Third branchial anomalies: Avoiding recurrences

Lateral cervical cysts, sinuses, and fistulas have been described as anomalies of the normal development of the branchial apparatus. Third branchial apparatus anomalies are rare and constitute less than 1% of all such cases. Three cases of third branchial cleft cysts and sinus tracts are presented. Two patients had previously undergone multiple attempts at extirpation. Complete removal of recurrent branchial anomalies is difficult because of scarring and fascial plane disruption. Recurrences were often the result of inadequate excision, possibly of the tract communicating with the piriform sinus. To avoid this we advocate endoscopy prior to initial resection of a suspected branchial cleft anomaly to identify any pharyngeal communication. A combined, simultaneous endoscopic identification of the piriform sinus tract with a lateral external cervical dissection facilitates complete resection. In recurrent cases, wide-field extirpation of the cyst, tract, and scar tissue is necessary to ensure complete removal of the branchial cleft anomaly. A review of the literature and of branchial apparatus embryology is also presented.