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.

Branchial cleft anomaly excision.
Symptomatic branchial cleft lesions including swelling and recurrent infections. Symptoms may also occur secondary to mass effect such as dysphagia, dyspnea, or pain. The patient may elect for excision for cosmetic improvement.
Active infection is a relative contraindication as it may make complete excision of the anomaly more difficult, particularly if incision and drainage has previously violated the epithelium of the cyst which may make the dissection more difficult.
Standard soft tissue room set-up is used with appropriate trays and standard draping procedures. Additional equipment to consider are Bomwan lacrimal probes and nerve stimulator control unit and instrument (if working near the facial nerve). The fibrin glue injection has two two separate syringes: (1) calcium chloride, and thrombin and (2) aprotinin. An insulin needle is used to inject sterile methylene blue into the syringe containing calcium chloride thrombin at a concentration of 0.01 mL per 2 mL of fibrin glue. The syringes are stirred well and the device is loaded on the coupled syringes according to the manufacturer's instructions.
Often the diagnosis can be made with history and physical examination alone. Ultrasound may assist in characterizing the extent of the lesion which will appear as a uniform, hypoechogenic mass without internal septations. MRI or CT may be used to delineate from other lesions and and assess whether the lesion is invading other structures.
Branchial cleft anomalies result from incomplete obliteration of the cleft (external) or pouch (internal) resulting in a cyst, sinus, or fistula. 2nd branchial cleft anomalies are the most common (70- 90%). The cutaneous portion is located at the lower third of sternocleidomastoid muscle on anterior border. The course of the fistula is superior-lateral to CN IX and XII and between the internal and external carotid arteries. If true fistula, it will connect to the tonsillar fossa internally.
Advantages: -Clearer visualization of fistular tract without spillage of dye into nearby tissue. -Fibrin sealant does not impede the anatomic pathologic examination of the specimen.
Common surgical risks include bleeding, infection, recurrence, and damage to surrounding structures (marginal mandibular nerve, hypoglossal nerve, superior laryngeal nerve, glossopharyngeal nerve).
Piccioni, M., Bottazzoli, M., Nassif, N., Stefini, S., Nicolai, P. Intraoperative use of fibrin glue dyed with methylene blue in surgery for branchial cleft anomalies.Laryngoscope. 2016 Sep;126(9):2147-50. doi: 10.1002/lary.25833.

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

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