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4th Branchial Cleft Cyst
Bernadette L. Koch, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          • Diagnostic Checklist

            TERMINOLOGY

            • Synonyms

              • Pyriform sinus "fistula"
                • Most 4th branchial anomalies are actually sinus tracts, not fistulas or cysts
            • Definitions

              • 4th branchial apparatus sinus tract
                • Course from apex of pyriform sinus to upper aspect of left thyroid lobe
              • Branchial sinus tract: 1 opening-to-skin surface, external auditory canal, pharynx or hypopharynx
              • Branchial fistula: 2 openings; skin and lumen of foregut
                • Arises as epithelial-lined tract left behind when there is persistence of both branchial cleft and its corresponding pharyngeal pouch

            IMAGING

            • General Features

              • Fluoroscopic Findings

                • CT Findings

                  • MR Findings

                    • Ultrasonographic Findings

                      • Nuclear Medicine Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Gross Pathologic & Surgical Features

                                CLINICAL ISSUES

                                • Presentation

                                  • Demographics

                                    • Natural History & Prognosis

                                      • Treatment

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          Selected References

                                          1. Goff CJ et al: Current management of congenital branchial cleft cysts, sinuses, and fistulae. Curr Opin Otolaryngol Head Neck Surg. 20(6):533-9, 2012
                                          2. Bajaj Y et al: Branchial anomalies in children. Int J Pediatr Otorhinolaryngol. 75(8):1020-3, 2011
                                          3. Pahlavan S et al: Microbiology of third and fourth branchial pouch cysts. Laryngoscope. 120(3):458-62, 2010
                                          4. Thomas B et al: Revisiting imaging features and the embryologic basis of third and fourth branchial anomalies. AJNR Am J Neuroradiol. 31(4):755-60, 2010
                                          5. Nicoucar K et al: Management of congenital fourth branchial arch anomalies: a review and analysis of published cases. J Pediatr Surg. 44(7):1432-9, 2009
                                          6. Mantle BA et al: Fourth branchial cleft sinus: relationship to superior and recurrent laryngeal nerves. Am J Otolaryngol. 29(3):198-200, 2008
                                          7. James A et al: Branchial sinus of the piriform fossa: reappraisal of third and fourth branchial anomalies. Laryngoscope. 117(11):1920-4, 2007
                                          8. Garrel R et al: Fourth branchial pouch sinus: from diagnosis to treatment. Otolaryngol Head Neck Surg. 134(1):157-63, 2006
                                          9. Koch BL: Cystic malformations of the neck in children. Pediatr Radiol. 35(5):463-77, 2005
                                          10. Jeyakumar A et al: Various presentations of fourth branchial pouch anomalies. Ear Nose Throat J. 83(9):640-2, 644, 2004
                                          11. Pereira KD et al: Management of anomalies of the third and fourth branchial pouches. Int J Pediatr Otorhinolaryngol. 68(1): 43-50, 2004
                                          12. Chaudhary N et al: Fistula of the fourth branchial pouch. Am J Otolaryngol. 24(4): 250-2, 2003
                                          13. Wang HK et al: Imaging studies of pyriform sinus fistula. Pediatr Radiol. 33(5):328-33, 2003
                                          14. Liberman M et al: Ten years of experience with third and fourth branchial remnants. J Pediatr Surg. 37(5): 685-90, 2002
                                          15. Link TD et al: Fourth branchial pouch sinus: a diagnostic challenge. Plast Reconstr Surg. 108(3): 695-701, 2001
                                          16. Minhas SS et al: Fourth branchial arch fistula and suppurative thyroiditis: a life-threatening infection. J Laryngol Otol. 115(12): 1029-31, 2001
                                          17. Cases JA et al: Recurrent acute suppurative thyroiditis in an adult due to a fourth branchial pouch fistula. J Clin Endocrinol Metab. 85(3): 953-6, 2000
                                          18. Mandell DL: Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am. 33(6): 1309-32, 2000
                                          19. Nicollas R et al: Congenital cysts and fistulas of the neck. Int J Pediatr Otorhinolaryngol. 55(2): 117-24, 2000
                                          20. Park SW et al: Neck infection associated with pyriform sinus fistula: imaging findings. AJNR Am J Neuroradiol. 21(5):817-22, 2000
                                          21. Stone ME et al: A new role for computed tomography in the diagnosis and treatment of pyriform sinus fistula. Am J Otolaryngol. 21(5):323-5, 2000
                                          22. Yang C et al: Fourth branchial arch sinus: clinical presentation, diagnostic workup, and surgical treatment. Laryngoscope. 109(3): 442-6, 1999
                                          23. Nicollas R et al: Fourth branchial pouch anomalies: a study of six cases and review of the literature. Int J Pediatr Otorhinolaryngol. 44(1): 5-10, 1998
                                          24. Cote DN et al: Fourth branchial cleft cysts. Otolaryngol Head Neck Surg. 114(1): 95-7, 1996
                                          25. Choi SS et al: Branchial anomalies: a review of 52 cases. Laryngoscope. 105(9 Pt 1): 909-13, 1995
                                          26. Benson MT et al: Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. Radiographics. 12(5):943-60, 1992
                                          27. Rosenfeld RM et al: Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head Neck Surg. 105(1): 44-50, 1991
                                          28. Godin MS et al: Fourth branchial pouch sinus: principles of diagnosis and management. Laryngoscope. 100(2 Pt 1): 174-8, 1990
                                          29. Lucaya J et al: Congenital pyriform sinus fistula: a cause of acute left-sided suppurative thyroiditis and neck abscess in children. Pediatr Radiol. 21(1):27-9, 1990
                                          30. Taylor WE Jr et al: Acute suppurative thyroiditis in children. Laryngoscope. 92(11):1269-73, 1982
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Top Differential Diagnoses

                                                • Clinical Issues

                                                  • Diagnostic Checklist

                                                    TERMINOLOGY

                                                    • Synonyms

                                                      • Pyriform sinus "fistula"
                                                        • Most 4th branchial anomalies are actually sinus tracts, not fistulas or cysts
                                                    • Definitions

                                                      • 4th branchial apparatus sinus tract
                                                        • Course from apex of pyriform sinus to upper aspect of left thyroid lobe
                                                      • Branchial sinus tract: 1 opening-to-skin surface, external auditory canal, pharynx or hypopharynx
                                                      • Branchial fistula: 2 openings; skin and lumen of foregut
                                                        • Arises as epithelial-lined tract left behind when there is persistence of both branchial cleft and its corresponding pharyngeal pouch

                                                    IMAGING

                                                    • General Features

                                                      • Fluoroscopic Findings

                                                        • CT Findings

                                                          • MR Findings

                                                            • Ultrasonographic Findings

                                                              • Nuclear Medicine Findings

                                                                • Imaging Recommendations

                                                                  DIFFERENTIAL DIAGNOSIS

                                                                    PATHOLOGY

                                                                    • General Features

                                                                      • Gross Pathologic & Surgical Features

                                                                        CLINICAL ISSUES

                                                                        • Presentation

                                                                          • Demographics

                                                                            • Natural History & Prognosis

                                                                              • Treatment

                                                                                DIAGNOSTIC CHECKLIST

                                                                                • Consider

                                                                                  Selected References

                                                                                  1. Goff CJ et al: Current management of congenital branchial cleft cysts, sinuses, and fistulae. Curr Opin Otolaryngol Head Neck Surg. 20(6):533-9, 2012
                                                                                  2. Bajaj Y et al: Branchial anomalies in children. Int J Pediatr Otorhinolaryngol. 75(8):1020-3, 2011
                                                                                  3. Pahlavan S et al: Microbiology of third and fourth branchial pouch cysts. Laryngoscope. 120(3):458-62, 2010
                                                                                  4. Thomas B et al: Revisiting imaging features and the embryologic basis of third and fourth branchial anomalies. AJNR Am J Neuroradiol. 31(4):755-60, 2010
                                                                                  5. Nicoucar K et al: Management of congenital fourth branchial arch anomalies: a review and analysis of published cases. J Pediatr Surg. 44(7):1432-9, 2009
                                                                                  6. Mantle BA et al: Fourth branchial cleft sinus: relationship to superior and recurrent laryngeal nerves. Am J Otolaryngol. 29(3):198-200, 2008
                                                                                  7. James A et al: Branchial sinus of the piriform fossa: reappraisal of third and fourth branchial anomalies. Laryngoscope. 117(11):1920-4, 2007
                                                                                  8. Garrel R et al: Fourth branchial pouch sinus: from diagnosis to treatment. Otolaryngol Head Neck Surg. 134(1):157-63, 2006
                                                                                  9. Koch BL: Cystic malformations of the neck in children. Pediatr Radiol. 35(5):463-77, 2005
                                                                                  10. Jeyakumar A et al: Various presentations of fourth branchial pouch anomalies. Ear Nose Throat J. 83(9):640-2, 644, 2004
                                                                                  11. Pereira KD et al: Management of anomalies of the third and fourth branchial pouches. Int J Pediatr Otorhinolaryngol. 68(1): 43-50, 2004
                                                                                  12. Chaudhary N et al: Fistula of the fourth branchial pouch. Am J Otolaryngol. 24(4): 250-2, 2003
                                                                                  13. Wang HK et al: Imaging studies of pyriform sinus fistula. Pediatr Radiol. 33(5):328-33, 2003
                                                                                  14. Liberman M et al: Ten years of experience with third and fourth branchial remnants. J Pediatr Surg. 37(5): 685-90, 2002
                                                                                  15. Link TD et al: Fourth branchial pouch sinus: a diagnostic challenge. Plast Reconstr Surg. 108(3): 695-701, 2001
                                                                                  16. Minhas SS et al: Fourth branchial arch fistula and suppurative thyroiditis: a life-threatening infection. J Laryngol Otol. 115(12): 1029-31, 2001
                                                                                  17. Cases JA et al: Recurrent acute suppurative thyroiditis in an adult due to a fourth branchial pouch fistula. J Clin Endocrinol Metab. 85(3): 953-6, 2000
                                                                                  18. Mandell DL: Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am. 33(6): 1309-32, 2000
                                                                                  19. Nicollas R et al: Congenital cysts and fistulas of the neck. Int J Pediatr Otorhinolaryngol. 55(2): 117-24, 2000
                                                                                  20. Park SW et al: Neck infection associated with pyriform sinus fistula: imaging findings. AJNR Am J Neuroradiol. 21(5):817-22, 2000
                                                                                  21. Stone ME et al: A new role for computed tomography in the diagnosis and treatment of pyriform sinus fistula. Am J Otolaryngol. 21(5):323-5, 2000
                                                                                  22. Yang C et al: Fourth branchial arch sinus: clinical presentation, diagnostic workup, and surgical treatment. Laryngoscope. 109(3): 442-6, 1999
                                                                                  23. Nicollas R et al: Fourth branchial pouch anomalies: a study of six cases and review of the literature. Int J Pediatr Otorhinolaryngol. 44(1): 5-10, 1998
                                                                                  24. Cote DN et al: Fourth branchial cleft cysts. Otolaryngol Head Neck Surg. 114(1): 95-7, 1996
                                                                                  25. Choi SS et al: Branchial anomalies: a review of 52 cases. Laryngoscope. 105(9 Pt 1): 909-13, 1995
                                                                                  26. Benson MT et al: Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. Radiographics. 12(5):943-60, 1992
                                                                                  27. Rosenfeld RM et al: Fourth branchial pouch sinus: diagnosis and treatment. Otolaryngol Head Neck Surg. 105(1): 44-50, 1991
                                                                                  28. Godin MS et al: Fourth branchial pouch sinus: principles of diagnosis and management. Laryngoscope. 100(2 Pt 1): 174-8, 1990
                                                                                  29. Lucaya J et al: Congenital pyriform sinus fistula: a cause of acute left-sided suppurative thyroiditis and neck abscess in children. Pediatr Radiol. 21(1):27-9, 1990
                                                                                  30. Taylor WE Jr et al: Acute suppurative thyroiditis in children. Laryngoscope. 92(11):1269-73, 1982