Branchial fistula : Case report and review of literature

Perspectives in MNR Medical Research; 30th September 2018: Vol. - 2, Issue - 1

Srinivasa Karthik et al 1-2

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Case Report

INTRODUCTION

CASE REPORT

Remnants of embryonic brachial apparatus are common in children and may present as cyst, sinus, fistula and cartilaginous cyst rest. Although congenital by definition they are often unrecognized or misdiagnosed until symptoms or complications initiate an evaluation.

The term Branchial apparatus was described by Von Baer(1827) [1] term branchial fistula by Simpson(1969) . All of these lesions have

risk of infection and can present as an abcess or with drainage and [2] surrounding erythema, rarely remnants may harbour malignancy .

Equally common in males and female usually present in childhood [3].or early adulthood

Second branchial cleft anomalies are more common, representing [3]95% of all branchial cleft malformations .

A 6 year female girl presented with chief complaints of opening in lower part of right side of neck since birth and recurrent mucoid to mucopurulent discharge from opening since 2 years, and with associated upper respiratory tract infection. Discharge from opening relieved after a course of antibiotic therapy. On physical examination there was a small punctum in the skin at junction of middle two third to lower one third of anterior border of sternocleidomastoid muscle.

Ear, nose, throat and general examination was normal. There are no other congenital abnormalities, and all other routine investigations are normal. On the basis of clinical history and general physical examination, it is diagnosed as second branchial fistula, sinogram done which demonstrated sinus tract up to oropharynx, after confirmation of diagnosis planned for surgical excision. Anesthesia fitness was taken, pediatrician opinion for fitness was taken and posted for total excision of fistula tract under GA. Intra operatively, for easy accessibility ,dissection and excision of total tract cannula was passed through the fistula after which methelene blue dye injected.

An elliptical incision was taken around the fistula opening over the neck and blunt dissection was carried under sub-platysmal plane along the carotid sheath up to bifurcation of carotids. Second incision made at the level of hyoid bone and dissected portion of tract passed through undermined sub platysmal plane and exposed and proceeded for further higher dissection. Tract separated from

Fig 1 : Dissection of branchial fistula tact

Fig 2 : Fistula tact complete exposure

Fig 3: ligation of fistula tact at base

1 2 2 3Srinivasa Karthik , Chakrapani , Kumar Raja , Mounika Vasa1. Assistant. Professor, Department of General Surgery, MNRMCH 2. Pediatrician3. Junior Resident Department of Pharmacology*Corresponding author : Dr. Srinivasa KarthikEmail Id: Date of Submission: 3rd August 2018; Date of Publication : 30th September 2018.

askmbbs@gmail.com

Cite this article as: Srinivasa Karthik, Chakrapani, Kumar Raja, MounikaVasa. Branchial fistual : case report and review of literature. PMNRMR.2018; 2(1):1-2

underlying soft tissues, and identified the tract entering into parapharyngeal space towards the tonsillar fossa between internal and external carotid artery which is ligated till the reach of tonsillar fossa to prevent recurrence .post excision of tract hemostasis secured and wound closure done in layers using 3-0 catgut and 3-0 prolene subcuticular sutures applied over skin followed by application of sterile dressing.

Post operatively patient is hemodynamically stable and treated with higher antibiotics ,analgesics, antacids ,daily aseptic dressing and treated symptomatically and discharged in hemodynamically stable state and follow up review done after 5 days, 2 weeks and after 3months with no complications noted

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th th During 4 and 5 week after fertilization, 4 pairs of wel developed ridges and associated clefts and pouches are prominent in lateral cervical region of human embryo. The mature structures of head and

neck are derivatives of these paired branchial arches, clefts and [4]pouches of embryo .

The first branchial arch forms the mandible and a portion of upper jaw, and the part of first branchial cleft remains open as the Eustachian tube and external auditory canal. Abnormal development results in anomalies such as cleft lip and palate, abnormal shape contour of external ear and malformation of internal ossicles. The second branchial arch from the hyoid bone and cleft of tonsillar fossa. Second branchial cleft remanants are found along any part of a line extending from the tonsillar fossa inferiorly to a point on the lower third of anterior border of sternocleidomastoid muscle. Third cleft migrates low in the neck to form the inferior parathyroid gland and the thymoma. Fourth cleft also migrates but stop higher up in the neck and form superior parathyroid gland and C-cells of thyroid gland. Second arch anomalies are classified into 4 types.

Type1. Lesion lies anterior to the sternocleidomastoid muscle and do not contact the carotid sheath. Type2. Lesion are the most common and pass deep to the sternocleidomastoid and either anterior or posterior to the carotid sheath. Type3. Lesion passes between internal and external carotid arteries and are adjacent to pharynx. Type4. Lesion lies medial to carotid sheath close to the pharynx adjacent to the tonsillar fossa .

The second branchial cleft and sinuses are encountered along the anterior border of the sternocleidomastoid muscle in its lower third

[5,6]and may be bilateral is around 10% . Presence of complete [7]branchial fistula with external and internal opening is not common .

Preoperative fistulogram of tract with contrast material demonstrate the entire course of the tract, helps in surgical planning, differentiate

[3]between sinus and fistula, and decrease the chance of recurrence . In some cases complete tract cannot be delineated because it may be blocked by secretion and granulation. Anatomically fistulous tract passes deep to Platysma muscle between second and third pharyngeal arch structures by ascending along the carotid sheath and passing medially between internal and external carotid arteries above the glossopharyngeal nerve and below the stylohyoid

[8]ligament . The fistula may open into pharynx, usually into tonsillar st ndfossa. It is most commonly presented in 1 and 2 decades. Two to

ten percent of them can be bilateral. 6% of the patient with complete [7]fistula can have a family history of branchial fistula anomalies .

Branchial cysts are more common (80.8%) than branchial fistulae.

The definite treatment of branchial anomalie is complete surgical excision of tract, most suitable age for surgery is 2 to 3 year or as early as possible if it is already delayed and among surgical

[7,3]techniques stepladder incision is most accepted method , as it provide better visualisation of tract near pharynx which is combined with transoral approach for complete excision of tract, other

Fig 4: Sub cuticular suturing - stepladder appearance along thelines of creases

modality of treatment includes a) Sclerosing agents which is seldom used today due to the associated inflammatory reaction and the risk of necrosis with perforation into the pharynx, b) stripping method

[9]was described by Taylor and Bicknell in 1977 , but this has not been widely used due to great risk of damage to adjacent structures.

Complication of surgery includes recurrence, which could be 3% in fresh cases 7 % and up to 20% in second surgical attempts. Other complication include secondary infection, injury to facial, hypoglossal, glossopharyngeal, spinal accessory nerves, injury to internal jugular vein, and hematoma formation.

1. Simpson, R.A. lateral cervical cysts and fistulae, laryngoscope, 1969; 79, 30-59.

REFERENCE:

2. SoperRT, Pringle KC cysts and sinuses of the neck In:Welch thKJ,Randolph JG, Ravitch MM etal.,. edspeditric surgery, 4

edition, Chicago :year book 1986,p.539.

3. Proctor B, Proctor C. Congenital lesion of the head and neck. , OtolaryngolClin N Am 1970; 3:221-248.

4. Gray SW, SkandalakisJE.the pharynx and its deivatives IN:embryology for surgeons :the embryological basis for the treatment of congenital defects .Philadelphia :WB Saunder, 1972.

5. Waldhausen JHT. Branchial cleft and arch anomalies in children. SeminPediatrsurg 2006; 15: 64-9.

6. Enepekides DJ. Management of congenital anomalies of the neck. Facial plastsurgclin north Am 2001; 9: 131-45.

7. Ford G R., Balakrishnan, A., Evans, J. N. G., Bailey, C. M. journal of laryngology and otology 1992; 106: 137-143.

8. Chandler R, Mitchell B. Branchial cleft cysts, sinuses, and fistulas. OtolaryngolClin N Am 1981; 14:175-186.

9. Taylor PS and Bicknell PG,Branchial cleft cysts, sinuses, and fistulaslaryngolotol 1977; 61:141.

Srinivasa Karthik et al 2-2

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Perspectives in MNR Medical Research; 30th September 2018: Vol. - 2, Issue - 1