Minimally Invasive Laryngoscopically Assisted Management of an Enlarging...

Fourth branchial cleft remnants usually present as cysts, sinuses, or fistulae

Fourth branchial cleft remnants are characterized by their origin in the pyriform sinus and intimate relationship with the thyroid gland

Surgical management remains the standard approach for 4th branchial cleft remnants

Traditional surgical operation for 4th branchial cleft remnants can be morbid and exposes the patient to multiple risks

Antenatal ultrasound showed a 2 centimeter left lateral neck cystic mass with no signs of airway compression at corrected gestational age 29 weeks

Postnatal neck ultrasound showed a large 3 by 1.6 by 1 centimeter cystic mass located deep to the subcutaneous tissues, tracking from slightly above the left thyroid into the left neck base

On day of life 70, following routine two-month vaccines and upper respiratory tract infection symptoms, the patient had a significant increase in the size of the left neck mass

MRI showed a large lesion in the left neck visceral space with slight displacement of the thyroid towards the right side and anterior displacement of the isthmus

The lesion had thick, irregular walls with multiple enhancing papillary projections and fluid-filled center with different signal intensity levels indicating possible mucinous or proteinaceous content

A focus of blooming artifact on the anterior aspect of the cystic lesion was suggestive of air, denoting communication with an airway

The lesion extended superiorly to the level of the pyriform sinus and extended along the thoracic inlet, indenting the thymus

MRI findings were suggestive of a brachial cleft anomaly type 4 with involvement of the left thyroid and surrounding inflammatory changes

At bronchoscopy and laryngoscopy, findings included short epiglottic folds, mild tracheomalacia, laryngospasm, and significant right-sided airway deviation

Mucinous and suppurative material began to drain spontaneously from the cyst during the procedure

The fraction of inspired oxygen was decreased to 21% before firing the monopolar electrosurgical probe in the cyst cavity and along the sinus tract

Patient was extubated on postoperative day one

The pigtail catheter was removed on postoperative day 6

Patient completed a 10 day course of cefazolin

Repeat ultrasound on postoperative day 18 showed a 3.3 by 2.4 by 1.5 centimeter heterogeneous focus representing collapsed cyst after drainage

At 3 months' follow-up, the patient's cyst had not reaccumulated and she continued to be symptom-free