title: Fourth branchial cleft anomaly: management strategy in acute presentation.
abstract: OBJECTIVE
  Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician's decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the "ultima ratio" treatment to avoid recurrence.
  
  
  METHODS
  We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus.
  
  
  RESULTS
  A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis.
  
  
  CONCLUSIONS
  Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.
authors.affiliation: Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy. Electronic address: filippocarta@unica.it.
authors.forename: Filippo
authors.initials: F
authors.lastname: Carta
authors.affiliation: Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Sionis
authors.affiliation: Department of Pediatric Surgery, ASL 8, P.O. SS Trinità, Via Is Mirrionis 92, 09121 Cagliari, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Mascia
authors.affiliation: Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Puxeddu
mesh_terms: D000038:Abscess / Q000601:surgery*; D000208:Acute Disease; D001934:Branchial Region / Q000002:abnormalities* / Q000601:surgery; D002675:Child, Preschool; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D009333:Neck; D013517:Otorhinolaryngologic Surgical Procedures; D014057:Tomography, X-Ray Computed
keywords: Acute managment; Fourth branchial sinus