Stridor as a presentation of fourth branchial pouch sinus

Background:Anomalies of the fourth arch are the rarest of all the branchial anomalies. They arise as a result of failure of involution of the cleft during embryogenesis, and manifest clinically as sinuses, cysts or abscesses in the neck, commonly presenting in childhood.Methods:This article describes a case of a neonate presenting with stridor which was secondary to a fourth branchial pouch sinus. The presentation, investigations, operative findings and treatment are discussed.Results:Microlaryngobronchoscopy was done to evaluate the stridor. A swelling in the posterolateral pharyngeal wall and a sinus opening in the pyriform fossa on the left side were identified. There were no external neck swellings. Magnetic resonance imaging confirmed a swelling in the expected region filled with air and fluid. After the diagnosis was confirmed, the swelling was aspirated and the fourth arch pouch treated. Microlaryngobronchoscopy was repeated six weeks later, showing complete resolution of the pharyngeal swelling. At this stage, the child had no airway symptoms and was feeding normally.Conclusion:This is an interesting case of a fourth branchial cleft pouch presenting with stridor. The child was treated without any complications and recovered well.

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

“Anatomy of the abnormal”—a branch of surgical anatomy—deals with relations of an anomaly to surrounding entities. Here, lateral congenital anomalies of the pharyngeal apparatus are examined; their relations to entities of the neck can be explained embryologically. Location of embryonic pharyngeal arches, clefts, and pouches in the adult is presented and terminology of these anomalies (fistulas, sinuses, cysts) is defined. First “cleft and pouch” anomalies relate with the parotid and facial nerve. Second cleft and pouch anomalies course deeply to second arch structures and superficially to third arch structures. Consequently, they relate with hypoglossal and glossopharyngeal nerves and internal and external carotid arteries. Third cleft and pouch anomalies pass deep to third arch entities and superficial to those of the fourth arch and relate with glossopharyngeal, hypoglossal, superior and recurrent laryngeal nerves, and the internal carotid artery. The complicated course of fourth cleft and pouch anomalies brings them into relationship with glossopharyngeal, hypoglossal, superior and recurrent nerves, internal carotid, aorta, and subclavian arteries. Found superficially are veins (external and anterior jugular, common facial, communicating), nerves (transverse cervical, great auricular, mandibular, cervical branches of facial), and relevant spinal nerves (e.g., accessory). Knowledge of these anatomical relations helps prevent anatomical complications.

Complete Pyriform Sinus Fistulas: Case Series and Review of Literature

ABSTRACT Pyriform sinus fistula belongs to the rarest group of cervical fistulae accounting for 3 to 10% of all branchial anomalies.1 The first clinical and embryological studies were described in the early seventies by Sandborn and Tucker, but embryological knowledge in this field remains incomplete. Children and adults usually complaint of painful neck swelling accompanied by fever that is preceded by upper respiratory infection, otalgia and odynophagia. Neonates and infants may have respiratory distress, sometimes with stridor, due to tracheal compression by the abscess.1,5,6 However, the most common mode of presentation is the recurrent episodes of acute thyroiditis. Eighty percent of patients with recurrent acute suppurative thyroiditis due to persistent pyriform sinus fistula present during the first decade of life. Making the distinction between third and fourth arch fistulas is difficult on clinical grounds alone and hence they are often collectively termed pyriform sinus fistula. Owing to the rarity of the condition and varied clinical presentation, diagnosis and ultimate management is often delayed leading to undue morbidity to the patient and professional frustration for the treating surgeon. We, hereby, present a case series of three classical cases of complete pyriform sinus fistulas with review of available literature in an attempt to clarify issues regarding presentation, diagnosis and management of this condition.

Isolated origin of the left subclavian artery from the left pulmonary artery

We describe two children with isolated origin of the left subclavian artery from the left pulmonary artery detected by echocardiography during the assessment of their congenital cardiac malformations. Both patients demonstrated pre-operative evidence of subclavian steal. This entity results from persistence of the dorsal segment of the sixth left arch, with regression of the left fourth arch and interruption of the left dorsal arch distal to the origin of the seventh left intersegmental artery. The significance of this finding relates to the potential for pulmonary overcirculation, which could have significant post-operative ramifications if not detected prior to surgical repair of an associated cardiac malformation. This entity differs from cases with a right aortic arch and aberrant left subclavian artery which has the potential to form a vascular ring, unlike cases with isolated origin of the left subclavian artery from the pulmonary artery that do not cause compression of the airway.

Fourth branchial arch fistula: a case report

Fourth branchial arch fistula is a rare anomaly. This report describes in detail the presentation and management of a fourth arch fistula.

XXIX. Conjectures on an antient Tomb in Salisbury Cathedral. By Mr. Gough

On the south side of the nave of Salisbury cathedral, under the fourth arch from the west, lies a monument of blue speckled marble, with the figure of a bishop in pontificalibus, his right hand lifted up to give the blessing, his left hand holding the crosier. On the perpendicular sides or edge all round is cut an inscription in large capitals; and on the front of the robe, another in letters somewhat similar. The slab lay to deeply bedded in the stone foundation on which the pillars of the nave rest, that the first of these inscriptions had entirely escaped the notice of the curious, or if any had noticed it, the lower half of the letters being out of sight, rendered it unintelligible. Last summer I procured it to be raised, and the pavement disposed round it in such a manner, that it can henceforth receive no injury, but will remain the second oldest monument in that church, if the conjectures I have formed upon it are founded in truth.

XXIX. Conjectures on an antient Tomb in Salisbury Cathedral. By Mr. Gough

On the south side of the nave of Salisbury cathedral, under the fourth arch from the west, lies a monument of blue speckled marble, with, the figure of a bishop in pontificalibus, his right hand lifted up to give the blessing, his left hand holding the crosier. On the perpendicular sides or edge all round is cut an inscription, in large capitals; and, on the front of the robe, another in letters somewhat similar. The slab lay to deeply bedded in the stone foundation on which the pillars of the nave reft, that the first of these inscriptions had intirely escaped the notice of the curious, or if any had noticed it, the lower half of the letters being out of sight, rendered it unintelligible. Last summer I procured it to be raised, and the pavement disposed round it in such a manner, that it can henceforth receive no injury, but will remain the second oldest monument in that church, if the conjectures I have formed upon it are founded in truth.