This composite of three images illustrates a surgical resection of a branchial pouch sinus (fourth branchial cleft fistula). Panel A is an endoscopic view of the piriform fossa, showing a metal probe (black arrow) inserted into the internal opening (white arrow) of the fistula tract. Panels B and C are intraoperative clinical photographs of an open neck dissection. Panel B shows the surgical field with labeled anatomical structures: the thyroid gland (Th), the fistula (F) being retracted, the recurrent laryngeal nerve (RLN) visualized as a thin white strand, and the carotid artery (CA) deeper in the field. Panel C demonstrates the completed tracing and excision of the fistula (F) using the metal probe as a guide. The image highlights the proximity of the fistula to critical neurovascular structures and the thyroid gland, emphasizing the importance of careful dissection to preserve the RLN and CA during the removal of the tract and associated scar tissue.

This clinical diagnostic image shows a direct laryngoscopic view of the right pyriform sinus apex in a patient with a suspected branchial cleft cyst. Centrally, the image demonstrates a small, dark, oval fistulous tract opening. The immediate perifistular tissue exhibits a blanched, white-to-light-gray appearance, characteristic of chemical cauterization following the application of 40% trichloroacetic acid (TCA). The surrounding pharyngeal mucosa is reddish-pink with a moist, glistening texture. This visual represents the intraoperative endpoint of chemocauterization for the management of a branchial cleft fistula, where the goal is to induce mucosal inflammation and subsequent fibrosis to achieve tract closure. The anatomical context is critical for otolaryngologists in identifying and treating congenital neck anomalies through endoscopic approaches.

This clinical photograph provides an intraoperative view of the surgical excision of a branchial fistula tract in the right neck. The operative field is exposed through a surgical incision, with drapes and retractors maintaining visibility. A gloved finger and surgical forceps are seen manipulating the tissues. Two key structures are labeled: 'TG' (Thyroid Gland) and 'PS' (Pyriform Sinus). A distinct, elongated, fibrous fistula tract is clearly visible, extending from the superior pole of the right thyroid gland toward the right pyriform sinus. The thyroid tissue appears hemorrhagic and partially dissected, reflecting the surgical manipulation required to isolate the tract. The image illustrates the complex anatomical relationship between the branchial fistula and adjacent endocrine and pharyngeal structures, specifically highlighting the pathway where a fourth branchial pouch sinus typically traverses. This material is educationally relevant for otorhinolaryngology and endocrine surgery trainees to understand the surgical anatomy of congenital neck fistulas.

This clinical diagnostic image shows an endoscopic view of the left piriform sinus, located within the hypopharynx. The mucosa is predominantly reddish-pink and demonstrates prominent superficial vascularization. At the apex of the piriform sinus, a distinct, abnormal opening is visible, representing a branchial cleft fistula or sinus tract. The orifice of the fistula appears as a dark, circular indentation with irregular, slightly elevated, and erythematous margins, suggesting localized chronic inflammation or tissue remodeling. The surrounding mucosal texture is uneven, transitioning from smooth areas to more granular surfaces near the pathological opening. This visual finding is characteristic of a congenital branchial anomaly, specifically a third or fourth branchial cleft remnant, which typically presents with recurrent neck infections or abscesses. The image serves as a key educational reference for identifying anatomical landmarks and pathological findings during direct laryngoscopy in Otolaryngology (ENT).

This composite image consists of a clinical photograph and a diagnostic CT scan illustrating a branchial cleft cyst in the neck. (A) A clinical photograph showing the left side of a patient's neck, where a large, prominent mass is visibly protruding from the skin in the upper cervical region. The overlying skin appears intact without obvious erythema. (B) An axial non-contrast CT scan of the neck at the level of the cervical vertebrae. It reveals a well-circumscribed, hypodense, ovoid mass (indicated by a white arrow) located on the left lateral aspect of the neck, deep to the platysma and lateral to the carotid sheath. The low-density center is characteristic of fluid-filled cystic structures. The lesion is located inferior to the parotid gland and anterior to the sternocleidomastoid muscle. The case illustrates the classic presentation of a branchial cleft cyst, which in this clinical context was diagnosed as a primary branchial cleft carcinoma (squamous cell carcinoma).

This dual-panel diagnostic image presents clinical imaging of the head and neck, specifically evaluating a suspected first branchial cleft cyst. Image (a) is a coronal CT scan of the temporal bones and skull base, highlighting a congenital anomaly: a bony canal (fistulous tract) measuring approximately 12.21 mm. This canal is situated in the deep portion of the tympanic bone, medial to the facial nerve and originating from the pre-tympanic region of the external auditory canal. Image (b) is a coronal T2-weighted MRI scan of the same patient, revealing a large, hyperintense, well-circumscribed parapharyngeal cyst in the left peri-tonsillar region. The cyst measures approximately 40.09 mm in its craniocaudal dimension. Together, these images illustrate the characteristic multi-component presentation of branchial cleft anomalies, involving both a cartilaginous/bony tract near the ear and a deeper soft tissue cystic component in the parapharyngeal space. The imaging modality and precise measurements are essential for pre-operative planning in otolaryngology to avoid injury to the adjacent facial nerve and carotid vasculature.

Diagnostic axial CT scan of the neck with contrast demonstrating a large, multiloculated cystic lesion in the left parapharyngeal and cervical space. The image series shows a hypoattenuating (fluid-density) mass indicated by white arrows, characterized by thin, internal enhancing septae. Anatomically, the lesion extends vertically from the level of the mandible down to the C7 vertebral level and the superior mediastinum. It is situated posteromedial to the left sternocleidomastoid muscle, displacing adjacent vascular structures. The clinical presentation is highly suggestive of a branchial cleft cyst or an ectopic cervical thymic cyst. This imaging highlights key diagnostic features of deep neck cystic masses, including internal architecture, density, and spatial relationship to cervical fascia and major vessels, essential for surgical planning and differential diagnosis in otolaryngology and radiology.

This diagnostic axial CT scan of the neck with contrast demonstrates an ill-defined, heterogeneous lesion in the left paratracheal soft tissue. A white arrow points to the primary pathology: a fourth branchial cleft cyst showing as a hypodense, fluid-filled area with rim enhancement, suggesting inflammation or infection. Key anatomical landmarks visible include the central air-filled trachea (dark circular structure) and the cervical vertebra (bright white structure posterior to the airway). The image captures the characteristic fistulous tract associated with this congenital anomaly, which is seen extending from the paratracheal region toward the left pyriform sinus. The lesion is located medial to the vascular structures of the carotid sheath and lateral to the trachea, illustrating the typical course of a fourth branchial arch remnant. This image is used to teach medical students and radiology residents the diagnostic presentation of a rare branchial cleft anomaly and its anatomical relationship to the upper aerodigestive tract.