Embryologic anomalies of the fourth branchial pouch are rarely seen. They usually present as recurring episodes of deep neck infections and/or abscesses or acute suppurative thyroiditis. Failure to recognize these unusual cases may result in misdiagnosis, inadequate treatment, and subsequent recurrence. We report 3 cases of patients with fourth branchial anomalies. Diagnosis starts with a preoperative evaluation consisting of a barium swallow or sonogram followed by direct hypopharyngoscopy at the time of surgery. Treatment of acutely infected sinuses is best done with appropriate antibiotics and, if necessary, with incision and drainage. Surgical excision should be planned after the inflammation has completely resolved.