From the Research
Management of a third branchial cleft fistula requires complete surgical excision as the definitive treatment, with a combined therapeutic approach using flexible fiber-optic pharyngoscopy to identify and resect the entry site of the fistula into the pyriform sinus, as described in the most recent and highest quality study 1. The procedure involves identifying the fistulous tract, which typically originates from the pyriform sinus and extends through the thyroid gland to the skin of the lower neck.
- Surgery should begin with a step ladder incision along the anterior border of the sternocleidomastoid muscle, followed by careful dissection to trace the entire tract.
- Complete excision is essential to prevent recurrence, which means removing the tract from its cutaneous opening all the way to its origin at the pyriform sinus.
- This often requires laryngoscopy during the procedure to visualize the internal opening.
- Preoperative imaging with CT, MRI, or fistulography is recommended to map the tract's course, as noted in 2 and 3.
- Patients should receive perioperative antibiotics to prevent infection.
- The procedure is technically challenging due to the tract's proximity to vital structures including the recurrent laryngeal nerve, carotid artery, and jugular vein.
- Postoperatively, patients should be monitored for potential complications including vocal cord paralysis, hemorrhage, and infection, as highlighted in 4 and 5.
- Complete excision is emphasized because incomplete removal leads to high recurrence rates, often necessitating repeat surgery. Key points to consider in the management of third branchial cleft fistulas include:
- The use of a combined therapeutic approach with flexible fiber-optic pharyngoscopy to minimize recurrence rates, as demonstrated in 1.
- The importance of complete excision of the fistulous tract to prevent recurrence.
- The need for careful dissection and identification of vital structures to avoid complications.
- The role of preoperative imaging in mapping the tract's course and planning the surgical approach.