Open and Endoscopic Management of Fourth Branchial Pouch Sinus – Our Experience
11 February 2015
17 May 2015
13 July 2015 (online)
Introduction Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common and usually present with recurrent left thyroid lobe abscesses.
Objectives The authors present their experience in treating such cases that were observed exclusively in children.
Methods The study involved performing a retrospective review of five cases in PSG Institute of Medical Sciences & Research. All cases were evaluated radiologically and with Direct Rigid hypopharyngoscopy. Definitive surgery was performed, including hemithyroidectomy.
Results The patients consisted of five children, two boys and three girls. All of them presented with recurrent episodes of neck infection. Investigations performed included computed tomography (CT) fistulography, rigid hypopharyngoscopy and ultrasound, which were useful in preoperatively delineating pyriform sinus fistulous tract. All patients underwent neck exploration with excision of the fistulous tract and hemithyroidectomy. Upon follow-up, all patients are asymptomatic.
Conclusions Recurrent neck abscesses in a child should alert the clinician to the possibility of a fourth branchial arch anomaly; therefore, children with this condition require a complete evaluation so the anomaly can be ruled out.
- 1 Takai SI, Miyauchi A, Matsuzuka F, Kuma K, Kosaki G. Internal fistula as a route of infection in acute suppurative thyroiditis. Lancet 1979; 1 (8119) 751-752
- 2 Lucaya J, Berdon WE, Enriquez G, Regas J, Carreno JC. Congenital pyriform sinus fistula: a cause of acute left-sided suppurative thyroiditis and neck abscess in children. Pediatr Radiol 1990; 21 (1) 27-29
- 3 Tovi F, Gatot A, Bar-Ziv J, Yanay I. Recurrent suppurative thyroiditis due to fourth branchial pouch sinus. Int J Pediatr Otorhinolaryngol 1985; 9 (1) 89-96
- 4 Williams PL. Gray's Anatomy (38th ed.). New York, NY: Churchill Livingstone; 1995
- 5 Benson MT, Dalen K, Mancuso AA , et al. Congenital anomalies of the branchial apparatus: embryology and pathologic. Radiographics 1992; 12: 943-960
- 6 Shrime M, Kacker A, Bent J, Ward RF. Fourth branchial complex anomalies: a case series. Int J Pediatr Otorhinolaryngol 2003; 67 (11) 1227-1233
- 7 Tucker HM, Skolnick ML. Fourth branchial cleft (pharyngeal pouch) remnant. Trans Am Acad Ophthalmol Otolaryngol 1973; 77 (5) ORL368-ORL371
- 8 Godin MS, Kearns DB, Pransky SM, Seid AB, Wilson DB. Fourth branchial pouch sinus: principles of diagnosis and management. Laryngoscope 1990; 100 (2 Pt 1): 174-178
- 9 Nicoucar K, Giger R, Jaecklin T, Pope Jr HG, Dulguerov P. Management of congenital third branchial arch anomalies: a systematic review. Otolaryngol Head Neck Surg 2010; 142 (1) 21-28.e2
- 10 Patel AB, Hinni ML. The fourth branchial complex anomaly: a rare clinical entity. Case Rep Otolaryngol 2011; 2011: 958652
- 11 Yang C, Cohen J, Everts E, Smith J, Caro J, Andersen P. Fourth branchial arch sinus: clinical presentation, diagnostic workup, and surgical treatment. Laryngoscope 1999; 109 (3) 442-446
- 12 Cases JA, Wenig BM, Silver CE, Surks MI. Recurrent acute suppurative thyroiditis in an adult due to a fourth branchial pouch fistula. J Clin Endocrinol Metab 2000; 85 (3) 953-956
- 13 Tovi F, Gatot A, Bar-Ziv J, Yanay I. Recurrent suppurative thyroiditis due to fourth branchial pouch sinus. Int J Pediatr Otorhinolaryngol 1985; 9 (1) 89-96
- 14 Liberman M, Kay S, Emil S , et al. Ten years of experience with third and fourth branchial remnants. J Pediatr Surg 2002; 37 (5) 685-690
- 15 Nonomura N, Ikarashi F, Fujisaki T, Nakano Y. Surgical approach to pyriform sinus fistula. Am J Otolaryngol 1993; 14 (2) 111-115
- 16 Kubota M, Suita S, Kamimura T, Zaizen Y. Surgical strategy for the treatment of pyriform sinus fistula. J Pediatr Surg 1997; 32 (1) 34-37
- 17 Kim MG, Lee NH, Ban JH, Lee KC, Jin SM, Lee SH. Sclerotherapy of branchial cleft cysts using OK-432. Otolaryngol Head Neck Surg 2009; 141 (3) 329-334
- 18 Kim KH, Sung MW, Koh TY, Oh SH, Kim IS. Pyriform sinus fistula: management with chemocauterization of the internal opening. Ann Otol Rhinol Laryngol 2000; 109 (5) 452-456