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Background Fourth branchial apparatus anomalies, are rare clinical entities, and present as complex cysts, sinuses and fistulae in the neck that can be difficult to manage. Methods This is a retrospective review of a series of consecutive patients with fourth branchial apparatus anomalies treated at Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from Apr 2014 to Nov 2019. Results Ten patients with fourth branchial apparatus anomalies were identified, including 8 patients with fourth branchial fistula, and 2 patients with fourth branchial pouch sinus. There were 6 female patients and 4 male patients. Their age was from 6 years old to 39 years old (average age 20.4 years old, median age was 21 years old). All 8 fistulae were on the left side, while 2 pouch sinuses were both on the right side. Pre-operative examination with fiberoptic laryngoscope, barium swallow X-ray, CT or MRI identified internal orifice at pyriform fossa apex in 8 (80%) patients. All patients underwent challenging surgical resection by the senior author. Intra-operative direct laryngoscope confirmed or identified internal orifice in 9 (90%) patients. The tracts were all followed to the vicinity of inferior cornu of the thyroid cartilage and the cricothyroid space. Complete resection of cervical lesions and their attachment to hypopharynx were achieved in 9 cases. No complication occurred. One recurrence was detected, in the only patient whose internal orifice could not be located pre- or intra-operatively, and the hypopharyngeal attachment could not be removed. Conclusions Direct laryngoscopy under general anesthesia is a reliable method of diagnosis for the fourth branchial apparatus anomalies. Complete surgical removal of fourth branchial apparatus anomalies, including their hypopharyngeal attachment, is the treatment of choice, and the key to prevent recurrence.

Recurrent neck abscess is a typical feature of branchial anomaly. Open surgical excision has been the primary treatment modality for past decades however several alternative treatment modalities such as endoscopic electrocauterization has recently gained popularity and acceptance universally. This series aims to introduce endoscopic assessment as the first line diagnostic and therapeutic management for branchial fistula. 5 patients underwent examination under general anesthesia via direct laryngoscopy, endoscopic assessment and cauterization in our centre from 2016 to 2019. They were then followed up at our clinic to assess disease progression. Comparison between open neck surgery and endoscopic cauterization of internal sinus tract opening as the primary treatment has reported similar recurrence rate. Proposal of endoscopic assessment as the first line investigation and diagnostic tool with the aim of therapeutic cauterization at the same setting. MRI may be needed in scenarios such as failed endoscopic treatment or when open surgery is required.

We report the clinical presentation and CT and MR imaging findings in a child with an unusual first branchial apparatus fistula that extends from the external auditory canal to the oropharynx.

Branchial arch and cleft anomalies are congenital malformation of the first, second, third and fourth branchial arch and most frequently present as cysts, sinuses or fistulae in the auricular, mandibular or cervical areas. Good knowledge of embryological development helps to understand the anatomy and relationships of branchial anomalies with surrounding structures, especially the laryngeal nerves (superior and recurrent) and vascular structures. Diagnostic work up includes a good physical exam, ultrasonographical evaluation as well as MRI for cross-sectional imaging in more complicated cases. Fistulogram and endoscopy can also be helpful, especially in third and fourth branchial cleft anomalies. Surgical excision is usually the treatment of choice, on an elective basis. If the cervical cyst, sinus or fistula are infected, incision and drainage and antibiotic treatment are recommended, followed by elective excision when the inflammation has resolved.

Branchial fistulas are uncommon in the clinical setting. The coexistence of first and second branchial fistulas has not been previously reported. We herein describe a 12-year-old girl who presented with a 2-year history of repeated swelling and purulence behind the right earlobe and neck. According to the patient’s physical and auxiliary examination findings, she was diagnosed with coexisting first and second branchial fistulas, both of which were completely removed by surgery. No clinical signs of fistula recurrence were present at the patient’s 20-month postoperative follow-up. Ipsilateral coexisting first and second branchial fistulas are very rare; thus, a false-positive diagnosis can easily occur if the doctor does not carefully perform specialized physical examinations. Surgery is an effective method for treating this condition. Adequate preoperative imaging preparation is imperative to ensure the most effective course of treatment. The purpose of this article is to improve clinicians’ awareness of this disease, thereby effectively reducing the rates of missed diagnosis and recurrence.

We report a case of complete branchial fistula in a 13-year-old boy which could be evaluated by a contrast study. The tract was completely excised and the patient had an uneventful recovery. Branchial fistulae are formed due to the persistence of the embryonic second branchial cleft. Complete fistulae with the internal opening in the region of the tonsillar fossa are not common and should be properly evaluated before going to surgical exploration.TAJ 2011; 24(2): 145-147

Type 2 branchial cleft anomalies are the most common cause of lateral neck swelling. We report two cases of type 2 branchial cleft anomalies. The first case is branchial cleft cyst and the second one is branchial fistula. Both cases were managed surgically. The post operative outcomes were uneventful. Second branchial cleft anomalies are the most common branchial anomalies. Branchial cysts are more common than sinuses and branchial fistulae are extremely rare. There is no gender predilection. The location, clinical symptoms and imaging findings aid in the diagnosis of this condition. Surgical excision is the mainstay of treatment.Keywords: branchial cleft; branchial cyst; branchial fistula.

Objective To evaluate the efficacy of CO 2 laser cauterization with suspension microlaryngoscopy as a definitive surgical treatment for pediatric Congenital Pyriform Sinus Fistula (CPSF). Material and methods This is a cohort retrospective study. Thyroid function and cervical ultrasonography examinations were performed before operation. Enhanced magnetic resonance imaging (MRI) was performed on patients with a repeated infection (≥2 times) and/or if they had a prior open surgery. Patients were divided into two groups: the Results CO 2 laser cauterizations with suspension microlaryngoscopy were performed for 104 CPSF patients. No complications occurred. Three patients had a recurrence in the follow-up. The number of surgical cauterization operations was fewer than 3 in 85.1% of the patients. There was no significant difference in the number of cauterizations among the different age groups or between the initial treatment and retreatment groups ( P >0.05). Conclusion CO 2 laser cauterization with suspension microlaryngoscopy is a safe, effective, and minimally invasive approach to CPSF with optimal patient outcomes. Type of study Treatment Study. Level of evidence Level III.

Congenital pyriform sinus fistula is a very rare branchial apparatus malformation. Conventional open surgery for fistulectomy might fail to excise the lesion completely, leading to continual recurrence. The aim of this study was to provide an innovative endoscopic coblation technique for patients with pyriform sinus fistula and evaluate its intermediate-term effectiveness.Retrospective case series with 112 patients (age range 3-36 years) between 2013 and 2016 and underwent endoscopic coblation of the sinus fistula. Data collected including patient demographics, presenting symptoms, diagnostic methods, prior and subsequent treatments, length of hospital stay, and recurrence were analyzed.Of the 112 cases, there were no postoperative complications observed except temporary reddish swelling in three patients. Four cases were lost to follow-up. Of 108 patients, 106 experienced no recurrence after their first endoscopic coblation of the sinus tract. The remaining two patients with recurrence in the follow-up were ultimately treated with recoblation without complications or further recurrences. Also, Endoscopic coblation can be used to treat seven patients with recurrence who had experienced open resection. In our series, median follow-up period was 1.5 years.Endoscopic coblation is an effective approach for most patients. We advocate using this minimally invasive technique as first line of treatment for pyriform sinus fistula.

Branchial arch anomalies are one of the most common congenital anomalies and are usually unilateral in nature. The bilateral occurrence of more than one anomaly is not only rare, but its presence along with hearing loss results in branchiootic syndrome, which has important clinical and genetic implications. Branchiootic syndrome is a part of the spectrum of branchiootorenal syndrome, which is a rare autosomal dominant condition with incomplete penetrance characterized by the malformations of the external, middle, and inner ear, hearing loss, branchial fistulae, and renal abnormalities. We shall be discussing two such rare cases in this article.

Branchio-oto-renal syndrome (BOR), also known as Melnick-Fraser Syndrome, is an autosomal dominant genetic disorder resulting from a mutation of the EYA-1 gene and characterized by branchial cysts or fistulas, ear anomalies, hearing loss, agenesis or hypoplasia of the kidneys, and chronic renal disease. We describe a unique surgical case of a branchial cleft fistula excision and concurrent ipsilateral cochlear implantation in a pediatric patient with BOR. A 2-year-old female presented with a right draining second branchial cleft fistula and severe bilateral profound sensorineural hearing loss due to bilateral cochlear dysplasia and cochlear nerve hypoplasia. She had previously undergone a left cochlear implant and was diagnosed with BOR. Her parents were interested in a sequential right cochlear implant as she was demonstrating excellent function with her left implant. A computed tomography fistulogram with an injection of contrast dye into the external orifice of the draining structure revealed a fistula connecting the small pit in the right lateral neck to the area of the tonsillar fossa in the oropharynx suggesting the presence of a second branchial cleft anomaly. She underwent simultaneous tonsillectomy, right branchial fistula excision, and right cochlear implant surgery under one exposure to general anesthesia. This is a unique case where special consideration must be taken with the order of procedures, consolidation or separation of the surgeries, and the use of monopolar cautery.

Ninety-four patients with second branchial anomalies were retrospectively analysed at a tertiary care centre from January 2006 to September 2016 to determine the demographical data and management. Branchial sinus and fistula presented earlier as compared to branchial cyst. The mean age at presentation in case of branchial sinuses, fistulae and cysts was 5.07, 5.79 and 7.31 years respectively. There was preponderance in males as compared to females, more so in bilateral cases. Male to female sex ratio was 2.91:1. The branchial fistulae were the most common type of lesions, followed by the branchial sinuses. The branchial anomalies were more on the right side (65.96%) probably due to right handedness of the population. Only eight patients (8.51%) had bilateral anomalies. Four patients had familial association, it was seen in bilateral cases and they presented earlier than unilateral cases. Early and complete surgical excision is the treatment of choice. Preoperative sinogram/fistulogram and intraoperative methylene blue dye injection is not mandatory for excision of a branchial sinus/fistula. Post-operative wound infection was the most common complication (4.25%).

Background Neonatal and infantile fistulas are diverse and include many types. Conventional contrast images are used to delineate the fistulous tracts. The aim of this study is to illustrate the conventional radiological spectrum of neonatal and infantile fistula with surgical correlation. Methods Neonates and infants with suspected fistulas were included in this study. The patients may be presented by cutaneous fistula with discharge, profuse oral secretion and cyanosis on feeding, or imperforate anus. After full clinical data were taken, plain X-ray, contrast imaging, and abdominal sonography were done to the patients. Treatment was tailored according to the case. Results Our study included 34 patients (25 boys and 9 girls): one case of branchial fistula; 2 cases with thyroglossal fistula; 10 cases of tracheo-esophageal, esophago-cutaneous, and esophago-pleural fistulas; 3 cases with vitello-intestinal fistula; one case with urachal fistula; 12 cases with recto-urinary, recto-vaginal, and recto-perineal fistula; 4 cases with peri-anal fistulas; and finally one case with iatrogenic urethra-cutaneous fistula. Radiological findings were well correlated with the surgical data. Conclusion Many types of neonatal and infantile fistulas were shown in this series including tracheo-esophageal, recto-urinary, and other neonatal fistulas. Radiological and surgical data were well matched.

Branchio-oto-renal (BOR) syndrome is an autosomal dominant disorder characterized by the coexistence of branchial cysts or fistulae, external ear malformation with pre-auricular pits or tags, hearing impairment and renal malformations. However, the presence of the main features varies in affected families. Here, we present a 16-year-old boy admitted to the Department of Nephrology at the Pediatric Clinic, University Clinical Center of Kosovo, Pristina, Republic of Kosovo because of severe renal insufficiency diagnosed 6 years ago, which progressed to end-stage renal failure. Clinical examination on readmission showed a pale, lethargic and edematous child, with auricular deformity, pre-auricular tags and pits as well as bilateral branchial fistulae. Laboratory tests revealed high blood urea nitrogen (BUN) 15.96 mmol/L and serum creatinine 633.0 µmol/L; low glomerular filtration rate (GFR) 12 mL/min./ 1.73 m2 and massive proteinuria 4+. Abdominal ultrasound showed bilateral kidney hypoplasia. A novel mutation of the EYA1 gene was confirmed. Daily hemodialysis is continuing until renal transplantation is done. This case is presented to increase awareness among general practitioners to consider BOR syndrome or other renal abnormalities in patients with branchial fistula and/ or external ear anomalies or similar findings in other family members.

Objectives/Hypothesis We present a new method of optimizing the results of surgery for branchial cleft anomalies based on the intraoperative injection of fibrin glue combined with methylene blue dye. Study Design Retrospective single-center cohort study. Methods The method was applied in 17 patients suffering from branchial anomalies. Six (35.29%) had a preauricular lesion; three (17.65%) had lesions derived from the first arch/pouch/groove (type I), four (23.53%) had lesions derived from the first (type II), one (5.88%) had lesions derived from the second, one (5.88%) had lesions derived from the third, and two (11.76%) had lesions derived from the fourth. The median and mean age at surgery were 10 and 10.6 years, respectively. All patients were followed by periodic clinical and ultrasonographic examination. Results The combination of fibrin glue with methylene blue facilitated the correct assessment of the extension of the lesions and their intraoperative manipulation. After a mean follow-up of 47.8 months, all patients were free of disease. Conclusions Intraoperative injection of branchial fistulae and cysts by a mixture of fibrin glue and methylene blue is an effective, easy, and safe tool to track lesions and achieve radical resection. The technique requires a definitive validation on a large cohort with adequate stratification of patients. Level of Evidence 4 Laryngoscope, 2015

Fourth branchial pouch anomalies represent one of the rarest types of all branchial apparatus anomalies. They appear in the first lifedecade in a form of recurrent left-sided neck masses which demands surgical treatment. Accidental finding, appearance later in life and spontaneous resolving are really rare. We present a case of a 43-year- old man with accidental finding of asymptomatic fourth pouch cyst and fistula following follicular thyroid cancer surgery. The day after the surgery, suction bottle was filled with little white crumbs and the wound started to suppurate. Barium swallow revealed the presence of a fistulous canal that arose from the left pyriform sinus. Meanwhile, the pathologist confirmed the presence of a lateral neck cyst within this thyroid lobe. The patient was operated on but fistulous canal was not visualized. In the meantime, wound discharge ceased spontaneously. At 1-year follow up, the patient was still well and free from any symptoms. These anomalies may manifest not only in childhood but may stay asymptomatic for a long time. It seems that the fistula can resolve spontaneously and that conservative approach is an alternative to multiple surgical procedures.

Branchial arch anomalies are the most common congenital neck masses. The second branchial arch anomalies followed by first arch anomalies are seen commonly in the descending order. They originate from remnants of branchial arches and clefts. They may present as cysts, sinus tracts, fistulae or cartilaginous remnants. They are mostly located in the lateral aspect of the neck anterior to the sternocleidomastoid, anterior to the hyoid bone, preauricular region or at the angle of the mandible. A complete fistula communicating with a branchial arch cyst is a very rare congenital anomaly of the branchial apparatus. These patients are generally asymptomatic but may present with mucoid discharge from the tract. Here we present a case of branchial fistula associated with a branchial cyst in a 11 year old child.

IntroductionComplete branchial fistulae are rare anomalies of the branchial cleft apparatus. Incomplete fistulae occur more commonly and may be completely asymptomatic. They are often neglected as they do not lead to recurrent infection, while complete branchial fistula have persistent symptom of discharge. The branchial fistula very rarely has two openings. Usually, a thin membrane covering the internal opening is present even if both ends are patent. Demonstration of a complete branchial fistula on imaging studies is also very uncommon. This is a study of five cases of complete second branchial fistulae, which were diagnosed and treated surgically in a tertiary care teaching hospital over a period of 3 years. The case study also make special emphasis on preoperative imaging for the confirmation of diagnosis and for appropriate surgical approach for complete excision of fistulous tract in order to minimize the recurrence as the revision second-look surgery in neck region is usually difficult.How to cite this articleBist SS, Purohit K, Agarwal V, Bharti B, Monga U. Complete Second Branchial Fistula: Diagnostic Imaging and Surgical Aspects. Int J Otorhinolaryngol Clin 2016;8(1):6-10.

IntroductionBranchial arch fistula which results from a second arch anomaly is rarely seen in practice. The patients usually seek medical advice for persistent discharge from an opening in the neck or mucopurulent discharge from the opening of an infected fistulous tract. The treatment of choice for such a fistula is excision. Materials and MethodsA total of seven patients were operated for branchial fistula between 2010 and 2012. Among them, three children could not undergo a fistulogram due to allergy to the dye used and hence they were selected for our modified procedure. Surgical ProcedureA 3-0 or 4-0 polypropylene (Prolene™) thread was inserted into the fistulous tract. Both the ends of the tract were secured with the thread and the sinus tract was dissected out under gentle traction. ResultsThe patients who were allergic to dye could not have preoperative fistulograms and per-operative injection of dye was also avoided. The blue colour of the polypropylene thread inserted in the fistula tract helped in tracing and excision of the sinus tract. No major complications occurred during or after fistulectomy and the post-operative recovery was uneventful. No recurrence was seen in the scheduled follow-ups. ConclusionSurgical excision of branchial fistulas in children with allergy to dyes can be challenging. Insertion of a polypropylene thread into the fistula tract makes its subsequent dissection easy with minimal disruption of adjacent structures.

Sialoliths greater than 10 mm in size can be called as those of an unusual size. Only 7.65 % of the sialoliths are >15 mm. Cutaneous fistulas due to submandibular sialoliths are even rarer. A case of a submandibular gland sialolith of an unusual size presenting with a cervical fistula mimicking a branchial fistula has been reported. Intra-operatively, the fistulous tract was found to extend upto the supraclavicular space. Complete excision of the gland along with fistulous tract was performed. Histopathology revealed a sialolith with acute and chronic sialedinitis. The lesion also mimicked a Kuttnor's tumour however a final diagnosis of the same could not be made due to inconclusive Ig G value and absence of plasmacytic infiltration.

Patient years male A year old boy presented with the complaints of watery discharge from an opening in the right hand side of neck on and off since birth There was no history of trauma or operation nbsp

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. Fourth branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral pyriform fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. We present the clinical presentation and surgical management of a fourth branchial cleft fistula, in a 23-year-old male. Preoperative CECT fistulogram of the neck clearly demonstrated the fistula. Patient was managed using combined stepladder transcervical and intra

Congenital anomalies of the branchial arches are well known with fistulas presenting in the head and neck region. A proper diagnosis of this uncommon entity is mandatory for a successful surgical repair in the first attempt itself. In this case report, we profile a patient who was subjected to multiple surgeries only to result in subsequent breakdowns and resurfacing of symptoms. An innovative attempt was made with the use of endoscopes and minimally invasive surgical methods to repair this recurrent fistula and followed up with a repeat fistulogram which showed a complete closure of the tract without any co-morbidity.

Branchial cleft anomalies comprise approximately 30% of congenital neck mass and present as cyst, sinus or fistula. They occur due to disturbance in the maturation of the branchial apparatus during fetal development. They are congenital lesions usually present in childhood, but they are usually diagnosed in later childhood or early adulthood because of enlargement or infection. Branchial cleft fistulae are usually diagnosed earlier than cysts. Correct diagnosis leads to proper management. Complete surgical excision is the treatment of choice. Second branchial cleft and pouch anomalies are commonest amongst all branchial cleft lesions, but complete second branchial cleft anomalies with external and internal opening is rare. Branchial anomalies with family history are also very rare. Here we present a case report of complete branchial fistula with family history which was managed by complete excision of fistula through transcervical and transoral approaches. 3 members of one family in 2 generations presented with branchial apparatus anomalies (father and his two children, elder son and younger daughter). All of them were having branchial fistula on right side of neck since birth.

Although 2(nd) Branchial arch fistulae (from incomplete closure of Cervical sinus of His) are well known, 1(st) arch fistulae are much rarer (

Thyroglossal duct cysts followed by branchial cleft anomalies are the most common congenital neck masses encountered in practice, second branchial cleft cysts and sinuses are the most common type (LaRiviere and Waldhausen in Surg Clin North Am 92(3):583-597, 2012). Although both abnormalities are common individually, but rarely seen associated in same patient as described in our case. Congenitalcervical anomalies are important to consider in the differential of head and neck masses in children and adults. These lesions can present as palpable cystic masses, infected masses, draining sinuses, or fistulae. Thyroglossal duct cysts are most common, followed by branchial cleft anomalies. A synchronous presentation of both type of cyst and fistula in a same child patient is very rare with no such cases reported in literature till date.

An eight year old female was admitted via OPD with bilateral discharging sinuses. The ostium of the sinuses were at the anterior border of clavicular attachment of sternomastoid. There was H/O off and on whitish discharge, mucoid in consistency coming out from these external openings since last 6 years. It was not associated with any other complaint. There was no H/O respiratory infections, abscess formation, thyroiditis or swallowing difficulties associated with this. According to the location of external openings diagnosis of bilateral III pouch branchial fistula was made. Routine lab investigations showed normal profile. Fistulogram was attempted which was unsuccessful. Both the fistulous tracts were explored under general anaesthesia. The fistulous tract on left side was more developed as compared to the right. The left tract was extending upto the pyriform fossa and the right tract extended upto thyrohyoid membrane. Both tracts were completely excised. Postoperative recovery was uneventful. Clear liquids were permitted on the same day. Patient was discharged on second postoperative day and stitches were removed on fifth postoperative day. There were no complications on subsequent follow up for three months.

Branchial cleft anomalies result from abnormal persistence of branchial apparatus, which is located at the lateral part of the neck. These occur due to failure of obliteration of the branchial apparatus during embryonic development. Differential diagnoses of lateral neck mass are salivary gland or neurogenic neoplasms, paragangliomas, adenopathies, cystic hygroma or cystic metastasis from squamous cell carcinoma or thyroid papillary carcinoma. Clinically, a branchial cyst is smooth, round, fluctuant and non-tender, and usually occurs over the upper part of the neck, anterior to the sternocleidomastoid muscle. Sometimes, it may present as infected cyst (or abscess), a sinus or fistula. Surgical excision is the definitive treatment for branchial anomalies. The objective of the work was to study the demographic data, clinical presentation, definite diagnostic workup and treatment of patients diagnosed with branchial anomalies. This is a retrospective study of 26 patients who were diagnosed with branchial anomalies (branchial cyst and fistula), of which only 12 patients had data available between July 1999 and June 2009 at the Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre. Twelve cases of branchial anomalies were seen, in which 10 patients had second branchial cyst anomalies, 1 had third branchial fistula and 1 had bilateral branchial lesion. There were seven females and five males. The age of the patients varied over a wide range (4-44 years), but the majority of the patients were in their second and third decade of life. All branchial anomalies occurred at the classical site; eight patients had left-sided neck lesion. Correct clinical diagnosis was made only in five patients (41.6 %). All patients underwent surgical excision with no reported recurrence. Branchial anomalies are frequently forgotten in the differential diagnosis of lateral neck swelling. Diagnosis is usually delayed, leading to improper treatment. The diagnosis of patients who present with lateral neck cystic swelling with or without episodes of recurrent neck abscess should be considered with a high suspicion for branchial anomalies. FNA cytology is a good investigative tool in reaching toward a diagnosis of branchial lesion, with the concurrent assistance of radiological modalities. Surgical excision is the gold standard treatment of lesions of branchial anomalies.

Third or fourth branchial pouch anomaly is rare. It usually presents as an acute inflammatory swelling of the lower neck and frequently involves the thyroid gland. Surgical treatment is essential to prevent recurrence. USG, CT scan and barium esophagography help in the diagnosis. Complete excision of tract after proper identification is necessary to prevent recurrence. How to cite this article Bose A, Sengupta A, Sherpa TD, Paul N. Fourth Branchial Fistula: Revisited. Int J Head Neck Surg 2015;6(1):26-28.

Congenital lateral cervical fistula is a branchial anomaly that is formed by the abnormal evolution of the branchial cleft. Most lateral cervical fistulas only have an external opening, so a complete lateral cervical fistula with an external and internal opening is rare. We report a case with a left complete lateral cervical fistula from the second cleft. A 9-year-old girl complained of mucal discharge from an opening in the left lower neck. A fistulography was performed to confirm the tract of the fistula, and the tract was found to end in the area of the mouth. We diagnosed the patient as having a complete fistula. The fistula was totally extirpated under general anesthesia. During the operation, two horizontal incisions were made in the neck, and an angiography guidewire was very useful as a guide. An internal opening was recognized in the middle of the posterior palatine arch. We concluded that the complete lateral cervical fistula was derived from the second branchial cleft.

Fistulae arising from the second branchial apparatus are the most common anomalies than those arising from the third and fourthbranchial apparatus. Third branchial fistula is extremely rare in occurrence.1 Complete fistulae are uncommon as in the majority of casesthe tracts end blindly. Here, we report a case of complete congenital third branchial fistula on left side of the neck with an internal openingnear left pyriform fossa in a 12-year-old male patient.

Summary Background The presence of a branchial fistula with communication both internally and externally: a ‘true' branchial fistula is rare, and may arise in the context of autosomal dominant conditions such as branchiootic syndrome and branchiootorenal syndrome. Study We discuss the case of a true branchial fistula, which recurred after initial surgical excision, in a patient with branchiootic syndrome. The residual tract was dissected in a second operation through stepladder neck incisions and removed in toto via an intraoral approach. No renal abnormalities were detected on investigation with ultrasound. Discussion Incomplete excision of a branchial sinus is likely to cause recurrence however intraoperative visualisation of the tract can can sometimes prove challenging. An combined intraoral and external approach aids delineation and tract definition when there is a true branchial fistula and can therefore facilitate a complete excision. Suspicion of an hereditary aetiology should be raised in patients with bilateral or preauricular features, or a positive family history, which may then prompt additional renal and genetic investigation.

The third arch branchial fistula is a rare congenital abnormality that presents as an inflammatory process in the anterior neck, often in the region of the left lobe of thyroid. Incomplete fistula is not an uncommon finding extending from base of pyriform sinus to the thyroid or perithyroidal space, which predisposes to recurrent suppurative thyroiditis during episodes of upper respiratory infection. Complete fistula of third arch is extremely uncommon, especially of congenital origin. A 10-year-old male child presented with a small opening in the anterior neck since birth, with a swelling around it. Computerized tomography revealed a patent tract from neck skin to base of pyriform sinus. Total excision of the tract up to the left pyriform sinus with hemithyroidectomy was performed. There was no recurrence at 22 months of follow-up.

Third branchial cleft anomalies are rare accounting for 2-8% of all branchial abnormalities. We report a case of a 9 year old boy who presented with discharging sinus on the left side of neck. A sinogram revealed third branchial arch fistula. The tract was surgically removed, however, on follow up the fistula was recurred. He was later taken for endoscopic cauterization and injection of Histoacryl (n-Butyl cyanoacrylate ) glue into the tract, after which his wound healed swiftly. Historically, surgical excision of the fistulous tract has been the mainstay of treatment. Recently, minimally invasive methods are gaining wider acclaim and may potentially become the treatment of choice in the future.

Objective:We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy.Method:A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented.Results:A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence.Conclusion:To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Objectives To report authors’ experiences in the diagnosis and treatments of congenital first branchial fistula (congenital auriculocervical fistula). Materials and Methods Twelve cases of congenital first branchial fistula were reviewed. Of these, 8 underwent fistulectomy with facial nerve dissection and partial parotidectomy and 4 underwent simple fistulectomy. Results The inner openings (upper opening) of fistulae lay in the following sites: inferioposterior wall at the junction of cartilaginous and bony segments of the auricular canal and inferior wall of cartilaginous auricular canal. The outer openings(lower opening) lay along the anterior border of upper sternocleidomastoid muscle, at the mastoid tip and posterior to the mandibular angle. Complete fistulae resection was achieved in all but one case. Eleven cases were followed for 5 year with no recurrence. Recurrence occurred in 1 case 6 months after the primary surgery and revision surgery was performed. Conclusions Pre–operative radiography for the location and course of the fistula is crucial for successful fistula resection, especially in cases with past infections. Facial nerve dissection should be done routinely for deeply located fistulae.

First branchial cleft anomalies were diagnosed in 4 patients between 2000 and 2004; 3 cases were cysts and 1 case was a fistula. It is difficult to diagnose first branchial cysts before operation. An operation is often performed as for a parotid tumor, especially Warthin tumor located in the inferior pole. Although first branchial cleft anomalies account for less than 10% of all branchial abnormalities, some cases may be misdiagnosed as parotid gland tumor. On the other hand, first branchial fistula was easy to diagnose because it was open to the external auditory canal and/or infra-auricular skin. However, since first branchial fistula are often close to facial nerves, it is necessary to perform the surgery carefully.

We describe an endoscopically assisted dissection technique for cervical branchial fistulae that prevents the need for additional ‘ladder’ incisions in the neck. Two titanium clips are placed at the internal opening of the tract under endoscopic guidance through the initial skin incision. This technique is a useful adjunct to the usual technique if difficulties are experienced obtaining access higher in the neck. It enables an excellent view of surrounding structures.

Branchial fistula is a congenital anomaly resulting from failure of closure of one of the four branchial clefts. It is usually a clinical diagnosis, but dermoscopy helps in highlighting its features, thereby avoiding the need of imaging studies and other invasive diagnostic procedures. Here, we report a case of 3-year-old female patient who presented with asymptomatic tiny papule on the neck since early childhood. Dermoscopy was done to describe the features of branchial fistula and cleft.

Purpose The aim of this study is to evaluate a minimal invasive approach in the management of fourth branchial fistula using N-butyl cyanocrylate (histoacryl) and to study its feasibility. Patients and methods Between 2006 and 2011, a retrospective study of five children with fourth branchial fistula treated at Assiut University hospital was carried out. Their age ranged from 2 to 5.5 years. Three were females. Histoacryl (adhesive material) was injected through the tract under general anesthesia. Results All the children presented with a discharging fourth branchial fistula. Three of them had a left-sided fistula. Fistulogram was carried out in all patients; two of them had a complete fistula. The duration of the procedure ranged between 10 and 15 min. No complications were noted. The duration of follow-up ranged from 2 months to 1 year. No recurrence was encountered during the period of follow-up. Conclusion Histoacryl injection of the fourth branchial fistula is an effective, easy, and minimally invasive procedure that can be carried out by junior staff. Surgery may be performed as a backup if there is failure or recurrence after injection. Keywords : branchial fistula, children, fourth branchial fistula, histoacryl

The branchial arches are the embryological precursors of the face, neck and pharynx. Second most common congenital lesions of the head and neck in children are the anomalies of the branchial arches, with second arch anomalies by far the most common. Clinically, these congenital anomalies may present as cysts, sinus tracts, fistulae or cartilaginous remnants with typical clinical and radiological findings. We report the case of 11-month-old male child with congenital Type I Second branchial fistula on the left side of neck.

Branchial apparatus develop between the 3rd and 7th weeks of embryonic life. There are 5 mesodermal arches separated by invaginations of ectoderm and endoderm. During development the second arch grows caudally to cover the third and fourth arches and the second, third, and fourth pharyngeal clefts eventually fusing with the lower neck. The enclosed II, III, and IV clefts are called as the cervical sinus. If this process does not occur for some reason then it gives rise to branchial cyst, sinus or fistula. We are presenting two cases of second branchial arch anomaly. In first case there was bilateral branchial fistula with right side fistula associated with branchial cyst. In second case there was unilateral right side branchial fistula. We operated both the cases by giving step ladder incision. In second case we find fistulous track opening in the tonsillar bed. Both the patients recovered well with no recurrence since 1 year. Brachial cleft cyst is a common cause of soft tissue swelling in the neck of a young adult. They generally occur unilaterally and are typically seen in the lateral aspect of the neck. It is clinically apparent in late childhood or early adulthood. In older adults with this presentation, it is important to exclude metastatic lymphadenopathy, lymphoma or tuberculosis.