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Fistulography: a useful imaging modality for identifying the exact location and extent of complete branchial fistulas.

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The branchial apparatus, which gives rise to a wide array of structures that originate in the cervical area, is organized into arches, pouches (endoderm), and clefts (ectoderm). Developmental abnormalities of this apparatus are a common cause of congenital lateral neck masses. Most often these anomalies are seen in the pediatric population, accounting for 17% of all pediatric cervical masses, (1) but they also may present at a much later age. Most patients present with an intermittent mucoid discharge from a sinus opening in the neck or an acute infection in the lower part of neck with mucopurulent discharge.

A 15-year-old boy presented with a history of whitish discharge from a small opening on the right lower third of his neck since birth. On examination, a small opening was seen on the right side of the neck at the junction of the middle and lower third, just anterior to the sternocleidomastoid muscle. When pressed, it discharged a thick, whitish material. On pharyngoscopy, no internal opening was visualized. A clinical diagnosis of a right branchial sinus was made.

Fistulography was performed for confirmation, in anteroposterior, oblique, and lateral projection under image-intensifier guidance (figure). It revealed a long tract extending from the skin surface and traveling up posteriorly and cranially, entering the lateral wall of the oropharynx in the tonsillar bed. During the procedure the patient tasted dye shortly after it was injected, leading to a diagnosis of complete branchial fistula.

The patient underwent excision of the branchial fistula via a combined transcervical and transoral approach under general anesthesia. Because of the proximity of the tract to the patient's carotid arteries, a vascular surgeon was asked to be present during the operation in case any vascular complication arose. The fistulous tract was excised via a "stepladder" procedure, with two incisions made in the neck. A right-sided tonsillectomy was performed, and the tonsillar fossa was inspected for an internal opening, which was found near the inferior pole. The entire fistulous tract was excised, and the patient had an uneventful recovery. Histopathology of the specimen revealed a branchial fistula tract lined with pseudostratified columnar epithelium. At the 6-month follow-up, the patient was asymptomatic.

In 65 to 95% of cases, branchial anomalies arise from the second arch and may present as a cyst or sinus/fistula, with the former being far more common.' Usually the anomaly is a simple sinus opening that extends up the neck for a variable distance. In rare cases, a branchial sinus is also found to have an internal opening, thus forming a true branchial fistula.

Computed tomography (CT), ultrasound, and fistulography are useful in tracing the fistulous tract. Multidetector CT fistulography recently has been described for diagnosis of branchial fistula. (2) Radiologically demonstrable, complete branchial fistulas up to the tonsillar region are rare. Ford et al documented only 1 case in their series of 98 fistulas in which the entire tract was visualized. (3) The completeness of a fistula can be diagnosed by contrast-enhanced fistulography. It should be noted that sometimes a negative preoperative test becomes positive under general anesthesia because of muscle relaxation. Occasionally the fistula tract may be blocked by thick secretions or granulation tissue.

Fistulography is an effective method of showing the exact anatomy and topography of fistulas in the neck. It is easy to perform and painless. CT and MRI of the neck are also helpful in producing cross-sectional images of organs and other internal body structures (4) and are useful in delineating the relationship between the lesion and surrounding neurovascular structures.

The treatment of choice for branchial fistula is complete surgical excision. A "stepladder" approach exposes the fistula tract with less tissue dissection. In complete branchial fistula, a combined transcervical and transoral approach is preferred.

References

(1.) Kenealy IF, Torsiglieri AJ Jr., Tom LW. Branchial cleft anomalies: A five-year retrospective review. Trans Pa Acad Ophthalmol Otolaryngol 1990;42:1022-5.

(2.) Ryu CW, Lee JH, Lee HK, et al. Clinical usefulness of multi-detector CT fistulography of branchial cleft fistula. Clin Imaging 2006;30(5):339-42.

(3.) Ford GR, Balakrishnan A, Evans IN, Bailey CM. Branchial cleft and pouch anomalies, l Laryngol Otol 1992; 106(2): 137-43.

(4.) Palacios E, Valvassori G. Branchial cleft cyst. Ear Nose Throat 1 2001;80(5):302.

Sampan Singh Bist, MS; Saurabh Varshney, MS; Rakesh Kumar, MS; Nitin Gupta, MS

From the Department of ENT-Head and Neck Surgery, Himalayan Institute of Medical Sciences, HIHT University, Jolly Grant, Doiwala Dehradun, India.
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Title Annotation:IMAGING CLINIC
Author:Bist, Sampan Singh; Varshney, Saurabh; Kumar, Rakesh; Gupta, Nitin
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:9INDI
Date:Sep 1, 2009
Words:740
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