Preoperative and intraoperative workup
Operative indication was based on anamneses, prior infections /neck swelling, clinical presentation and ultrasound or a MRI/CT to state the diagnosis of a BCA. In case of an existing fistula, excision of the skin duct and preparation along the tract with full extirpation was performed. Unilateral tonsillectomy was only performed, when a tract to the tonsillar fossa could be identified.
By way of illustration, a second branchial cleft cyst in a female pre-tonsillectomized patient was operated over a modified neck dissection approach and transoral transection of the tonsillar region. The cyst had contact with the tonsillar fossa on the right side. (see Figure 2 and Figure 3)

3 Results

The data of 160 patients (48,75% female; 51,25% male) included, comprised a median age of 35 years [3M;83yrs]. The grouped age distribution is shown in Table 1. We could integrate 17 patients (10,6%), with a lateral branchial cleft fistulae, whereas the rest of 143 patients (89,4%) included, had a lateral branchial cleft cyst. Within the BCA, 54,37% were located on the left, and 45,63% located on the right side.
Due to Robbin‘s neck level [23] the most of BCA were located in the Level II (76,3%), followed by Level III (16,2%), Level I (2,7%), IV (2,0%) and V(1,4%), whereas 1,4% couldn’t be associated with a concrete Level.
When looking at the two BCA cohorts, within the fistula group, ipsilateral tonsillectomy was performed in 6 out of 17 patients (35,3%) and in 2 out of 143 patients within (1,4%) the branchial cleft cyst group. So, overall 8 out of 160 patients (5%) underwent ipsilateral simultaneous tonsillectomy.
Due to recurrence rate, we found relapses in 2 surgically treated patients within the branchial cleft cyst group (1,4%) and none within the branchial cleft fistula group, with a mean follow up of 31 months (26,9% readmission rate). Within the branchial cleft cyst group, 1 out of 2 patients underwent ipsilateral tonsillectomy, the other had no tonsillectomy. We could not prove a statistically significant difference in the recurrence-rate between the groups with or without tonsillectomy.

4 Discussion

The aim of this work was to figure out, whether the recurrency rate of BCA, where a tonsillectomy was performed, was lower than those BCA, where no tonsillectomy was performed. If this were the case, a simultaneous tonsillectomy during the extirpation of BCA would have been recommendable. In general, the recurrence rate of BCA after surgical excision is low. Within our data, in 2 out of 160 (1.25%) patients, we found BCA recurrency after surgical treatment. Both recurrency cases were evident within extirpated branchial cleft cysts (N=143), no recurrence occurred within the branchial cleft fistula group (N=17).
In literature, BCA recurrency-rates ranges from 0 to 4%. [13, 14, 21] Due to the low recurrency-rate within our data, a consistent conclusion cannot be drawn. To statistically achieve that, at least 30 recurrences would have been necessary, corresponding to a total number of cases of 2150.
The analysis of our data depicted, that tonsillectomies were performed in a reluctant manner. Tonsillectomies were solely performed in cases, where a fistula ended in the tonsillar fossa. This conservative behaviour is explained by the risk of postoperative bleeding, which is described in an occurrence-rate between 1,9% and 6% after tonsillectomies. [24, 25] Given the fact that recurrence-rate of BCA is lower to the risk of postoperative bleeding in tonsillectomy, the standardized ipsilateral tonsillectomy should be avoided. In our opinion, even in an residual tract in contact to the tonsillar fossa, tonsillectomy can be avoided due to the risk/benefit ratio, in accord with other authors. [5, 15-18]
Moreover, our data showed that 22.2% of patients that were initially suspected to have a BCA, in fact had a different diagnosis, that was of either benign or malignant histopathology. Eventhough we excluded those patients from our analysis we think, the reason for this was, that many of the patients were referred to the ENT department by either general practitioners or resident ENT specialists, that do not have the proper equipment to run necessary diagnostics. Further, preoperative diagnosis of cystic lateral neck masses can be crucial.
A weakness of our study is a certain loss-of-follow-up, which cannot be numericized. The underlying cause is the chosen study design. We do not know, whether all treated patients in the tertiary academic ENT department were readmitted to the same hospital in case of BCA recurrency. Furthermore, there is a chance, that some patients still relapse in the future. These factors could explain, why the recurrence rate within our data is lower than in literature about this topic.

5 Conclusion

The performance of an ipsilateral simultaneous tonsillectomy in the surgical workup of BCA cannot be recommended at the basis of our data due to the risk/benefit ratio.

6 References

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Figure 1 Study population and inclusion/exclusion algorithm