Recurrent fourth branchial arch fistula – a reverse surgical approach

Objective: To present a case of fourth branchial arch fistula with five episodes of recurrences with a late diagnosis in second decade of life, which was managed with a non conventional, reverse surgical technique.
Method: A thorough case report with a review of available literature about fourth branchial arch anomalies is presented.
Result: Diagnosed with laryngeal endoscopy and barium swallow esophagogram, complete excision of fistula tract was done via a reverse surgical technique. Histopathology revealed Branchial fistula tract with features of chronic inflammation.
Conclusion: Because of distorted anatomy, intervention in recurrent forth branchial arch fistula needs to be individualized. A reverse surgical approach during a quiescent period comprising complete excision of the fistula tract starting at the piriform sinus end and dissecting downward along the fistula tract upto skin end, combined with transfixation of both ends and division of thyroid isthmus is recommended for treatment of recurrent as well as primary cases for complete removal of disease and preventing recurrence.