Endoscopic‐Assisted Transcervical Excision of Second Branchial Cleft Anomalies in Young Children

Abstract

We describe an endoscopic‐assisted transcervical technique for excision of second branchial cleft anomalies in young children. In three cases (ages 2–8), this approach allowed safe identification and ligation of the tracts while providing improved visualization and allowing smaller incisions. Endoscopic assistance may be an effective alternative to traditional wide transcervical excision.

1. Introduction

Branchial cleft anomalies are among the most common congenital neck masses and result from failure of involution of the pharyngeal clefts during embryologic development, leading to persistent ectoderm‐derived cavities that may present as cysts, sinuses, or fistulae. Most anomalies arise from the second branchial cleft and typically present as fluctuant masses adjacent to the sternocleidomastoid muscle. However, branchial cleft anomalies may arise from any cleft and often follow predictable anatomic paths based on known embryologic development patterns [1].

Because branchial cleft anomalies are prone to recurrent infection, definitive management involves complete surgical excision of the tract. Surgical treatment often includes a transcervical approach to excise the majority of the tract, with transoral approaches used as needed to ligate or cauterize sinus openings into the upper aerodigestive tract. Traditional transcervical approaches typically require incisions spanning several centimeters to allow adequate open visualization of the tract and surrounding structures, which can result in visible scarring. In pediatric patients, scar burden is a particularly important consideration and may negatively affect quality of life.

Minimally invasive head and neck surgical techniques have become increasingly common and have been applied with greater frequency to transcervical procedures. These approaches often incorporate endoscopic assistance through small transcervical portals, allowing enhanced visualization of anatomic structures while minimizing tissue trauma, facilitating rapid recovery, and improving cosmetic outcomes [2]. Although early case series—largely involving adult patients—have demonstrated the feasibility of endoscopic‐assisted excision of branchial cleft anomalies, this technique remains underutilized and has not been reported in children younger than 10 years. Endoscopic assistance may improve aesthetic outcomes and reduce surgical morbidity while preserving the ability to achieve complete tract excision. In this study, we describe our experience with endoscopic‐assisted excision of branchial cleft anomalies in a pediatric population younger than 10 years.

2. Methods

Informed consent was obtained from the parents or legal guardians of all patients included in this study. Institutional Review Board approval was obtained prior to study initiation.

2.1. Pre‐Incision Considerations

Antibiotics are administered prior to incision. Patients are transorally intubated for the procedure. In cases with cutaneous fistulae, a small punctum typically defines the external component of the anomaly and may be cannulated with a lacrimal probe or large monofilament suture to establish tract depth. Methylene blue is then injected through a 22‐gauge angiocath‐tipped syringe to enhance visualization of the tract in relation to surrounding structures.

2.2. Surgical Steps

The surgical technique is described below and demonstrated in Video 1 (endoscopic‐assisted excision of branchial cleft anomalies in young children).

VIDEO 1.

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Endoscopic‐assisted excision of branchial cleft anomalies in young children. Video content can be viewed at https://onlinelibrary.wiley.com/doi/10.1002/lary.70533.

A small skin incision is marked within a natural skin crease and infiltrated with local anesthetic containing epinephrine to aid hemostasis. The incision is sized to allow adequate range of motion and instrumentation adjacent to the endoscope. When a sinus tract (or fistula) opening is present, the skin excision is performed in a fusiform manner to incorporate the punctum into the specimen. Lacrimal probes are used to cannulate the sinus tract, and optionally methylene blue may be injected into the sinus tract with an angiocath to improve visualization of the tract and lumenal extent during dissection.

Initial dissection is performed under direct visualization using a combination of blunt and sharp techniques along the capsule of the anomaly, aided by methylene blue staining of the tract lumen. The capsule and tract are gently retracted from the neck to identify deeper components extending toward the pharynx.

When further dissection cannot be safely performed under direct vision, the 4‐mm, 0‐degree endoscope is introduced through the incision, and external to the tract. Deeper dissection proceeds under endoscopic visualization. An assistant maintains traction on the anomaly to provide tension (Figure 1), facilitating delineation of the tract from surrounding structures and aiding blunt dissection (Figure 2). This further aids in reducing the tortuosity of the tract. Bleeding control is achieved via standard techniques, primarily via electrocautery under endoscopic visualization. At the distal extent, the tract is ligated with a surgical clip and divided (Figures 3 and 4). The specimen is submitted in formalin for pathologic analysis.

FIGURE 1.

Branchial cleft tract is kept on tension throughout the procedure using Langenbeck retractor and Allis clamp.

FIGURE 2.

Skeletonization of tract using tonsil hemostat forceps.

FIGURE 3.

Distal end of tract and relative anatomical landmarks.

FIGURE 4.

Ligation of distal end of tract using medium clip applier.

The skin incision is closed in layers using absorbable sutures. A postoperative CT scan may be considered 6 months after excision to visualize the radio‐opaque surgical clips at the terminus of dissection and assess for residual pathology.

3. Results

Between 2023 and 2025, three pediatric patients aged 2, 3, and 8 years underwent primary endoscopic‐assisted excision of branchial cleft anomalies at our institution. Indications for surgery included recurrent infections and persistent drainage from cutaneous pits concerning for second branchial cleft anomalies.

Skin incisions ranged from 2.0 to 3.1 cm, tailored to lesion size and tract complexity (Figure 5). No intraoperative complications occurred. The 2‐ and 8‐year‐old patients recovered uneventfully and were discharged the same day. The 3‐year‐old patient underwent bilateral first and second branchial cleft anomaly excisions and experienced postoperative nausea and vomiting, requiring overnight admission. He was discharged the following day in stable condition.

FIGURE 5.

Surgical marking prior to excision (left) and healed incision at follow‐up (right) on different patients.

Pathologic specimen length ranged from 3.5 to 6.2 cm, reflecting variability in fistula extent. Final pathology confirmed branchial cleft anomalies in all cases.

All patients have had a median post‐operative follow‐up time of 9 months (range from 2 months to over 2 years), with selective imaging obtained based on clinical concern and need for surveillance. The 2‐year‐old patient underwent contrast‐enhanced CT at 8 months postoperatively, demonstrating no residual tract or recurrence (Figure 6). At each patient's last clinical follow‐up, no wound complications or evidence of persistent or recurrent disease were identified. Patients continue routine longitudinal follow‐up with their primary care physicians for ongoing surveillance.

FIGURE 6.

Postoperative CT can be used to monitor for disease recurrence medial to the surgical clip (axial view left, coronal view right).

4. Discussion

This study demonstrates the feasibility of an endoscopic‐assisted transcervical approach for branchial cleft anomaly excision in the youngest reported pediatric patients, including children as young as 2 years. Compared with loupes, the rigid endoscope provides superior illumination and magnified visualization deep within the wound [3]. This enhanced visualization may allow for a more precise dissection through a smaller incision without the need for additional exposure. Use of the endoscope also improves surgeon ergonomics, as visualization is obtained on a monitor rather than requiring sustained neck flexion or alignment with the operative field. Together, these advantages facilitate controlled dissection along the tract while maintaining excellent visualization, particularly in deeper or narrower surgical corridors.

Previous case series have shown endoscopic‐assisted branchial cleft anomaly excision to be safe and effective in adult and adolescent populations. In one adult case series, endoscopic‐assisted excision via a transcervical incision was performed through significantly smaller neck incisions (2–2.5 cm; n = 8) compared with standard open approaches (2–6 cm; n = 10; p = 0.006), without significant differences in cyst diameter or operative time between groups [3].

A review of the published literature on transcervical endoscopic‐assisted branchial cleft anomaly excision, encompassing 38 patients, identified only two reported complications: one transient great auricular nerve palsy and one transient marginal mandibular nerve palsy, both of which resolved spontaneously [3, 4, 5]. No long‐term complications were described, and the youngest previously reported patient was 13 years old. Our experience demonstrates that this approach can be successfully extended to primary excision of second branchial anomalies, a younger pediatric cohort with excellent outcomes. While we have not applied this technique to revision cases, we anticipate similar feasibility with appropriate case‐by‐case consideration.

Endoscopic‐assisted transcervical excision improves visualization compared with the standard open approach and eliminates the need for a stair‐step incision. Future multicenter studies comparing endoscopic‐assisted and standard open transcervical approaches in larger pediatric cohorts may further establish equivalence with respect to recurrence rates, intraoperative complications, and operative time while potentially improving patient satisfaction related to scar cosmesis.

Funding

Dr. Hosam H. Alkhatib and Dr. Shaunak Amin were supported by an NIH/NIDCD R25 Grant (1R25DC021791‐01) during their work on this manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Kieu T. T., Alkhatib H. H., Amin S., Zhou S., and Johnson K., “Endoscopic‐Assisted Transcervical Excision of Second Branchial Cleft Anomalies in Young Children,” The Laryngoscope 136, no. 9 (2026): 4039–4042, 10.1002/lary.70533.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.