Minimally Invasive Laryngoscopically Assisted Management of an Enlarging...

Fourth brachial cleft remnants usually present as cysts, sinuses, or fistulae. These are characterized by their origin in the pyriform sinus and intimate relationship with the thyroid gland. Surgical management remains the standard approach. However, this operation can be morbid and exposes the patient to multiple risks. We report a case of an infected large 4th brachial cleft cyst with extension into the thoracic inlet and the novel therapeutic approach that was used to provide minimally invasive management of this lesion. An ex-preterm infant twin female born at 27 weeks and 6 days of gestation was referred to our care at corrected gestational age 29 weeks. The patient had an antenatal ultrasound diagnosis of a 2 centimeter left lateral neck cystic mass with no signs of airway compression. The mother was a healthy 32-year-old G1P0A0 whose spontaneous pregnancy was notable for monody twinning, a history of migraines, and a subclinical gestational thyrotoxicosis. She was admitted to the hospital at 25 weeks' gestation for incompetent cervix. She underwent a low transverse cesarean section following premature rupture of membranes during active labor. Our patient was delivered breech. Apgar scores were 57, and 8. Initial heart rate was greater than 100 beats per minute, but then dropped, requiring positive pressure ventilation. The patient was placed on CPAP and transferred to the NICU. On examination, the infant was noted to have normal faces. The neck was asymmetric. A non-specific fullness was appreciated deep to the left sternocleidomastoid muscle. Postnatal neck ultrasound showed presence of a large 3 by 1.6 by 1 centimeter cystic mass. Located deep to the subcutaneous tissues tracking from a level slightly above the left thyroid into the level of the left neck base. The internal content was predominantly anechoic. On day of life 60, the patient received routine two-month vaccines. In the following days, the patient developed non-specific upper respiratory tract infection symptoms. On day of life 70, the patient was noted to have a significant increase in the size of the left neck mass. Patient's airway was slightly. Deviated to the contralateral side, though she exhibited no signs of respiratory compromise, an urgent MRI was performed. The MRI showed a large lesion in the left neck visceral space. Slight displacement of the thyroid was noted towards the right side. The isthmus was displaced anteriorly with a clawine noted in the medial wall of the lesion. The lesion had thick, irregular walls with multiple enhancing papillary projections. The fluid-filled center of the lesion displayed different signal intensity levels indicating possible mucinous or protinaceous content. Furthermore, there was a focus of blooming artifact on the anterior aspect of the cystic lesion, suggestive of air, denoting communication with an airway. There was no evidence of hemorrhage. The lesion extended superiorly to the level of the pyriform sinus and extended along the thoracic inlet, indenting the thymus. These findings were suggestive of a brachial cleft anomaly type 4 with involvement of the left thyroid and surrounding inflammatory changes. The parents were counseled about the usual surgical procedure. The possibility of endoscopic tract coagulation was also presented jointly with otolaryngology. The patient was taken to the operating room on day of life 71. Two failed glidescope intubations triggered a decision to perform intubation under rigid bronchoscopy by the ENT specialist. At the time of bronchoscopy and laryngoscopy, the findings of short epiglottic folds, mild tracheomalacia, laryngospasm, and significant right-sided airway deviation were noted. The rigid bronchoscope was used to localize the left pyriform sinus tract and cannulate it using an echogenic guide wire which was advanced into the brachial remnant cyst. Guidewire location was confirmed using bedside ultrasound. Mucinous and supative material began to drain spontaneously from the cyst during this procedure. A monopolar electrosurgical probe was advanced along the guide wire into the sinus and cyst. After decreasing the fraction of inspired oxygen to 21%. The monopolar probe was fired in the cyst cavity and along the sinus tract. Following this stage of the procedure, the neck was prepped and draped in the usual fashion, and an ultrasound-guided percutaneous drainage was performed using the Seldinger technique to access the brachial cyst, where a size 8 French pigtail catheter was inserted and secured to a drainage bag. The patient tolerated the procedure well and was transferred to NICU in stable condition. The patient was Extubated on postoperative day one, and the pigtail catheter was removed on postoperative day six, the patient completed a 10 day course of cefazolin. A repeat ultrasound was performed prior to discharge on postoperative day 18, which showed a 3.3 by 2.4 by 1.5 centimeter heterogeneous focus within the expected location of a previously noted cystic lesion representing collapsed cyst after drainage. At 3 months' follow-up, the patient's cyst had not reaccumulated, and she continued to be symptom-free. Thank you.