Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes

Abstract

Objective: Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. Methods: A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. Results: A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. Conclusion: A combination approach to fourth branchial apparatus lesions—including endoscopic cauterization, external excision, and hemithyroidectomy—is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

Respiratory distress in a neonate: Inflation of a third branchial anomaly with positive airway pressure

“…More recently, minimally invasive endoscopic cauterization of the piriform sinus tract has been shown to have similar success rates as open resection 2,6,7 . A recently published retrospective study demonstrated a success rate of 94% for a combined approach of surgical excision with concurrent endoscopic cauterization as primary treatment 8 . Complications following endoscopic cauterization are exceedingly rare and include temporary superior or RLN paralysis 2,6,9 .…”

“… 2 , 6 , 7 A recently published retrospective study demonstrated a success rate of 94% for a combined approach of surgical excision with concurrent endoscopic cauterization as primary treatment. 8 Complications following endoscopic cauterization are exceedingly rare and include temporary superior or RLN paralysis. 2 , 6 , 9 Thus, many today advocate for endoscopic cauterization as the primary treatment for third branchial cleft anomalies as it is minimally invasive, has a comparable success rate, and is associated with fewer complications compared to surgical resection.…”