Excision Of Branchial Cysts

Excision Of Branchial Cysts

Discuss briefly branchial fistula.

• It is persistent precervical sinus between 2nd branchial cleft and 5th branchial cleft having opening in the skin at lower l/3rd of neck on the inner margin of sternocleidomastoid muscle, often ends as a sinus just proximal to the posterior pillar of fauces behind tonsil which is also the site of inner opening when presents as a fitula.
• Fistula runs between the structures related to second and 3rd branchial arches.
  From external opening at skin below,it runs in subcutaneous plane to pierce deep fascia at level of thyroid cartilage; to travel between 2nd arch artery and third arch artery behind posterior digastric belly and stylohyoid; outer to stylopharyngeus, hypoglossal and glossopharyngeal nerves; perforates superior constrictor
• to reach the internal opening.
• Occasionally, acquired branchial fitula can occur due to rupture of or after drainage of infected branchial cyst or incomplete excision of the cyst tract.
  This type of fitula is located outside at skin at the level of upper third of sternomastoid muscle.

• It is a persistent second branchial cleft with a communication outside to the exterior. It is commonly a congenital fitula.
• Occasionally, the condition is secondary to incised infected branchial cyst.
• Often it is bilateral.
• External orifie of the fitula is situated in the lower third of the neckn earth eanterior border of the sternomastoid muscle.
• Internal orifie is located on the anterior aspect of the posterior pillar of the fauces, just behind the tonsils.
• Sometimes fitula ends internally as blind end.
• It is common in children and early adolescent period.
• Equals in both sexes.
• External orifie is very small with a dimple which becomes more prominent on dysphagia with tuck in appearance.
• Discharge is mucoid or mucopurulent.

• Under general anesthesia, methylene blue is injected into the tract.
  • Probe is passed into the fitulous tract.
  • Through circumferential/elliptical incision around the fistula opening, entire length of the tract is dissected until the internal orifie.
  • Care should be taken to safeguard carotids,jugular vein, hypoglossal nerve, glossopharyngeal nerve and spinal accessory nerve.
  • Entire tract should be excised.
• Step-ladder dissection is done using two parallel incisions one below at lower part another above at upper part of the neck, will make dissection easier and complete.