First Branchial Cleft Anomalies Otologic Manifestations and Treatment Outcomes

Original ResearchOtology and Neurotology

First Branchial Cleft Anomalies: OtologicManifestations and Treatment Outcomes

OtolaryngologyHead and Neck Surgery2015, Vol. 152(3) 506512 American Academy ofOtolaryngologyHead and NeckSurgery Foundation 2014Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0194599814562773http://otojournal.org

Justin R. Shinn1, Patricia L. Purcell, MD1, David L. Horn, MD1,2,Kathleen C. Y. Sie, MD1,2, and Scott C. Manning, MD1,2

Sponsorships or competing interests that may be relevant to content are dis-

closed at the end of this article.

Abstract

Objective. This study describes the presentation of first bran-chial cleft anomalies and compares outcomes of first bran-chial cleft with other branchial cleft anomalies withattention to otologic findings.

Study Design. Case series with chart review.

Setting. Pediatric tertiary care facility.

Methods. Surgical databases were queried to identify childrenwith branchial cleft anomalies. Descriptive analysis definedsample characteristics. Risk estimates were calculated usingFishers exact test.

Results. Queries identified 126 subjects: 27 (21.4%) hadfirst branchial cleft anomalies, 80 (63.4%) had second, and19 (15.1%) had third or fourth. Children with first anoma-lies often presented with otologic complications, includingotorrhea (22.2%), otitis media (25.9%), and cholesteatoma(14.8%). Of 80 children with second branchial cleftanomalies, only 3 (3.8%) had otitis. Compared with chil-dren with second anomalies, children with first anomalieshad a greater risk of requiring primary incision and drai-nage: 16 (59.3%) vs 2 (2.5%) (relative risk [RR], 3.5; 95%confidence interval [CI], 2.4-5; P \ .0001). They weremore likely to have persistent disease after primary exci-sion: 7 (25.9%) vs 2 (2.5%) (RR, 3; 95% CI, 1.9-5; P =.0025). They were more likely to undergo additional sur-gery: 8 (29.6%) vs 3 (11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P =.0025). Of 7 persistent first anomalies, 6 (85.7%) weremedial to the facial nerve, and 4 (57.1%) required ear-specific surgery for management.

Conclusions. Children with first branchial cleft anomalies oftenpresent with otologic complaints. They are at increased risk ofpersistent disease, particularly if anomalies lie medial to thefacial nerve. They may require ear-specific surgery such astympanoplasty.

Keywords

branchial cleft, otitis, congenital neck mass, pediatricotolaryngology

Received August 22, 2014; revised November 10, 2014; accepted

November 14, 2014.

Branchial cleft anomalies (BCAs) are the second most

common type of congenital neck mass after thyro-

glossal duct cyst.1 Branchial cleft anomalies can

result from duplication of the first branchial cleft, or ear

canal, or from failure of fusion of the second, third, or fourth

branchial arches.2 Most anomalies occur as second branchial

cleft sinuses and cysts.3 Third or fourth branchial anomalies,

also referred to as piriform sinus fistulae, are the least

common,4 while first branchial anomalies account for about

10% of cases.5 Because first BCAs are rare, attempts to

describe the characteristics and management of these anoma-

lies have historically been limited. Previous case series have

raised concerns regarding the frequency of misdiagnosis and

complications with treatment of first BCAs.6 Previous studies

have often focused on complications related to injury of the

facial nerve, which can be found in close association to these

lesions.7

In 1972, Work8 proposed a classification system for first

BCAs. Work type I lesions are cysts that lie superficial to the

facial nerve in closer proximity to the pinna, while Work

type II anomalies communicate with the external auditory

canal (EAC) or tympanic membrane (TM) and often lie

medial to the facial nerve. Olsen et al9 then introduced a clas-

sification of the defects into cysts, sinuses, and fistulas based

on the number of surface openings present.

The TM is considered a fusion point for the 3 primary

vestigial layers of the first branchial apparatus; therefore,

abnormal embryologic development in this region often

leads to otologic abnormalities.10 Considering this embryologic

1Department of Otolaryngology, University of Washington, Seattle,

Washington, USA2Division of Pediatric Otolaryngology, Seattle Childrens Hospital, Seattle,

Washington, USA

This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO

EXPOSM; September 21-24, 2014; Orlando, Florida.

Corresponding Author:

Patricia L. Purcell, Department of Otolaryngology, University of

Washington, 1959 NE Pacific St, Box 356515, Seattle, WA 98195-6515,

USA.

Email: [email protected]

at IMSS on May 26, 2015oto.sagepub.comDownloaded from

source, the primary objective of the current study was to

describe the presentation of first BCAs at our institution,

with attention to otologic manifestations of disease. A

second objective was to compare treatment outcomes of

children with first BCAs to children with other types of

BCAs to determine the extent to which children with first

anomalies are at greater risk of delayed diagnosis or per-

sistent disease. Our hypothesis was that children with per-

sistent disease would often require ear-specific surgery

for definitive management.

Methods

This investigation is a case series that received institutional

review board approval from Seattle Childrens Hospital, a

pediatric tertiary care facility. All children and adolescents

who were surgically treated for congenital neck masses between

2004 and 2013 were identified through query of the facilitys

surgical database using the following Current Procedural

Terminology (CPT) codes: 21556, 21557, 38510, 42408, 42815,

60280, and 60281.

A retrospective chart review was performed to identify

subjects from age birth to 21 years who were treated for

BCA. Diagnosis of branchial anomaly was made on the

basis of clinical evaluation, imaging characteristics, and sur-

gical pathology.

First BCAs were defined by a pit or cyst identified in

level I or level II or the postauricular region with imaging

and surgical confirmation of a tract leading toward the ear

canal. Second branchial cleft sinuses and fistulae were

defined by a congenital pit along the anterior border of the

sternocleidomastoid muscle with surgical confirmation of a

tract heading partially or completely to the tonsillar fossa.

Second branchial cleft cysts were defined by an isolated

level II cyst lined by ciliated columnar epithelium. Third or

fourth branchial anomalies were defined by level III or level

IV neck inflammation, thyroid involvement, and/or a pit in

the ipsilateral piriform sinus. In all cases, diagnosis of bran-

chial cleft anomaly was confirmed by review of final

pathology reports.

Data were collected regarding demographic characteris-

tics, presenting signs and symptoms, procedures performed,

and treatment outcomes. Clinical records of children with

first and second BCAs were reviewed with attention to oto-

logic manifestations of disease.

Statistical Analysis

Univariate analyses were carried out to obtain descriptive

statistics such as means, confidence intervals, and frequen-

cies for both groups. To make comparisons between the

groups, we performed inferential testing using one-way

analysis of variance. Risk estimates were obtained through

calculation of risk ratios using Fishers exact test. P \ .05was considered statistically significant. Stata 13.1 (StataCorp,

College Station, Texas) statistical software was used for all

analyses.

Results

Review identified 126 patients with BCAs. Of these, 27

(21.4%) had first BCAs, 80 (63.4%) had second BCAs, and

19 (15.1%) had third or fourth branchial anomalies.

Clinical characteristics and presenting symptoms of the sub-

jects are summarized in Table 1. Subjects with first BCAswere more likely to be female (63%) and to have left-sided

lesions (63%). Patients with second BCAs were more likely to

have right-sided lesions (63.7%), while patients with third or

fourth BCAs had predominantly left-sided lesions (89.5%).

While most children were correctly diagnosed with BCA,

chart review also identified a subgroup of patients who did

not have BCA but rather the more commonly encountered

entity of preauricular pits. These children most commonly

presented with infected pits or abscesses anterior to the

tragus or helical root; these lesions were identified on the

right, left, or bilaterally nearly in equal numbers (5 bilater-

ally, 4 on the left, and 6 on the right). Findings during surgi-

cal excision included a pit, mass, or skin tag anterior to the

tragus or helical root in all cases.

Children with first and second BCAs had similar age at

diagnosis, 2.08 years versus 1.51 years (P = .4, not signifi-

cant). In contrast, children with third or fourth BCAs were

significantly older with a mean age of 6.37 years (P \.001). Children with first BCAs most commonly presented

with otologic complaints (40.7%), while those with second

BCAs were most likely to present with draining sinus or fis-

tulae (62.5%). All children with third or fourth BCAs pre-

sented with neck mass or abscess.

Table 2 lists otologic examination findings of the sub-jects. Although a small number of patients with second

BCAs had otitis media or EAC deformity, an otologic prob-

lem was not given as the primary complaint for any of these

Table 1. Characteristics of Different Types of Branchial Cleft Anomalies.

Laterality, No. (%) Presenting Symptom, No. (%)

Type of

Anomaly No.

Age at Diagnosis,

Mean (95% CI), y

Female Sex,

No. (%) Left Right Bilateral

Draining

Pit

Neck

Abscess

Otologic

Problem

First 27 2.08 (1.07-3.08) 17 (63) 17 (63) 10 (37) 0 6 (22.2) 10 (37) 11 (40.7)

Second 80 1.51 (0.67-2.36) 34 (42.5) 24 (30) 51 (63.7) 5 (6.3) 50 (62.5) 30 (37.5) 0

Third 19 6.37 (4.12-8.62) 10 (52.6) 17 (89.5) 2 (10.5) 0 0 19 (100) 0

Abbreviation: CI, confidence interval.

Shinn et al 507


patients. In contrast, patients with first BCAs had a variety of

otologic complications, ranging from EAC cyst to cholestea-

toma. Even if not the presenting complaint, the presence of

otitis media was noted from clinical examination records.

Seven of 27 children with first BCAs and 3 of 80 children

with second BCAs were noted to have otitis media (relative

risk [RR], 2.8; 95% confidence interval [CI], 1.6-4.7; P =

.006). Among the 7 children with first BCAs who had otitis, 4

had a history of acute otitis media, while 3 had a history of

chronic otitis media with effusion. None had TM perforation.

An EAC web, or abnormal connection between the

anterior-inferior or posterior-inferior canal wall and TM,

can signal the presence of a first branchial cleft anomaly; 6

of our subjects (22.2%) were discovered to have such a web

on evaluation. In addition, children with first BCAs dis-

played a range of other EAC deformities: 5 (18.5%) had an

EAC mass or cyst, while 5 (18.5%) had EAC duplication.

In comparison, 3 (3%) of the children with second BCAs

displayed EAC deformities, which were associated with

hemifacial microsomia or Down syndrome.

Table 3 contains a comparison of outcomes amongpatients with first and second BCAs. Compared with chil-

dren with second BCAs, children with first BCAs had a

greater incidence of primary incision and drainage: 16

(59.3%) vs 2 (2.5%) (RR, 3.5; 95% CI, 2.4-5; P\ .0001).

Of the 16 children with first BCAs who underwent primary

incision and drainage, 11 presented with an acute abscess,

while 5 children presented with a draining pit. After resolu-

tion of their acute infection, the children underwent primary

excision. Compared with children with second BCAs, chil-

dren with first BCAs were more likely to have persistent

disease following primary excision: 7 (25.9%) vs 2 (3.8%)

(RR, 3; 95% CI, 1.9-5; P = .0025). They were also more

likely to undergo additional surgery: 8 (29.6%) vs 3

(11.1%) (RR, 2.9; 95% CI, 1.8-4.7; P = .0025). There was

not a significant difference in rates of persistent disease

between children with first and children with third or fourth

BCAs. Of the 19 children with third or fourth BCAs, 11

(57.9%) underwent incision and drainage prior to excision,

7 (36.8%) experienced persistent disease, and 7 (36.8%)

required additional surgery.

Length of follow-up period was not significantly differ-

ent among the anomaly types. Children with first BCAs had

a mean follow-up period of 16 months (95% CI, 6-27

months), children with second BCAs had a mean follow-up

length of 8 months (95% CI, 4-12 months), and those with

third or fourth anomalies had a follow-up of 11 months

(95% CI, 1-21 months).

Table 4 describes the surgical management of the 27patients with first BCAs. Thirteen subjects (48.1%) underwent

Table 3. Comparison of Surgical Outcomes among First and Second Branchial Cleft Anomalies.

Type of Anomaly Primary I&D Persistent Disease Multiple Surgeriesa (Excluding Primary I&D)

First, No. (%) 16 (59.3) 7 (25.9) 8 (29.6)

Second, No. (%) 2 (2.5) 2 (2.5) 3 (11.1)

Relative risk (95% CI) 3.5 (2.4-5) 3 (1.9-5) 2.9 (1.8-4.7)

P value \.0001 .0025 .0025

Abbreviations: CI, confidence interval; incision and drainage.aMultiple surgeries: includes both repeat excision and treatment of complication.

Table 4. Surgical Management of Patients with First Branchial Cleft Anomalies.

Procedure(s) Performed, No. (%)

Local Excision Superficial Parotidectomy Meatoplasty/Tympanomastoidectomy

Primary excision (n = 27) 13 (48.1) 13 (48.1) 5 (18.5)

Repeat excision (n = 7) 1 (14.3) 2 (28.6) 4 (57.1)

Table 2. Otologic Examination Findings of Patients with First and Second Branchial Cleft Anomalies.

Type of

Anomaly

Otorrhea,

No. (%)

Acute Otitis

Media, No. (%)

Chronic Otitis

Media, No. (%)

Cholesteatoma,

No. (%)

EAC Web,

No. (%)

Other EAC

Deformity, No. (%)

First 6 (22.2) 4 (14.8) 3 (11.1) 4 (14.8) 6 (22.2) 13 (48.1)

Second 0 2 (2.5) 1 (1.3) 0 0 3 (3)

Abbreviation: EAC, external auditory canal.

508 OtolaryngologyHead and Neck Surgery 152(3)


superficial parotidectomy on primary excision, with 4 of these

patients also undergoing tympanoplasty or tympanomastoidect-

omy. One patient underwent tympanomastoidectomy alone

after the identification of an EAC duplication, a type of first

branchial cleft anomaly. The duplication was located superfi-

cial to the facial nerve. The remainder of children underwent

simple excision at the time of primary surgery. Among the 7

patients who required revision surgery, more than half (57.1%)

underwent otologic surgery, either tympanoplasty or tympano-

mastoidectomy. There were 9 patients (33.3%) who had Work

type II anomalies that coursed medial to the facial nerve; all

eventually required parotidectomy either at primary or repeat

excision. Of the 7 patients who required additional surgery, 6

(85.7%) had anomalies medial to the facial nerve.

Facial nerve complications were also evaluated among

the patients with first BCAs. Only 1 patient (3.7%) had con-

firmation of permanent facial nerve weakness, an adolescent

who presented to our facility with facial nerve palsy after

undergoing multiple procedures at outside facilities. In addi-

tion, 3 patients (11.1%) developed temporary weakness of

the marginal mandibular nerve that completely resolved,

while 2 (7.4%) patients experienced weakness of unknown

duration due to loss to follow-up. Among the 5 cases that

occurred at our institution, the first branchial cleft anomaly

was identified medial to the facial nerve during the excision

procedure.

Discussion

Children with first BCAs often undergo multiple procedures

to treat infectious complications and ultimately remove

these lesions. In the current study, more than half of the

children were treated with incision and drainage prior to

excision, and over a quarter required repeated excision pro-

cedures. Risk of persistent disease and repeat surgery were

much higher for these children than for children with

second BCAs. This indicates that the diagnosis of first BCA

may not be recognized until the anomaly is infected and

requires incision and drainage. Interestingly, our findings

suggest that children with third or fourth branchial anoma-

lies also have high rates of persistent disease, which is con-

sistent with previously published literature11 and should be

explored further in future investigations.

Careful otologic evaluation can assist providers in

making correct diagnosis of first BCAs.12 Previous case

series have described otologic complications, including cho-

lesteatoma13; however, we were surprised by the high fre-

quency of children who presented with a primary otologic

complaint. Otologic complications were the most frequent

presenting symptoms, occurring in nearly half of the cases.

Otorrhea and otitis media were identified in about one-

fourth of the cases, and 15% of patients were found to have

cholesteatoma. Seven children with first BCAs had otitis

media, of whom 4 had a history of acute otitis media and 3

had a history of chronic otitis media with effusion. None of

these children had tympanic membrane perforation. In addi-

tion, more than half of the patients were noted to have an

EAC anatomical deformity.

Perhaps the most complicated case encountered was a 2-

year-old male who presented with a left level II neck abscess

and purulent otorrhea. The patient was ultimately diagnosed

with both Work type I and Work type II anomalies. During

the childs initial incision and drainage procedure, pressure

on the neck abscess resulted in copious expression of pus

from the ear canal (Figure 1), confirming the diagnosis of aWork type II anomaly. After antibiotic therapy, the patient

had persistent erythema and drainage at the original incision

site and in the postlobular crease (Figure 2). Otoscopyrevealed both anterior-inferior and posterior-inferior TM

webs along with some persistent granulation at the anterior

inferior sulcus (Figure 3). The 2 first branchial anomalieswere then excised via a superficial parotidectomy approach

with facial nerve dissection (Figure 4). The proximal cartila-ginous portion of the main fistula, which ran deep to the

facial nerve, was shaved off at the bony cartilaginous junc-

tion of the anterior ear canal. The patient experienced con-

tinued wound infection at the incision area directly inferior

to the lobule. Cultures grew Pseudomonas, indicating a

likely continued connection to the ear canal or middle ear.

Otoscopy demonstrated a persistent area of granulation at

the point of origin of the anterior web at the anterior

sulcus. A tympanoplasty was performed with excision of

the anterior-inferior TM, curettage of the pit at the anterior

sulcus, and reconstruction with fascia. The infection

resolved, and the ear canal and tympanic membrane healed

(Figure 5). This is a rare case of 2 first branchial anoma-lies in 1 patient and emphasizes the point that Work type

II fistulae can present at a young age with a sinus tract

running deep to the facial nerve. Failure to adequately

address the otologic component of the lesion can result in

persistent infection, as was the case for this patient.

The approach to a child with a first branchial cleft anom-

aly lies in accurate diagnosis; Figure 6 contains a potentialalgorithm for management. First anomalies should be among

Figure 1. Left level II cervical abscess. Application of pressure pro-duces otorrhea.

Shinn et al 509


the differential diagnoses considered when children present

with a pit or inflammatory response in neck level I, high in

level IIa/IIb, on the face, or in the postauricular area. A thor-

ough otoscopic examination is indicated, with the use of

binocular microscopy if available. The examiner should look

specifically for a canal web, granulation tissue, or middle ear

disease. Evidence of purulent expression from the ear with

simultaneous pressure on the neck or infected lesion indicates

a communication between the lesion and the EAC. Imaging,

either with contrast computed tomography (CT) or magnetic

resonance imaging (MRI), can help clarify the diagnosis. If a

child presents with acute infection, incision and drainage and

antibiotics are indicated prior to definitive excision.

When deciding the optimal approach for primary exci-

sion, patients who present with a pit or abscess anterior to

the angle of mandible, at cervical level I or II, are more

likely to have an anomaly deep or medial to the facial nerve

(Work type II). In our study, all of these patients required

parotidectomy, and many required otologic surgery. If there

is any suspicion of Work type II anomaly, then imaging

should be performed to assist with operative planning and

to determine where the tract lies in relation to the facial

nerve. A parotidectomy approach with preliminary identifi-

cation of the facial nerve and excision of the entire tract is

indicated. Concurrent tympanoplasty or canalplasty should

be performed if a connection between the superficial skin

and EAC or TM is seen or if a cyst involves the external

ear. Facial nerve monitoring should be considered in all

cases. In the current study, all patients with facial nerve

weakness had a Work type II anomaly medial to the nerve.

If the child has a Work type I anomaly, indicated by a

pit or cyst around the lobule, then imaging may not be

Figure 4. Parotidectomy approach. Ruptured abscess and earcanal duplication (*) are delivered from a location medial to thefacial nerve trunk, which is elongated. The anomaly is then excisedfrom the anterior ear canal.

Figure 5. Otoscopy after tympanoplasty showing healing of ante-rior ear drum and ear canal. Posterior web remains. Umbo indi-cated by (*).

Figure 3. Otoscopy showing anterior inferior granulation (*) andanterior (#) and posterior ($) webs.

Figure 2. Left level II incision and drainage site as a sign of Worktype II anomaly; persistent postlobule infection as evidence ofWork type I anomaly.



required, although preferences will likely be institution spe-

cific. Surgical excision of the tract, superficial to the facial

nerve, is performed with a mini-facelift incision behind

the tragus and around the lobule with facial nerve monitor-

ing. If there is a visible connection or cyst on the tympanic

membrane or external auditory canal, then concurrent tym-

panoplasty or canalplasty should be performed.

Children with preauricular pits may be misdiagnosed as

having a first BCA; however, we found these children to

always present with a lesion near the helical root. These

children most commonly presented with infected pits or

abscesses and were identified on the right, left, or bilaterally

nearly in equal numbers. Preauricular pits are a distinct

diagnosis and should not be confused with BCA. They

occur anterior to the tragus or helical root, often become

infected, and do not involve the facial nerve. Imaging prior

to surgical excision is often not necessary.

As a retrospective study, this investigation has a number

of limitations, including incomplete records, loss to follow-

up, and potential misclassification of anomaly type.

However, the large difference in persistent disease between

first and second BCAs strongly suggests that there is a need

for improvement in surgical management of first BCAs.

Misdiagnosis and inadequate treatment of first BCAs

have the potential to result in recurrent infection, scarring

due to multiple procedures, and facial nerve injury. For chil-

dren with chronic or recurrent upper neck infections,

especially in the setting of ipsilateral ear disease, providers

should strongly consider the possibility that the subject may

have a first branchial cleft anomaly. Children with anoma-

lies that occur medial to the nerve are especially at risk for

persistent disease. Preoperative imaging should be per-

formed to define this relationship, so that families can be

counseled appropriately. If otologic involvement is sus-

pected, then it should be addressed with otologic surgery at

the time of primary excision if possible.

Conclusion

First BCAs are associated with a wide range of otologic

manifestations. These children, particularly those with Work

type II lesions medial to the facial nerve, experience a rela-

tively high frequency of persistent disease, and otologic sur-

gery may be required for definitive surgical management.

Acknowledgment

We thank Rose Jones-Goodrich, clinical research associate, for

administrative support of this project.

Author Contributions

Justin R. Shinn, study design, data collection, manuscript prepara-

tion; Patricia L. Purcell, study design, data analysis, manuscript

revision; David L. Horn, data collection, manuscript revision;

Kathleen C. Y. Sie, data collection, manuscript revision; Scott C.

Figure 6. Algorithm for management of first branchial cleft anomalies. BCA, branchial cleft anomaly; CT, computed tomography; MRI, mag-netic resonance imaging.

Shinn et al 511


Manning, study conceptualization, study design, data collection,

manuscript preparation and revision.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: Patricia L. Purcell is completing a research fel-

lowship supported by grant 2T32DC000018, the Institutional

National Research Service Award for Research Training in

Otolaryngology from the National Institute on Deafness and Other

Communication Disorders.

References

1. Al-Khateeb TH, Al Zoubi F. Congenital neck masses: a

descriptive retrospective study of 252 cases. J Oral Maxillofac

Surg. 2007;65:2242-2247.

2. LaRiviere CA, Waldhausen JH. Congenital cervical cysts,

sinuses, and fistulae in pediatric surgery. Surg Clin North Am.

2012;92:583-597, viii.

3. Bajaj Y, Ifeacho S, Tweedie D, et al. Branchial anomalies in

children. Int J Pediatr Otorhinolaryngol. 2011;75:1020-1023.

4. Chen EY, Inglis AF, Ou H, et al. Endoscopic electrocauteriza-

tion of pyriform fossa sinus tracts as definitive treatment. Int J

Pediatr Otorhinolaryngol. 2009;73:1151-1156.

5. Schroeder JW Jr, Mohyuddin N, Maddalozzo J. Branchial

anomalies in the pediatric population. Otolaryngol Head Neck

Surg. 2007;137:289-295.

6. Triglia JM, Nicollas R, Ducroz V, Koltai PJ, Garabedian EN.

First branchial cleft anomalies: a study of 39 cases and a review

of the literature. Arch Otolaryngol Head Neck Surg. 1998;124:

291-295.

7. Guo YX, Guo CB. Relation between a first branchial cleft

anomaly and the facial nerve. Br J Oral Maxillofac Surg.

2012;50:259-263.

8. Work WP. Newer concepts of first branchial cleft defects.

Laryngoscope. 1972;82:1581-1593.

9. Olsen KD, Maragos NE, Weiland LH. First branchial cleft

anomalies. Laryngoscope. 1980;90:423-436.

10. Waldhausen JH. Branchial cleft and arch anomalies in chil-

dren. Semin Pediatr Surg. 2006;15:64-69.

11. Madana J, Yolmo D, Kalaiarasi R, Gopalakrishnan S, Saxena

SK, Krishnapriya S. Recurrent neck infection with branchial

arch fistula in children. Int J Pediatr Otorhinolaryngol. 2011;

75:1181-1185.

12. Tom LW, Kenealy JF, Torsiglieri AJ Jr.First branchial cleft

anomalies involving the tympanic membrane and middle ear.

Otolaryngol Head Neck Surg. 1991;105:473-477.

13. Nicollas R, Tardivet L, Bourlie`re-Najean B, Sudre-Levillain I,

Triglia JM. Unusual association of congenital middle ear cho-

lesteatoma and first branchial cleft anomaly: management and

embryological concepts. Int J Pediatr Otorhinolaryngol. 2005;

69:279-282.



First Branchial Cleft Anomalies Otologic Manifestations and Treatment Outcomes

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