A Case of Type I and Type II First Branchial Cleft Sinus and Fistula

Posted By Iara Lacerda
A Case of Type I and Type II First Branchial Cleft Sinus and Fistula

The diagnosis of head and neck masses and fistulas can be challenging. Differential diagnoses include tumors, infections, or congenital lesions. Knowledge of embryology and anatomy of both common and rare anomalies, as well as indications for imaging, is required for timely diagnosis. We describe a branchial anomaly with atypical presentation as an uninfected “pit” in the earlobe that required multiple procedures to achieve complete resection. Reviewing the challenges experienced in the treatment of this case and the literature, we discuss the role of imaging in surgical planning to avoid incomplete resection, prevent recurrence, and minimize need for multiple procedures. CASE REPORT A healthy 3-year-old girl presented to the Otolaryngology clinic with history of rare moisture draining from a pit in her left earlobe. Though the pit was present since her birth, she passed her newborn hearing test. One prior infection of the earlobe was reported which responded to oral antibiotics. There was a second miniscule pale spot (no opening) under the mandible which has never drained. On physical examination, the left auricle and external auditory meatus were normal without evidence of duplication of the external auditory canal. On the anterior surface of the left earlobe was a 1-mm punctum with no obvious cyst or mass. Scant moisture was expressed when massaged. In the level II neck below the border of the mandible, a 2–3-mm flat, pale spot was noted. On palpation, the left parotid and face were normal without masses or facial nerve paresis. A clinical diagnosis of congenital left earlobe pit/fistula with left neck branchial remnant was made. Surgical excisions of both lesions were offered, and preoperative imaging was not ordered. When elliptical surgical excision for the neck spot was performed, no tract was identified deep to the skin. A separate elliptical incision was made around the ear lobe pit, and a lacrimal duct probe was used to identify potential fistula or tract. The probe only passed about 2 mm and did not lead to any tract, and the wound was closed primarily. The patient presented 3 weeks postoperative with a swollen and erythematous ear lobe with mucopurulent, sticky drainage (Figure 1). Cephalexin did not lead to improvement. The patient was taken to the operating room for incision and drainage of presumed localized wound abscess. Intraoperative exploration within the left earlobe soft tissue showed no identifiable tract or meatus. The wound was loosely closed to allow healing by secondary intention, and the patient was treated postoperatively with a course of antibiotics and topical 2% mupirocin ointment. Cultures for aerobic and anaerobic organisms were negative. The patient developed recurrent symptoms and another excision was performed with extension of dissection to the tragus. After removing all granulation, the surgeon identified a fistula completely lined by skin from the earlobe towards the auricle, appearing to end at th

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