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In Reference to Analysis of the Clinical Features and Surgical Outcomes of First Branchial Cleft Anomalies

The article by Yang et al. on the clinical features and surgical outcomes of first branchial cleft anomalies (FBCAs) was very intriguing. They reported that FBCAs accounted for 46% (109/237) of the four cleft types. This contradicts the results of most previous studies reporting an FBCA occurrence <10%. Yang et al. state that their results corroborate with those of the study by Li et al. However, Li et al. reported that the proportion of FBCA cases was 34% (30/87). Moreover, there is a significant difference in the ratios of Work I and II lesions between these two studies (85:24 vs. 18:12). Because the Methods section lacked information regarding the classification into certain types of the branchial cleft anomalies and large share of the FBCA cases from their research had no otologic symptoms and/or relationship with the facial nerve (45% and 66%, respectively), I believe that Yang et al. might not have been entirely accurate in the disease classification. This primarily refers to misclassifying second branchial cleft anomalies as FBCAs because the authors state that FBCAs occur due to incomplete obliteration of the first and second branchial arches. Similarly, the authors point out that the usual anatomical position of FBCAs is in the lateral parts of the neck, although majority of these lesions are found in the periauricular and parotid regions. Furthermore, the study is missing data regarding the histopathological characteristics of FBCAs. It is well known that Work I lesions comprise only ectodermal (squamous epithelium) elements, while Work II lesions have both ectodermal and mesodermal (cartilage) elements. Still, there is no information on the presence of lymph tissue; hence, it is unclear how the authors distinguished between the FBCAs and preauricular pits (hillocks of His anomalies). As seen from the study results, the chief symptoms of FBCAs were periauricular or auricular and upper neck or maxillofacial puncta/draining/ abscess/mass, as observed in 79% and 17% of the cases, respectively. However, these symptoms are also seen in preauricular pits, which occur at similar anatomic locations, are susceptible to infections, and show predominance in East Asian populations (prevalence 10%). From previous experiences, the nomenclature of FBCAs may often be confusing and misleading, especially in lesions located at the anatomic areas bordering the branchial arches. Hence, a more concise and practical classification of branchial cleft anomalies is warranted. One possible way to do this is applying the novel pathoanatomical-based “BN” classification system.