Sclerotherapy as treatment of a branchial cleft fistula in a pediatric patient





Abstract


Branchial cleft fistulae are benign congenital tracts in the neck that connect the pharynx to the skin resulting from improper involution of the branchial apparatus. Surgical excision is the most common treatment. While alternative treatments exist, there is a paucity of literature detailing nonsurgical managements. We describe a branchial cleft fistula successfully treated with sclerotherapy to suggest this alternative management. A seven-week-old boy presented to our hospital with daily fluid drainage from a punctate skin opening at the anterior base of his neck. At one year of age, this was confirmed to be a second branchial cleft fistula and treated with sclerotherapy in Interventional Radiology (IR). The entire tract was catheterized from the skin opening to the pharynx and then sclerosed with doxycycline in an outpatient procedure under general anesthesia. There were no complications and his clinical symptoms resolved completely post-procedure suffering no recurrence as of his last follow-up 26 months later. This case demonstrates branchial cleft fistulae can be eradicated with sclerotherapy making it a clinically feasible minimally invasive alternative to surgical excision.


Highlights





  • Branchial cleft fistulae are benign congenital lesions.



  • Complete surgical excision is the predominant treatment.



  • Less invasive treatments may also be effective with lower risk.



  • Sclerotherapy is a feasible treatment alternative as demonstrated in this case report.



Introduction


The branchial arches are embryonic entities that give rise to numerous structures in the head and neck. Improper involution of these arches is the second most common congenital neck abnormality and can result in cysts, sinuses, or fistulae [ ]. Fistulae connect the pharynx to the skin and typically present with external drainage and recurrent infection. Surgical excision is the most common treatment for branchial cleft fistulae, and complete removal is considered by many to be necessary for clinical resolution [ ]. Surgical management has a complication rate of 2–4% which includes infection, hemorrhage, and nerve injury [ , ] Incomplete resection or recurrence of the tract occurs in up to 22% of cases [ ].


In hopes of offering a minimally invasive alternative, sclerotherapy has recently been used to treat various branchial system remnants [ , ]. Branchial cleft fistulae make up a very small percentage of the reported cases with the majority of reports focusing on cysts [ , ]. In an effort to add to this body of literature we report our successful experience performing sclerotherapy of a branchial cleft fistula in a young child.


Case presentation


A seven-week-old boy presented with daily fluid drainage from a low anterior skin pit on the right side of his neck just medial to the sternocleidomastoid muscle. Ultrasound (US) examination failed to find a tract at that time. At one year of age, his otolaryngologist sent him to IR for a fistulagram which showed a long thin tract extending from the skin pit cephalad draining into the pharynx behind the right tonsillar pillar ( Fig. 1 ). The clinical and radiologic diagnosis was therefore a second branchial fistula. Surgery was recommended but the family did not wish to pursue a surgical exploration and resection given the relatively benign symptoms and requested a less invasive option.


Jul 5, 2021 | Posted by in OTOLARYNGOLOGY | Comments Off on Sclerotherapy as treatment of a branchial cleft fistula in a pediatric patient
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