Many children experience swelling in the neck at some point, often the result of swollen lymph glands from a bacterial or viral infection. Though some patients will have an abscess that requires drainage, when the infection goes away, the swelling usually does as well. But for a rare few, the swelling comes from another source altogether: a branchial cleft fistula.

 

These openings occur when one or more of the pharyngeal arches—which eventually become cartilage, bone, blood vessels, and muscles—forms abnormally during development, leaving behind a sinus. This anatomical anomaly often goes unnoticed. But eventually, some patients’ fistulas become infected, necessitating treatment. However, notes pediatric otolaryngologist David Tunkel, many branchial cleft fistulas as a cause of infections often go undiagnosed, even if they recur in the same location.

 

When a patient has recurring infections in the neck, he says, imaging can reveal the telltale marks of an abnormal sinus. In the past, open surgery to remove the sinus or cyst, or to close off this gap connecting the pharynx and the neck, was the treatment of choice. However, open surgery comes with a host of drawbacks. These fistulas can be associated with important nerves, such as the facial or laryngeal nerve, thus open surgery significantly increases the risk of weakness or even paralysis. Recovery time can include several days with drains in place, a delay before patients can resume a normal diet, and substantial pain. This treatment can also be difficult because of scar tissue left by prior drainage surgery.

 

Tunkel and colleagues across the country now prefer treating many branchial cleft fistulas with endoscopic surgery, using a laser or cauterization to eliminate these openings. Unlike open surgery, this option is usually an outpatient procedure done by exposing the fistula in the hypopharynx with scopes. By the same night, patients are often home drinking normally with little or no pain medicine.

 

“Another nice thing about the endoscopic procedure is that you burn no bridges,” Tunkel says. “Because little scar tissue develops, if another infection develops years later, you have the option of performing another endoscopic surgery or open surgery then.”

 

Tunkel has been offering the endoscopic procedure to patients for 15 years. Although he counsels patients that there’s a small chance of recurrence after treatment, he has rarely seen a repeat infection in any of his patients during that time.

 

“It’s extremely gratifying,” he says, “to work at a place where I can offer this level of care.”