Pulse granuloma presenting as a lateral neck mass: An unusual presentation of a fourth branchial cleft fistula

BackgroundThe pulse granuloma (PG) is believed to represent a distinctive foreign body reaction to ingested particles of legumes. Its presentation in the neck is entirely unexpected.MethodsA woman presented with a mass of the lower neck that recurred following incision and drainage. The recurrent mass was found to be associated with an open sinus tract at the apex of the left pyriform sinus. The opening of the sinus tract was closed and the cyst was removed.ResultsHistologic examination of the neck mass showed vegetable material with an associated granulomatous reaction known as PG.ConclusionsThe documentation of a PG arising in the neck would seemingly discredit the legume theory, but it only further supports it. Its association with a fourth branchial cleft cyst provides evidence for the existence of the complete fourth branchial cleft fistula with seeding of ingested material through sinus tract opening.