Primary branchial cleft carcinoma is a diagnostic challenge. The majority of cases have been shown, following the application of rigid criteria, to have developed from an occult metastasis elsewhere.

We describe what we believe to be only the second reported case in a patient who fulfils all of the established criteria.

Second branchial cleft and pouch anomalies are by far the commonest of the branchial anomalies. In most cases, however, there is a unilateral cleft sinus. A complete fistula with external and internal openings is rare. We present a case with a complete branchial fistula in which the tract was followed from the neck to the tonsillar fossa using a combined approach.

Congenital first branchial cleft fistulae, their embryology, anomalies, varied relationships to the facial nerve and surgical techniques for their excision have been well described in the literature. We report a case of a type II first cleft fistula in a three-year-old child which required a modification of the standard surgical approach to achieve safe and complete excision with identification and preservation of the facial nerve.

Four cases of first branchial arch defects are presented. The literature relating to such defects is reviewed and a possible embyrogenic mechanism is proposed with particular reference to the disposition of the facial nerve. The classification of these defects into Types I and II by Work (1972) is supported