The fourth branchial pouch sinus is a very rare developmental anomaly; it usually presents as a recurring abscess in the left side of the neck. A high index of suspicion, combined with Barium swallow and computed tomography scan, aids in diagnosis. A case of branchial pouch anomaly is reported here for its rarity and late presentation. Complete excision of the entire epithelial tract combined with ipsilateral thyroid lobectomy remains the mainstay of management.
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