Surgical treatment of fourth branchial apparatus anomalies: A case series study

Abstract

Background Fourth branchial apparatus anomalies, are rare clinical entities, and present as complex cysts, sinuses and fistulae in the neck that can be difficult to manage. Methods This is a retrospective review of a series of consecutive patients with fourth branchial apparatus anomalies treated at Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from Apr 2014 to Nov 2019. Results Ten patients with fourth branchial apparatus anomalies were identified, including 8 patients with fourth branchial fistula, and 2 patients with fourth branchial pouch sinus. There were 6 female patients and 4 male patients. Their age was from 6 years old to 39 years old (average age 20.4 years old, median age was 21 years old). All 8 fistulae were on the left side, while 2 pouch sinuses were both on the right side. Pre-operative examination with fiberoptic laryngoscope, barium swallow X-ray, CT or MRI identified internal orifice at pyriform fossa apex in 8 (80%) patients. All patients underwent challenging surgical resection by the senior author. Intra-operative direct laryngoscope confirmed or identified internal orifice in 9 (90%) patients. The tracts were all followed to the vicinity of inferior cornu of the thyroid cartilage and the cricothyroid space. Complete resection of cervical lesions and their attachment to hypopharynx were achieved in 9 cases. No complication occurred. One recurrence was detected, in the only patient whose internal orifice could not be located pre- or intra-operatively, and the hypopharyngeal attachment could not be removed. Conclusions Direct laryngoscopy under general anesthesia is a reliable method of diagnosis for the fourth branchial apparatus anomalies. Complete surgical removal of fourth branchial apparatus anomalies, including their hypopharyngeal attachment, is the treatment of choice, and the key to prevent recurrence.

Successful management of pyriform sinus cyst and fistula using endoscopic electrocauterization

“… 1 PSC is commonly identified during the newborn period and causes respiratory failure, neck abscess, or thyroiditis. 1 , 2 , 10 It originates from the failure obliteration of the third or fourth pharyngeal pouches, which are connected to the pharynx by the pharyngobranchial duct. 1 , 2 Owing to its rarity in neonates, the diagnosis and treatment of PSC remains complicated and not clearly described.…”

“…Complete removal of the fistula and cyst with or without affected thyroid tissue was previously the most commonly used and most thorough treatment. 1 , 2 , 10 …”

Branchial Cleft Anomalies: Embryogenesis, Clinical Features, Diagnosis, and Management

“…Third and fourth branchial anomalies are extremely rare entities and account for less than 1% of branchial malformations. 63 These lesions typically present as cystic structures at the lower, anterior border of the SCM at the level of the superior pole of the thyroid and manifest clinically as repeated episodes of neck swelling, abscess formation, and suppurative thyroiditis. 47,64 They are often diagnosed in childhood and occur predominantly on the left side with slight female predominance.…”

“…Given the high recurrence rate, the general consensus remains that complete surgical resection via open or endoscopic techniques in a quiescent state is the definitive treatment for these lesions. 63,75,76 Studies have shown that partial thyroidectomy can further reduce recurrence rates as branchial remnants and cysts may be found partly or completely enveloped in thyroid tissue. 67 Meticulous dissection is necessary to visualize and avoid injury to the superior and recurrent laryngeal nerves.…”

“…Nonetheless, the most common complication of surgical resection is vocal cord paralysis and the recurrence rate of fourth BCAs remain the highest of all the branchial cleft anomalies, reported between 10% and 30%. 63,67,72…”