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Thyroglossal duct cysts followed by branchial cleft anomalies are the most common congenital neck masses encountered in practice, second branchial cleft cysts and sinuses are the most common type (LaRiviere and Waldhausen in Surg Clin North Am 92(3):583-597, 2012). Although both abnormalities are common individually, but rarely seen associated in same patient as described in our case. Congenitalcervical anomalies are important to consider in the differential of head and neck masses in children and adults. These lesions can present as palpable cystic masses, infected masses, draining sinuses, or fistulae. Thyroglossal duct cysts are most common, followed by branchial cleft anomalies. A synchronous presentation of both type of cyst and fistula in a same child patient is very rare with no such cases reported in literature till date.

An eight year old female was admitted via OPD with bilateral discharging sinuses. The ostium of the sinuses were at the anterior border of clavicular attachment of sternomastoid. There was H/O off and on whitish discharge, mucoid in consistency coming out from these external openings since last 6 years. It was not associated with any other complaint. There was no H/O respiratory infections, abscess formation, thyroiditis or swallowing difficulties associated with this. According to the location of external openings diagnosis of bilateral III pouch branchial fistula was made. Routine lab investigations showed normal profile. Fistulogram was attempted which was unsuccessful. Both the fistulous tracts were explored under general anaesthesia. The fistulous tract on left side was more developed as compared to the right. The left tract was extending upto the pyriform fossa and the right tract extended upto thyrohyoid membrane. Both tracts were completely excised. Postoperative recovery was uneventful. Clear liquids were permitted on the same day. Patient was discharged on second postoperative day and stitches were removed on fifth postoperative day. There were no complications on subsequent follow up for three months.

Branchial cleft anomalies result from abnormal persistence of branchial apparatus, which is located at the lateral part of the neck. These occur due to failure of obliteration of the branchial apparatus during embryonic development. Differential diagnoses of lateral neck mass are salivary gland or neurogenic neoplasms, paragangliomas, adenopathies, cystic hygroma or cystic metastasis from squamous cell carcinoma or thyroid papillary carcinoma. Clinically, a branchial cyst is smooth, round, fluctuant and non-tender, and usually occurs over the upper part of the neck, anterior to the sternocleidomastoid muscle. Sometimes, it may present as infected cyst (or abscess), a sinus or fistula. Surgical excision is the definitive treatment for branchial anomalies. The objective of the work was to study the demographic data, clinical presentation, definite diagnostic workup and treatment of patients diagnosed with branchial anomalies. This is a retrospective study of 26 patients who were diagnosed with branchial anomalies (branchial cyst and fistula), of which only 12 patients had data available between July 1999 and June 2009 at the Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Centre. Twelve cases of branchial anomalies were seen, in which 10 patients had second branchial cyst anomalies, 1 had third branchial fistula and 1 had bilateral branchial lesion. There were seven females and five males. The age of the patients varied over a wide range (4-44 years), but the majority of the patients were in their second and third decade of life. All branchial anomalies occurred at the classical site; eight patients had left-sided neck lesion. Correct clinical diagnosis was made only in five patients (41.6 %). All patients underwent surgical excision with no reported recurrence. Branchial anomalies are frequently forgotten in the differential diagnosis of lateral neck swelling. Diagnosis is usually delayed, leading to improper treatment. The diagnosis of patients who present with lateral neck cystic swelling with or without episodes of recurrent neck abscess should be considered with a high suspicion for branchial anomalies. FNA cytology is a good investigative tool in reaching toward a diagnosis of branchial lesion, with the concurrent assistance of radiological modalities. Surgical excision is the gold standard treatment of lesions of branchial anomalies.

Third or fourth branchial pouch anomaly is rare. It usually presents as an acute inflammatory swelling of the lower neck and frequently involves the thyroid gland. Surgical treatment is essential to prevent recurrence. USG, CT scan and barium esophagography help in the diagnosis. Complete excision of tract after proper identification is necessary to prevent recurrence. How to cite this article Bose A, Sengupta A, Sherpa TD, Paul N. Fourth Branchial Fistula: Revisited. Int J Head Neck Surg 2015;6(1):26-28.

Congenital lateral cervical fistula is a branchial anomaly that is formed by the abnormal evolution of the branchial cleft. Most lateral cervical fistulas only have an external opening, so a complete lateral cervical fistula with an external and internal opening is rare. We report a case with a left complete lateral cervical fistula from the second cleft. A 9-year-old girl complained of mucal discharge from an opening in the left lower neck. A fistulography was performed to confirm the tract of the fistula, and the tract was found to end in the area of the mouth. We diagnosed the patient as having a complete fistula. The fistula was totally extirpated under general anesthesia. During the operation, two horizontal incisions were made in the neck, and an angiography guidewire was very useful as a guide. An internal opening was recognized in the middle of the posterior palatine arch. We concluded that the complete lateral cervical fistula was derived from the second branchial cleft.

Fistulae arising from the second branchial apparatus are the most common anomalies than those arising from the third and fourthbranchial apparatus. Third branchial fistula is extremely rare in occurrence.1 Complete fistulae are uncommon as in the majority of casesthe tracts end blindly. Here, we report a case of complete congenital third branchial fistula on left side of the neck with an internal openingnear left pyriform fossa in a 12-year-old male patient.

Summary Background The presence of a branchial fistula with communication both internally and externally: a ‘true' branchial fistula is rare, and may arise in the context of autosomal dominant conditions such as branchiootic syndrome and branchiootorenal syndrome. Study We discuss the case of a true branchial fistula, which recurred after initial surgical excision, in a patient with branchiootic syndrome. The residual tract was dissected in a second operation through stepladder neck incisions and removed in toto via an intraoral approach. No renal abnormalities were detected on investigation with ultrasound. Discussion Incomplete excision of a branchial sinus is likely to cause recurrence however intraoperative visualisation of the tract can can sometimes prove challenging. An combined intraoral and external approach aids delineation and tract definition when there is a true branchial fistula and can therefore facilitate a complete excision. Suspicion of an hereditary aetiology should be raised in patients with bilateral or preauricular features, or a positive family history, which may then prompt additional renal and genetic investigation.

The third arch branchial fistula is a rare congenital abnormality that presents as an inflammatory process in the anterior neck, often in the region of the left lobe of thyroid. Incomplete fistula is not an uncommon finding extending from base of pyriform sinus to the thyroid or perithyroidal space, which predisposes to recurrent suppurative thyroiditis during episodes of upper respiratory infection. Complete fistula of third arch is extremely uncommon, especially of congenital origin. A 10-year-old male child presented with a small opening in the anterior neck since birth, with a swelling around it. Computerized tomography revealed a patent tract from neck skin to base of pyriform sinus. Total excision of the tract up to the left pyriform sinus with hemithyroidectomy was performed. There was no recurrence at 22 months of follow-up.

Third branchial cleft anomalies are rare accounting for 2-8% of all branchial abnormalities. We report a case of a 9 year old boy who presented with discharging sinus on the left side of neck. A sinogram revealed third branchial arch fistula. The tract was surgically removed, however, on follow up the fistula was recurred. He was later taken for endoscopic cauterization and injection of Histoacryl (n-Butyl cyanoacrylate ) glue into the tract, after which his wound healed swiftly. Historically, surgical excision of the fistulous tract has been the mainstay of treatment. Recently, minimally invasive methods are gaining wider acclaim and may potentially become the treatment of choice in the future.

Objective:We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy.Method:A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented.Results:A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence.Conclusion:To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Objectives To report authors’ experiences in the diagnosis and treatments of congenital first branchial fistula (congenital auriculocervical fistula). Materials and Methods Twelve cases of congenital first branchial fistula were reviewed. Of these, 8 underwent fistulectomy with facial nerve dissection and partial parotidectomy and 4 underwent simple fistulectomy. Results The inner openings (upper opening) of fistulae lay in the following sites: inferioposterior wall at the junction of cartilaginous and bony segments of the auricular canal and inferior wall of cartilaginous auricular canal. The outer openings(lower opening) lay along the anterior border of upper sternocleidomastoid muscle, at the mastoid tip and posterior to the mandibular angle. Complete fistulae resection was achieved in all but one case. Eleven cases were followed for 5 year with no recurrence. Recurrence occurred in 1 case 6 months after the primary surgery and revision surgery was performed. Conclusions Pre–operative radiography for the location and course of the fistula is crucial for successful fistula resection, especially in cases with past infections. Facial nerve dissection should be done routinely for deeply located fistulae.

First branchial cleft anomalies were diagnosed in 4 patients between 2000 and 2004; 3 cases were cysts and 1 case was a fistula. It is difficult to diagnose first branchial cysts before operation. An operation is often performed as for a parotid tumor, especially Warthin tumor located in the inferior pole. Although first branchial cleft anomalies account for less than 10% of all branchial abnormalities, some cases may be misdiagnosed as parotid gland tumor. On the other hand, first branchial fistula was easy to diagnose because it was open to the external auditory canal and/or infra-auricular skin. However, since first branchial fistula are often close to facial nerves, it is necessary to perform the surgery carefully.

We describe an endoscopically assisted dissection technique for cervical branchial fistulae that prevents the need for additional ‘ladder’ incisions in the neck. Two titanium clips are placed at the internal opening of the tract under endoscopic guidance through the initial skin incision. This technique is a useful adjunct to the usual technique if difficulties are experienced obtaining access higher in the neck. It enables an excellent view of surrounding structures.

Branchial fistula is a congenital anomaly resulting from failure of closure of one of the four branchial clefts. It is usually a clinical diagnosis, but dermoscopy helps in highlighting its features, thereby avoiding the need of imaging studies and other invasive diagnostic procedures. Here, we report a case of 3-year-old female patient who presented with asymptomatic tiny papule on the neck since early childhood. Dermoscopy was done to describe the features of branchial fistula and cleft.

Purpose The aim of this study is to evaluate a minimal invasive approach in the management of fourth branchial fistula using N-butyl cyanocrylate (histoacryl) and to study its feasibility. Patients and methods Between 2006 and 2011, a retrospective study of five children with fourth branchial fistula treated at Assiut University hospital was carried out. Their age ranged from 2 to 5.5 years. Three were females. Histoacryl (adhesive material) was injected through the tract under general anesthesia. Results All the children presented with a discharging fourth branchial fistula. Three of them had a left-sided fistula. Fistulogram was carried out in all patients; two of them had a complete fistula. The duration of the procedure ranged between 10 and 15 min. No complications were noted. The duration of follow-up ranged from 2 months to 1 year. No recurrence was encountered during the period of follow-up. Conclusion Histoacryl injection of the fourth branchial fistula is an effective, easy, and minimally invasive procedure that can be carried out by junior staff. Surgery may be performed as a backup if there is failure or recurrence after injection. Keywords : branchial fistula, children, fourth branchial fistula, histoacryl

The branchial arches are the embryological precursors of the face, neck and pharynx. Second most common congenital lesions of the head and neck in children are the anomalies of the branchial arches, with second arch anomalies by far the most common. Clinically, these congenital anomalies may present as cysts, sinus tracts, fistulae or cartilaginous remnants with typical clinical and radiological findings. We report the case of 11-month-old male child with congenital Type I Second branchial fistula on the left side of neck.

Branchial apparatus develop between the 3rd and 7th weeks of embryonic life. There are 5 mesodermal arches separated by invaginations of ectoderm and endoderm. During development the second arch grows caudally to cover the third and fourth arches and the second, third, and fourth pharyngeal clefts eventually fusing with the lower neck. The enclosed II, III, and IV clefts are called as the cervical sinus. If this process does not occur for some reason then it gives rise to branchial cyst, sinus or fistula. We are presenting two cases of second branchial arch anomaly. In first case there was bilateral branchial fistula with right side fistula associated with branchial cyst. In second case there was unilateral right side branchial fistula. We operated both the cases by giving step ladder incision. In second case we find fistulous track opening in the tonsillar bed. Both the patients recovered well with no recurrence since 1 year. Brachial cleft cyst is a common cause of soft tissue swelling in the neck of a young adult. They generally occur unilaterally and are typically seen in the lateral aspect of the neck. It is clinically apparent in late childhood or early adulthood. In older adults with this presentation, it is important to exclude metastatic lymphadenopathy, lymphoma or tuberculosis.

The branchial cyst, fistula, and sinuses are the anomalies of the branchial apparatus which consists of five mesodermal arches separated by invaginations of the ectoderm called as clefts. The branchial fistula is not a true fistula as it rarely has two openings. More often even if both ends are patent there is a thin membrane covering the internal opening.1 Demonstration of a complete branchial fistula on imaging studies is uncommon.2 We present a case of a complete branchial fistula in a young lady with a special emphasis on imaging.

We report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa. Cysts, fistulas, and sinuses of the second branchial cleft are the most common developmental anomalies arising from the branchial apparatus. In our case, a 43-year-old man presented with a several-year history of a discharging sinus from the right side of his neck, consistent with a branchial fistula. He underwent various investigations and finally was treated with a one-stage complete surgical excision of the fistula tract. We describe the general clinical presentation, investigations, and surgical outcome of this case.

A retrospective analysis of 183 patients undergoing surgical treatment for branchial cleft cysts and fistulae between 1970 and 1990 was carried out. There were 148 (80.8%) cases of branchial cleft cysts and 35 (19.2%) cases of branchial cleft fistulae. In patients with branchial cysts, the most frequent clinical presentation consisted of a left-sided, painless, cervical mass. Patients with a branchial fistula presented with persistent mucous discharge from a skin opening in the neck. The introduction of ultrasonography, computed tomography, and magnetic nuclear resonance imaging has improved the accuracy of traditional radiologic methods such as parotid sialography and fistulography. Complete excision under general anesthesia is the treatment of choice, and the procedure is associated with a low incidence of local complications and neurologic sequelae. The overall recurrence rate was 4.9% after a follow-up of 2 years.

The Branchial apparatus has been well described and held accountable for many congenital anomalies of the head and neck region. A congenital fistula is not as commonly encountered as a cyst or sinus, and a complete congenital fistula from the third branchial apparatus is a rare occurrence. According to the branchial apparatus theory, the course of a branchial fistula is derived from its embryological origin. Here, we report a case of a complete branchial fistula of the right side and a branchial sinus on the left side, which is a rare occurrence.

Most of the congenital anomalies of the branchial apparatus are from the second arch, pouch, and cleft; some are from the first and third arches. Fourth branchial pouch remnants are very rare. We present a rare case of fourth branchial fistula, with characteristic clinical features of recurrent left-sided neck abscess that burst spontaneously, forming a fistula. Diagnosis of fourth branchial pouch fistula was confirmed by contrast radiography (ie, fistulogram and barium swallow) revealing the internal opening in the apex of the left pyriform fossa.

The incomplete branchial fistula is not an uncommon congenital anomaly of branchial apparatus but a complete one is rare. Here we report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa.

A case of orocutaneous fistula secondary to submandibular sialolithiasis, which was masquerading clinically as branchial fistula is presented. This case highlights the importance of conducting fistulogram in the evaluation of discharging lesions in the neck.

A clinical study was conducted of patients with congenital neck masses and fistulas treated surgically in the Department of Otolaryngology, Niigata University School of Medicine between 1981 and 1992. There were 37 cases (male : 22, female :15), which occupied 0.85% of all 4, 340 hospitalized patients. Ages ranged from 4 months to 81 years old, and the median age was 26 years old. In 15 cases, ages were below 20 years old, and in 22 cases, over 20 years old, indicating that the number of patients over 20 years old was not small. There were three cases of first branchial fistula, one case of second branchial fistula, 11 cases of lateral cervical cyst, four cases of pyrif orm sinus fistula, 12 cases of cervical median cyst, two cases of ectopic thyroid gland, three cases of cystic hygroma, and one case of benign infantile hemangioendothelioma of the parotid gland. When congenital diseases were considered in the differential, diagnosis was generally easy from anamnesis and local findings. Efficient radiological examination was important for immediate differentiation in the diagnosis. Essential treatment was complete surgical removal of the lesion. Aspiration and/or open biopsy should be avoided whenever possible.

Branchiootoic syndrome is part of the spectrum of brachiootorenal disorders. Brachiootorenal disorder is a rare autosomal dominant condition, characterized by malformations of the outer, middle, and inner ear, which are associated with branchial and renal anomalies. We describe a case of bilateral branchiootoic syndrome and discuss the anatomy of second branchial cleft fistulae and the surgical management of this uncommon condition. We report the case of a 6-year-old girl referred to our department with bilateral intermittently discharging neck swellings. Clinical examination revealed bilateral branchial fistulae and preauricular sinuses, on a background of a positive family history of branchial fistulae. A magnetic resonance imaging scan confirmed the diagnosis of bilateral second branchial cleft fistulae. In view of her symptoms, she underwent bilateral branchial fistula excision and tonsillectomy with an uneventful postoperative recovery.

We report a case of congenital heterotopic salivary gland with draining sinus in the lower neck on the right side of a 10-year-old female, which we initially thought to be a branchial fistula. Heterotopic salivary glands are rare lesions in the neck and when present appear very similar to branchial cleft sinus or fistula. This congenital lesion is rare. This is probably the first report from India. It is important to report this case to raise the awareness of this condition.

We describe an extremely rare case of a complete fistula, a combination of the first 2 branchial arches as a component of branchiootorenal syndrome. A 13-year-old girl presented with the complaint of intermittent drainage from bilateral preauricular and right lower neck external openings. A contrast fistulogram revealed a complete fistula. Diagnostic features and surgical techniques are discussed in detail.

Anomalies of third or fourth branchial apparatus origin are very uncommon and present as recurrent neck infections or thyroiditis with a predominant left-sided involvement. Radiological diagnosis requires a high index of suspicion and is critical for initiation of proper treatment. We describe a case of branchial sinus of pyriform fossa with external fistulization that presented in adulthood and was diagnosed on computed tomographic scan. The radiological features of this rare anomaly are revisited.

A 5-year-old girl was admitted to our Medical Imaging Departement for ultra - sonography of a painful and non-erythematous cervical mass on the left side of the neck. She previously complained of pain and dysphagia for several days. There is no fever and no history of infection.

A case of a 14-year-old boy had a complete type of lateral cervical fistula. The internal orifice of the fistula was recognized at the upper pole of the left tonsillar fossa, and the external orifice was on the skin of the left side of the neck at the level of the cricoid cartilage. To confirm the anatomical location of the fistula, dye staining and fistulography were performed before surgery. These techniques were very helpful as a guide to the surgical removal of the fistula. The fistula was located between the internal jugular vein and the internal carotid artery and crossed over cranial nerves IX and XII, then penetrated the upper pharyngeal constrictor of the tonsil just under the digastric muscle. Histopathological observation disclosed that the lining of the fistula was stratified squamous epithelium, and that the pharyngeal part of the fistula was lined with pseudostratified ciliated cells. Infiltration of lymphocytes and neutrophils was observed in the connective tissue surrounding the epithelial cells of the fistula, and lymphocyte aggregations were seen in the connective tissue. These findings suggest that the fistula was a complete branchial fistula originating from the rupture of the membrane between the 2nd pharyngeal cleft and pouch.

First branchial cleft cysts are rare and can present as a diagnostic challenge to the physician. There can be frequent misdiagnoses, leading to a delay in treatment. This may result in mismanagement, causing an increased rate of recurrence. Moreover, their close relationship to the facial nerve would necessitate the exposure and preservation of the facial nerve. We report a case of a patient with the classical presentation of a Work type II branchial cleft cyst. Imaging showed a lesion just adjacent to the external auditory canal. Intraoperatively, a cartilagelined blind-ending sac with hair-bearing contents duplicating the external auditory canal was found. The case highlights the need to consider the diagnosis of first branchial cleft anomaly especially in the presence of cysts and sinuses within the region of the parotid and the upper neck. Complete surgical excision would be the mainstay of treatment to prevent future recurrence. Keywords : branchial cleft cyst, branchial anomaly, branchial fistula, congenital defects, pediatric neck mass

Branchial anomalies, a result of aberrant embryonic development, are rarely seen in clinical practice. Lesions of the second branchial pouch commonly present as a neck lump or discharging sinus that may be complicated by infection. Clinical examination often reveals the lesion to be related to the junction of the upper two thirds and the lower one third of the sternocleidomastoid muscle. Branchial fistulas often present as a discharging sinus in the neck with the fistula tract extending upward within the deep neck tissue for a variable distance. A complete branchial fistula is one that has a defined internal opening in the tonsillar area and an external opening at the skin overlying the sternocleidomastoid muscle at the junction of the upper two thirds and the lower one third of the muscle. The incidence of such lesions is extremely rare. Surgical excision is the treatment of choice for branchial anomalies. We present the case of a patient who presented with a complete branchial fistula and discuss the clinical presentation and surgical management of such lesions, with a review of the relevant literature.

Complete second branchial fistula is a rare clinical entity. The classical presentation of second branchial fistula is recurrent discharge from the external opening with or without recurrent painful neck swelling. We report an unusual case whose presenting symptom was a long-standing history of throat discomfort with recurrent blood stained saliva. Her symptoms resolved after her branchial fistula was excised.

We present a retrospective study of 106 patients with branchial cleft and pouch anomalies who presented to the Hospital for Sick Children between 1948 and 1990. The relevant embryology of the branchial apparatus is summarized and a theoretical description of individual anomalies given.Second branchial cleft sinuses were the most common anomalies, and the majority were managed simply, with adequate excision and a low recurrence rate. Five cases of first branchial cleft anomalies are presented, emphasizing the delay in diagnosis, the need for complete excision to prevent recurrence, and for a parotidectomy incision to protect the facial nerve from damage. The two third branchial pouch anomalies presented with a cystic neck swelling, one with recurrent infection and discharge, and the other with stridor. In both, the diagnosis was made at operation. The single fourth branchial pouch cyst was an unexpected finding in a patient with stridor.

Branchio-oto-renal (BOR) and branchio-oto (BO) syndromes are autosomal dominant hereditary disorders characterized by the presence of hearing loss and branchial fistulae and cysts, with (BOR syndrome) or without (BO syndrome) renal malformations of varying degrees of severity. Mutations in the human homologous of the Drosophila eyes absent (EYA1) gene are frequently the cause of BOR/BO syndrome. Here we describe a Korean family with BO syndrome; the proband had preauricular pit, cup-shaped auricles, branchial fistula, and hearing loss, without renal involvement. Molecular genetic study revealed a novel mutation occurring in the consensus acceptor splice site of intron 8 (c.868-2A > G) in the EYA1 gene. To the best of our knowledge, this is the first report of a splice site mutation in a family with BO syndrome without renal involvement, further extending the phenotypic-genotypic heterogeneity of BOR/BO syndrome.

Branchial abnormalities constitute 32% to 45% of all neck pathologies in children. They may be a part of branchiootorenal (BOR) syndrome, which is characterized by branchial arch anomalies, preauricular pits, hearing impairment, and renal malformations. Typically, the management of a branchial fistula does not necessarily require an extensive diagnostic workup. However, in patients with a branchial fistula associated with external ear anomalies on physical examination and/or a history of hearing loss and a similar history and findings in other family members, an additional workup should be performed to eliminate the possibility of BOR syndrome. The aim of this report is to make pediatric surgeons aware of the BOR syndrome in patients presenting with branchial arch anomalies.

Second branchial arch anomalies such as cysts, sinuses and fistulae are the most common congenital defects among other branchial arch anamolies. Among them, complete branchial fistulas with external and internal opening are rare. We present a case report of complete branchial fistula confirmed by fistulogram and excised by combined approach of the fistula by both transcervically and transorally. The pathogenesis, anatomy, clinical features, diagnosis, investigations, histopathology and treatment are discussed in detail.

We read with interest the article Branchial fistula arising from pyriform sinus: CT diagnosis of a case and discussion of radiological features by Chauhan et al. [1]. The authors have reviewed the literature well and presented the classic computed tomography findings of a rarely encountered condition. In their patient, the barium swallow study did not visualize the fistulous tract. We would like to share a similar case and highlight the barium study findings. A 21-year-old male presented with history of repeated neck infections since the age of 3 years. He had been treated multiple times with antibiotics and repeated incisions and drainage. On examination, he had extensive scar tissue in the left anterior neck; along with multiple cutaneous openings (Fig. 1). There was a soft fluctuant swelling at the local site. The patient underwent needle aspiration, which drained approximately 20 ml of pus. Subsequently, on the same day, a barium study was performed. The barium examination revealed a blind-ending tract extending from the tip of left pyriform sinus coursing anteroinferiorly, with increased pretracheal soft tissue (Figs. 2, 3). The contrast enhanced MRI performed 3 days later revealed a rim enhancing air-filled cavity in the soft tissue in the anterior neck (Fig. 4), which might have formed following the aspiration of pus. There was no intrathoracic extension; however, we need to be wary of it because of multiple pathways of spread of infections between cervical and thoracic regions [2]. We concluded the diagnosis of pyriform sinus fistula because of the clinical features and the characteristic radiological findings. It has been suggested that barium studies should be performed after clearing the acute infection to decrease the rate of false–negative results [3,4]. In an article published by J Bar Ziv et al. [3], they reported two patients with negative initial esophagograms during the acute phase. Subsequent esophagogram following treatment was successful in filling up the tract in both the patients. Gan et al. [5] also reported a case in which the barium examination was negative despite it being performed 2 weeks following the

We thank Dr Wood and his colleagues for their comments regarding our recently published article titled “Lateral Pharyngeal Diverticulum” and for sharing their information on branchial anomalies.Classically, both third and fourth branchial anomalies arise from the pyriform fossa of the hypopharynx. A third branchial fistula pierces the inferior constrictor muscle medially to the greater cornu of the hyoid bone and then courses laterally to the superior laryngeal nerve. It loops over the hypoglossal nerve, runs inferiorly to the glossopharyngeal nerve, and passes poste-riorly to the internal carotid artery. Then, the fistula opens into the skin over the anterior border of the sternocleidomastoid mus-cle. A third branchial cyst or sinus may be found at any point along this course.

It is well known that the persistence of alterations in the normal embryological development of branchial arches can lead to preauricular and cervical fistulas within a family. However, until 1970, there were no reports of dysplasia affecting the branchial, otic, and renal systems (BOR syndrome) with dominant autosomic inheritance. The authors report on a family with BOR syndrome of different expressivity in three generations, and describe an unusual case of bilateral fistulas of the first and second branchial arches in a newborn.