Branchial Sinus Fistula

Branchial sinus/ fistula

Branchial fistula or branchial sinus is an abnormal (present since birth) tract of the body that develops as a result of the incomplete closure of the embryological branchial apparatus.

• Sinus has a single opening (typically on the skin)
• A fistula contains two holes (one on the neck and the other internally)

These are the tracts mostly of the second branchial arch. They might go without any notice over a period of years until infection, discharge or swelling takes place.

Branchial Sinus/Fistula types

First Branchial Cleft Sinus/ Fistula

• Located above the ear or the ear canal.
• Runs close to facial nerve
• May bring about frequent ear infections or swelling.

Second Branchial Cleft Sinus/Fistula (Most common)

• In most cases, it opens at the lower part of the neck and lies anterior to the sternocleidomastoid muscle. 
• The internal opening can be close to the tonsil.
• Most prevalent among children and young adults.

Third Branchial Cleft Sinus/Fistula (Uncommon)

• Tracks to the pyriform sinus
• Has potential to cause repeated neck infection or abscess to the thyroid region.

Very Rare -Fourth Branchial Cleft Sinus/Fistula

• Forms around the thyroid or pyriform sinus
• Presents with deep neck recurrent infections.

Branchial fistula symptoms

A branchial fistula is a defective, congenital, tract that contains two holes; one on the skin of the neck and the other inside (typically, around the throat). The symptoms will be dependent on the kind, duration, and infection or not.

Common Symptoms:

Persistent Neck Discharge

• Mucus or purulent discharge of watery nature, out of a small opening in the neck.
• Most common complaint
• Increase of discharge can be associated with upper respiratory infections.

Small Opening in the Neck

The pinpoint hole is usually found:

• On the anterior margin of the sternocleidomastoid muscle (SCM) in 2nd arch fistulas.
• Along the ear in 1st arch lesions.
• Frequently there since childhood, though not realized until then.

Recurrent Neck Infections

• Recurring swelling, reddening, pain.
• Infection can be quenched with antibiotics and recurs.
• May develop abscesses when untreated.

Neck Swelling

• Localised swelling of fistula tract.
• Possibly sensitive to infection.

Activity Discharge

Infrequently, discharge is elevated and:

• Eating
• Drinking
• Coughing

Because of pressure alterations in the throat (true internal fistulas are observed)

Skin Irritation

• Chronic moisture causes rashes, itching, or crusting of the outer opening.

Branchial sinus treatment

Branchial sinus is an epithelial-lined tract that has one external opening on the neck. It can be asymptomatic over years but usually occurs with intermittent discharge or infection. Surgical removal of the sinus tract is a definite treatment.

First Line of Management (During Infection)

A sinus may get infected and painful before a surgery.

Antibiotics

• Adjunctive use to treat acute infection.
• Prescription of oral antibiotics can be made.
• In case of abscess present - drainage might be needed.

Warm Compress & Local Care

• Helps reduce swelling
• Keep the area clean and dry

Do Not Operate in an Acute Infection

• The surgery is preferably performed when one is cured of infection to prevent complications and guarantee total removal.

Absolutes Therapy Surgical Excision

• Only operation is Permanent Cure.

Purpose of the Operation: 

• Remove entire sinus tract
• Avoid readmission or infection.
• Prevent scarring or abscesses.

Branchial fistula surgery

• A branchial fistula is a congenital tract which has two openings: an external one on the neck, and an internal one (usually in the tonsil or pyriform sinuus).
• The effectiveness of the only permanent cure is the surgical removal of the whole fistula tract.

Indications for Surgery

• Itching behind the neck intermittently.
• Recurrent neck infections
• Cosmetic concerns
• Medical management failure.
• Predating Prevention of abscess and scarring

Preparation before Surgery

Control Active Infection

• Antibiotic use during infection.
• Surgery is postponed till swelling and infection subsides.

Imaging (If Complex)

• Ultrasound – initial mapping
• CT/MRI- in case of deep or recurrent fistulas.
• Fistulogram/Sinogram- dye to trace the tract.
• Endoscopy- to identify internal opening 3rd/ 4th arch fistulas.

Anaesthesia Evaluation

• General anaesthetic surgery.

Branchial Fistula Surgery Operation

Total Duration

• Depending on the depth and complexity 1-2 hours.

Procedure

Anaesthesia

• General anaesthesia and intubation. 

Recognition of External Opening

• Marking of the skin opening
• To trace the tract, Dye (as methylene blue) or a probe can be used.

Incision

• The incision is carried out along a natural neckline, and the incision has a minimum scarring.
• In the long tracts, several incisions in the form of steps can be carried out.

Dissection of the Tract

• Surgeon tracts him cautiously up.

Fistula tract may include between major structures of the neck including:

• Carotid sheath
• Hypoglossal nerve
• Glossopharyngeal nerve
• Cranial nerve VII (first arch lesions)

Identification of Internal Opening

• In case of second arch fistula: the extremes are towards tonsillar fossa.
• Third/fourth arch fistula terminates in pyriform sinus
• Endoscopic guidance can be used by the surgeon to seal or cauterize the internal opening.

Complete Removal

• Whole fistula tract is removed.
• Internal opening is ligated or cauterized.

Closure

• Overlays with absorbable sutures.
• Small drain can be used in case of extensive dissection.

Post-surgery Care and Rehabilitation

Hospital Stay

• Typically 1 day, occasionally same day discharge.

Pain & Recovery

• Mild neck pain for 3–5 days
• Within 1 week, the swelling subsides.
• Return to school/work: 3–5 days
• Complete healing: 2–3 weeks

Wound Care

• Keep dressing dry
• Should not rub or stretch the neck.
• Visit to check the wound and remove the drain (in case of its use)

Best hospital for branchial sinus fistula India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

One of the congenital tracks that result in repeated neck discharges and infections is a branchial fistula; this condition fails to clear on its own. Although antibiotics have a role to play in curing acute infections, the only sure way of treatment is a full surgical excision of the entire fistula tract and sealing the internal aperture. The operation is safe and very effective, and when carefully dissected and operated on with appropriate preoperative assessment, the operation has very good long-term results and the lowest recurrence rates. Treatment at an early stage will help avoid recurrent infections, scarring, and complications and will guarantee a more efficient healing process and higher quality of life.

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FAQ

Is branchial fistula curable with medication alone?

• No. Antibiotics may give temporary control of infection, but the only way to remove the fistula is by surgery.

At what age can operation be done?

• It is ideal to operate on children after 6 months of age and on adults at any age.

Will there be a scar?

• Yes, but the surgeon typically cuts in a natural neck fold for minimal cosmetic scarring. 

Can the fistula recur after removal?

• Recurrence is extremely rare (<5%) if the full tract and internal opening are all excised.

Can I eat normal food after the surgery?

• Yes. The majority of patients are able to go back to their normal diet that same day unless otherwise noted.

Isn’t the surgery dangerous?

• The procedure is generally safe when performed by a skilled ENT/head–neck surgeon. Complications are rare.