Abstract
Purpose
This is a detailed description of the clinical and anatomical presentation of the first branchial cleft anomaly presenting as retroauricular infected mass. Our experience with a microscopic dissection with control of the sinus lumen from within the cyst is also described.
Materials and Methods
Between 2001 and 2008, patients with the final histologic diagnosis of first branchial cleft anomaly in the retroauricular area were managed with a microscopic dissection technique with control of the sinus lumen from within the cyst. Classifications were done in accordance with Work, Olsen, and Chilla. Outcomes measured intervention as a function of disease recurrence and complications including facial nerve function was used.
Result
Eight patients with a mean age of 14.2 years were enrolled, and this included 4 females and 4 males. Four type 1 and 4 type 2 lesions as per the Work’s and Chilla’s classification were found, and there were 5 sinuses, 2 fistulae, and 1 cyst according to Olsen’s classification. All patients presented to the department with acute infection at the time of diagnosis. Five of the 8 patients had previous surgical treatment, 2 of those had up to 3 previous operations. None of the patients were complicated by disease recurrence or had surgical related complications (facial nerve paresis or paralysis, infection, canal stenosis) requiring reoperation with more than 1 year of follow-up.
Conclusions
First branchial cleft anomaly presenting as retroauricular infected mass can be effectively treated by adopting a microscopic dissection technique with control of the sinus lumen from within the cyst.
1
Introduction
First branchial cleft anomaly (FBCA) represents a rare group of congenital anomaly in the head and neck area. The overall incidence of the lesions is fewer than 10% of all branchial cleft defects . A wide range of clinical manifestations with cervical, parotid, and otologic symptoms can occur with variable presenting loci. The anomalies usually present with acute infection at the initial diagnosis. The leading symptoms are swelling and pain in the region of fistula. Signs of inflammation such as swelling, pain, and erythema are found in more than 70% of the time. In 1 report , up to 44% of the patients were complicated by recurrence following failed surgical excision, and 1 patient had up to 7 previous excisions.
In 1972, Work categorized FBCA into type 1 and type 2 anomalies. Work type 1 anomaly usually presents in the very young children as a thin-walled, soft mass protruding in the external auditory canal (EAC) almost causing complete occlusion. The Work type 2 anomaly presents at a somewhat later age as a fistulous opening within the Poncet area , where it is bounded superiorly by the EAC, anteriorly by the mental region, laterally by the parotid region, inferiorly by the hyoid bone, and posteriorly by the upper part of the sternocleidomastoid muscle (SCM). Olsen et al proposed another classification and divided the anomaly into cyst: no opening; sinus, 1 opening; and fistula, 2 openings. Chilla and Miehlke distinguish 3 subtypes of FBCA according to their anatomical relationship with the facial nerve (FN): type 1 follows a lateral course, type 2 follows a medial course, and type 3 divides the FN.
Surgical excision of the anomalous epithelial tract is generally regarded as the treatment modality of choice . Misdiagnosis could lead to inadequate surgical resection with the ensuing high recurrent rate. Iatrogenic injury of the FN is also possible . A safe complete resection may require complete exposure of the FN, because the lesions can be variably associated with the nerve . Accurate identification and complete resection of the entire epithelial tract is crucial in the prevention of subsequent recurrence.
In 2005, Baatenburg de Jong proposed an “inside-out technique” in treatment of preauricular sinus in 23 patients and had a satisfactory result. This method highlights a (1) small incision, (2) glistening lining (“inside”), and the outer wall of the tract (“out”) are dissected free of the surrounding tissue with magnification, and (3) A primary closure is accomplished easily because of small incision and subcutaneous dissection. However, we have developed the similar technique of microscopic dissection with control of the sinus lumen from within the cyst in managing preauricular sinus and FBCA since 2001.
The purpose of this retrospect review is to present our experience in the management of 8 cases of infected FBCA presenting in the retroauricular area. The microscopic dissection technique with control of the sinus lumen from within the cyst is described. The merit of this method in treating these lesions is also discussed.
2
Materials and Methods
2.1
Subjects
Eight patients with the final diagnoses of FBCA treated in Chang Gung Memorial Hospital, Linkou, Taiwan from March 2001 to March 2008 were included. The records of these patients were reviewed and summarized in Table 1 . This includes sex; age at initial presentation; the side of anomaly; classification according to Work, Olsen, and Chilla; infection status at presentation; inner tract loci; previous history (including surgical intervention and incision and drainage [I&D]); and complication. Diagnoses were mainly made on the basis of the anatomical location and the histopathology of the cyst. Histologic slides were examined to check for the presence of keratinized stratified squamous epithelium, adnexal skin structures, and cartilage. This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital.
| Sex | Age (y) | Side | Work ⁎ | Olsen ⁎ | Chilla ⁎ | Infection | Inner tract opening | History | Complications | |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 10 | R | 2 | Sinus | 2 | Yes | Blind sac, 1 to junction of cartilaginous and bony EAC and 1 blind sac deep to SCM | 1× surgery | No |
| 2 | F | 23 | L | 2 | Sinus | 2 | Yes | Blind sac deep to SCM | 3 × surgery | No |
| 3 | M | 28 | L | 1 | cyst | 1 | Yes | Junction of cartilaginous and bony EAC | 1× I&D | No |
| 4 | M | 19 | R | 2 | Sinus | 2 | Yes | Blind sac deep to SCM | 1× I&D, 1× surgery | No |
| 5 | F | 10 | R | 1 | Fistula | 1 | Yes | Junction of cartilaginous and bony EAC | 3× surgery | No |
| 6 | M | 28 | R | 1 | Sinus | 1 | Yes | Junction of cartilaginous and bony EAC | 2× I&D | No |
| 7 | F | 4 | L | 2 | Sinus | 2 | Yes | Blind sac 1 to junction of cartilaginous and bony EAC and 1 blind sac deep to SCM | 1× I&D, 1× surgery | No |
| 8 | F | 16 | R | 1 | Fistula | 1 | Yes | Junction of cartilaginous and bony EAC | 2× I&D | No |
2.2
Surgical technique procedure of microscopic dissection with control of the sinus lumen from within the cyst
The routine use of an operating microscope is mandatory. It facilitates a more delicate dissection by enabling the identification and following of the epithelial tracts. An elliptical excision of the tract orifice with the minimal inclusion of the surrounding skin is performed initially. The inflammatory tissue around the infected cyst (retroauricular mass; Fig. 1 ) superficial to the SCM can be completely excised without the fear of injuring the FN.
The sinus or fistula content is removed immediately after the sinus is opened with sharp scissors. This enables the sinus to be clearly visualized and followed from both the outside (as in classic procedures) and from the inside ( Fig. 2 ). Each subsequent tract is opened and followed in a similar way until every blind end is identified. Usually, the blind end or the sinus can be found near the junction of cartilaginous and bony portion of the EAC in Work type 1 ( Fig. 3 ) or deeper in Work type 2. Technically, under magnification, the inner glistening cyst lining and the outer wall of the tract can be dissected free of the surrounding infected tissue ( Fig. 4 ).
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