From the Research
The surgery to address a branchial cleft fistula is complete surgical excision of the entire fistulous tract, as supported by the most recent and highest quality study 1. This procedure involves making an incision along the anterior border of the sternocleidomastoid muscle, carefully dissecting and following the entire tract from its external opening on the neck to its internal termination, which may be in the pharynx or tonsillar fossa. The key points to consider in this procedure are:
- Complete excision of the fistulous tract is necessary to prevent recurrence, as any remaining epithelial tissue can lead to reformation of the fistula 2.
- The procedure is typically performed under general anesthesia and may require a step-ladder approach with multiple incisions if the tract is extensive.
- Preoperative imaging such as CT, MRI, or fistulography is often used to map the course of the fistula, although it may not always be necessary 1.
- Postoperatively, patients may need antibiotics to prevent infection, and drainage tubes might be placed temporarily.
- Recovery usually takes 1-2 weeks, with minimal scarring if the incisions follow natural skin creases.
- Complete excision is necessary because branchial cleft fistulas are lined with epithelium and represent embryologic remnants of the branchial apparatus that failed to involute during fetal development 3. Some studies have suggested that tonsillectomy may not be necessary in all cases 4, 1, and the approach to the internal opening can be tailored to the individual patient's anatomy. Overall, the goal of surgery is to completely remove the fistulous tract while minimizing morbidity and preserving surrounding neurovascular structures, as demonstrated in the largest series of branchial cleft fistulae excised using a uniform technique 2.