Third and fourth branchial cleft anomalies are rare congenital defects affecting children. They arise due to the incomplete obliteration of branchial clefts during embryogenesis. Nearly 90% of the third or fourth branchial pouch sinus tracts are situated on the left side of the neck. It is difficult to differentiate the third and fourth branchial cleft anomalies on radiological imaging due to their close proximity; hence, they may be treated as the same disease. In this report, we describe the case of a 17-year-old male patient with a persistent branchial cleft sinus tract and its clinical presentation, diagnostic evaluation, and surgical management and discuss the preoperative evaluation, pitfalls in diagnosis, and surgical management, including strategies for the management of third or fourth branchial cleft sinus. RésuméLes anomalies des troisième et quatrième fentes branchiales sont des malformations congénitales rares chez l’enfant. Elles résultent d’une oblitération incomplète des fentes branchiales au cours de l’embryogenèse. Près de 90 % des fistules des troisième et quatrième poches branchiales sont situées du côté gauche du cou. Il est difficile de différencier les anomalies des troisième et quatrième fentes branchiales sur les images radiologiques en raison de leur proximité; de ce fait, elles peuvent être traitées comme une seule et même pathologie. Dans ce rapport, nous décrivons le cas d’un patient de 17 ans présentant une fistule branchiale persistante, ainsi que sa présentation clinique, son bilan diagnostique et sa prise en charge chirurgicale. Nous discutons également du bilan préopératoire, des difficultés diagnostiques et de la prise en charge chirurgicale, notamment des stratégies de traitement des fistules des troisième et quatrième fentes branchiales. Branchial cleft cysts are congenital anomalies arising from the first through fourth pharyngeal clefts. The most common type of branchial cleft cyst arises from the second cleft, with anomalies derived from the first, third, and fourth clefts being rarer. As this is a congenital anomaly, brachial cleft cysts are present at birth, although they may not be obvious or symptomatic until later. The majority of lesions present in childhood as a visible punctum on the skin of the anterior neck with or without periodic drainage; however, they may present as a neck mass or as recurrent abscesses due to infections within the tract. Branchial cleft anomalies occur in 1 of 3 forms: cysts, sinuses, or fistulae. Cysts are epithelial-lined structures that do not have external openings that connect to the skin or pharynx, and as such, may be asymptomatic and only noticed incidentally. Such cysts may not present until adulthood. Sinus tracts connect either the skin or the pharynx to a blind pouch. Sinus tracts may communicate externally with skin as a visible punctum or internally with the pharynx or larynx, where the punctum opening will only be visible on endoscopy. Branchial cleft fistulae are true communications connecting the pharynx or larynx with the external skin.

The third and fourth branchial cleft and pouch anomalies are the rarest among the anomalies of branchial arches and can pose diagnostic and management challenges in pediatric patients. Our study aimed to describe the clinical presentation, management, and treatment outcomes of the third and fourth branchial cleft and pouch anomalies over a 10-year period in our hospital. A retrospective analysis was conducted on pediatric patients aged 1-18 years who underwent otolaryngologic and pediatric surgical interventions for the third and fourth branchial cleft and pouch anomalies from 2013 to 2022. Clinical data including age, gender, presenting symptoms, age of onset of symptoms, laterality, imaging findings, surgical procedures, complications, and follow-up outcomes were collected, and the database was maintained. Eleven pediatric patients (5 females and 6 males) with a mean age of 4 years (range: 1-9 years) were identified. Common presenting symptoms included neck swelling and recurrent neck infections. Diagnosis was established based on imaging findings on ultrasound and magnetic resonance imaging (MRI)/computed tomography neck aided by suspension microlaryngoscopic visualization of internal opening in the pyriform sinus. Surgical excision of the tract with/without partial thyroidectomy along with endoscopic ablation/cauterization of pyriform sinus opening was the primary treatment modality, with favorable outcomes and no complications. No recurrence was reported during follow-up. A high index of clinical suspicion coupled with MRI and microlaryngoscopic evaluation is vital for accurate diagnosis of these lesions. Treatment should prioritize complete excision of the tract while quiescent. Internal opening ablation/cauterization reduces the risk of recurrence.

Branchial cleft anomalies (BCA) are a group of relatively common congenital pediatric neck masses, which exhibit wide variability in clinical presentation and treatment approaches. This study attempts to fill this gap by evaluating BCA clinical, radiographic, and treatment features in a large cross-sectional cohort. We performed a retrospective cross-sectional study of patients with BCA presenting to a single pediatric quaternary care center between 2017 and 2023. The radiology information system was queried for the term "branchial," with diagnostic confirmation based on radiology and medical records review including patient demographics, clinical presentation and symptoms, genetic testing, interventions, and pathology. Relevant statistical tests were performed. We retrospectively identified 302 unique patients with 412 imaging examinations that included the term "branchial" in the radiology information system between 2017 and 2023. The final cohort included 167 patients with a total of 246 imaging examinations. Among patients with BCA, median age at presentation was 3.3 years (range 0-22.9). Leading clinical presentations included a neck mass (88%, 147) and skin drainage (29%, 29). BCA classification was first in 37% (61), second in 44% (73), third in 4% (7), and fourth in 15% (26). Interventions included incision and drainage in 70% (121) and complete excision in 54% (91). Among patients with resected BCA, 22% (20/91) experienced at least 1 recurrence. BCA have diverse clinical manifestations for which imaging aids in localization, classification, and interventional planning.

The objective of this study was to investigate and assess the clinical data of 123 patients diagnosed with congenital branchial cleft anomalies (CBCAs), to summarize pivotal aspects concerning their clinical diagnosis and treatment process. The authors conducted a retrospective analysis of 123 patients who underwent surgical intervention for CBCAs at our institution between August 2005 and September 2021. The clinical demographic characteristics of the patients, primary symptoms, treatment chronology, preoperative diagnostic assessments, surgical strategies, occurrences of postoperative complications, and rates of recurrence were subjected to statistical analysis. Among the enrolled patients, there were 43 cases (34.9%) of congenital first branchial cleft anomalies (CFBCA), 76 cases (61.8%) of congenital second branchial cleft anomalies (CSBCA), and 4 cases (3.3%) of congenital third branchial cleft anomalies (CTBCA), with no cases of congenital fourth branchial anomalies (CFBA). Notably, among all cases, 43 anomalies were situated in the upper one-third of the sternocleidomastoid muscle, while 80 anomalies were located in the lower one-third. Different surgical approaches were selected for patients based on the specific type of anomaly presented. Following surgery, there was recurrence in 14 cases, with factors such as patient age, clinical categorization, lesion type, and history of preoperative infection and surgical intervention identified as primary risk factors for it. CBCAs represent comparatively uncommon disorders affecting the head and cervical regions in clinical practice. Diagnostic modes such as ultrasonography and lipiodol contrast radiography can be used for accurate diagnosis, with surgical intervention serving as the primary therapeutic method.

A pyriform sinus fistula (PSF) is a rare congenital anomaly due to failed obliteration of the third or fourth pharyngeal pouch. Diagnosis and management of PSF remains controversial. We present a case of PSF and discuss its diagnosis and management. Case report and literature review. A 26-year-old female with a chronic left lateral neck abscess was diagnosed with a left PSF. She underwent surgery through a combined approach to close the openings of the PSF, internally and externally. We first placed a blunted ET tube into the internal opening of the PSF. We then performed an external transcervical approach to close the PSF at the cricothyroid membrane. Briefly, after a neck debridement and washout of the chronic neck infection, we identified the recurrent laryngeal nerve (RLN) in Lore's triangle. We performed left hemithyroidectomy to facilitate the dissection and protection of the RLN to its entrance into the larynx. A flexible laryngoscope was then inserted into the left piriform sinus through the ET tube to guide external dissection by transillumination. The scar tissue attached to the superior pole of the left thyroid lobe was then ligated and divided along the cricothyroid membrane. Lastly, we cauterized the internal opening of the PSF. The patient has remained recurrence-free for 1.5 years with normal vocal cord mobility. Histopathology revealed presence of a squamous-lined tract adjacent to the thyroid tissue. Surgical treatment for patients with PSF should be aimed at closing the internal and external openings of the PSF, debriding chronic neck infection, and protecting the laryngeal nerves, instead of removing the entire tract. A concurrent hemithyroidectomy facilitates the identification and protection of the RLN, as well as excision of the tract. Differentiation between third and fourth branchial cleft fistulae may not be clinically necessary, as it is unlikely to alter the therapeutic plan.