Eur Arch Otorhinolaryngol DOI 10.1007/s00405-013-2837-x
HEAD AND NECK
Endoscope-assisted second branchial cleft cyst resection via an incision along skin line on lateral neck Junming Chen • Weixiong Chen • Jianli Zhang Fayao He • Zhaofeng Zhu • Sucheng Tang • Yuejian Wang
•
Received: 19 September 2013 / Accepted: 21 November 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract The aim of the study is to report the feasibility of endoscope-assisted second branchial cleft cyst resection via a small incision along the skin line on the lateral neck. In total, 41 patients from the Department of Otolaryngology, Foshan Hospital of Yat-sen University were randomly assigned to conventional (20 patients) or endoscope-assisted (21 patients) second branchial cleft cyst resection. The patient clinical characteristics, operation time, operative bleeding volume, postoperative complications, and subjective satisfaction with the incision scar (measured using a visual analog scale) were compared between the groups. All 41 s branchial cleft cyst resections were successfully performed, and the wounds healed uneventfully. The bleeding volume (6.3 ± 2.5 ml) and incision length (2.7 ± 0.3 cm) differed between the groups (P \ 0.00). The mean patient satisfaction score was 8.0 ± 0.8 in the endoscope-assisted surgery group and 6.4 ± 0.9 in the control group (P \ 0.00). All of the patients in the endoscope-assisted surgery group were satisfied with their cosmetic results. No marginal nerve palsy occurred. No complications such as bleeding, salivary fistula, or paresis of the marginal mandibular branch occurred. All of the patients were disease free through a follow-up period of 6–24 months (median: 14 months). Endoscope-assisted J. Chen and W. Chen contributed equally to this work.
Electronic supplementary material The online version of this article (doi:10.1007/s00405-013-2837-x) contains supplementary material, which is available to authorized users. J. Chen W. Chen J. Zhang F. He Z. Zhu S. Tang Y. Wang (&) Department of Otolaryngology, The First People’s Hospital of Foshan, Lin nan da dao road 81, Foshan 528000, People’s Republic of China e-mail: [email protected]
second branchial cleft cyst resection via a small incision along the dermatoglyph on the lateral neck is a feasible technique. This procedure may serve as an alternative approach, allowing a minimally invasive incision and better cosmetic results. Keywords Endoscope assisted Second branchial cleft cyst Small incision
Introduction Second branchial cleft cysts represent 67–93 % of all branchial anomalies, which are developmental disorders of the neck. Branchial cleft cysts and fistulae represent approximately 20 % of cervical masses in children [1]. They typically present as a painless, smooth, round neck mass located along the upper third of the anterior border of the sternocleidomastoid muscle and often appear after an upper respiratory infection [2]. Additional imaging, including ultrasound, computed tomography (CT), or MRI, may be helpful in defining the lesion and its anatomic course. Computed tomography is the most commonly used radiograph by practitioners [3]. MRI is also accurate in detecting branchial cysts [4]. Surgical resection of a second branchial cleft cyst is considered the definitive treatment of choice. Conventional resection requires a wide transverse cervicotomy incision and occasionally leaves a prominent 5-cm scar on the neck [5]. Endoscopic surgery, such as endoscopic parathyroidectomy, thyroidectomy, and second branchial cleft cyst resection, has been frequently used in the head and neck area [1]. Various approaches concerning the second branchial cleft have been reported over the past decades, including the facelift approach, the retroauricular approach, and the endoscope-assisted neck approach.
123
Eur Arch Otorhinolaryngol Table 1 Comparison of endoscope-assisted surgery and conventional surgery Endoscopeassisted surgery (20 cases)
Conventional surgery (21 cases)
P value
9/11
8/13
0.65
Age (years)
29 ± 8
32 ± 11
0.51
Length of the incision (cm)
2.7 ± 0.3
6.4 ± 0.5
0.00*
Operative bleeding volume (ml)
6.3 ± 2.5
9.0 ± 3.4
0.00*
Operation time (min)
83 ± 18
94 ± 21
0.07
Cyst diameter (cm)
4.8 ± 1.4
5.2 ± 1.6
0.36
Subjective satisfaction with incision scar (VAS)
8.0 ± 0.8
6.4 ± 0.5
0.00*
Sex: male/female (number of cases)
* P \ 0.05
Although the retroauricular approach is more subtle, the surgical incision is longer and may damage the great auricular nerve, lesser occipital nerve, and external jugular vein [1]. Distal incision is not conducive to hemostasis [6]. Guerrissi et al. [7] reported second branchial cleft cyst resection via a small incision in the lateral neck, but the report did not include a detailed summary of case characteristics, surgical approach, benefits, or indications. It is uncertain which endoscopic surgery is the most suitable for second branchial cleft cysts. Here, we present results showing the feasibility of an endoscope-assisted approach for the resection of a second branchial cleft cyst via a small incision along the dermatoglyph on the lateral neck.
Patients and methods Patients From January 2009 to December 2012, 41 patients diagnosed with a second branchial cleft cyst (confirmed by fineneedle aspiration cytology and CT) were enrolled into this prospective clinical study. The patients were from the Department of Otolaryngology, Foshan Hospital of Yat-sen University, Foshan, China. They were randomly assigned to the endoscope-assisted second branchial cleft cyst resection group or the standard cervical incision group. Informed consent was obtained from each patient. A total of 20 consecutive patients who underwent the endoscope-assisted procedure for the removal of second branchial cleft cysts were enrolled into the case group of this study, which included 9 males and 11 females ranging in age from 20 to 49 years (median 29 years) (Table 1). Their clinical symptoms and physical signs were painless masses located along
123
the upper third of the anterior border of the sternocleidomastoid muscle. The surface of the mass was smooth with a clear border. Preoperative CT scans (Fig. 1a, b) showed that the longest cyst diameter ranged from 3 to 7 cm (median 4.8 cm). The control group consisted of 8 males and 13 females with a mean age of 32 years (range: 21–59 years) who underwent conventional surgery (Table 1). The groups of patients were matched for age, sex, diameter of the cyst, and anesthesia. All patients with a previous neck surgery or irradiation were excluded. For each group, the method of surgery was explained to the patients and their families prior to the procedure. The informed consent form was approved by the institutional review board of Foshan Hospital of Yat-sen University. Instruments A 4-mm-diameter 0° endoscope, a television monitor, equipment for endoscopic thyroid surgery (Karl Storz Corporation, Tuttlingen, Germany), and a Harmonic scalpel (Johnson & Johnson Corporation, Shanghai, P.R. China) were used. Surgical technique In the endoscope-assisted group, all 20 patients were placed in a supine position with a pillow under their shoulder and were placed under general anesthesia. The operating team consisted of the chief surgeon, the endoscope assistant, and a scrub nurse. A lateral neck incision was made in the skin, subcutaneous tissue, and platysma muscle. The incision was made along the skin line below the lower bound of the cyst (Fig. 1c). The working space was created by elevating the skin flap with self-designed custom-made retractors to establish a stable operative space (Fig. 2a). The wound margin was protected by two applications to avoid injury from the ultrasonic scalpel (Fig. 2b). Dissection using the ultrasonic scalpel was performed to free the attachments of the cyst. When we separated the cyst, we took care to avoid impairing the common carotid artery, internal jugular vein, vagus nerve, hypoglossal nerve, and accessory nerve. The cyst was completely removed. For very large cysts (longest diameter of 7 cm) (Fig. 2c), decompression was often performed by fluid aspiration and needle pricking (Fig. 2b). For the final histologic examination, all specimens were sent for paraffin sectioning. The wound was closed by a subcuticular suture with 4-0 Dexon, and a small ventricular drainage tube was inserted. There was one case of congenital branchial cleft fistula. The fistula extended to the ipsilateral tonsils and was completely removed. In the control group, a curvilinear incision was made along the natural skin creases overlying the lesions of the
Eur Arch Otorhinolaryngol
Fig. 1 CT scans showing a well-circumscribed cystic lesion that was confined to the left side of the neck (a, b). A skin incision was made along the skin line in the lateral side of the neck below the cyst (c)
Fig. 2 The margin of the wound was protected by two applications (b). Working space was created using self-designed retractors (a). The cyst was exposed (c). Decompression was performed (b). A patient 6 months after surgery (d)
upper neck, typically 4–5 cm below the lower border of the mandible. The other procedures for the extirpation of lesions were the same as the above-mentioned surgical methods.
Inc., Chicago, IL) for Windows. P \ 0.05 was regarded as statistically significant.
Results Statistical analysis The outcomes of the two groups were compared in terms of operation time, operative bleeding volume, complication rates, and subjective satisfaction with the incision scars evaluated at 6 months after surgery using a visual analog scale ranging from 0 to 10, with a higher score representing better patient satisfaction. The operative time was defined as the time from incision to closure. The data for each group were expressed as the mean ± standard deviation (SD). Statistical comparisons between the two groups were performed with Student’s t test using SPSS 11.0 (SPSS
The cysts were completely resected in all 41 cases (both groups). All 20 operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. All of the wounds healed uneventfully. The postoperative pathological examinations showed branchial cleft cysts. In the endoscope-assisted surgery group, the cyst diameter was 4.8 ± 1.4 cm, the operative bleeding volume was 6.3 ± 2.5 ml, and the operating time was 83 ± 18 min. In the conventional surgery group, the cyst diameter was 5.2 ± 1.6 cm, the bleeding volume was 9.0 ± 3.4 ml, and the operating time
123
Eur Arch Otorhinolaryngol
was 94 ± 21 min. Using a t test analysis, the bleeding volume of endoscopic surgery was found to be less than that of conventional surgery (P = 0.006), and the operation time was the same for both groups (P = 0.07). On a visual analog scale, the mean score of patient satisfaction with the incision scars was much higher in the endoscope-assisted group compared with the control group (P = 0.00) (Table 1). The scars of the patients in the endoscopeassisted group were less prominent because of the skin-line incision (Fig. 2D). No marginal nerve palsy occurred. No complications, such as bleeding, salivary fistula, or paresis of the marginal mandibular branch, occurred. All patients were disease free at a follow-up at 6–24 months (median 16 months).
Discussion The surgical approach for removing second branchial cleft cysts is through an incision over the entire protruding zone. The excision requires a wide transverse cervicotomy incision, with the transcervical approach being the safest and most suitable for cyst removal. This approach results in a visible scar more than 5 cm in length on the neck. The endoscopic technique provides good illumination and magnification of surgical procedures using a video monitor. Tissues such as the carotid sheath and the spinal accessory and hypoglossal nerves are identified and visualized clearly and can be dissected efficiently [1]. Endoscopic techniques for head and neck surgery have been applied to thyroidectomy, parotidectomy, submandibular gland excision, and selective neck dissection, with satisfactory results [8]. We designed a gasless endoscope-assisted second branchial cleft cyst resection via a small incision lateral neck. Compared with traditional surgery, this surgical procedure has several advantages. First, 1/3 of second branchial cysts occur in the leading edge of the deep sternocleidomastoid muscle, and most are Bailey’s type II [1]. Small incisions in the lateral neck are suitable for second branchial cleft cyst resection. Because a small incision can be hidden in the skin line, the incision is difficult to find when the patient’s neck is in a natural position. Guerrissi et al. [7] treated cystic disease of the neck via a small incision in the lateral neck to achieve a cosmetic result in the natural position. In our randomized controlled study, we found that the level of satisfaction compared with a conventional incision was better (P \ 0.05); the scar and the length of the incision decreased significantly. Although the neck has no natural cavities, a sufficiently stable surgical space can be created by stretching and suspending the skin. In an endoscopic parotidectomy study, Huang et al. [9] showed that sufficient surgical space could be established through neck skin
123
and muscle stretching. In this study, by pulling on the retractors, we established a stable operative space. Using retractors to build a stably suspended surgical space, blood contamination affecting visibility can be avoided, the operation time can be shorted, and the number of assistants and surgeons can be reduced, all of which can avoid fatiguing the assistant. Second, the operative distance is short when using conventional surgical instruments and without the excessive flap separation, which avoids excessive trauma. In our approach, the flap has no angulation and is less prone to necrosis. Chen et al. [1] previously reported that flaps with a corner were prone to necrosis. Our surgical approach did not result in flap necrosis or adverse complications. Compared with other incisions made behind the ear [1], our surgical approach did not expose the great auricular nerve, lesser occipital nerve or external jugular vein, which allowed us to avoid damaging them. In addition to the cosmetic advantages and the protection of important nerves and blood vessels, the use of an endoscope allowed clear visualization of the fistula, which facilitated complete resection and reduced the possibilities of leaving residual fistula and fistula recurrence. Chen et al. [1] reported that an endoscope showed the neural and vascular structure more clearly than conventional surgery. The present study supported this observation. One patient had a fistula that was successfully resected through our method without recurrence during the postoperative follow-up. Regardless of the cyst size, the surgical technique can be combined with the cyst fluid extraction technique [1], which can reduce tumor volume and expand the operating space, allowing the cyst to be easily separated without increasing the size of the incision. In some cases, the cyst diameter was greater than 6 cm, and these cysts were successfully excised. It is possible to directly extend a small incision and convert it into a traditional Blair’s incision if there is more blood loss than expected or if malignancy is detected [6]. The incision can be expanded along the original incision to facilitate tumor resection and lymph node dissection [6]. However, there were some limitations to this study. The number of included patients was small. A larger series of patients with a longer followup is required to determine whether this safety profile is sustainable. However, our early results appear encouraging.
Conclusion In conclusion, endoscopic-assisted small incisions along the dermatoglyph in the lateral neck can reduce the invasiveness of surgery and achieve better surgical cavity visualization. Endoscopic-assisted small incisions can be
Eur Arch Otorhinolaryngol
used in cases with large cysts. Simultaneously, this procedure is associated with a lower risk of nerve and blood vessel damage, reducing the likelihood of skin flap necrosis. This procedure is a safe, feasible, and cosmetic method of endoscopic surgery. Acknowledgments The authors thank Yiqing Zheng, MD, Department of Otolaryngology, the 2nd Affiliated Hospital of Sun Yat-sen University, for revising this manuscript. Conflict of interest All of the authors have no conflicts of interest or financial ties to disclose.
References 1. Chen LS, Sun W, Wu PN, Zhang SY, Xu MM, Luo XN, Zhan JD, Huang X (2012) Endoscope-assisted versus conventional second branchial cleft cyst resection. Surg Endosc 26(5):1397–1402. doi:10.1007/s00464-011-2046-x 2. Goff CJ, Allred C, Glade RS (2012) Current management of congenital branchial cleft cysts, sinuses, and fistulae. Curr Opin Otolaryngol Head Neck Surg 20(6):533–539. doi:10.1097/MOO. 0b013e32835873fb
3. Schroeder JW Jr, Mohyuddin N, Maddalozzo J (2007) Branchial anomalies in the pediatric population. Otolaryngol Head Neck Surg 137(2):289–295. doi:10.1016/j.otohns.2007.03.009 4. Black CJ, O’Hara JT, Berry J, Robson AK (2010) Magnetic resonance imaging of branchial cleft abnormalities: illustrated cases and literature review. J Laryngol Otol 124(2):213–215. doi:10.1017/S0022215109990995 5. Chen WL, Fang SL (2009) Removal of second branchial cleft cysts using a retroauricular approach. Head Neck 31(5):695–698. doi:10. 1002/hed.20980 6. Xie L, Zhang D, Lu MM, Gao BM (2012) Minimally invasive endoscopic-assisted resection of benign tumors in the accessory parotid gland: 5 case studies. Head Neck 34(8):1194–1197. doi:10. 1002/hed.21751 7. Guerrissi JO (2010) Minimal invasive surgery in head and neck: video-assisted technique. J Craniofac Surg 21(3):882–886. doi:10. 1097/SCS.0b013e3181d80933 8. Muenscher A, Dalchow C, Kutta H, Knecht R (2011) The endoscopic approach to the neck: a review of the literature, and overview of the various techniques. Surg Endosc 25(5):1358–1363. doi:10.1007/s00464-010-1452-9 9. Huang X, Zheng Y, Liu X, Sun W, Zeng L, Cai X, Liu W, Xu Y, Zhang Z, Huang H (2009) A comparison between endoscopeassisted partial parotidectomy and conventional partial parotidectomy. Otolaryngol Head Neck Surg 140(1):70–75. doi:10.1016/j. otohns.2008.09.015
123
HEAD AND NECK
Endoscope-assisted second branchial cleft cyst resection via an incision along skin line on lateral neck Junming Chen • Weixiong Chen • Jianli Zhang Fayao He • Zhaofeng Zhu • Sucheng Tang • Yuejian Wang
•
Received: 19 September 2013 / Accepted: 21 November 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract The aim of the study is to report the feasibility of endoscope-assisted second branchial cleft cyst resection via a small incision along the skin line on the lateral neck. In total, 41 patients from the Department of Otolaryngology, Foshan Hospital of Yat-sen University were randomly assigned to conventional (20 patients) or endoscope-assisted (21 patients) second branchial cleft cyst resection. The patient clinical characteristics, operation time, operative bleeding volume, postoperative complications, and subjective satisfaction with the incision scar (measured using a visual analog scale) were compared between the groups. All 41 s branchial cleft cyst resections were successfully performed, and the wounds healed uneventfully. The bleeding volume (6.3 ± 2.5 ml) and incision length (2.7 ± 0.3 cm) differed between the groups (P \ 0.00). The mean patient satisfaction score was 8.0 ± 0.8 in the endoscope-assisted surgery group and 6.4 ± 0.9 in the control group (P \ 0.00). All of the patients in the endoscope-assisted surgery group were satisfied with their cosmetic results. No marginal nerve palsy occurred. No complications such as bleeding, salivary fistula, or paresis of the marginal mandibular branch occurred. All of the patients were disease free through a follow-up period of 6–24 months (median: 14 months). Endoscope-assisted J. Chen and W. Chen contributed equally to this work.
Electronic supplementary material The online version of this article (doi:10.1007/s00405-013-2837-x) contains supplementary material, which is available to authorized users. J. Chen W. Chen J. Zhang F. He Z. Zhu S. Tang Y. Wang (&) Department of Otolaryngology, The First People’s Hospital of Foshan, Lin nan da dao road 81, Foshan 528000, People’s Republic of China e-mail: [email protected]
second branchial cleft cyst resection via a small incision along the dermatoglyph on the lateral neck is a feasible technique. This procedure may serve as an alternative approach, allowing a minimally invasive incision and better cosmetic results. Keywords Endoscope assisted Second branchial cleft cyst Small incision
Introduction Second branchial cleft cysts represent 67–93 % of all branchial anomalies, which are developmental disorders of the neck. Branchial cleft cysts and fistulae represent approximately 20 % of cervical masses in children [1]. They typically present as a painless, smooth, round neck mass located along the upper third of the anterior border of the sternocleidomastoid muscle and often appear after an upper respiratory infection [2]. Additional imaging, including ultrasound, computed tomography (CT), or MRI, may be helpful in defining the lesion and its anatomic course. Computed tomography is the most commonly used radiograph by practitioners [3]. MRI is also accurate in detecting branchial cysts [4]. Surgical resection of a second branchial cleft cyst is considered the definitive treatment of choice. Conventional resection requires a wide transverse cervicotomy incision and occasionally leaves a prominent 5-cm scar on the neck [5]. Endoscopic surgery, such as endoscopic parathyroidectomy, thyroidectomy, and second branchial cleft cyst resection, has been frequently used in the head and neck area [1]. Various approaches concerning the second branchial cleft have been reported over the past decades, including the facelift approach, the retroauricular approach, and the endoscope-assisted neck approach.
123
Eur Arch Otorhinolaryngol Table 1 Comparison of endoscope-assisted surgery and conventional surgery Endoscopeassisted surgery (20 cases)
Conventional surgery (21 cases)
P value
9/11
8/13
0.65
Age (years)
29 ± 8
32 ± 11
0.51
Length of the incision (cm)
2.7 ± 0.3
6.4 ± 0.5
0.00*
Operative bleeding volume (ml)
6.3 ± 2.5
9.0 ± 3.4
0.00*
Operation time (min)
83 ± 18
94 ± 21
0.07
Cyst diameter (cm)
4.8 ± 1.4
5.2 ± 1.6
0.36
Subjective satisfaction with incision scar (VAS)
8.0 ± 0.8
6.4 ± 0.5
0.00*
Sex: male/female (number of cases)
* P \ 0.05
Although the retroauricular approach is more subtle, the surgical incision is longer and may damage the great auricular nerve, lesser occipital nerve, and external jugular vein [1]. Distal incision is not conducive to hemostasis [6]. Guerrissi et al. [7] reported second branchial cleft cyst resection via a small incision in the lateral neck, but the report did not include a detailed summary of case characteristics, surgical approach, benefits, or indications. It is uncertain which endoscopic surgery is the most suitable for second branchial cleft cysts. Here, we present results showing the feasibility of an endoscope-assisted approach for the resection of a second branchial cleft cyst via a small incision along the dermatoglyph on the lateral neck.
Patients and methods Patients From January 2009 to December 2012, 41 patients diagnosed with a second branchial cleft cyst (confirmed by fineneedle aspiration cytology and CT) were enrolled into this prospective clinical study. The patients were from the Department of Otolaryngology, Foshan Hospital of Yat-sen University, Foshan, China. They were randomly assigned to the endoscope-assisted second branchial cleft cyst resection group or the standard cervical incision group. Informed consent was obtained from each patient. A total of 20 consecutive patients who underwent the endoscope-assisted procedure for the removal of second branchial cleft cysts were enrolled into the case group of this study, which included 9 males and 11 females ranging in age from 20 to 49 years (median 29 years) (Table 1). Their clinical symptoms and physical signs were painless masses located along
123
the upper third of the anterior border of the sternocleidomastoid muscle. The surface of the mass was smooth with a clear border. Preoperative CT scans (Fig. 1a, b) showed that the longest cyst diameter ranged from 3 to 7 cm (median 4.8 cm). The control group consisted of 8 males and 13 females with a mean age of 32 years (range: 21–59 years) who underwent conventional surgery (Table 1). The groups of patients were matched for age, sex, diameter of the cyst, and anesthesia. All patients with a previous neck surgery or irradiation were excluded. For each group, the method of surgery was explained to the patients and their families prior to the procedure. The informed consent form was approved by the institutional review board of Foshan Hospital of Yat-sen University. Instruments A 4-mm-diameter 0° endoscope, a television monitor, equipment for endoscopic thyroid surgery (Karl Storz Corporation, Tuttlingen, Germany), and a Harmonic scalpel (Johnson & Johnson Corporation, Shanghai, P.R. China) were used. Surgical technique In the endoscope-assisted group, all 20 patients were placed in a supine position with a pillow under their shoulder and were placed under general anesthesia. The operating team consisted of the chief surgeon, the endoscope assistant, and a scrub nurse. A lateral neck incision was made in the skin, subcutaneous tissue, and platysma muscle. The incision was made along the skin line below the lower bound of the cyst (Fig. 1c). The working space was created by elevating the skin flap with self-designed custom-made retractors to establish a stable operative space (Fig. 2a). The wound margin was protected by two applications to avoid injury from the ultrasonic scalpel (Fig. 2b). Dissection using the ultrasonic scalpel was performed to free the attachments of the cyst. When we separated the cyst, we took care to avoid impairing the common carotid artery, internal jugular vein, vagus nerve, hypoglossal nerve, and accessory nerve. The cyst was completely removed. For very large cysts (longest diameter of 7 cm) (Fig. 2c), decompression was often performed by fluid aspiration and needle pricking (Fig. 2b). For the final histologic examination, all specimens were sent for paraffin sectioning. The wound was closed by a subcuticular suture with 4-0 Dexon, and a small ventricular drainage tube was inserted. There was one case of congenital branchial cleft fistula. The fistula extended to the ipsilateral tonsils and was completely removed. In the control group, a curvilinear incision was made along the natural skin creases overlying the lesions of the
Eur Arch Otorhinolaryngol
Fig. 1 CT scans showing a well-circumscribed cystic lesion that was confined to the left side of the neck (a, b). A skin incision was made along the skin line in the lateral side of the neck below the cyst (c)
Fig. 2 The margin of the wound was protected by two applications (b). Working space was created using self-designed retractors (a). The cyst was exposed (c). Decompression was performed (b). A patient 6 months after surgery (d)
upper neck, typically 4–5 cm below the lower border of the mandible. The other procedures for the extirpation of lesions were the same as the above-mentioned surgical methods.
Inc., Chicago, IL) for Windows. P \ 0.05 was regarded as statistically significant.
Results Statistical analysis The outcomes of the two groups were compared in terms of operation time, operative bleeding volume, complication rates, and subjective satisfaction with the incision scars evaluated at 6 months after surgery using a visual analog scale ranging from 0 to 10, with a higher score representing better patient satisfaction. The operative time was defined as the time from incision to closure. The data for each group were expressed as the mean ± standard deviation (SD). Statistical comparisons between the two groups were performed with Student’s t test using SPSS 11.0 (SPSS
The cysts were completely resected in all 41 cases (both groups). All 20 operations were successfully performed endoscopically, and no conversions to conventional open resection were necessary. All of the wounds healed uneventfully. The postoperative pathological examinations showed branchial cleft cysts. In the endoscope-assisted surgery group, the cyst diameter was 4.8 ± 1.4 cm, the operative bleeding volume was 6.3 ± 2.5 ml, and the operating time was 83 ± 18 min. In the conventional surgery group, the cyst diameter was 5.2 ± 1.6 cm, the bleeding volume was 9.0 ± 3.4 ml, and the operating time
123
Eur Arch Otorhinolaryngol
was 94 ± 21 min. Using a t test analysis, the bleeding volume of endoscopic surgery was found to be less than that of conventional surgery (P = 0.006), and the operation time was the same for both groups (P = 0.07). On a visual analog scale, the mean score of patient satisfaction with the incision scars was much higher in the endoscope-assisted group compared with the control group (P = 0.00) (Table 1). The scars of the patients in the endoscopeassisted group were less prominent because of the skin-line incision (Fig. 2D). No marginal nerve palsy occurred. No complications, such as bleeding, salivary fistula, or paresis of the marginal mandibular branch, occurred. All patients were disease free at a follow-up at 6–24 months (median 16 months).
Discussion The surgical approach for removing second branchial cleft cysts is through an incision over the entire protruding zone. The excision requires a wide transverse cervicotomy incision, with the transcervical approach being the safest and most suitable for cyst removal. This approach results in a visible scar more than 5 cm in length on the neck. The endoscopic technique provides good illumination and magnification of surgical procedures using a video monitor. Tissues such as the carotid sheath and the spinal accessory and hypoglossal nerves are identified and visualized clearly and can be dissected efficiently [1]. Endoscopic techniques for head and neck surgery have been applied to thyroidectomy, parotidectomy, submandibular gland excision, and selective neck dissection, with satisfactory results [8]. We designed a gasless endoscope-assisted second branchial cleft cyst resection via a small incision lateral neck. Compared with traditional surgery, this surgical procedure has several advantages. First, 1/3 of second branchial cysts occur in the leading edge of the deep sternocleidomastoid muscle, and most are Bailey’s type II [1]. Small incisions in the lateral neck are suitable for second branchial cleft cyst resection. Because a small incision can be hidden in the skin line, the incision is difficult to find when the patient’s neck is in a natural position. Guerrissi et al. [7] treated cystic disease of the neck via a small incision in the lateral neck to achieve a cosmetic result in the natural position. In our randomized controlled study, we found that the level of satisfaction compared with a conventional incision was better (P \ 0.05); the scar and the length of the incision decreased significantly. Although the neck has no natural cavities, a sufficiently stable surgical space can be created by stretching and suspending the skin. In an endoscopic parotidectomy study, Huang et al. [9] showed that sufficient surgical space could be established through neck skin
123
and muscle stretching. In this study, by pulling on the retractors, we established a stable operative space. Using retractors to build a stably suspended surgical space, blood contamination affecting visibility can be avoided, the operation time can be shorted, and the number of assistants and surgeons can be reduced, all of which can avoid fatiguing the assistant. Second, the operative distance is short when using conventional surgical instruments and without the excessive flap separation, which avoids excessive trauma. In our approach, the flap has no angulation and is less prone to necrosis. Chen et al. [1] previously reported that flaps with a corner were prone to necrosis. Our surgical approach did not result in flap necrosis or adverse complications. Compared with other incisions made behind the ear [1], our surgical approach did not expose the great auricular nerve, lesser occipital nerve or external jugular vein, which allowed us to avoid damaging them. In addition to the cosmetic advantages and the protection of important nerves and blood vessels, the use of an endoscope allowed clear visualization of the fistula, which facilitated complete resection and reduced the possibilities of leaving residual fistula and fistula recurrence. Chen et al. [1] reported that an endoscope showed the neural and vascular structure more clearly than conventional surgery. The present study supported this observation. One patient had a fistula that was successfully resected through our method without recurrence during the postoperative follow-up. Regardless of the cyst size, the surgical technique can be combined with the cyst fluid extraction technique [1], which can reduce tumor volume and expand the operating space, allowing the cyst to be easily separated without increasing the size of the incision. In some cases, the cyst diameter was greater than 6 cm, and these cysts were successfully excised. It is possible to directly extend a small incision and convert it into a traditional Blair’s incision if there is more blood loss than expected or if malignancy is detected [6]. The incision can be expanded along the original incision to facilitate tumor resection and lymph node dissection [6]. However, there were some limitations to this study. The number of included patients was small. A larger series of patients with a longer followup is required to determine whether this safety profile is sustainable. However, our early results appear encouraging.
Conclusion In conclusion, endoscopic-assisted small incisions along the dermatoglyph in the lateral neck can reduce the invasiveness of surgery and achieve better surgical cavity visualization. Endoscopic-assisted small incisions can be
Eur Arch Otorhinolaryngol
used in cases with large cysts. Simultaneously, this procedure is associated with a lower risk of nerve and blood vessel damage, reducing the likelihood of skin flap necrosis. This procedure is a safe, feasible, and cosmetic method of endoscopic surgery. Acknowledgments The authors thank Yiqing Zheng, MD, Department of Otolaryngology, the 2nd Affiliated Hospital of Sun Yat-sen University, for revising this manuscript. Conflict of interest All of the authors have no conflicts of interest or financial ties to disclose.
References 1. Chen LS, Sun W, Wu PN, Zhang SY, Xu MM, Luo XN, Zhan JD, Huang X (2012) Endoscope-assisted versus conventional second branchial cleft cyst resection. Surg Endosc 26(5):1397–1402. doi:10.1007/s00464-011-2046-x 2. Goff CJ, Allred C, Glade RS (2012) Current management of congenital branchial cleft cysts, sinuses, and fistulae. Curr Opin Otolaryngol Head Neck Surg 20(6):533–539. doi:10.1097/MOO. 0b013e32835873fb
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