Imaging studies of pyriform sinus fistula

Endoscopic Suture With Chemocauterization: An Effective Treatment of Congenital Pyriform Sinus Fistula

OBJECTIVE

Endoscopic cauterization is an effective method for treating pyriform sinus fistula (PSF). However, these approaches sometimes result in a higher failure rate. We present an effective technique utilizing suture combined with chemocauterization as first-line treatment in patients with PSF and evaluate the safety and efficacy of its use in 126 patients.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

METHODS

Retrospective case review of patients treated between March 2012 and June 2021 at our institution with descriptive statistical analysis.

RESULTS

A total of 126 patients with PSF were included in this study with a mean age of 14.7 years. There was no sex predilection. The majority of patients presented with a left-sided neck lesion (89.7%). Ten patients presented following prior attempts at the surgery of the PSF at another institution; 8 via open surgery and 2 following endoscopic CO2 laser cauterization; other patients only had a history of repeat incision and drainage or antibiotic treatment. The success rate of obliteration of the internal opening was 96.83% after a single treatment without complications. Following reoperation, a successful outcome was achieved in the remaining 4 patients. Length of stay ranged from 10 to 14 days. No recurrences occurred within 12 to 120 months followed-up.

CONCLUSION

Endoscopic suture combined with chemocauterization is a safe and effective treatment of PSF. Surgery can be performed during the acute cervical inflammatory period without increased risk of complication or recurrence, however, patients found to have acute changes affecting the pyriform sinus should be treated with a staged surgery strategy.

A Case of Bacterial Thyroid Abscess: A Rare Complication With Potentially Serious Consequences

Thyroid abscess is a rare but potentially serious condition that can affect young females. It is characterized by a localized collection of pus within the thyroid gland, often resulting from a bacterial infection. The occurrence of thyroid abscesses is a rare complication even in immune-compromised individuals. Nevertheless, when they do occur, they can present with symptoms such as neck swelling, pain, fever, and other systemic manifestations. The diagnostic tool of choice for thyroid abscess is ultrasound, and the mainstay of treatment involves a combination of abscess drainage and antibiotics. In this case report, we describe the case of an 11-year-old girl who presented with neck swelling and pain and was subsequently diagnosed with thyroid abscess. The patient was successfully managed with incision and drainage, followed by a course of antibiotics.

Preferred diagnostic methods of pyriform sinus fistula in different situations: A systematic review

PURPOSE

Pyriform sinus fistula (PSF) diagnosis is often easily delayed and incorrect. Diagnostic values of modalities vary in different situations. The aim of this study was to recommend optimal schemes for diagnosing PSF at different ages and infection stages.

METHODS

A search of PubMed, Embase, Cochrane Library, and CBM databases was conducted to identify articles written in Chinese and English concerning PSF diagnosis using keywords: "pyriform sinus fistula", "diagnosis", and relevant synonymous terms. Quality assessment was performed using the Joanna Briggs Institute (JBI) levels of evidence and critical appraisal checklist tool.

RESULTS

111 studies describing 3692 patients were included. The highest true positive rate (TPR) of ultrasonography was 66.67 % in adult cases. Computed tomography (CT) yielded a good TPR (approximately 73 %) in both neonatal and adult patients, and contrast-enhanced CT (84.21 %) was better in adult patients. Most children cases could be accurately diagnosed by barium swallow (BS) examination which was significantly different in acute and non-infection stages (AIS, NIS). Magnetic resonance imaging (MRI) produced a nice TPR in fetal cases (69.23 %) and neonatal cases (54.44 %). Laryngoscopy was also affected by infection stages. TPR of gastroscopy (GS) was the highest in children (86.36 %) and adult cases (87.50 %).

CONCLUSION

For fetal cases suspected of PSF, an MRI is recommended. MRI or CT is preferred for neonatal cases regardless of infection stages. Children and adult patients are advised to undergo GS during NIS or AIS, while BS is suggested for NIS. Contrast-enhanced CT can also diagnose adults with PSF in AIS.

Thyrotoxicosis Due to Acute Suppurative Thyroiditis in a Pediatric Patient: A Case Report

Acute suppurative thyroiditis is a rare and potentially life-threatening cause of thyroid inflammation requiring prompt recognition and management. There are few reported cases of thyrotoxicosis due to acute suppurative thyroiditis. We are reporting the case of a 9-year-old boy who presented to the emergency room with fevers, neck pain and swelling, night terrors, and emotional lability. He was hemodynamically stable with initial lab work remarkable for neutrophilia without leukocytosis, elevated inflammatory markers, and hyperthyroidism. Imaging of the neck revealed a heterogenous collection in the region of the left thyroid concerning for suppurative thyroiditis and adenitis. He was admitted to the hospital and initiated on intravenous antibiotics. Given lack of significant improvement in pain, he was taken to the operating room for drainage on hospital day 4 with remarkable clinical improvement in pain. He was discharged on oral antibiotics. Lab work obtained on postoperative day 15 showed resolution of hyperthyroidism and decreasing inflammatory markers. Subsequent imaging following resolution of the acute illness did not reveal any anatomic abnormality that may have predisposed him to developing acute suppurative thyroiditis. Thyrotoxicosis as a complication of acute suppurative thyroiditis is a rare occurrence, and is thought to be due to the release of preformed thyroid hormone from damaged thyroid follicles. The thyrotoxic state is often transient and resolves with appropriate management of acute suppurative thyroiditis. This complication is important to recognize, as failure to appropriately diagnose and treat acute suppurative thyroiditis can lead to poor outcomes, such as airway compromise and death.

["Massive hemoptysis" and shock after fever and cough]

A boy, aged 11 years, was admitted due to intermittent fever for 15 days, cough for 10 days, and "hemoptysis" for 7 days. The boy had fever and cough with left neck pain 15 days ago, and antibiotic treatment was effective. During the course of disease, the boy developed massive "hemoptysis" which caused shock. Fiberoptic bronchoscopy revealed a left pyriform sinus fistula with continuous bleeding. In combination with neck and vascular imaging examination results, the boy was diagnosed with internal jugular vein injury and thrombosis due to congenital pyriform sinus fistula infection and neck abscess. The boy was improved after treatment with temperature-controlled radiofrequency ablation for the closure of pyriform sinus fistula, and no recurrence was observed during the follow-up for one year and six months. No reports of massive hemorrhage and shock due to pyriform sinus fistula infection were found in the searched literature, and this article summarizes the clinical features, diagnosis, and treatment of this boy, so as to provide a reference for the early diagnosis of such disease and the prevention and treatment of its complications.

Piriform fossa sinus tract - a 15-year retrospective review with a focus on atypical neonatal presentations

BACKGROUND

Third and fourth branchial anomalies are rare, accounting for less than 10% of all branchial anomalies. The piriform fossa sinus tract (PFST) typically presents with left-side suppurative thyroiditis, although it can present earlier in neonates as a non-inflamed cystic neck mass. PFST poses a considerable diagnostic challenge with variable clinical and imaging features, leading to long delays to definitive diagnosis and appropriate management.

OBJECTIVE

To analyse the patterns of presentation and imaging findings in children with PFST, with a particular focus on neonatal presentation.

MATERIALS AND METHODS

This was a retrospective review of the clinical presentation, imaging findings and management in 16 cases of PFST presenting to our tertiary children's hospital between 2003 and 2018. Cases were identified by medical records and picture archiving and communication system (PACS) search using relevant International Classification of Diseases (ICD)-10 coding.

RESULTS

Age at presentation ranged from prenatal to 16 years, with a male-to-female ratio of 2:1. All patients presented with neck swelling. Thirteen patients (81%) had suppurative thyroiditis at initial presentation. Two patients had severe thyroiditis/mediastinitis that required intensive care unit admission. Three neonates presented with noninfected, asymptomatic large cystic neck masses; two of these were detected prenatally and misdiagnosed as lymphatic malformations with subsequent spontaneous clinical resolution that later represented with evidence of PFST. The PFST was on the left side in 15/16 (94%) patients. All patients had neck imaging before definitive diagnosis. Imaging studies included radiographs, ultrasound, computed tomography, magnetic resonance imaging and barium esophagram studies. No single modality was diagnostic of PFST in all patients. Seventy-five percent of patients had multimodal imaging before diagnosis. All PFSTs were confirmed by endoscopic visualisation. Management of PFST was by endoscopic cauterisation in 13 patients and open surgery in 2. One patient did not require surgical correction.

CONCLUSION

Our study highlights the complex nature of PFST. The anomaly is uncommon, has variable clinical and imaging features and may have a lengthy, complicated course if not considered at initial presentation. An episode of suppurative thyroiditis in a child should prompt investigation for PFST. We describe atypical presentations with cystic masses in neonates that appear to resolve but represent later as typical clinical features of PFST.

Fourth Branchial Anomalies: Diagnosis, Treatment, and Long-Term Outcome

Introduction: Fourth branchial anomalies, the rarest among anomalies of the branchial apparatus, often present diagnostic and therapeutic challenges. We evaluated the clinical presentation and radiographic features, the treatment and the long-term outcome of patients in this setting.

Patients and Methods: Of 12 patients treated in the University Hospitals Leuven from 2004 until 2020, 12 variables were collected: date of birth, gender, age of onset of the symptoms, age at final diagnosis, presentation, laterality, previous procedures, diagnostic tools, treatment (open neck surgery, endoscopic laser excision, or combination), complications, recurrence, and period of follow-up. Descriptive statistics were calculated and results were compared to the existing literature.

Results: The most common clinical manifestations were recurrent neck infections with and without abcedation. Definitive diagnosis using direct laryngoscopy, visualizing the internal sinus opening, was possible in all patients. A CT study revealed the typical features of fourth branchial anomalies in seven patients out of nine, an ultrasound study in five out of nine patients. All patients underwent open neck surgery. If this was insufficient, secondary endoscopic laser resection of the ostium at the apex of the piriform sinus was performed (n = 4). In eight patients a thyroid lobectomy was needed for safe complete resection. Postoperative complications were minimal and at long-term, none of the patients showed further recurrence. Average time of follow-up was 8.6 years.

Conclusions: Direct laryngoscopy and CT are the most accurate diagnostic tools. Our recommended treatment schedule consists of complete excision of the sinus tract by open neck surgery as the primary treatment because this ensures the best results. In case of recurrence afterwards, endoscopic laser resection of the pharyngeal ostium solved the problem.

Misdiagnosis of asymptomatic intrathyroidal pyriform sinus fistula: a case report

Pyriform sinus fistula is uncommon and easily misdiagnosed. Most reported cases occur in children and are associated with either acute suppurative thyroiditis or deep neck infection. Asymptomatic pyriform sinus fistula is difficult to diagnose because it can manifest as an incidental thyroid nodule with highly suspicious malignant features on ultrasonography. The patient was a 41-year-old man with asymptomatic thyroid nodules incidentally detected on ultrasonography. Surgery was performed under the suspicion of thyroid cancer. Pathology findings revealed multiple cystic walls lined by ciliated columnar cells with stratified squamous epithelial cysts in a background of inflammatory and lymphoid cells. Barium swallow examination performed 2 weeks later revealed a sinus tract measuring 1.8 cm that arose from the apex of the left pyriform sinus. The diagnosis and management of pyriform sinus anomalies are challenging. The majority of physicians, including some otolaryngologists, lack an understanding of the disease, which should be considered one of the important differential diagnoses of neck masses. Barium swallow examination, ultrasonography, computed tomography, and laryngoscopy are useful to diagnose this condition.

Endoscopic coblation treatment for congenital pyriform sinus fistula in children

Congenital pyriform sinus fistula (CPSF) is a very rare branchial apparatus malformation. Traditional open surgery for fistulectomy might fail to excise the lesion completely, leading to continual recurrence. Herein, we report our experience of endoscopic coblation technique for treatment of CPSF in children.To observe the clinical efficacy of endoscopic coblation treatment of CPSF in children, especially for those in acute infection stage.Retrospective case series with 54 patients (including 20 cases in acute infection stage and 34 cases in non infection stage) who were diagnosed with CPSF between October 2017 to November 2019, all patients were treated with endoscopic coblation to close the piriform fossa fistula, neck abscess incision and drainage performed simultaneously for acute infection stage cases. Data collected including age of diagnosis, presenting symptoms, diagnostic methods, prior and subsequent treatments, length of hospitalization, and recurrence were analyzed.Of the 20 cases in acute infection stage, there were 3 children with transient vocal cord paresis all of which resolved with 1 month. Four children of the 34 cases in non infection stage appeared reddish swelling of the neck on the 4th, 5th, 6th, and 7th days after coblation and then underwent abscess incision and drainage. All cases experienced no recurrence, vocal cord paralysis, pharyngeal fistula and massive hemorrhage after their first endoscopic coblation of the sinus tract in the follow up of 3 to 28 months.Endoscopic coblation is an effective and safe approach for children with CPSF, neck abscess incision and drainage could be performed simultaneously in acute infection stage. We advocate using this minimally invasive technique as first line of treatment for CPSF.

Pyriform sinus fistula in children: A comparison of endoscopic-assisted surgery and endoscopic radiofrequency ablation

BACKGROUND

Pyriform sinus fistula (PSF) is a rare congenital anomaly, and the preferred definitive treatment is yet to be verified. In this study, we investigated the treatment outcomes of PSF specifically comparing endoscopic-assisted surgery and endoscopic radiofrequency ablation (RA).

METHODS

The medical records of patients treated for PSF at the Shanghai Children's Hospital between October 2016 and September 2019 were retrospectively evaluated.

RESULTS

There were 93 girls and 98 boys. The median age at onset and operation was 3 years and 5 years, respectively. Endoscopic-assisted surgery was performed in 143 patients. During the same period, RA was performed in 48 patients, and 10 of them concurrently underwent incision and drainage of neck abscesses. Longer hospital stay was found in the endoscopic-assisted surgery group than in the RA group (10.50 ± 3.93 vs. 5.02 ± 3.30 days, P < 0.001). Postoperative complications were not significantly different between the two groups, except for neck infection (0 vs. 8.3%, P = 0.004). After a median follow-up period of 21 months, no significant difference was found between the two groups in terms of recurrence (1.4% vs. 0, P = 0.560).

CONCLUSION

Patients treated with RA had a significantly shorter hospital stay than those treated with endoscopic-assisted surgery. Outcomes of endoscopic-assisted surgery and RA were not significantly different for the management of PSF and treatment method should be tailored to the patient.

LEVEL OF EVIDENCE

IV.

Pediatric thyroid ultrasound: a radiologist's checklist

Ultrasonography (US) is the imaging method of choice for evaluating the pediatric thyroid gland, complemented by scintigraphy and thyroid function tests, especially when evaluating children with suspected congenital hypothyroidism, goiter, infectious or autoimmune diseases, or neoplasm. Diagnostic considerations in newborns with congenital hypothyroidism mainly include dysgenesis, dyshormonogenesis, transient hypothyroidism and central (hypophyseal) hypothyroidism. The midline of the neck should be scrutinized for thyroid tissue from the floor of the mouth to the thoracic inlet. Cystic and echogenic ultimobranchial remnants should not be misinterpreted as orthotopic thyroid tissue. Diffuse thyroid diseases affect older children; these comprise Hashimoto and Graves diseases and infectious thyroiditis and exhibit features similar to those in adults. It is important to note that the diffuse sclerosing variant of papillary thyroid cancer can complicate thyroiditis and should not be confused with Hashimoto disease. In children with solid nodules the threshold for fine-needle aspiration biopsy or surgery should be lower compared to adults because of a higher likelihood of malignancy compared with adults. Biopsy should be considered in nodules with suspicious ultrasonographic features, even when smaller than 1 cm. Adult classification systems of thyroid nodules, although useful, are not sufficient to safely discriminate the nodules' likelihood of malignancy in children. We describe key sonographic findings and suggest a standard checklist that might be considered while performing and interpreting thyroid US in neonates and children.

Pyriform Sinus Fistula in Children: Preferred Imaging Modality and Risk Factors for Diagnostic Delay

Background: Diagnostic delay of pyriform sinus fistula (PSF) continues to challenge clinicians, and the preferred imaging modality is yet to be verified. The purpose of this study was to investigate the preferred imaging modality for PSF and the possible risk factors for a longer diagnostic delay. Methods: Medical records of patients with a surgically confirmed PSF from 2014 to 2018 were retrospectively evaluated. A comparison of the first esophagography timing with a true-positive (TP) result and that with a false-negative (FN) result was made. Data of computed tomography (CT) performed immediately after esophagography were also analyzed. In addition, the factors related to diagnostic delay were analyzed using multivariate regression models. Results: A total of 147 patients ranging in age from 0 to 16 years (median: 5.2 years) were included. The mean time since the symptom onset of the first esophagography with TP result was significantly longer than that of the examination with FN result (95.18 ± 79.12 vs. 52.59 ± 42.40 days, P = 0.032). When the time since the symptom onset was less than 12 weeks, the false-negative rate (FNR) of the first esophagography was declining dramatically with a longer time interval. Among 18 cases with an FN result of the first esophagography, the fistulous tract was finally identified in seven cases using an immediate CT. The mean of diagnostic delay was 12.28 months. Besides, rural residency was an independent risk factor for a longer diagnostic delay. Conclusion: Joint examination of esophagography and an immediate CT is the preferred imaging modality for the diagnosis of PSF in children. It is inadvisable to perform the first esophagography when the time since the symptom onset is less than 12 weeks. Besides, the rural residency is an independent risk factor for a longer diagnostic delay.

Pyriform Sinus Fistula in the Fetus and Neonate: A Systematic Review of Published Cases

Purpose: To provide recommendations for the diagnosis and treatment of pyriform sinus fistula (PSF) in the fetus and neonate through a systematic review of the published literature. Methods: PubMed and Embase (1968-2019) were searched, and additional publications were obtained by searching the references by hand. The two reviewers assessed all papers and extracted the following variables: demographics, clinical features, diagnostic tests, interventions, and prognoses. Results: Forty-two papers were included, comprising a total of 158 cases. PSF presented almost exclusively on the left side (95.56%). Patients usually presented with a neck mass (100%) and respiratory distress (43.18%). The false-negative rate (FNR) of prenatal ultrasonography (US) was significantly higher than that of prenatal magnetic resonance imaging (MRI) (P < 0.01). For the diagnosis of PSF in neonates, computerized tomography (CT) and MRI were the most accurate diagnostic modalities. Ex utero intrapartum treatment (EXIT) was performed during delivery in 6 patients (26.09%). Among 135 patients with a reported date of definitive surgery, 117 (86.67%) underwent surgery during the neonatal period. Complications after definitive surgery appeared in 5 patients (3.16%), and all of them recovered spontaneously within 3 months. Furthermore, recurrence occurred in 4 patients (2.53%). Conclusion: In fetal cases with PSF suspected by US, MRI is necessary to confirm the diagnosis. During the neonatal period, patients with PSF typically present with a neck mass and respiratory distress, and CT/MRI appears to be the preferred diagnostic method. Definitive surgery is effective for treating neonatal PSF, with a low complication rate and low recurrence rate.

Congenital pyriform sinus fistula presenting as a neck abscess in a newborn: A case report

RATIONALE

Congenital pyriform sinus fistula (CPSF) is a branchial abnormality originating from the third or fourth branchial pouch and is an important cause of anterior cervical abscess in children. Here we present a case of neck abscess in a newborn that was diagnosed as CPSF.

PATIENT CONCERNS

A male infant with a birth weight of 3660 g was admitted to hospital 25 minutes after birth after discovery of a cystic mass with extensive skin swelling in the left side of the neck. B-mode ultrasonography of the left neck showed an anterior cervical cystic mass of indeterminate nature.

DIAGNOSIS

Congenital pyriform sinus fistula.

INTERVENTIONS

The neck abscess was incised and drained under general anesthesia. Examination under suspension laryngoscopy revealed a pyriform sinus fistula. Laser cauterization was performed simultaneously. The wound was dressed and anti-inflammatory treatment was provided.

OUTCOMES

The neck wound healed uneventfully. After 3 months, the fistula was confirmed to be closed by laryngoscopy under general anesthesia. No recurrence was detected during 9 months of follow-up.

LESSONS

CPSF should be strongly suspected in a patient with an unexplained neck abscess or recurrent acute suppurative thyroiditis, especially on the left side.

Salmonella Thyroid Abscess Treated by Serial Aspiration: Case Report and Literature Review

Thyroid abscesses are the most rare conditions of the thyroid gland but it could be potentially life threatening. Most patients are immunocompromised or has an underlying chronic thyroid disorder. We report a case of a 58 year-old lady with underlying uncontrolled diabetes mellitus and a long standing uninvestigated goiter who presented with lethargy, a new anterior neck swelling with dysphagia and change of voice. Ultrasound and computed tomography were performed and showed collection with multiple air pockets in the right thyroid lobule extending to the anterior mediastinum. She was started on intravenous antibiotics and underwent serial bedside aspiration. Her symptoms improved and complete resolution was achieved after serial aspirations and antibiotics.

Ultrasonographic Characteristics of Pyriform Sinus Fistulas Involving the Thyroid Gland

OBJECTIVES

Ultrasonography (US) has been considered to have a more limited role in the diagnosis of pyriform sinus fistulas than computed tomography. The aim of this study was to evaluate the US characteristics of pyriform sinus fistulas involving the thyroid gland in an attempt to improve our ability to diagnose this condition using US.

METHODS

Between 2005 and 2016, 14 patients with pyriform sinus fistulas presenting as suppurative thyroiditis or as thyroid nodules were enrolled in the study. Their US images were reviewed to identify US characteristics indicating the presence of an underlying pyriform sinus fistula and compared with the computed tomographic images.

RESULTS

A hypoechoic tubular lesion across the thyroid gland was identified in 9 patients (64.3%). Hyperechoic foci or echogenic lines were found within the lesion in 10 patients (71.4%). A hypoechoic rim was found at the boundary of the lesion in 7 patients (50.0%). A lesion emerging from the posterolateral aspect of the thyroid cartilage was found in 4 patients (28.6%). Thirteen (92.9%) of the 14 patients had 1 of these 4 findings.

CONCLUSIONS

Ultrasonography would be a useful diagnostic modality for indicating the presence of an underlying pyriform sinus fistula in patients with suppurative thyroiditis or a thyroid nodule and can be used as a first-line diagnostic tool to screen for pyriform sinus fistulas.

Optimal Timing of the First Barium Swallow Examination for Diagnosis of Pyriform Sinus Fistula

OBJECTIVE

Observation of a sinus tract during a barium swallow examination is important for the diagnosis of pyriform sinus fistula; however, to our knowledge, no reports have existed regarding the optimal timing of the examination in relation to the onset of symptoms. The purpose of this study was to compare the timing of the examination, patient age, the number of inflammatory episodes that occurred before the examination, and the barium concentration used for examinations with true-positive results versus those with false-negative results for the diagnosis of pyriform sinus fistula.

MATERIALS AND METHODS

Twenty-three children with pyriform sinus fistula were included. The timing of the examination, patient age, the number of the inflammatory episodes that occurred before examination, and the barium concentration used were compared between examinations with true-positive results and examinations with false-negative results, by use of the Mann-Whitney U test.

RESULTS

The examination had true-positive results for 60.9% (14/23) of patients and false-negative results for 39.1% (9/23) of patients. The mean (± SD) interval since the onset of symptoms was significantly shorter for patients with false-negative examination results than for those with true-positive examination results (26.33 ± 21.17 days vs 48.57 ± 17.67 days; p = 0.020). By 6 weeks after the onset of symptoms, more than half of the examinations had false-negative results. No significant difference in patient age (p = 0.238) or number of previous inflammatory episodes (p = 0.431) existed between examinations with true-positive and false-negative results; however, a significant difference was noted in the mean barium concentration used (88.57% ± 31.53% vs 52.86% ± 18.68% weight/volume, respectively; p = 0.014).

CONCLUSION

Barium swallow examinations with false-negative results were significantly more likely when the examination was performed soon after the onset of symptoms. Therefore, early first examinations would not be recommended for the diagnosis of pyriform sinus fistula, especially in terms of radiation exposure. A higher barium concentration may be useful.

CO2 laser cauterization approach to congenital pyriform sinus fistula

OBJECTIVE

To evaluate the efficacy of CO₂ laser cauterization with suspension microlaryngoscopy as a definitive surgical treatment for pediatric Congenital Pyriform Sinus Fistula (CPSF).

MATERIAL AND METHODS

This is a cohort retrospective study. Thyroid function and cervical ultrasonography examinations were performed before operation. Enhanced magnetic resonance imaging (MRI) was performed on patients with a repeated infection (≥2 times) and/or if they had a prior open surgery. Patients were divided into two groups: the <8-year-old group and the ≥8-year-old group. The differences in the number of cauterization procedures between the two age groups and between the initial treatment and the retreatment groups were analyzed.

RESULTS

CO₂ laser cauterizations with suspension microlaryngoscopy were performed for 104 CPSF patients. No complications occurred. Three patients had a recurrence in the follow-up. The number of surgical cauterization operations was fewer than 3 in 85.1% of the patients. There was no significant difference in the number of cauterizations among the different age groups or between the initial treatment and retreatment groups (P>0.05).

CONCLUSION

CO₂ laser cauterization with suspension microlaryngoscopy is a safe, effective, and minimally invasive approach to CPSF with optimal patient outcomes.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level III.

Management of thyroid gland abscess

BACKGROUND

Thyroid abscess or acute suppurative thyroiditis is an unusual clinical condition. We present our experience with cases attended over 41 years.

MATERIALS AND METHODS

A retrospective study was performed on these patients reviewing their epidemiological characteristics and the diagnostic and therapeutic manoeuvres chosen for them all, as well as their clinical outcome. A group of 9 males and 5 females was studied, with ages ranging from 19 to 68 (mean of 40.6±15.4). These patients suffered 22 acute episodes, and 2 patients each had 4 episodes.

RESULTS

Suppurative thyroiditis comprised 0.29% of the neck abscesses. Fine needle aspiration was performed in 13 cases to evacuate the collection and isolate the aetiological agent. Mycobacterium tuberculosis and Staphylococcus aureus were the most frequently identified. Nine patients underwent ultrasound and 7 computed tomography imaging studies. Surgery was the option for 10 patients, including drainage for 7, thyroidectomy for 4 and hemithyroidectomy for the remaining 2. Systemic or intralesional antibiotics and sclerosis of the gland were also carried out. Although one case presented with hyperthyroidism and thyrotoxicosis in the acute phase, definitive hypothyroidism was observed in 5 patients at 6 months following discharge. The rate of success was 100%.

CONCLUSION

Thyroid gland suppuration is a very infrequent circumstance in neck pathology, and the options for its treatment are varied, from conservative to invasive techniques according to the microbial and radiologic findings.

How to make an accurate diagnosis of fetal pyriform sinus fistula in utero: experience at a single medical center in mainland China

OBJECTIVE

The aim of this study was to make an accurate diagnosis of pyriform sinus fistula (PSF) for prenatal diagnosis.

STUDY DESIGN

Medical records were reviewed for all 35 pyriform sinus fistula patients presenting between 2011 and 2017. Ultrasonography (US), fetal magnetic resonance imaging (MRI) and karyotyping were offered during gestation, while computer tomography (CT) and barium esophagography were performed after birth.

RESULTS

Patients included 21 males (60%) and 14 females (40%) with a sex ratio of 1.5:1. The lesion was located on the left side in 32 (91.4%) cases, the right side in 2 (5.7%), and was bilateral (2.8%) in only one case. The sensitivity of CT, MRI, ultrasonography and barium esophagography were 100% (35/35), 69.2% (9/13), 22.9% (8/35), and 80% (20/25), respectively. If the diagnosis was correct, there was almost no recurrence after treatment. Karyotype analysis of all fetuses was normal.

CONCLUSIONS

Pyriform sinus fistula is more commonly seen in the left side. Compared with ultrasonography, MRI has more advantages in prenatal diagnosis, and it is more accurate in postpartum CT examination. The outcome of children with pyriform sinus fistula may be guarded when it correct diagnosis.

Diagnosis and management of pyriform sinus cyst in neonates: 16-year experience at a single center

BACKGROUND/PURPOSE

The purpose of this study was to review our experience in diagnosing and managing neonatal pyriform sinus cyst (PSC) and to assess its outcomes.

METHODS

We retrospectively reviewed 38 cases of neonatal PSC from 2001 to 2016. Clinical features, PSC diagnosis, treatment, and outcomes were analyzed.

RESULTS

Cervical masses were detected prenatally in 8 patients (21.1%). Neck cyst and respiratory distress were frequent symptoms among these patients. Preoperative PSC diagnosis was made in 15 cases (39.5%) by esophagography. CT or MRI images showed an air-filled cyst in 22 patients (57.9%). Cyst drainage was performed in 8 infected cases (21.1%). Cyst and fistula excision was performed in 30 cases (78.9%). Fistula excision assisted by endoscopy was required in 13 PSC patients (34.2%). Fistula detection failed in 4 cases (10.5%). Patients aged between 0 to 7days presented with low infection and high cyst removal rate. No fistula recurrence occurred in cases with cyst resection.

CONCLUSIONS

CT or MRI images with an air-filled cyst are significant indications in diagnosing PSC. Surgical options for PSC depend on levels of cervical infection. The optimal timing for surgical intervention is between 0 to 7days after birth. Our surgical approaches were effective in treating neonatal PSC.

LEVELS OF EVIDENCE

Treatment study, level IV (retrospective study).

Five neonatal cases of pyriform sinus fistula with cervical cystic lesion: a comparison between sonography and other modalities

Pyriform sinus fistulas are an unusual cause of neck cystic lesions in neonates. A definitive diagnosis requires detection of the fistula, which originates from the pyriform sinus and extends to the cystic lesion. Sonography has been reported to be useful for detecting fistulas. However, there have been no reports of neonatal cases in which sonography could detect fistulas not detected by other modalities, such as barium esophagography, computed tomography (CT), or magnetic resonance imaging (MRI). We describe five neonatal patients with pyriform sinus fistula-appearing cervical cystic lesions. All patients were examined by sonography; of these, three patients were also examined by barium esophagography, two by CT, and one by MRI. The fistula was detected by sonography but not CT in one patient and by barium esophagography but not MRI in one. Two patients whose fistulas were detected by sonography had an oval-shaped and relatively small cystic lesion. One patient whose fistula could be detected only by barium esophagography had a relatively large cystic lesion. In two patients, whose fistulas were not detected by sonography or barium esophagography, sonography revealed air bubbles within the cystic lesions, and a pyriform sinus fistula was suspected. Without requiring ionizing radiation, sonography was thus useful in diagnosing pyriform sinus fistula-appearing cervical cystic lesions in neonatal cases. On the other hand, in two patients whose fistulas were not detected by sonography, the shape of the cystic lesion was polygonal or multicystic. In two of three patients with infectious signs, a fistula could not be detected. The shape and size of the cystic lesion and the presence of infectious signs may be important factors for detecting fistulas.

Diagnosis and management of pyriform sinus fistula: experience in 48 cases

PURPOSE

Pyriform sinus fistula (PSF) is often overlooked, and presents diagnostic and management challenge. The aim of this study was to highlight the value of intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide in searching for the fistula.

METHODS

The charts of 48 patients diagnosed with PSF during January 1990 until January 2013 were retrospectively reviewed. The records were analyzed for sex, side of lesion, age at onset/diagnosis, initial presentations, diagnostic methods, microbiologic cultures, pathologic findings, treatments and outcomes.

RESULTS

There were 22 males and 26 females, with a median age at onset and diagnosis of 2 years (range, 8 months to 9 years) and 4 years (range, 12 months to 13 years), respectively. The lesions were predominantly left sided (93.7%). The most common presentation was neck abscess (62.5%). Other presentations were acute suppurative thyroiditis/thyroid abscess (7), neck mass with or without dyspnea (9), and thyroid nodule (2). Barium esophagography showed the sinus tract in 100% cases. The positive predictive value of other modalities was oral-contrast CT 88.9%, intravenous contrast-enhanced CT 53.8%, noncontrast CT 33.3%, and sonography 7.9%. Thyroid function were reported normal in most tested cases (14/15, 93.3%). The fistula tract was lined with pseudostratified squamous epithelium or ciliated columnar epithelium, often associated with inflammatory changes. Bacteria cultured from the discharge were found to be oral flora. Partial thyroidectomy was operated on 11 cases. Two patients (2/8, 25%) who underwent open surgery without endoscopic assistance exhibited recurrence, while no recurrence was noted in children with the help of intraoperative endoscopy. Postoperative results were good in majority (93.7%).

CONCLUSION

PSF should be considered in any children with repeated neck or thyroid infection/mass. The combination of barium esophagography, CT scan and ultrasound is useful to establish the diagnosis. Intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide can facilitate identification of the tract during dissection.

Diagnosis of pyriform sinus fistula in children via ultrasonography

A pyriform sinus fistula is a rare congenital abnormality of the third or fourth branchial pouch that usually affects children. We report one case of the condition; ultrasound (US) imaged a heterogeneous mass with a hypoechoic area and air bubbles representing an abscess. Although these manifestations are rare, prominent and characteristic findings on US may facilitate the diagnosis of pyriform sinus fistula.

Thyroid abscess as a complication of bacterial throat infection

Thyroid abscesses are rare complications of neck infections. We report the case of a teenager who developed increasing neck pain and swelling following treatment for a Streptococcus throat infection. Imaging demonstrated a complex fluid collection in the left thyroid lobe. Ultrasound guided aspiration was performed for diagnostic purposes, yielding purulent fluid that grew multiple bacterial species. Following initial antibiotic treatment, the patient underwent definitive surgical management. Underlying risk factors and imaging techniques will be reviewed.

Acute bacterial suppurative thyroiditis: a clinical review and expert opinion

BACKGROUND

Acute suppurative thyroiditis (AST) resulting from a bacterial infection is an infrequent but potentially life-threatening endocrine emergency. Traditional management of this disease has been surgery in conjunction with targeted antibiotic therapy. Recent nonrandomized reports of small series have demonstrated good outcomes using less invasive approaches. No randomized clinical trials have been performed. Here, we provide a review of the literature and an approach to this problem based on expert opinion.

METHODS

The literature was reviewed utilizing PubMed, and a representative case of AST was presented to a panel of experts. Endocrinology, surgery, and infectious disease experts responded to a series of questions regarding diagnosis, management, prognosis, and harm.

RESULTS

Combining a broad spectrum of clinical expertise and the published literature, the authors suggest a clinical algorithm as a guide to management, addressing both diagnosis and acute and long-term management.

CONCLUSIONS

Published studies indicate a trend toward less invasive management during active inflammation and infection and regarding definite therapy. Remaining questions are presented to foster an evidence-based approach to this disease. Ideally, future randomized, controlled trials will provide data to improve the therapy and outcome of AST.

Management of Congenital Third Branchial Arch Anomalies: A Systematic Review

OBJECTIVE: To systematically review the existing literature on third branchial arch anomalies and suggest guidelines for their management.

DATA SOURCES: We searched PubMed, Medline, and Embase using Scopus, and collected additional publications cited in bibliographies. We included all English-language articles and all foreign-language articles with an English abstract.

REVIEW METHODS: Two investigators reviewed all cases explicitly identified as third arch anomalies or meeting anatomical criteria for third arch anomalies; they assessed presentation, diagnostic methods, intervention, and outcome.

RESULTS: We found 202 cases of third arch anomalies; they presented primarily on the left side (89%), usually as neck abscess (39%) or acute suppurative thyroiditis (33%). Barium swallow, direct laryngoscopy, and magnetic resonance imaging were the most useful diagnostic tools. The recurrence rate varied among the treatment options: incision and drainage, 94 percent; endoscopic cauterization of the sinus tract opening, 18 percent; open-neck surgery and tract excision, 15 percent; and partial thyroidectomy during open-neck surgery, 14 percent. Complications after surgery appeared somewhat more frequently in children eight years of age or younger.

CONCLUSION: Third arch anomalies are more common than previously reported. They appear to be best treated by complete excision of the cyst, sinus, or fistula during a quiescent period. Repeated incision and drainage yields high rates of recurrence and should be avoided. Complications might be minimized by first initiating antibiotic treatment, delaying surgical treatment until the inflammatory process is maximally resolved, and by using endoscopic cauterization.

Trumpet maneuver in the sonographic diagnosis of an external laryngocele

Laryngocele is an uncommon disease defined as an abnormal dilatation or herniation of the laryngeal saccule, forming an air-filled cavity. Radiologic evaluation of a suspected laryngocele generally includes plain radiographs, CT, and MRI. There are very few reports in the literature on sonographic findings of laryngocele. Trumpet maneuver has been reported in CT examination for the diagnosis of laryngocele. However, to the best of our knowledge, the use of trumpet maneuver in the sonographic diagnosis of laryngocele has not been previously described. This report presents the sonographic findings of an external laryngocele while performing the trumpet maneuver.

Revisiting imaging features and the embryologic basis of third and fourth branchial anomalies

BACKGROUND AND PURPOSE

There is wide discrepancy between common clinical and radiologic presentations of branchial sinuses arising from the pyriform fossa and the theoretic course of third and fourth branchial arch anomalies. The purpose of this study was to revisit the clinical presentations and imaging features of such anomalies in children.

MATERIALS AND METHODS

A retrospective review of institutional and diagnostic imaging data bases from 1998 to 2008 for reported cases of third and fourth branchial cleft anomalies was conducted. Clinical presentation, pharyngoscopy results, and imaging features in all the patients were evaluated. Surgical and histopathology correlation in patients who underwent excision of the tract was also obtained.

RESULTS

Twenty reported cases described as third or fourth branchial apparatus anomalies were identified. There were 12 females and 8 males with a mean age of 84.6 months. The most common presentation was an inflammatory neck mass (18/20, 90%) almost always involving the thyroid gland. Most lesions were on the left side (16/20, 80%). Pharyngoscopy showed a sinus opening at the piriform fossa in 18/20 (90%) cases. None of the cases followed the classic theoretic pathway of third and fourth arch remnants. Histopathology showed tracts lined with pseudostratified squamous epithelium or ciliated columnar epithelium often associated with inflammatory changes in 17 surgically resected cases.

CONCLUSIONS

Branchial sinuses arising from the pyriform fossa often present with an inflammatory neck mass involving the thyroid lobe, most often on the left side. Imaging and surgical findings suggest that they arise from the embryonal thymopharyngeal duct of the third branchial pouch, because they do not follow the hypothetic course of third or fourth arch fistulas.

Magnetic resonance imaging of branchial cleft abnormalities: illustrated cases and literature review

Objective:

We report two cases of branchial cleft abnormalities investigated using magnetic resonance imaging.

Background:

There appears to be no clear imaging technique that is universally recommended for imaging branchial cleft abnormalities. Options include fistulography, computed tomography, magnetic resonance imaging and ultrasonography.

Method:

Case reports and literature review.

Case reports:

Two cases, although not unusual in themselves, are described to illustrate the use of magnetic resonance imaging to define the anatomy and to assist surgical planning.

Conclusion:

Magnetic resonance imaging is able to accurately depict the extent and course of branchial cleft abnormalities, and in the current cases could have been relied upon to determine the necessary surgical procedure. Branchial cleft abnormalities are sufficiently rare for magnetic resonance imaging to be recommended as the first-line imaging modality.

Recurrent acute thyroid swellings because of pyriform sinus fistula

Anterior neck abscesses are not rare; but their origin from within the usually infection-resistant thyroid gland is not thought of in the first instance. We encountered 3 patients with differing presentations (tender nodule over anterior neck, recurrent abscess overlying the thyroid gland, and nonhealing fistula with inflammation of the anterior neck). These were caused by persistent embryological communication from the pyriform sinus to the thyroid gland to the left lobe. Excluding the first patient in whom an abnormal communication with oropharynx was suspected when actinomyces was detected in the aspiration cytology of a thyroid nodule, the other 2 patients underwent drainage as for any neck abscess. Fistulous communication was confirmed on barium swallow (in 2 patients) or computed tomographic scan (in 1 patient). En bloc excision of the affected thyroid along with the fistulous tract was performed in all patients. Long-term follow-up confirmed a cure.

Imaging of cystic or cyst-like neck masses

Cystic or cyst-like neck masses form a unique category within head and neck radiology with unique differential diagnoses. The precise anatomical location and imaging appearances are important for accurate diagnosis and formulating the differential diagnoses of cystic lesions in the neck. In vast majority of cases ultrasound, sometimes supplemented by fine-needle aspiration cytology (FNAC), is adequate for pre-treatment assessment. For large, deep-seated lesions assessment using magnetic resonance imaging (MRI) or computed tomography (CT) often provides useful supplementary information. Radiologists should be aware of imaging findings of common cystic neck masses to help in their appropriate management.

Acute suppurative thyroiditis in children secondary to pyriform sinus fistula

Acute suppurative thyroiditis (AST), a potential complication of pyriform sinus fistula (PSF), is a rare clinical condition as the thyroid gland is remarkably resistant to infections. Lack of awareness of the entity contributes to the rarity and frustrating recurrences. We performed a retrospective review of all cases of AST due to PSF treated at our institution over a 10-year period. The clinical data, investigations, operative findings and procedures, microbial culture reports and follow-up were recorded and analyzed. Between January 1997 and September 2006, 12 cases (8 males and 4 females) of AST due to PSF were treated. Nine patients (75%) underwent successful complete excision, seven of whom had initial incision and drainage procedures. In three patients (25%) with recurrence, one underwent complete excision at a later procedure, one patient had multiple recurrences with six incision and drainage procedures and two failed attempts of excision of PSF before final successful complete excision. The third patient is awaiting re-excision of the PSF tract. All patients, except the one awaiting re-excision, are well with no further recurrences during the follow-up period that ranged from 18 to 96 months (median, 46.5 months). AST due to PSF is a challenging entity in terms of diagnosis and management as recurrences are common despite meticulous dissection. High index of suspicion and radiological investigations such as barium studies and computed tomography scan aid in the delineation and excision of the fistulous tract.

[Diagnostic imaging of piriform sinus fistulas]

OBJECTIVES

To establish the usefulness of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and barium contrast swallow studies in the diagnosis of piriform sinus fistulas (PSF).

MATERIAL AND METHODS

We reviewed the clinical histories and imaging studies of four pediatric patients diagnosed with PSF. Cervical ultrasound was the first imaging study performed in all cases. Three patients subsequently underwent intravenous contrast-enhanced CT examination and one underwent MRI. Barium contrast swallow studies were performed in all patients at a later time. All cases were confirmed at surgery.

RESULTS

Ultrasound enabled the lesions to be located on the left side and showed the existence of heterogeneous collections in and around the thyroid glands in all four patients. Posterior CT and MRI studies determined the exact size of the abscessed lesions. Barium contrast swallow studies demonstrated the existence of the PSF in all four cases.

CONCLUSIONS

The presence of a recurrent inflammatory process and acute suppurating thyroiditis located on the left side should raise suspicions of PSF. Both CT and MRI are useful in the study of PSF; however, in our experience, ultrasound examination is the technique of choice for initial evaluation and follow-up. After the acute process, barium swallow studies continue to be the main method for diagnosing the trajectory of the fistulous tract.

Cystic malformations of the neck in children

The most common cystic malformations of the neck are the result of abnormal embryogenesis involving the thyroglossal duct (TGD), lymphatic primordia and the branchial apparatus. When the basic embryology of these structures is considered, a reasonable differential diagnosis-and in some cases a definitive diagnosis-can be achieved based on the location and the imaging characteristics of the cystic mass.