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Joseph Junewick, MD FACR
over 9 years ago
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4th Branchial Sinus

Case Detail

Anatomy: Neck-Face
Joseph Junewick, MD FACR
Diagnostic Category: Developmental or Congenital
Created: over 10 years ago
Updated: over 10 years ago
Tags: PEDS
Modality/Study Types: CT
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Previously well 3 year old with painful neck mass and fever.

Case Images


4th Branchial Sinus


CT – Axial and coronal reformatted images demonstrate complex fluid collection with irregular enhancing rim extending from the piriform sinus to the suprastenal notch. A few bubbles of air are also present. The left lobe of the thyroid is heterogeneous. The airway is deviated to the right but not effaced.


The branchial apparatus is a series of mesodermal arches separated externally by ectoderm (branchial clefts) and internally by endoderm (pharyngeal pouches). Branchial anomalies are vestigial remnants resulting from incomplete obliteration of the branchial apparatus or buried epithelial rests.

Branchial anomalies are classified as cysts (no internal or external communication), sinuses (internal or external drainage with or without a cyst) or fistulas (internal and external communication with or without a cyst). Anatomic location can help differentiate the branchial arch origin.

Fourth branchial anomalies extend from the pyriform sinus to the mediastinum and penetrate the thyrohyoid membrane. Fourth branchial anomalies are cradled by the superior and recurrent laryngeal nerves and often course through the thyroid gland. Differential diagnoses include: laryngocele, suppurative adenitis, suppurative thyroiditis, and foreign body reaction.


Benson MT et al. Congenital anomalies of the branchial apparatus: Embryology and pathologic anatomy. Radiographics (1992); 12(5):943-960.

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