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Branchial cleft anomalies remain controversial because of their complexity and the changing anatomical relationships which occur during embryological life.

First branchial cleft anomalies are frequently not recognized clinically because of quite low incidence, less than 1% of all branchial cleft anomalies. For the proper diagnosis and appropriate treatment, the understandings of the embryological development and the related surgical anatomy of this anomaly are essential.

The surgical approach always includes the probability of facial nerve exposure and protection because of the variable relation to the nerve.