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.
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Figure 1 Study population and
inclusion/exclusion algorithm