Clinical Techniques and Technology
Management of First Branchial Cleft Anomalies via a Cartilage-Splitting Technique
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(6) 1149–1151 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815577357 http://otojournal.org
Richard Schmidt, MD1, David Conrad, MD1, Erin Field, PA-C1, and Robert O’Reilly, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract First branchial cleft anomalies are uncommon lesions that often present as periauricular infections. They have high recurrence rates, due in part to scarring secondary to prior infections and their management. These lesions have a close relationship with the facial nerve, and most authors recommend its identification and dissection because of this relationship. Nonetheless, facial nerve palsy has been reported in up to 15% of cases. We describe a novel technique for the management of first branchial cleft anomalies. Such lesions that presented in an infra- or postauricular location were approached via an incision through the cartilage of the pinna, between the tragus and antitragus. This technique affords direct access to the lesion without the need for facial nerve dissection. Six patients were treated. Five had prior surgery, including 3 with previous attempts at excision. There were no complications. The median follow-up was 35 months. One patient developed a recurrence. Keywords branchial cleft, treatment, surgery, facial nerve Received September 15, 2014; revised January 30, 2015; accepted February 23, 2015.
F
irst branchial anomalies (FBAs) are uncommon congenital lesions. They reportedly represent less than 10% of all branchial anomalies and typically occur in early childhood.1 Work2 classified these as either type I lesions, duplications of the membranous external auditory canal (EAC) containing ectoderm only, or type II lesions, duplications of the membranous and cartilaginous portions of the EAC. The former are located lateral to the facial nerve (FN), whereas the latter frequently pass through the parotid gland and can have a variable relationship with the FN. Olsen et al3 subclassified type II lesions as cysts, sinuses, or fistulas. Cysts contain no external opening, sinuses open into the EAC, and fistulas open into the EAC and skin of
the neck. Cysts were most common in this study, although the majority presented in adulthood. Twelve patients had sinuses or fistulas, the majority of whom were children. Eleven of the 12 lesions were found to be superficial to the FN. When the authors’ series was combined with additional reports from the literature, a postauricular cyst with an associated sinus tract running parallel to the EAC was the most common sinus identified, representing about half of all sinuses. Regardless of the type of FBA, patients often present with an acute infection and will frequently require incision and drainage procedures before definitive surgery.4 The complicated relationship between FBAs and the FN may make complete excision difficult at times and contribute to a rate of FN palsy (temporary or permanent) as high as 15% after definitive surgery.5 Even after definitive surgery, recurrences are common and caused by incomplete excision. To reduce the risk of recurrence and decrease the likelihood of FN palsy, most authors advocate a surgical approach that involves wide exposure and FN dissection.2,3,5 For the past several years, the senior authors (R.O., R.S.) have taken another approach to manage postauricular cysts/ sinuses when there is no evidence of involvement of the parotid gland by magnetic resonance imaging or computed tomography scan. This approach involves a cartilagesplitting incision between the tragus and antitragus providing direct access to the lesion without the need for FN dissection.
Technique With the patient under general anesthesia and appropriate FN monitoring in place, an incision is then marked out 1 Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
This work was originally presented as a poster at the Society for Ear Nose and Throat Advances in Children (SENTAC) meeting; December 6-8, 2013; Long Beach, California. Corresponding Author: Richard Schmidt, MD, Division of Pediatric Otolaryngology, Nemours/ Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA. Email: [email protected]
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Otolaryngology–Head and Neck Surgery 152(6)
Figure 1. Marking out the incision (A, B), including an ellipse of involved skin.
Figure 3. Typical appearance of the incision 1 month after surgery.
Figure 2. Direct access to the sinus tract (black arrow) is obtained through the cartilage-splitting incision (white arrow). Allis is on the ellipse of involved skin.
running between the tragus and antitragus before extending superiorly in the postauricular crease (Figure 1A,B). Any involved skin is excised as an ellipse as part of this incision. The incision is created with a scalpel, and the cartilage of the pinna is incised at the same time (Figure 2). This provides direct access to the inferior aspect of the EAC, and any lesional tissue, including any cartilaginous component, is identified at this time. The lesion is generally located posterior to the parotid gland and lateral to the stylomastoid foramen, allowing for complete removal of the lesion without FN identification. Although it is often necessary to remove some cartilage from the pinna to ensure complete excision, closure is cosmetically acceptable (Figure 3).
Results After obtaining approval from the Nemours/Alfred I. duPont Hospital for Children Institutional Review Board, we reviewed the charts of the first 6 children treated with this technique. Results are presented in Table 1. The mean age was 5.8 years (median 3 years), and the mean follow-up was 43 months. Four children had surgery before presenting
to our hospital, including 3 with at least 1 prior attempt at excision. There were no cases of FN injury or other perioperative complications. There was 1 recurrence. This occurred about 9 months after surgery. Repeat imaging when the lesion was acutely infected revealed a preauricular component that was not apparent on prior imaging or at the time of the patient’s initial excision. This lesion was ultimately treated with a parotidectomy approach with FN dissection and preservation.
Discussion Although uncommon, most FBAs will present in early childhood.3,5 Olsen and colleagues3 noted that a large proportion of these Work type II lesions present as a postauricular cyst with associated sinus tract opening in the EAC. Most of these lesions were superficial to the FN.3 This has been our experience also (Figure 4). When the first patient in our series presented with a recurrent lesion after excision elsewhere that had resulted in a temporary facial palsy, the approach described above was used in an attempt to avoid extensive FN dissection during her revision surgery. The approach worked well, and we subsequently used the technique on more routine cases with good results. The importance of accurate diagnosis and appropriate treatment of these lesions cannot be overstated. Numerous authors have reported that a plurality of patients with first branchial lesions has undergone at least 1 procedure, often
Downloaded from oto.sagepub.com by guest on November 16, 2015
Schmidt et al
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Table 1. Patient Demographics and Results. Age, y 2 2 17 2 4 8
Sex Female Female Female Female Male Female
Side Complications Recurrence Follow-up, mo Imaging R R R L L R
None None None None None None
N N N Y N N
7 41 58 41 29 84
N MRI MRI MRI CT MRI
Notes Previously operated on elsewhere Prior I&D Multiple prior I&D and excisions Presented with infection, recurred 9 mo after first surgery Originally removed elsewhere with FN palsy postoperatively
Abbreviations: CT = computed tomography; FN, facial nerve; I&D, incision and drainage; L, left; MRI, magnetic resonance imaging; R, right.
difficult and potentially increase the risk of FN injury. For this reason, FBAs should be removed electively in a timely fashion, once any infection has been controlled. Although most authors recommend excision via a parotidectomy approach with FN dissection,2,3,5 we believe that this is not usually necessary for the postauricular cysts with a sinus tract connecting to the EAC. These lesions are almost universally located lateral to the FN and can be removed safely and completely through a less invasive cartilage-splitting approach. Author Contributions Richard Schmidt, conception of work, acquisition and analysis of data, drafting and revision of work, final approval; David Conrad, analysis of data, drafting and revision of work, final approval; Erin Field, acquisition of data, revision of work, final approval; Robert O’Reilly, conception of work, analysis of data, revision of work, final approval.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
References
Figure 4. Illustration depicting the relationship between the branchial anomaly and facial nerve. (Figure used with permission.)
to manage infection, before curative surgery.1,4,5 This was certainly the case in our series where 5 of 6 patients had prior infection, surgery, or both. Prior infection or surgery will lead to scarring between the lesion and surrounding soft tissues. Scar tissue, regardless of the cause, will make surgical dissection more
1. Ford GR, Balakrishnan A, Evans JN, Bailey CM. Branchial cleft and pouch anomalies. J Laryngol Otol. 1992;106:137-143. 2. Work WP. Newer concepts of first branchial cleft defects. Laryngoscope. 1972;82:1581-1593. 3. Olsen KD, Maragos NE, Weiland LH. First branchial cleft anomalies. Laryngoscope. 1980;90:423-436. 4. Aronsohn RS, Batsakis JG, Rice DH, Work WP. Anomalies of the first branchial cleft. Arch Otolaryngol. 1976;102:737-740. 5. 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.
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Management of First Branchial Cleft Anomalies via a Cartilage-Splitting Technique
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(6) 1149–1151 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815577357 http://otojournal.org
Richard Schmidt, MD1, David Conrad, MD1, Erin Field, PA-C1, and Robert O’Reilly, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract First branchial cleft anomalies are uncommon lesions that often present as periauricular infections. They have high recurrence rates, due in part to scarring secondary to prior infections and their management. These lesions have a close relationship with the facial nerve, and most authors recommend its identification and dissection because of this relationship. Nonetheless, facial nerve palsy has been reported in up to 15% of cases. We describe a novel technique for the management of first branchial cleft anomalies. Such lesions that presented in an infra- or postauricular location were approached via an incision through the cartilage of the pinna, between the tragus and antitragus. This technique affords direct access to the lesion without the need for facial nerve dissection. Six patients were treated. Five had prior surgery, including 3 with previous attempts at excision. There were no complications. The median follow-up was 35 months. One patient developed a recurrence. Keywords branchial cleft, treatment, surgery, facial nerve Received September 15, 2014; revised January 30, 2015; accepted February 23, 2015.
F
irst branchial anomalies (FBAs) are uncommon congenital lesions. They reportedly represent less than 10% of all branchial anomalies and typically occur in early childhood.1 Work2 classified these as either type I lesions, duplications of the membranous external auditory canal (EAC) containing ectoderm only, or type II lesions, duplications of the membranous and cartilaginous portions of the EAC. The former are located lateral to the facial nerve (FN), whereas the latter frequently pass through the parotid gland and can have a variable relationship with the FN. Olsen et al3 subclassified type II lesions as cysts, sinuses, or fistulas. Cysts contain no external opening, sinuses open into the EAC, and fistulas open into the EAC and skin of
the neck. Cysts were most common in this study, although the majority presented in adulthood. Twelve patients had sinuses or fistulas, the majority of whom were children. Eleven of the 12 lesions were found to be superficial to the FN. When the authors’ series was combined with additional reports from the literature, a postauricular cyst with an associated sinus tract running parallel to the EAC was the most common sinus identified, representing about half of all sinuses. Regardless of the type of FBA, patients often present with an acute infection and will frequently require incision and drainage procedures before definitive surgery.4 The complicated relationship between FBAs and the FN may make complete excision difficult at times and contribute to a rate of FN palsy (temporary or permanent) as high as 15% after definitive surgery.5 Even after definitive surgery, recurrences are common and caused by incomplete excision. To reduce the risk of recurrence and decrease the likelihood of FN palsy, most authors advocate a surgical approach that involves wide exposure and FN dissection.2,3,5 For the past several years, the senior authors (R.O., R.S.) have taken another approach to manage postauricular cysts/ sinuses when there is no evidence of involvement of the parotid gland by magnetic resonance imaging or computed tomography scan. This approach involves a cartilagesplitting incision between the tragus and antitragus providing direct access to the lesion without the need for FN dissection.
Technique With the patient under general anesthesia and appropriate FN monitoring in place, an incision is then marked out 1 Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
This work was originally presented as a poster at the Society for Ear Nose and Throat Advances in Children (SENTAC) meeting; December 6-8, 2013; Long Beach, California. Corresponding Author: Richard Schmidt, MD, Division of Pediatric Otolaryngology, Nemours/ Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA. Email: [email protected]
Downloaded from oto.sagepub.com by guest on November 16, 2015
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Otolaryngology–Head and Neck Surgery 152(6)
Figure 1. Marking out the incision (A, B), including an ellipse of involved skin.
Figure 3. Typical appearance of the incision 1 month after surgery.
Figure 2. Direct access to the sinus tract (black arrow) is obtained through the cartilage-splitting incision (white arrow). Allis is on the ellipse of involved skin.
running between the tragus and antitragus before extending superiorly in the postauricular crease (Figure 1A,B). Any involved skin is excised as an ellipse as part of this incision. The incision is created with a scalpel, and the cartilage of the pinna is incised at the same time (Figure 2). This provides direct access to the inferior aspect of the EAC, and any lesional tissue, including any cartilaginous component, is identified at this time. The lesion is generally located posterior to the parotid gland and lateral to the stylomastoid foramen, allowing for complete removal of the lesion without FN identification. Although it is often necessary to remove some cartilage from the pinna to ensure complete excision, closure is cosmetically acceptable (Figure 3).
Results After obtaining approval from the Nemours/Alfred I. duPont Hospital for Children Institutional Review Board, we reviewed the charts of the first 6 children treated with this technique. Results are presented in Table 1. The mean age was 5.8 years (median 3 years), and the mean follow-up was 43 months. Four children had surgery before presenting
to our hospital, including 3 with at least 1 prior attempt at excision. There were no cases of FN injury or other perioperative complications. There was 1 recurrence. This occurred about 9 months after surgery. Repeat imaging when the lesion was acutely infected revealed a preauricular component that was not apparent on prior imaging or at the time of the patient’s initial excision. This lesion was ultimately treated with a parotidectomy approach with FN dissection and preservation.
Discussion Although uncommon, most FBAs will present in early childhood.3,5 Olsen and colleagues3 noted that a large proportion of these Work type II lesions present as a postauricular cyst with associated sinus tract opening in the EAC. Most of these lesions were superficial to the FN.3 This has been our experience also (Figure 4). When the first patient in our series presented with a recurrent lesion after excision elsewhere that had resulted in a temporary facial palsy, the approach described above was used in an attempt to avoid extensive FN dissection during her revision surgery. The approach worked well, and we subsequently used the technique on more routine cases with good results. The importance of accurate diagnosis and appropriate treatment of these lesions cannot be overstated. Numerous authors have reported that a plurality of patients with first branchial lesions has undergone at least 1 procedure, often
Downloaded from oto.sagepub.com by guest on November 16, 2015
Schmidt et al
1151
Table 1. Patient Demographics and Results. Age, y 2 2 17 2 4 8
Sex Female Female Female Female Male Female
Side Complications Recurrence Follow-up, mo Imaging R R R L L R
None None None None None None
N N N Y N N
7 41 58 41 29 84
N MRI MRI MRI CT MRI
Notes Previously operated on elsewhere Prior I&D Multiple prior I&D and excisions Presented with infection, recurred 9 mo after first surgery Originally removed elsewhere with FN palsy postoperatively
Abbreviations: CT = computed tomography; FN, facial nerve; I&D, incision and drainage; L, left; MRI, magnetic resonance imaging; R, right.
difficult and potentially increase the risk of FN injury. For this reason, FBAs should be removed electively in a timely fashion, once any infection has been controlled. Although most authors recommend excision via a parotidectomy approach with FN dissection,2,3,5 we believe that this is not usually necessary for the postauricular cysts with a sinus tract connecting to the EAC. These lesions are almost universally located lateral to the FN and can be removed safely and completely through a less invasive cartilage-splitting approach. Author Contributions Richard Schmidt, conception of work, acquisition and analysis of data, drafting and revision of work, final approval; David Conrad, analysis of data, drafting and revision of work, final approval; Erin Field, acquisition of data, revision of work, final approval; Robert O’Reilly, conception of work, analysis of data, revision of work, final approval.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
References
Figure 4. Illustration depicting the relationship between the branchial anomaly and facial nerve. (Figure used with permission.)
to manage infection, before curative surgery.1,4,5 This was certainly the case in our series where 5 of 6 patients had prior infection, surgery, or both. Prior infection or surgery will lead to scarring between the lesion and surrounding soft tissues. Scar tissue, regardless of the cause, will make surgical dissection more
1. Ford GR, Balakrishnan A, Evans JN, Bailey CM. Branchial cleft and pouch anomalies. J Laryngol Otol. 1992;106:137-143. 2. Work WP. Newer concepts of first branchial cleft defects. Laryngoscope. 1972;82:1581-1593. 3. Olsen KD, Maragos NE, Weiland LH. First branchial cleft anomalies. Laryngoscope. 1980;90:423-436. 4. Aronsohn RS, Batsakis JG, Rice DH, Work WP. Anomalies of the first branchial cleft. Arch Otolaryngol. 1976;102:737-740. 5. 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.
Downloaded from oto.sagepub.com by guest on November 16, 2015
