Fourth Branchial Pouch Sinus: From Diagnosis to Treatment

Abstract

A-1.

Neonatal vs Delayed-Onset Fourth Branchial Pouch Anomalies

“…The most frequent complication described in the literature is a transitory or permanent paralysis of the larynx, reported in 0% to 33% of cases. [1][2][3][4]12 This occurs more often when the tract of the sinus to be dissected is encased in scar or inflammatory tissue. 12,19,21 Recurrence is limited to cases in which complete excision of the tract cannot be performed, which occurs most often when the surgery is undertaken at the time of active inflammation and the tract is difficult to identify.…”

“…3,13,22 The recurrence rate varies from 0% to 16% during a follow-up range from 2 months to 4 years. 1,2,4,11,12,14,23 Toward the end of the 1990s, a new surgical endoscopic technique was developed involving cauterization of the sinus tract orifice at the base of the piriform fossa using local coagulation, thereby destroying the tract, avoiding a subsequent adjacent "cyst" and theoretically leading to its involution. 24 While intuitively this approach might seem inadequate, it has been used to achieve real therapeutic successes without systematic relapses or abscess formation.…”

“…1 Such lesions developing from the third and fourth branchial pouches are less frequent (3% to 10%). 1,2 The distinction between third and fourth branchial pouch abnormalities can only be established at the time of dissection because their clinical presentations are similar. From a practical point of view, the anatomic differences between these 2 lesions are of little significance because their clinical presentations and management strategies are often the same.…”

“…10 The best diagnostic examination is endoscopy, which allows confirmation of the diagnosis by direct visualization of the orifice of the tract in the piriform fossa and the Betz fold ( Figure 3). 2,11,12 The classic management described in the literature is surgical resec-CME available online at www.jamaarchivescme.com and questions on page 856 tion using a cervical approach. However, in the last 15 years a less invasive treatment has evolved, namely, endoscopic cauterization limited to the sinus tract orifice.…”

Right fourth branchial cyst presenting as retropharyngeal collection in a neonate

“…2 The diagnosis is usually made in the first two decades of life and never later than the third. 3 A fourth branchial pouch is usually diagnosed after recurrent cervical infections that mimic thyroid suppurations. Diagnosis in the newborn is exceptional, but clinical presentation is typical: presence of dyspnea with neck enlargement a few days after birth, leading to a diagnosis of retropharyngeal cyst or abscess.…”