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TUBERCULOSIS OF COLLAURAL FISTULA PRESENTING AS

PAROTID ABSCESS
*Manish Chandra, **Rajeev Krishna Gupta, ***Ritika Bhatt
ABSTRACT
Collaural fistula is a rare 1st branchial cleft anomaly having 2 openings, one in external auditory canal and other
in upper part of neck.We present a case of 10 year old male boy who presented with swelling on left side of neck
in infraaural region and pit like depression in the conchal bowl on lateral most part of left external auditory
canal.Postive AFB smear of aspirated pus confirmed the swelling to be tubercular abscess.CECT neck demonstrated
a fistulous tract from left external auditory canal traversing through the parotid to upper part of neck with
parotid abscess.The rarity and diverse presentation of 1st branchial cleft anomalies have frequently led to
misdiagnosis and inappropriate treatment.We aim to highlight the clinical features of this case which can aid in
diagnosis of 1st branchial cleft anomalies.
Keywords: Collaural fistula, branchial cleft, parotid abscess.
CASE REPORT:
st

Anomalies of 1 branchial cleft includes


preauricular cysts, preauricular sinuses, collaural fistula
and branchial fistula.1 st branchial cleft anomalies
accounts for less than 8%of all branchial anomalies1.
Though these congential anomalies are not a major
problem to patient,they can become site for repeated
infection which is troublesome to a patient.Misdiagnosis
of these anomalies result in inadequate treatment,
subsequent reoccurance and definitive surgery becomes
complicated2. A highindex of suspicion, carefull history
along with thorough examination is required to make
diagnosis.
A collaural fistula is rarest of 1st banchial cleft
anomalies and is formed because of failure of resorption
of ventral part of 1st branchial groove.It courses from
external auditory meatus or tragal notch down into
neck.Opening in neck lies between angle of mandible
and sternocleidomastoid. Both the opening differ in
location in every patient. The track runs through the
parotid gland and may pass medial to lateral to or
through the facial nerve.Sinogram and Contrast
enhanced CT Sinogram help to delineate the course of
tract. Management is surgical exploration and excision
of defect with preservation of facial nerve and to
reconstruct otological structures if necessary.

A 10 year old male patient came to the OPD with


swelling on the left side of neck below and behind the
left lobule since 2 months.The swelling was painless,
progressive in size.There was history of on and off
discharge from an opening in external auditory canal
since childhood.There was history of recurrent bouts
of skin infection in upper part of neck which
responded to antibiotic treatment. On examination,
swelling was present on the left side of neck in infraaural
region and an opening was seen at 6oclock position on
conchal bowl on lateral side of left external auditory
canal(Fig1&2). There was excoriation of skin around the
opening in external auditory canal. Bilateral tympanic
membrane were intact.
A sinogram demonstrated a linear sinus tract from
infraaural region extending upto 2nd molar, probably
coursing through the terminal branches of facial nerve,
Affiliations:
*Assistant Professor,.**Resident, ***Resident,
Eras Lucknow Medical College, Lucknow.
Address of Correspondence:
Dr. Rajeev Krishna Gupta
Resident, Department of ENT
Eras Lucknow Medical College & Hospital,
Sarfarazganj, Hardoi road, Lucknow-226003
Email- dr.rajeevgupta11@gmail.com
Mobile No-94506890745.

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Vol.-9, Issue-II, July-Dec. - 2015

INTRODUCTION

on left side, suggestive of fistulous communication with


parotid duct and gland.
CECT neck demonstrated a fistulous tract from
left external auditory canal traversing through the
parotid to upper part of neck with collection in
superficial lobe of left parotid suggestive of parotid
abscess(Fig3).
Pus was aspirated from neck swelling and sent for
culture and sensitivity and AFB. Pus smear was positive
for acid fast bacilli. Montoux test was positive. Routine
investigations were within normal limits except for
raised TLC and ESR. No investigations regarding HIV
infection suggested any positivity.
After full course of antitubercular treatment
surgery was planned.Fistulous tract was completely

Fig 3. Axial cut CECT showing parotid abscess

excised with a small cuff of external ear canal cartilage


and skin, with primary closure.
DISCUSSION:

Vol.-9, Issue-II, July-Dec. - 2015

Fig 1. Opening on lateral side of left external auditory canal

Pharyngeal arches are rod like thickening of


mesoderm present in the wall of embryonic foregut.
In the interval between two arches on inside lies the
endodermal pouches and outside lies the ectodermal
clefts. Initially there are six arches, but the fifth is
vestigial and disappears. Four branchial pouches
internally and four branchial grooves (clefts) externally,
separate the remaining five branchial arches. The
branchial apparatus were first described by Von Baer
while its anomalies were first described by Von
Ascheroni 3 . Anomaly of 1 st branchial cleft are
uncommon and account for less than 8 percentage of
all the branchial abnormalties. Collaural fistula is 1st
branchial cleft anamoly. Collaural fistula accounts for
less than 5% of branchial cleft anomalies.
Although congenital in origin, first branchial cleft
anomalies can present later in life, at a mean age of 18.9
years (range, 20days to 82 years)1. Presenting symptoms
include recurrent otorrhoea in absence of chronic otitis,
cystic swelling or discharge from the fistulous opening.
There may be history of ottitis externa, incision and
drainage of abscess around the ear.

Fig 2. Opening seen on upper part of neck.


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On examination opening of fistula can be


appreciated as pit in external auditory canal and higher
up in neck. In our case fistulous opening in external
auditory canal was quite obvious. Fistulous opening in
external auditory canal is present in only 44% of patient

Sinogram and contrast enhanced CT sinogram


help to delineate the course of tract.
The relationship of 1st branchial cleft anomalies
to facial nerve is variable. In a study of 10 patient, 7
lesions ran medial to facial nerve,2 were lateral and 1
ran between the branches of facial nerve4. Because of
close relationship to facial nerve, excision of these
anomalies requires identification and a wide exposure
of nerve along with facial nerve monitoring5.
After acute infective episode has cleared, surgical
exploration and excision of defect is definitive
treatment. This should be followed by repair of excised
auditory canal. Tuberculosis of parotd gland is
uncommon and only 100 cases have been reported in
literature in immuno competent patients6. In our case
we did not notice any features of HIV. The infection
of TB of collaural fistula might be primary which is
very very to occur in literature to be reported.

DISCLOSURES
(a)
(b)
(c)
(d)

REFERENCES:
1.

DSouza AR, Uppal HS, De R and Zeitoun H.


Updating concepts of first branchial cleft defect :
a literature review. International Journal of Pediatr
Otorhinolaryngology2002; 62 :103-109.

2.

Siddiq M A. Emerg. Med. J. 2003; 20: 103-104.


doi:10.1136/emj.20.1.103.

3.

De PR, Mikhail T. A combined approach excision


of branchial fistula.

4.

Solares CA, Chan J, Koltai PJ. Anatomical


variations of the facial nerve in the first branchial
cleft anomalies.Arch Otolaryngol. Head Neck
Surg. 2003; 129: 351-5.

5.

Triglia JM, Nicollas R, Ducroz V, Koltai PJ,


Garabedian EN. First branchial cleft anomalies: a
study of 39 cases and a review of the literature.
Arch Otolaryngol Head Neck Surg. 1998; 124:
291-5.

6.

Rangel AL, Coletta RD, Almeida OP, Graner E,


Lucena A, Sadiva PH, Vargas PA. parohd
mycobacteriosis is frequently caused by
mycobacterium tubercubsis in advanced AIDS.
J. oral pathol. med. 2005, Aug; 34(7): 407-12.

CONCLUSION:
Branchial cleft anomalies can present as
preauricular or postauricular or high in neck cyst,
sinuses or fistulous tract. Collaural fistula presents with
two openings one in external auditory canal and other
in upper part of neck.Although congenital in origin,
these can present latter in life. A high index of suspicion,
carefull history and thorough clinical examination is
helpful in making diagnosis. Surgical excision of defect
is treatment of choice after full treatment with
antituberculor drugs.

Competing interests/Interests of Conflict- None


Sponsorships - None
Funding - None
No financial disclosures

Vol.-9, Issue-II, July-Dec. - 2015

and even if present it may not be obvious4. There can


be associated otological anomalies.

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