Fig. 7.1
A clinical photograph showing a branchial fistula. Note the location of the external opening at the anterior border of the lower third of the sternocleidomastoid muscle. The internal opening is usually upwards in the tonsillar fossa
These fistulas may be bilateral in 10–15 % of the cases.
Types
First branchial cleft cysts (10–20 %) :
First branchial cleft cysts are divided into type I and type II.
Type-I cysts are located near the external auditory canal.
Most commonly, they are seen inferior and posterior to the tragus (base of the ear) but they may also be in the parotid gland or at the angle of the mandible.
Type-II cysts are associated with the submandibular gland or found in the anterior triangle of the neck.
Second branchial cleft cysts (75–85 %):
This is the most common type.
They are found along the anterior border of the upper third of sternocleidomastoid muscle, passes through the carotid bifurcation, and opens into the tonsillar pillar.
These cysts may present anywhere along the course of a second branchial fistula, which proceeds from the skin of the lateral neck, between the internal and external carotid arteries, and into the palatine tonsil.
Third branchial cleft cysts :
Third branchial cleft cysts are rare.
A third branchial fistula extends from the skin along the anterior border of the lower third of sternocleidomastoid muscle and courses posterior to the carotid arteries, under the glossopharyngeal nerve and over the vagus nerve and pierces the thyrohyoid membrane to enter the larynx, terminating on the lateral aspect of the pyriform sinus.
Third branchial cleft cysts occur anywhere along that course (e.g., inside the larynx), but they are characteristically located deep to the sternocleidomastoid muscle.
Fourth branchial cleft cyst :
Fourth branchial cleft cysts are extremely rare.
A fourth branchial fistula arises from the lateral neck and parallels the course of the recurrent laryngeal nerve (around the aorta on the left and around the subclavian artery on the right), terminating in the apex of the pyriform sinus.
Fourth branchial cleft cysts occur in several locations, including the thyroid gland and mediastinum.
They may present as abscesses in the lower part of the neck, on the left side usually more than the right, and may be associated with infection of the thyroid gland.
Surgical removal may require excision of the upper pole of the thyroid gland along with the connection that goes into the pyriform sinus.
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