Reporting a Right Sided 4TH Branchial Anomaly, Case Report and Reporting the Technical Issues (original) (raw)

Congenital fistula of the fourth branchial pouch

European Archives of Oto-Rhino-Laryngology, 1998

patients were treated for various head and neck congenital malformations at Saint-Luc University Hospital, Louvain. We report three cases of fourth branchial pouch cysts requiring surgical removal. One of these cases presented with a third branchial pouch remnant on the same side and subsequently a fourth branchial pouch sinus. To our knowledge, this is the first case published in the literature. A fourth branchial pouch sinus tract can become manifest clinically by recurrent episodes of neck abscess or acute suppurative thyroiditis (especially in infants). The tract can be identified with a barium swallow during the period of latency and hypopharyngeal endoscopy under general anesthesia. Total excision of the fistula with dissection up to the pyriform sinus with or without a left thyroid gland lobectomy and isthmectomy is the treatment of choice.

Management of anomalies of the third and fourth branchial pouches

International Journal of Pediatric Otorhinolaryngology, 2004

Third and fourth branchial pouch anomalies are rare and usually present as lateral neck masses, abscesses or with acute suppurative thyroiditis. An opening in the piriform sinus can be identified in most cases. We present four cases of fourth branchial pouch sinuses, one of a third branchial cyst and discuss our management. Cannulation of the sinus tract at laryngoscopy, followed by complete surgical excision, via a modified oblique thyrotomy above the cricothyroid joint after detaching the inferior constrictor was used to treat the fourth branchial pouch anomalies. This surgical approach adequately exposes the piriform sinus apex and also affords protection to the recurrent laryngeal nerve. The third pouch cyst and tract were excised at the level of the thyrohyoid membrane. There were no complications or recurrences.

Fistula of the fourth branchial pouch

American Journal of Otolaryngology, 2003

Most of the congenital anomalies of the branchial apparatus are from the second arch, pouch, and cleft; some are from the first and third arches. Fourth branchial pouch remnants are very rare. We present a rare case of fourth branchial fistula, with characteristic clinical features of recurrent left-sided neck abscess that burst spontaneously, forming a fistula. Diagnosis of fourth branchial pouch fistula was confirmed by contrast radiography (ie, fistulogram and barium swallow) revealing the internal opening in the apex of the left pyriform fossa. (Am J Otolaryngol 2003;24:250-252. The human branchial apparatus comprises 5 paired mesodermal arches, separated by 4 pairs of endodermal and ectodermal invaginations that are called pouches and clefts. A branchial fistula forms when there is remnant of both the pouch and the cleft with rupture of the interposed branchial plate. A sinus is formed when the tract is open either to the gut or to the skin but not both, and a cyst is formed when there is no communication to either of the 2. It has been found that 95% of the congenital anomalies of the branchial apparatus are derived from the second branchial arch, pouch, and cleft. The rest stem from the first and third arch. The remnants of the fourth branchial arch are exceedingly rare. The fistulas of the fourth branchial pouch have an external opening in the neck and the inner opening at the apex of the pyriform fossa. The tract passes from the left lobe of the thyroid, resulting in acute suppurative thyroiditis in most of the cases. 4-6

Fourth branchial cleft anomaly: Management strategy in acute presentation

International Journal of Pediatric Otorhinolaryngology, 2014

Objectives: Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician's decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the "ultima ratio" treatment to avoid recurrence. Methods: We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus. Results: A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis. Conclusion: Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.

Management of congenital fourth branchial arch anomalies: a review and analysis of published cases

Background/Purpose: Congenital fourth branchial arch anomalies are uncommon entities, heretofore described only in case reports, affecting primarily children, and typically presenting as a cervical inflammatory process. The aim of the study was to collect appropriate data on the diagnosis, treatment, and outcome of this condition and to suggest guidelines for its management. Methods: We conducted a structured review of the literature for cases explicitly identified as congenital fourth branchial arch anomalies or meeting anatomical criteria for this condition. We computed descriptive statistics and performed several post hoc 2-way comparisons of subgroups of cases. Results: We located and critically evaluated 526 cases. Fourth arch anomalies were usually located on the left (94%) and generally presented as acute suppurative thyroiditis (45%) or recurrent neck abscess (42%). Barium swallow and direct laryngoscopy were the most useful diagnostic tools. Treatment options differed mainly in recurrence rates: incision and drainage, 89%; open neck surgery and tract excision, 15%; endoscopic cauterization of the sinus tract opening, 15%; and open neck surgery with partial thyroidectomy, 8%. Complications after surgery occurred primarily in children 8 years or younger. Conclusion: Fourth arch anomalies are more common than once thought. Treatment of these disorders with repeated incision and drainage yields high rates of recurrence; thus, complete excision of the entire fistula tract during a quiescent period appears preferable. Combining this surgery with partial thyroidectomy may further decrease recurrence rates. Complications can likely be minimized by using antibiotic treatment of acute infections or endoscopic cauterization in children 8 years or younger, and delaying open neck surgery.

Branchial Anomalies: Diagnosis and Management

International Journal of Otolaryngology, 2014

Objective. To find out the incidence of involvement of individual arches, anatomical types of lesions, the age and sex incidence, the site and side of predilection, the common clinical features, the common investigations, treatment, and complications of the different anomalies. Setting. Academic Department of Otolaryngology, Head and Neck Surgery. Design. A 10 year retrospective study. Participants. 30 patients with clinically proven branchial anomalies including patients with bilateral disease totaling 34 lesions. Main Outcome Measures. The demographical data, clinical features, type of branchial anomalies, and the management details were recorded and analyzed. Results and Observations. The mean age of presentation was 18.67 years. Male to female sex ratio was 1.27 : 1 with a male preponderance. Of the 34 lesions, maximum incidence was of second arch anomalies (50%) followed by first arch. We had two cases each of third and fourth arch anomalies. Only 1 (3.3%) patients of the 30 presented with lesion at birth. The most common pathological type of lesions was fistula (58.82%) followed by cyst. 41.18% of the lesions occurred on the right side. All the patients underwent surgical excision. None of our patients had involvement of facial nerve in first branchial anomaly. All patients had tracts going superficial to the facial nerve. Conclusion. Confirming the extent of the tract is mandatory before any surgery as these lesions pass in relation to some of the most vital structures of the neck. Surgery should always be the treatment option. injection of dye, microscopic removal and inclusion of surrounding tissue while excising the tract leads to a decreased incidence of recurrence.