Minimally Invasive Laryngoscopically Assisted Management of an Enlarging...

Fourth brachial 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 fourth branchial cleft remnants

Standard surgical operation for fourth branchial cleft remnants can be morbid and exposes the patient to multiple risks

Patient was an ex-preterm infant twin female born at 27 weeks and 6 days of gestation

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 level of 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 findings showed a focus of blooming artifact on the anterior aspect of the cystic lesion, suggestive of air, denoting communication with an airway

MRI showed 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

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

Mucinous and supative 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

A size 8 French pigtail catheter was inserted using ultrasound-guided percutaneous drainage with the Seldinger technique

Patient was extubated on postoperative day one

The pigtail catheter was removed on postoperative day six

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