Branchial cleft cysts are congenital anomalies resulting from incomplete obliteration of branchial cleft structures during embryonic development. The fourth branchial cleft anomalies are extremely rare, constituting only 2% of all cases. This case study details a 32-year-old female, presented with recurrent left deep neck infections, subsequently diagnosed with a fourth branchial cleft cyst via a barium swallowing test. Despite initial hesitation about receiving surgery, the patient eventually underwent laryngoscopic electrocauterization following a recurrence. Three months post-surgery, a barium swallowing study was conducted, revealing no residual sinus tract. The case accentuates the complexity of early and accurate diagnosis and management of fourth branchial cleft cysts. Electric cauterization was utilized to minimize complications and morbidities, avoiding the need for extensive total sinus excision and addressing recurrent infections that might otherwise require repetitive surgery. Different diagnostic tools, and treatment options for branchial anomalies, including the benefits and drawbacks of surgical excision and endoscopic cauterization were also discussed. (J Taiwan Otolaryngol Head Neck Surg 2023; 58:231-236)
