title: Fourth branchial pouch sinus - an unusually late initial presentation.
abstract: OBJECTIVE
  Here we present an unusual case of a male patient with 4th branchial pouch sinus with an initial presentation of pseudothyroiditis at an unusually late age of 20 years.
  
  
  METHODS
  Case report and a review of the world literature concerning 4th branchial pouch sinus is presented.
  
  
  RESULTS
  The patient was diagnosed by radiology and endoscopy and treated surgically. Histopathology revealed chronic inflammatory changes, which pointed towards recurrent sub clinical low-grade inflammations over the years keeping the condition occult till 20 years of age.
  
  
  CONCLUSIONS
  According to available literature it almost always presents in the first decade of life when it might be misdiagnosed. However our report shows it may also exist with sub clinical inflammations or infections and present at a much later stage in life, when the possibility of such a sinus shouldn't be ruled out on the basis of lack of history of recurrent neck inflammations.
authors.affiliation: Department of ENT & HNS, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India.
authors.forename: Indranil
authors.initials: I
authors.lastname: Pal
authors.forename: Subhabrata
authors.initials: S
authors.lastname: Sengupta
authors.forename: R
authors.initials: R
authors.lastname: Balakrishnan
authors.forename: Amlan
authors.initials: A
authors.lastname: Gupta
keywords: 4th branchial pouch; pseudothyroiditis