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Third branchial anomaly: Endoscopic management revisited

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April 1, 2012
by Mala Tanna, MD, Monica R. Sharma, DDS, and Bijal Patel, MD

Third and fourth branchial apparatus anomalies may be misidentified as a recurrent deep neck abscess that does not respond to appropriate medical or surgical therapy or as recurrent acute suppurative thyroiditis, respiratory distress, or retropharyngeal abscess.

Laryngoscopic Clinic

A 4-year-old boy was brought to the emergency department at The George Washington University with a 1-day history of fever, odynophagia, decreased oral intake, and left lateral neck swelling. He had been diagnosed at birth with a left congenital neck cyst but was subsequently lost to follow-up. All other history was noncontributory.

The patient was febrile, and physical examination revealed a left lateral neck fluctuance and swelling that were tender on palpation. Laboratory testing revealed leukocytosis. Computed tomography (CT) showed a round, 2.2-cm, rim-enhancing lesion with both air and loculations at the level of the thyroid gland.

The patient was admitted for a suspected acute infection of the congenital cyst. Direct laryngoscopy and bronchoscopy were performed initially to determine whether an internal communication of the branchial anomaly was detectable, given the presence of air on CT. During laryngoscopy, the left piriform sinus was found to be inflamed. Laryngoscopy also showed that with lateral compression of the left neck mass, purulent clumps of possible fermented food debris were expressed from the piriform sinus (figure). The apex of the left piriform sinus was probed with a soft catheter, thereby confirming the sinus tract. After the procedure, the patient remained on intravenous antibiotics, and his remaining hospital course was uneventful. He was discharged with no recurrence of infection.

Figure. Laryngoscopy shows the purulent clumps of possible fermented food debris being expressed from the ipsilateral piriform sinus with palpation of the left side of the neck.

Third and fourth branchial apparatus anomalies are a rare cause of pediatric neck masses. These anomalies may be misidentified as a recurrent deep neck abscess that does not respond to appropriate medical or surgical therapy or as recurrent acute suppurative thyroiditis, respiratory distress, or retropharyngeal abscess. Failure to recognize a branchial apparatus anomaly may result in repeated incision-and-drainage procedures. Ultimately, this may result in an incomplete excision of the anomaly.

Throughout the literature, branchial anomalies have been described with a variety of terminologies. The terms branchial and lateral cervical have been used interchangeably in the literature, with the former referring to the origin of the anomaly and the latter describing the typical location. Branchial anomalies can be classified into three types: cysts, sinuses, and fistulas.

A branchial cyst is a self-contained structure without an internal or external opening. A branchial sinus is a blind-ending tract that connects with either the skin or the pharynx. Those that communicate with the skin are called branchial cyst sinuses, and those that connect to the viscera are called branchial pouch sinuses. A branchial fistula communicates with both the skin and the viscera. As such, it features a connection between a lasting pouch and a cleft.1

Third branchial sinuses have been reported to pre-sent as suppurative thyroiditis.2 Neonates with large branchial pouch anomalies have presented with stridor.1 Self-contained cysts can cause dyspnea, dysphagia, or dysphonia as they enlarge over time. Other diagnoses to consider when presented with a lateral neck mass include but are not limited to thyroglossal duct cyst, cystic hygroma, lymphadenopathy, lipoma, hemangioma, lymphoma, dermoid tumor, and carotid body tumor.3

An early diagnosis is critical to prevent recurrence. Recurrent infections of branchial anomalies can lead to scarring and fibrosis, which increase the difficulty of definitive treatment and contribute to the morbidity associated with excision. A complete and thorough physical examination is essential, but a high index of suspicion is also required. Many imaging methods have been used, including ultrasonography, barium-swallow examination, CT, and magnetic resonance imaging (MRI).1,2 CT and MRI not only delineate the mass, but they also can occasionally trace the sinus tract.4 To definitively diagnose a third branchial pouch sinus, direct laryngoscopy is required to identify the opening of the sinus into the pharynx. The diagnosis is often uncertain until surgical exploration.1

The treatment of choice is complete surgical excision. Patients who present with anomalies that are currently infected should be treated with intravenous antibiotics, and excision should be delayed until the infection resolves.5 Complete excision includes removal of the surrounding external skin, the tract,6 and the cystic component, which is essential to diminish the risk of recurrence.

From the Department of Radiology, Lenox Hill Hospital, New York City (Dr. Tanna); the Department of Dentistry, Brookdale University, Brooklyn, N.Y. (Dr. Sharma); and the Department of Medicine, The George Washington University, Washington, D.C. (Dr. Patel).


  1. Rea PA, Hartley BE, Bailey CM. Third and fourth branchial pouch anomalies. J Laryngol Otol 2004; 118 (1): 19-24.
  2. Taylor WE Jr., Myer CM III, Hays LL, Cotton RT. Acute suppurative thyroiditis in children. Laryngoscope 1982; 92 (11): 1269-73.
  3. Chandler JR, Mitchell B. Branchial cleft cysts, sinuses, and fistulas. Otolaryngol Clin North Am 1981; 14 (1): 175-86.
  4. Choi SS, Zalzal GH. Branchial anomalies: A review of 52 cases. Laryngoscope 1995; 105 (9 Pt 1): 909-13.
  5. Kadhim AL, Sheahan P, Colreavy MP, Timon CV. Pearls and pitfalls in the management of branchial cyst. J Laryngol Otol 2004; 118 (12): 946-50.
  6. Dutt SN, John H, Nayar RC, et al. Surgical management of a case of third branchial pouch fistula. J Laryngol Otol 1994; 108 (12): 1095-6.

Ear Nose Throat J. 2012 April;91(4):150-1