Anomalies of the fourth arch are the rarest of all the branchial anomalies. They arise as a result of failure of involution of the cleft during embryogenesis, and manifest clinically as sinuses, cysts or abscesses in the neck, commonly presenting in childhood.

This article describes a case of a neonate presenting with stridor which was secondary to a fourth branchial pouch sinus. The presentation, investigations, operative findings and treatment are discussed.

Microlaryngobronchoscopy was done to evaluate the stridor. A swelling in the posterolateral pharyngeal wall and a sinus opening in the pyriform fossa on the left side were identified. There were no external neck swellings. Magnetic resonance imaging confirmed a swelling in the expected region filled with air and fluid. After the diagnosis was confirmed, the swelling was aspirated and the fourth arch pouch treated. Microlaryngobronchoscopy was repeated six weeks later, showing complete resolution of the pharyngeal swelling. At this stage, the child had no airway symptoms and was feeding normally.

This is an interesting case of a fourth branchial cleft pouch presenting with stridor. The child was treated without any complications and recovered well.