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. Figure 1: Gross specimen showing left earlobe abscess with erythema, edema, and purulent drainage. Figure 2: Coronal T2 weighted fat saturated image through the mid parotid gland. Dark arrow shows the double dark lines representing the walls of the fistula (tubular structure) starting from the lower ear lobe extending medially in a horizontal fashion, diving down dividing the parotid gland (white arrows) into a medial and lateral part. Figure 3: Sagital T2 weighted fat saturated image showing similar finding in a different plane. Black arrow shows the double black tube (fistula) dives anteriorly and inferiorly from the horizontal component of the fistula after making almost a 90-degree angle. The distal end of the fistula ends at the pit of the left mandibular angle. The fistula divides the parotid gland into an anterior and posterior part on this plane. Figure 4: Intraoperative gross specimen: Parotidectomy approach with facial nerve dissected and identified. The entire tubular fistula is found to be deep to the facial nerve. A lacrimal duct probe has been inserted though the fistula (dark arrow) proximally with an Ellis clamp. The fistula ends distally near the mandible. Figure 5: Image with H&E staining at 12.5x magnification. Fistula tract lined by stratified squamous keratinizing epithelium (single-headed arrow) and adjacent parotid gland tissue (double-headed arrow).