Abstract
Fourth branchial cleft anomalies are an exceptionally rare cause of recurrent neck mass in pediatric and adult patients. In this report, we present a case of an infected fourth branchial cleft cyst in a 20-year-old woman that presented with recurrent throat pain and deep neck abscesses. After undergoing repeated incision and drainage procedures, the patient underwent definitive management with direct laryngoscopy, ablation of the left pyriform sinus tract, left hemithyroidectomy, and excision of the branchial anomaly without evidence of recurrence. In addition to diagnosis and management, this case report highlights the unique anatomical relationship between fourth branchial anomalies and the pyriform fossa as well as the superior and recurrent laryngeal nerves.
Highlights
Unlike third branchial anomalies, they terminate at the apex of the piriform sinus and are more intimately associated with the recurrent laryngeal nerve
We report the case of an infected fourth branchial cleft cyst, which presented as a recurrent deep neck infection in a young adult female treated at a large academic center
Intraoperative view of the fourth branchial cleft cyst with fistulous tract coursing beneath the recurrent laryngeal nerve toward the thyroid cartilage/pyriform sinus apex
Summary
Branchial anomalies are believed to arise from incomplete obliteration of the branchial elements. CT neck with contrast demonstrated an ill-defined heterogeneous lesion of the left paratracheal region with a fistulous tract extending toward the left pyriform sinus (Figure 1) These findings, along with her history and physical examination, were suspicious for infected left fourth branchial cleft cyst. Intraoperative cultures were obtained, and the patient was subsequently given culturedirected antibiotics After improvement in her acute inflammatory symptoms, she was taken back to the OR for definitive excision of the branchial cleft cyst and endoscopic management of the fistulous tract. Intraoperative view of the fourth branchial cleft cyst (white arrow) with fistulous tract coursing beneath the recurrent laryngeal nerve (orange arrow) toward the thyroid cartilage/pyriform sinus apex. At most recent follow up nine months post-operatively, the patient has healed well and not experienced any pain or infection
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