Recurrent Neck Mass: A Case Report

Abstract

Fourth branchial cleft anomalies are an exceptionally rare cause of recurrent neck mass in pediatric and adult patients. In this report, we present a case of an infected fourth branchial cleft cyst in a 20-year-old woman that presented with recurrent throat pain and deep neck abscesses. After undergoing repeated incision and drainage procedures, the patient underwent definitive management with direct laryngoscopy, ablation of the left pyriform sinus tract, left hemithyroidectomy, and excision of the branchial anomaly without evidence of recurrence. In addition to diagnosis and management, this case report highlights the unique anatomical relationship between fourth branchial anomalies and the pyriform fossa as well as the superior and recurrent laryngeal nerves.

Keywords: branchial anomaly; branchial arch malformation; congenital neck mass; embryology; recurrent neck mass.

Figure 1. CT neck with contrast

White arrow demonstrates the left fourth branchial cleft cyst tracking towards the left pyriform sinus.

Figure 2. Direct laryngoscopy showing opening at the apex of the left pyriform sinus.

Figure 3. Intraoperative image

Intraoperative view of the fourth branchial cleft cyst (white arrow) with fistulous tract coursing beneath the recurrent laryngeal nerve (orange arrow) toward the thyroid cartilage/pyriform sinus apex. Green arrow and blue arrow denote thyroid and trachea, respectively.