Trans-oral endoscopic approach to exposure of a type IV branchial cleft anomaly sinus tract in the left piriform recess and closure using cauterization and tisseel application.
Co-author: Yi-Chun Carol Liu
Endoscopic Closure of a Type IV Branchial Cleft Anomaly Sinus Tract:
1) After direct laryngoscopy, place in laryngeal suspension using an appropriately-sized lindholm laryngoscope
2) Identify the sinus tract at the apex of the piriform recess
3) Cannulate the tract with a vessel loop to confirm patency
4) Introduce the bugby cautery set at settings of 10-12, and cauterize starting distally to proximally
5) Use the cautery to denude the mucosa surrounding the sinus opening
6) Apply the tisseel glue to the sinus tract and opening
>90% occur on the left side. The pathway for the type IV branchial cleft tract is to begin at the apex of the piriform and travel inferiorly along the trachea but posterior to the thyroid lobe. It loops underneath the aortic arch on the left side or the subclavian artery on the right side before ascending posterior to the carotid artery and over the hypoglossal nerve. It ends at the anterior border of the sternocleidomastoid muscle usually low in the neck.
Complications of endoscopic closure of a type IV branchial cleft anomaly include bleeding, persistence of infection and fistula, dysphagia, injury to the recurrent laryngeal nerve and possibly external branch of the superior laryngeal nerve with subsequent sequelae, and injury to adjacent major vasculature