Surgical Approaches to First Branchial Cleft Anomaly Excision: A Case Series

Abstract

Objectives. First branchial cleft anomalies (BCAs) constitute a rare entity with variable clinical presentations and anatomic findings. Given the high rate of recurrence with incomplete excision, identification of the entire tract during surgical treatment is of paramount importance. The objectives of this paper were to present five anatomic variations of first BCAs and describe the presentation, evaluation, and surgical approach to each one. Methods. A retrospective case review and literature review were performed. We describe patient characteristics, presentation, evaluation, and surgical approach of five patients with first BCAs. Results. Age at definitive surgical treatment ranged from 8 months to 7 years. Various clinical presentations were encountered, some of which were atypical for first BCAs. All had preoperative imaging demonstrating the tract. Four surgical approaches required a superficial parotidectomy with identification of the facial nerve, one of which revealed an aberrant facial nerve. In one case the tract was found to travel into the angle of the mandible, terminating as a mandibular cyst. This required en bloc excision that included the lateral cortex of the mandible. Conclusions. First BCAs have variable presentations. Complete surgical excision can be challenging. Therefore, careful preoperative planning and the recognition of atypical variants during surgery are essential.

Figure 1

Case  1. MRI, coronal cut in T2 sequence, showing location of mass lateral to left parotid (arrow) and exerting mass effect towards the left EAC (arrowhead).

Figure 2

(a)(1-2) Case  2. Axial CT scan of the neck with contrast demonstrating a left rim-enhancing fluid collection (arrow) centered between the left parotid gland (arrowhead) and sternocleidomastoid muscle (star), posteroinferior to the EAC. (b) Duplicated EAC (arrow) containing skin and cartilage adnexae. (c) Specimen after removal. The cartilaginous duplication of the EAC along with its tract is shown.

Figure 3

Case  3. (a)(1–4) Preoperative CT scans. White arrow depicts the right-sided lesion. (a)(1-2) Representative axial images revealing a well-defined right neck cyst (arrow) located posterior and deep to the parotid gland, with no clear connection to the skin. (a)(3-4) The extent of the right mandibular defect containing the cyst (arrow). (b) Identification of the tract extending deep to the facial nerve. In the inferior quadrant of the picture, a forcep is stenting the tract open as the facial nerve is being retracted. (FN: facial nerve; T: BCA tract). (c) Isolated tract after separating it from the facial nerve. A clamp is on the tract while the facial nerve is being retracted. (FN: facial nerve; T: BCA tract). (d) Tract extending medially entering the angle of the mandible. A clamp is on the tract (FN: facial nerve; M: mandible).

Figure 4

Case  4. (a)(1–4) MRI with and without contrast, T1-weighted images in coronal cuts, showing tract (arrow) travelling from adjacent to left EAC superiorly, down towards left submandibular fossa, posterior to the submandibular gland, and ending at the skin inferiorly. (b) Facial nerve identified and protected during surgery. The tract is seen passing deep to the nerve (FN: facial nerve; M: mandible). (c) Specimen after removal, consistent with a duplication of the EAC, containing cartilage (separate piece dissected off main specimen after excision).

Figure 5

Case  5. (a)(1-2) CT scan with contrast, axial cuts demonstrating a left rim-enhancing postauricular abscess (arrow) adjacent to the conchal bowl (where puncta were identified at time of surgery), causing EAC stenosis (arrowhead). (b) Modified Blair incision incorporating postauricular granulation tissue (site of prior I&D). The limb of the marked incision extending down along a neck crease was marked as a possibility but not incised during the surgery, since it was unnecessary for visualization of the digastric and SCM muscles. (c) After identifying the facial nerve, an elliptical incision was carried out around the antitragal pit and dissected down. (d) Both the gentian violet within the tract and the lacrimal probe were used throughout the case to identify the tract. After initial dissection, the ellipsed skin around the pit and the contiguous tract was passed deep to the auricle and brought out through the postauricular incision keeping the entire tract intact.