{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,1]],"date-time":"2025-10-01T16:19:09Z","timestamp":1759335549658,"version":"3.41.2"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,9,28]],"date-time":"2021-09-28T00:00:00Z","timestamp":1632787200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:p><jats:bold>Introduction:<\/jats:bold> Fourth branchial anomalies, the rarest among anomalies of the branchial apparatus, often present diagnostic and therapeutic challenges. We evaluated the clinical presentation and radiographic features, the treatment and the long-term outcome of patients in this setting.<\/jats:p><jats:p><jats:bold>Patients and Methods:<\/jats:bold> Of 12 patients treated in the University Hospitals Leuven from 2004 until 2020, 12 variables were collected: date of birth, gender, age of onset of the symptoms, age at final diagnosis, presentation, laterality, previous procedures, diagnostic tools, treatment (open neck surgery, endoscopic laser excision, or combination), complications, recurrence, and period of follow-up. Descriptive statistics were calculated and results were compared to the existing literature.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> The most common clinical manifestations were recurrent neck infections with and without abcedation. Definitive diagnosis using direct laryngoscopy, visualizing the internal sinus opening, was possible in all patients. A CT study revealed the typical features of fourth branchial anomalies in seven patients out of nine, an ultrasound study in five out of nine patients. All patients underwent open neck surgery. If this was insufficient, secondary endoscopic laser resection of the ostium at the apex of the piriform sinus was performed (<jats:italic>n<\/jats:italic> = 4). In eight patients a thyroid lobectomy was needed for safe complete resection. Postoperative complications were minimal and at long-term, none of the patients showed further recurrence. Average time of follow-up was 8.6 years.<\/jats:p><jats:p><jats:bold>Conclusions:<\/jats:bold> Direct laryngoscopy and CT are the most accurate diagnostic tools. Our recommended treatment schedule consists of complete excision of the sinus tract by open neck surgery as the primary treatment because this ensures the best results. In case of recurrence afterwards, endoscopic laser resection of the pharyngeal ostium solved the problem.<\/jats:p>","DOI":"10.3389\/fsurg.2021.748351","type":"journal-article","created":{"date-parts":[[2021,9,28]],"date-time":"2021-09-28T06:02:33Z","timestamp":1632808953000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Fourth Branchial Anomalies: Diagnosis, Treatment, and Long-Term Outcome"],"prefix":"10.3389","volume":"8","author":[{"given":"Annelien","family":"Boonen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Greet","family":"Hens","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeroen","family":"Meulemans","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Hermans","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pierre","family":"Delaere","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vincent","family":"Vander Poorten","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2021,9,28]]},"reference":[{"key":"B1","first-page":"368","article-title":"Fourth branchial cleft remnant","volume":"77","author":"Tucker","year":"1973","journal-title":"Trans Am Acad Ophthalmol Otolaryngol."},{"key":"B2","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1016\/j.otohns.2005.05.653","article-title":"Fourth branchial pouch sinus: from diagnosis to treatment","volume":"134","author":"Garrel","year":"2006","journal-title":"Otolaryngol Head Neck Surg."},{"key":"B3","doi-asserted-by":"publisher","first-page":"1309","DOI":"10.1016\/S0030-6665(05)70283-8","article-title":"Head and neck anomalies related to the branchial apparatus","volume":"33","author":"Mandell","year":"2000","journal-title":"Otolaryngol Clin North Am."},{"key":"B4","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1016\/j.otohns.2009.09.001","article-title":"Management of congenital third branchial arch anomalies: a systematic review","volume":"142","author":"Nicoucar","year":"2010","journal-title":"Otolaryngol Head Neck Surg."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1432","DOI":"10.1016\/j.jpedsurg.2008.12.001","article-title":"Management of congenital fourth branchial arch anomalies: a review and analysis of published cases","volume":"44","author":"Nicoucar","year":"2009","journal-title":"J Pediatr Surg."},{"key":"B6","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1016\/S0165-5876(00)00384-0","article-title":"Congenital cysts and fistulas of the neck","volume":"55","author":"Nicollas","year":"2000","journal-title":"Int J pediatr Otorhinolaryngol."},{"key":"B7","doi-asserted-by":"publisher","first-page":"391","DOI":"10.1017\/S0022215100133730","article-title":"Fourth branchial arch fistula","volume":"110","author":"Johnson","year":"1996","journal-title":"J Laryngol Otol."},{"key":"B8","doi-asserted-by":"publisher","first-page":"909","DOI":"10.1288\/00005537-199509000-00007","article-title":"Branchial anomalies: a review of 52 cases","volume":"105","author":"Choi","year":"1995","journal-title":"Laryngoscope"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1309","DOI":"10.1016\/s0030-6665(05)70283-8","article-title":"Head and neck anomalies related to the branchial apparatus","volume":"33","author":"Mandell","year":"2000","journal-title":"Otolaryngol Clin North Am."},{"key":"B10","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1053\/j.sempedsurg.2006.02.002","article-title":"Waldhausen, MD. Branchial cleft and arch anomalies in children","volume":"15","author":"John","year":"2006","journal-title":"Semin Pediatr Surg."},{"key":"B11","first-page":"836","article-title":"Chapter 16: Branchial cleft cysts","volume-title":"An Atlas of Head and Neck Surgery. 4th ed","author":"Medina","year":""},{"key":"B12","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1016\/S0196-0709(03)00026-7","article-title":"Fistula of the fourth branchial pouch","volume":"24","author":"Chaudhary","year":"2003","journal-title":"Am J Otolaryngol."},{"key":"B13","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1016\/S0194-5998(96)70290-5","article-title":"Fourth branchial cleft cysts","volume":"114","author":"Cote","year":"1996","journal-title":"Otolaryngol Head Neck Surg."},{"key":"B14","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1016\/S0165-5876(98)00023-8","article-title":"Fourth branchial pouch anomalies: a study of six cases and review of the literature","volume":"44","author":"Nicollas","year":"1998","journal-title":"Int J pediatr Otorhinolaryngol."},{"key":"B15","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1053\/jpsu.2002.32253","article-title":"Ten years of experience with third and fourth branchial remnants","volume":"37","author":"Liberman","year":"2002","journal-title":"J Pediatr Surg."},{"key":"B16","doi-asserted-by":"publisher","first-page":"712","DOI":"10.1016\/j.ijom.2018.11.014","article-title":"A unique location of branchial cleft cyst: case report and review of the literature","volume":"48","author":"Meng","year":"2019","journal-title":"Int. J. Oral Maxillofac. Surg."},{"key":"B17","doi-asserted-by":"publisher","first-page":"1119","DOI":"10.1001\/archotol.132.10.1119","article-title":"Piriform sinus tracts in children","volume":"132","author":"Pereira","year":"2006","journal-title":"Arch Otolaryngol Head Neck Surg."},{"key":"B18","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1258\/002221504322731574","volume":"118","year":"2004","journal-title":"J Laryngol Otol."},{"key":"B19","doi-asserted-by":"publisher","first-page":"520","DOI":"10.1177\/019459988108900402","article-title":"Fourth branchial fistula","volume":"89","author":"Liston","year":"1981","journal-title":"Otolaryngol Head Neck Surg."},{"key":"B20","first-page":"189","article-title":"Bui P, Dehesdin D. Recurrent lateral cervical suppuration Role of fistulae and cysts of fourth branchial pouch","volume":"105","author":"Andrieu-Guitrancourt","year":"1988","journal-title":"Ann Oto-Laryngol (Paris)."},{"key":"B21","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1177\/019459989110500107","article-title":"Fourth branchial pouch sinus: diagnosis and treatment","volume":"105","author":"Rosenfeld","year":"1991","journal-title":"Otolaryngol Head Neck Surg."},{"key":"B22","doi-asserted-by":"publisher","first-page":"328","DOI":"10.1007\/s00247-003-0887-8","article-title":"Imaging studies of pyriform sinus fistula","volume":"33","author":"Wang","year":"2003","journal-title":"Pediatr Radiol."},{"key":"B23","doi-asserted-by":"publisher","first-page":"376","DOI":"10.1242\/dev.3.4.376","article-title":"The development of the ultimobranchial body in Xenopus laevis Daudin and its relation to the thyroid gland and epithelial bodies","volume":"3","author":"Sax\u00e9n","year":"1955","journal-title":"Development."},{"key":"B24","first-page":"391","article-title":"Le fond du sinus piriform dans le traitement chirurgical des fistules de la quatri\u00e8me poche endobranchiale","volume":"105","author":"Manac'h","year":"1988","journal-title":"Otolaryngol (Paris)."},{"key":"B25","doi-asserted-by":"publisher","first-page":"150","DOI":"10.4103\/0973-029X.131950","article-title":"Branchial cleft cyst: a case report and review of literature","volume":"18","author":"Chavan","year":"2014","journal-title":"J Oral Maxillofacial Pathol."},{"key":"B26","doi-asserted-by":"publisher","first-page":"236","DOI":"10.1177\/014556131809700820","article-title":"Fourth branchial pouch sinus: a report of 7 cases and review of the literature","volume":"97","author":"Pal","year":"2018","journal-title":"Ear Nose Throat J."},{"key":"B27","doi-asserted-by":"publisher","first-page":"885","DOI":"10.1001\/archoto.2010.148","article-title":"Neonatal vs delayed-onset fourth branchial pouch anomalies: therapeutic implications","volume":"136","author":"Leboulanger","year":"2010","journal-title":"Arch Otolaryngol Head Neck Surg."},{"key":"B28","first-page":"817","article-title":"Neck infection associated with pyriform sinus fistula: imaging findings","volume":"21","author":"Park","year":"2000","journal-title":"Am J Neuroradiol."},{"key":"B29","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1053\/ajot.2000.16169","article-title":"A new role for computed tomography in the diagnosis and treatment of pyriform sinus fistula","volume":"21","author":"Stone","year":"2000","journal-title":"Am J Otolaryngol."},{"key":"B30","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1016\/0196-0709(93)90049-D","article-title":"Surgical approach to pyriform sinus fistula","volume":"14","author":"Nonomura","year":"1993"},{"key":"B31","doi-asserted-by":"publisher","first-page":"442","DOI":"10.1097\/00005537-199903000-00019","article-title":"Fourth branchial arch sinus: clinical presentation, diagnostic workup, and surgical treatment","volume":"109","author":"Yang","year":"1999","journal-title":"Laryngoscope."},{"key":"B32","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1016\/S0720-048X(98)00012-6","article-title":"Acute suppurative thyroiditis secondary to piriform sinus fistula: a case report","volume":"29","author":"Diez","year":"1998","journal-title":"Eur J Radiol."},{"key":"B33","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1016\/j.ijporl.2003.09.004","article-title":"Management of anomalies of the third and fourth branchial pouches","volume":"68","author":"Pereira","year":"2004","journal-title":"Int J pediatr Otorhinolaryngol."},{"key":"B34","first-page":"467","article-title":"Chapter 98. Developmental anomalies of the neck","volume-title":"Pediatric Otolaryngology","author":"Collin","year":""},{"key":"B35","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1007\/s13244-015-0454-5","article-title":"Branchial cleft anomalies: a pictorial review of embryological development and spectrum of imaging findings","volume":"7","author":"Adams","year":"2016","journal-title":"Insights Imaging."},{"key":"B36","doi-asserted-by":"publisher","first-page":"1029","DOI":"10.1258\/0022215011909701","article-title":"Fourth branchial arch fistula and suppurative thyroiditis: a life-threatening infection","volume":"115","author":"Minhas","year":"2001","journal-title":"J Laryngol Otol."},{"key":"B37","doi-asserted-by":"publisher","first-page":"452","DOI":"10.1177\/000348940010900503","article-title":"Pyriform sinus fistula: management with chemocauterization of the internal opening","volume":"109","author":"Kim","year":"2000","journal-title":"Ann Otol Rhinol Laryngol."},{"key":"B38","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1016\/j.ijporl.2013.12.027","article-title":"Management of third branchial pouch anomalies\u2014an evolution of a minimally invasive technique","volume":"78","author":"Wong","year":"2014","journal-title":"Int J Pediatr Otorhinolaryngol."},{"key":"B39","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1002\/lary.25321","article-title":"Surgery versus endoscopic cauterization in patients with third or fourth branchial pouch sinuses: a systematic review","volume":"126","author":"Derks","year":"2016","journal-title":"Laryngoscope."},{"key":"B40","article-title":"Thyroglossal Duct Cyst. (Updated Feb 23, 2019)","volume-title":"StatPearls [Internet]","author":"Amos","year":"2020"}],"container-title":["Frontiers in Surgery"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2021.748351\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,9,28]],"date-time":"2021-09-28T06:02:44Z","timestamp":1632808964000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2021.748351\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,9,28]]},"references-count":40,"alternative-id":["10.3389\/fsurg.2021.748351"],"URL":"https:\/\/doi.org\/10.3389\/fsurg.2021.748351","relation":{},"ISSN":["2296-875X"],"issn-type":[{"type":"electronic","value":"2296-875X"}],"subject":[],"published":{"date-parts":[[2021,9,28]]},"article-number":"748351"}}