Case series: Endoscopic management of fourth branchial arch anomalies

https://doi.org/10.1016/j.ijporl.2013.02.007Get rights and content

Abstract

Introduction

Fourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery.

Objectives

To determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute.

Methods

Retrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively.

Results

In total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO2 laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11–41 months).

Conclusion

Endoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.

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.

References (22)

  • J. Madana et al.

    Cervical infection secondary to pyriform sinus fistula of branchial origin

    Congenit Anom (Kyoto).

    (2009)
  • Cited by (50)

    • Retrospective review of 70 cases of pyriform sinus fistula

      2021, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      Trichloroacetic acid burning (a chemical burning method) is an alternative procedure for the management of PSF that is easy to perform and reduces recurrence [19,20]. Cuestas G et al. used endoscopic electrocauterization to successfully obliterate the path of the fistula, Watson, G. J. et al. successfully used endoscopic CO2 laser cauterization in PSF, and Cigliano et al. used an endoscopy-assisted method to inject fibrin glue through the internal opening and had good curative effect [21–23]. However, vocal cord paralysis and recurrence have been also noted postoperatively [24,25].

    View all citing articles on Scopus
    View full text