Branchial anomalies in children

doi:10.1016/j.ijporl.2011.05.008

International Journal of Pediatric Otorhinolaryngology

Volume 75, Issue 8, August 2011, Pages 1020-1023

https://doi.org/10.1016/j.ijporl.2011.05.008 Get rights and content

Abstract

Background

Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years.

Methods

All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study.

Results

In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome.

Conclusion

Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Introduction

Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. They present as cysts, fistulas, sinuses or cartilaginous remnants. The term branchial cyst was first used by Ascherson in 1832(1). By the 4th week of embryonic life, six branchial arches are recognisable. Five pairs of ectodermal clefts (grooves) and five endodermal branchial pouches separate these six arches, with a membrane located at the interface between the pouch and the cleft [1].

Various theories proposed for the development of these anomalies are branchial apparatus theory, cervical sinus theory, thymopharyngeal theory and inclusion theory [2]. The most widely accepted theory is that they result from incomplete obliteration of branchial clefts and pouches during embryogenesis [3].

Branchial anomalies represent 20% of cervical masses in children. They are bilateral in 1% of the cases, without any predilection to right or left side in unilateral cases [4]. Amongst the branchial anomalies, second cleft lesions account for 95%. First cleft anomalies account for 1–4% of these and third and fourth pouch anomalies are rare [5]. This article analyzes all the cases of branchial anomalies operated on at Great Ormond Street Hospital over the past 10 years.

Section snippets

Patients and methods

This study was conducted at the paediatric ENT department at Great Ormond Street Hospital, London, a tertiary paediatric referral centre. All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study.

The data were collected from patient records. The data collected included patients demographics, type of branchial anomaly as recorded by operating surgeon, operative details and their post operative course. Also recorded were

Results

In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, the branchial anomalies according to the type were 15 first cleft, 62 second cleft and 3 fourth pouch branchial anomalies.

In the subgroup of 15 children (8 male and 7 female) with first branchial anomalies, the anomalies were on the right side in eight cases and left side in six cases. Seven of these patients had recurrent infections in the past and

Discussion

Various terms have been used in the literature to describe branchial anomalies. There are some important definitions which need to be clarified. A sinus is a blind ending tract. Sinuses arising from the branchial apparatus may connect with either the skin or the pharynx. Those connecting to skin are termed branchial cleft sinuses and those connecting with the pharynx are termed branchial pouch sinuses [6]. Fistula, by definition is a communication between two epitheliazed surfaces. A congenital

Conclusions

Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the suspected arch of origin of the anomaly. Definitive excision is essential for good outcomes.

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Branchial anomalies in children

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

Semin. Pediatr. Surg.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Am. J. Otolaryngol.

Management of second branchial cleft anomalies

Rom. J. Morphol. Embryol.

Branchial cleft cysts, sinuses and fistulas

Otolaryngol. Clin. North Am.

Branchial cyst side predilection: fact or fiction?

Ann. Otol. Rhinol. Laryngol.

First branchial cleft sinuses: an analysis of current management strategy and treatment outcomes

J. Otolaryngol.

Third and fourth branchial pouch anomalies

J. Laryngol. Otol.

Branchial anomalies in the pediatric population

Otolaryngol. Head Neck Surg.