyriform sinus anomalies (third and fourth branchial anomalies) with a lower complication rate.

Bibliography

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Houck J. Excision of branchial cysts. Operative Techn Otolaryngol. 2005;16:213-222.

James A, Stewart C, Warrick P, Tzifa C, Forte V. Branchial sinus of the piriform fossa: reappraisal of third and fourth branchial anomalies. Laryngoscope. 2007;117(11):1920-1924.

Jordan JA, Graves JE, Manning SC, McClay JE, Biavati MJ. Endoscopic cauterization for treatment of fourth branchial cleft sinuses. Arch Otolaryngol Head Neck Surg. 1998;124(9):1021-1024.

Liberman M, Kay S, Emil S, et al. Ten years’ experience with third and fourth branchial remnants. J Pediatr Surg. 2002;37:685-690.

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Sai Prasad TR, Chong Cl, Mani A, et al. Acute suppurative thyroiditis in children secondary to pyriform sinus fistula. Pediatr Surg Int. 2007;23(8):779-783.

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Tracy TJ, Muratore CS. Management of common head and neck masses. Semin Pediatr Surg. 2007;16(1):3-13.

Verret DJ, McClay J, Murray A, Biavati M, Brown O. Endoscopic cauterization of fourth branchial cleft sinus tracts. Arch Otolaryngol Head Neck Surg. 2004;130(4):465-468.

Waldhausen JHT, Tapper D. Head and neck sinuses and masses. In: Ashcraft KW, Holcomb GW, Murphy JP, editors. Pediatric surgery. 4th ed. Philadelphia: Saunders; 2005:1054-1057.

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