Case series: Endoscopic management of fourth branchial arch anomalies
Introduction
Branchial arch anomalies are the second most common congenital abnormality and represent 20% of congenital anomalies in the head and neck region in the paediatric population. Second arch anomalies account for about 95% of these anomalies and first arch anomalies represent 1–4%. Third and fourth arch anomalies are rare, constituting <1% of branchial anomalies and present as recurrent neck abscesses or suppurative thyroiditis in older children. In neonates they may present as an infected neck mass with associated respiratory distress [1], [2].
Acute management of a child presenting with lower neck sepsis should consist of appropriate intravenous antibiotic therapy, with aspiration of any abscess. Rigid airway endoscopy should be undertaken to identify the presence of a sinus opening in the apex of the pyriform fossa. In order to prevent further infections open surgical excision of the sinus tract has previously been advocated by many authors [2], [3], [4], [5], [6], [7], [8]. Formal excision of the entire tract along with a thyroidectomy is associated with its incident risks and post-operative complications [9], [10].
An endoscopic approach to assist identification of the sinus opening in the pyriform fossa followed by cauterisation has been recommended to reduce the risk of post-operative complication and has a similar recurrence rate [2]. We present our experience of using this alternative, less invasive approach, utilising endoscopic techniques to obliterate a fourth arch sinus.
Section snippets
Method
We carried out a retrospective case note review of all patients diagnosed to have fourth branchial arch anomalies at the Royal Manchester Children's Hospital over the last 7 years, along with a comprehensive review of the literature. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary outcome measure was resolution of symptoms following endoscopic treatment and the secondary outcome measure was complications following treatment.
Results
We identified 5 cases (4 female and 1 male) over the seven year period (Table 1), with the mean age of the first presentation of a neck abscess being 5.2 years (range 2–12 years). All five children had a history of recurrent neck infections, ranging from 1 to 3 admissions at other hospitals prior to referral to our tertiary centre. They had been treated with intravenous antibiotics and in 3 patients incision and drainage of the abscess was performed. All the abscesses were on the left side of
Discussion
Development of the branchial apparatus starts in the second week of life and is complete by week 7. There are five mesodermal arches separated laterally by a branchial cleft lined by ectoderm and a branchial pouch lined by endoderm medially. Each arch gives rise to specific structures within the head and neck [11].
Fourth Branchial arch anomalies were first described by Tucker and Skolnick in 1973 [12]. The sinus opening may be identified at the apex of the pyriform fossa posterior to the fold
Conclusion
In our series endoscopic obliteration of pyriform fossa sinuses using CO2 laser and/or Silver Nitrate was demonstrated to be a safe method of treatment of fourth branchial arch anomalies with no recurrence of symptoms reported. Our experience and the published literature would suggest that this should be the first line treatment. Open surgical excision during a quiescent period may be reserved for older children or in patients with multiple recurrences following endoscopic cauterisation.
Conflict of interests
None declared.
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