From the Guidelines
Recurrent thyroiditis in the context of a branchial anomaly is typically associated with a branchial cleft anomaly, specifically a second branchial cleft anomaly, rather than a branchial arch anomaly. This distinction is important for proper diagnosis and management. Branchial cleft anomalies arise from incomplete obliteration of the branchial apparatus during embryonic development, with the second branchial cleft being the most commonly affected (approximately 95% of cases) 1. When these anomalies communicate with the thyroid gland, they can create a pathway for infection, leading to recurrent episodes of thyroiditis. The connection typically forms a sinus tract or fistula that extends from the anterior border of the sternocleidomastoid muscle to the thyroid gland. Treatment requires complete surgical excision of the entire tract, including any thyroid tissue involvement, to prevent recurrence. Simple incision and drainage or incomplete excision will likely result in continued infections. Preoperative imaging with CT, MRI, or fistulography is recommended to map the full extent of the tract before surgical intervention 1. Understanding this embryological relationship explains why these patients experience repeated thyroid inflammation episodes despite conventional thyroiditis treatments. Key considerations in management include:
- Complete surgical excision of the tract and involved thyroid tissue
- Preoperative imaging to define the extent of the anomaly
- Multidisciplinary care involving surgeons, endocrinologists, and radiologists
- Regular follow-up to monitor for recurrence and manage any related complications, as outlined in guidelines for managing complex conditions like 22q11.2 deletion syndrome 1.
From the Research
Recurrent Thyroiditis and Branchial Anomalies
- Recurrent thyroiditis can be associated with branchial anomalies, particularly third and fourth branchial cleft anomalies 2, 3, 4.
- These anomalies can present with suppurative thyroiditis and recurrent abscess formation, which can occur at any age, including adulthood 2.
- The internal opening of a fourth arch fistula is typically at the pyriform apex, and these fistulae are often left-sided and associated with suppurative thyroiditis 4.
Relationship Between Branchial Anomalies and Thyroiditis
- Branchial cleft remnants and anomalies can occur in association with thyroid disease, posing a diagnostic and management dilemma 3.
- In some cases, branchial cleft cysts can be found within the thyroid parenchyma, exhibiting features of autoimmune thyroiditis and secondary degenerative changes 5.
- The presence of a branchial anomaly can lead to recurrent thyroid abscesses, and treatment may involve excision of the tract with ipsilateral thyroid lobectomy 4.
Clinical Presentation and Management
- Patients with branchial cleft anomalies and thyroiditis may present with a range of symptoms, including anterior neck pain, masses, and signs of suppurative thyroiditis 2, 3, 4.
- Management options may include abscess drainage, primary thyroid lobectomy, or delayed thyroid lobectomy following abscess drainage 2.
- In some cases, fine needle aspiration and radiological correlation may be necessary for correct diagnosis and appropriate treatment 5.