Branchial-Cleft Sinus Manifesting as Recurrent Neck Abscess
A 24-year-old man presented to the otolaryngology clinic with a 2-day history of swelling on the left side of his neck and fever. He had twice had a similar neck abscess, 2 years and 6 years previously, that had been treated with antibiotic agents and incisional drainage. Clinical examination revealed a swelling, 2 cm in diameter, at the level of thyroid cartilage (Panel A). Barium esophagography and complementary computed tomography revealed a sinus tract extending from the region of the superior pole of the left thyroid lobe to the neck abscess (Panel B, arrow). The abscess was due to a sinus created by a branchial-cleft remnant. Branchial anomalies are due to abnormal development of the branchial apparatus, the embryologic origin of the head and neck. Anomalies in the third and fourth branchial arches are difficult to distinguish on imaging. The distinction can be made with the use of direct laryngoscopy on the basis of the opening of the sinus tract in the pharynx and its relationship to the superior laryngeal nerve: the fourth sinus tracts pass inferiorly, and third sinus tracts pass superiorly. Treatment involves antibiotics for infection and surgical excision for definitive management. The patient underwent incisional drainage and received antibiotics. Direct laryngoscopy and excision of the sinus tract were planned, but the patient was lost to follow-up.