Intraoperative Injection of Methylene Blue Dyed Fibrin Glue For 2nd Branchial Cleft Fistula Excision

The following video depicts the excision of a 2nd branchial cleft fistula in a 12-month-old male. Fibrin glue dyed with methylene blue was used to assist with following the fistula tract to ensure complete excision of the lesion. Branchial cleft anomalies include fistulae, sinuses and cysts and most commonly occur in the lateral neck arising from the second branchial cleft. The patient may be completely asymptomatic, mildly affected or continuously impacted by the lesion. Recurrent inflammation, infections, drainage, and pain are common symptoms associated with these congenital anomalies. Surgery is the standard of care and recommended to alleviate symptoms, but recurrence rates are high, particularly if excision is incomplete. Methylene blue has been used to assist with complete excision of these lesions, but has several key drawbacks including spillage into nearby tissues, incompletely highlighting the lesion, and making the pathological examination more challenging due to significant tissue staining. The addition of fibrin glue to the methylene blue enables for the lesion to be well visualized with the dye without spilling into the adjacent tissue, and thereby reducing the risk of damaging nearby structures. The mixture also allows for efficient pathological examination for correct post-operative confirmation of the diagnosis.