Complete branchial cleft fistula: diagnosis and surgical management

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. A complete fistula is a tract that has an internal opening and an external opening. Second branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral tonsil fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. Fistulae are usually clinically apparent after birth with up to 80% being diagnosed before age 5 years. There may be an obvious opening in the anterior neck between the hyoid bone and suprasternal notch. Recurrent mucoid discharge becoming purulent during acute infection or associated with upper respiratory tract infection is the usual course. Treatment is complete surgical excision of all abnormally placed epithelium, while preserving surrounding neurovascular structures, and using cosmetically acceptable incisions. Complete fistulae in adults are rare and diagnosis can be difficult. We present the clinical presentation and surgical management of a long (14 cm) second branchial cleft fistula, in a 25-year-old female. Preoperative CT and MRI scans of the neck clearly demonstrated the fistula. We recommend a "stepladder" or Mc Fee incision and intra-oral pull-through fistulectomy to allow safe and complete excision.