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Zhang S, Yuan Z, Xia Z, Chen H, Zhang Z, Chen M, Ye F. Clinical Features and Treatment of Congenital Pyriform Sinus Fistula: Analysis of 12 Cases. EAR, NOSE & THROAT JOURNAL 2024; 103:319-323. [PMID: 35968827 DOI: 10.1177/01455613221117004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Congenital pyriform sinus fistula (CPSF) is a rare congenital disease derived from the remnants of the third or fourth branchial cleft. OBJECTIVES To investigate the imaging characteristics, clinical manifestations, surgical methods, complications, and personalized treatment of CPSF. MATERIAL AND METHODS The clinical data of 12 CPSF patients admitted to the Department of Otorhinolaryngology Head and Neck Surgery of the First Affiliated Hospital of Wenzhou Medical University from March 2016 to May 2021 were retrospectively analyzed. Cryogenic plasma radiofrequency ablation, carbon dioxide laser resection, and external cervical excision were selected based on the individual condition, and postoperative complications and efficacy were evaluated. RESULTS There were 6 men and 6 women. Neck abscess or thyroiditis was considered at the initial diagnosis. In 11 of the cases, the CPSF was on the left side, whereas in the rest one case, it was on the right. A pyriform fossa fistula was observed during hypopharyngeal iodine angiography. Eight patients were treated with endoscopic piriform fossa fistula laser resection, two with cryogenic plasma radiofrequency ablation, and the rest with external cervical fistula resection. There was no evidence of postoperative hoarseness, pharyngeal fistula, dysphagia, and other complications. CONCLUSION AND SIGNIFICANCE CPSF is less common in adults than in children. For patients with recurrent neck abscesses, CPSF should be highly suspected, timely angiography should be performed as soon as possible, and care should be taken to avoid missed diagnoses. The primary method for piriform fossa fistula removal is surgical treatment. Finally, tailoring treatment regimens to the patient's condition can significantly improve curative efficacy.
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Affiliation(s)
- Shurou Zhang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ziyi Yuan
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhigang Xia
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huanqi Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ziheng Zhang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mengjiao Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fan Ye
- Department of Otorhinolaryngology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Meng L, He S, Dong R, Zheng S, Chen G. Preferred diagnostic methods of pyriform sinus fistula in different situations: A systematic review. Am J Otolaryngol 2023; 44:103747. [PMID: 36584597 DOI: 10.1016/j.amjoto.2022.103747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Lingdu Meng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai 201102, China
| | - Shiwei He
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai 201102, China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai 201102, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai 201102, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai Key Laboratory of Birth Defect and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai 201102, China.
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Zhai A, Peng X, Guo Y, Li J, Shao J. Multimodal imaging of congenital pyriform fossa fistula in children. Front Pediatr 2023; 11:1089241. [PMID: 37025293 PMCID: PMC10072278 DOI: 10.3389/fped.2023.1089241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
Objective Our aim was to explore the clinical value of multimodal imaging examinations in the diagnosis of congenital pyriform fossa fistula in children, so as to provide clues for the early diagnosis and treatment of congenital pyriform fossa fistula. Methods The clinical and imaging data of 55 children with pyriform fossa fistula diagnosed surgically in our hospital from 2015 to 2018 were analyzed retrospectively. All 55 patients underwent a CT scan. Of those patients, contrast enhancement CT was performed in 47 cases, MRI was performed in 2 cases, and barium esophagography was performed in 41 cases. Results Among the 55 cases, there were 24 male patients and 31 female patients. The age ranged from 11 months to 13 years old, and the median age was 3.8 years old. The lesions of 49 cases (89.1%) were located on the left side, and the imaging of CT showed soft tissue mass in the anterior cervical region blurred boundary. There was ipsilateral thyroid involvement in 50 cases (90.9%), trachea and/or carotid sheath extension in 43 cases (78.2%), abscess formation in 39 cases (70.9%), and pneumatosis in 25 cases (45.5%). The CT examination of 22 children after treatment showed a linear or tubular low-density shadow in the thyroid gland, gas accumulation in the anterior cervical region or thyroid, and residual contrast medium, partly. A total of 24 cases underwent barium esophagography during the acute phase, and 15 cases (62.5%) showed sinus formation from the pyriform fossa downward or punctate high-density shadow in the anterior cervical region. The 2 cases where MRI was performed showed abscess formation in one side of the neck and thyroid involvement. Conclusion Pyriform fossa fistula is most common in the left anterior cervical region, and it is closely related to the thyroid gland. The plain and enhanced-contrast CT scan can be used as the first choice during the infection stage. It helps to understand the location, extent, and structure of the surrounding tissue. The preliminary diagnosis of pyriform sinus fistula was according to the imaging features. It provided an important basis for clinical diagnosis and reduced the pain caused by repeated infection or surgical incision and drainage.
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Khoury M, Dong SX, Alsaffar H, Johnson-Obaseki S, Caulley L. Isolated oropharyngeal abscess with hypopharyngeal extension recurring 12 years after initial surgical management: A case report and review of the literature. SAGE Open Med Case Rep 2022; 10:2050313X221089119. [PMID: 35401981 PMCID: PMC8984837 DOI: 10.1177/2050313x221089119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
Pharyngeal abscesses require urgent management as they have the propensity to cause severe and life-threatening complications. The introduction of antibiotics has led to a dramatic decline in the incidence of these infections. Regardless, abscess formation continues to be observed in the peritonsillar, parapharyngeal, and retropharyngeal spaces. Oropharyngeal and hypopharyngeal abscesses that cause airway obstruction are scarcely reported and tend to be secondary to other processes. Herein, we describe the case of an 83-year-old man presenting with an idiopathic, obstructive, oropharyngeal wall abscess, extending from the infratonsillar region to the hypopharynx, which recurred after initial surgical management 12 years prior for the same process. He required reintervention during both episodes for rapid reaccumulation. A detailed electronic literature search of PubMed and MedLine was performed for studies reporting on recurrent pharyngeal abscesses and their management. Results were limited to articles published in English from inception to August 2021. The timely management of pharyngeal infections acutely obstructing the airway is crucial. Physicians should adopt close and frequent monitoring and have a low threshold for reimaging should symptoms worsen or fail to improve after the initial surgical intervention.
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Affiliation(s)
- Michel Khoury
- Department of Undergraduate Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Selina Xiangxu Dong
- Department of Undergraduate Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Hussain Alsaffar
- Department of Otolaryngology—Head and Neck Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Stephanie Johnson-Obaseki
- Department of Otolaryngology—Head and Neck Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Caulley
- Department of Otolaryngology—Head and Neck Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
- Knowledge Synthesis Group, Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Pereira KD, Highstein MJ, Greenwell AG, Isaiah A, Valdez TA. Suppurative Thyroiditis: A Management Paradigm Based on Microbiology. Pediatr Emerg Care 2021; 37:e1416-e1418. [PMID: 33003129 DOI: 10.1097/pec.0000000000002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis. DESIGN This study is a retrospective case series set in 2 tertiary care academic hospitals. METHODS The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study. RESULTS Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile. CONCLUSIONS The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.
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Affiliation(s)
| | | | | | - Amal Isaiah
- From the University of Maryland School of Medicine
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Boonen A, Hens G, Meulemans J, Hermans R, Delaere P, Vander Poorten V. Fourth Branchial Anomalies: Diagnosis, Treatment, and Long-Term Outcome. Front Surg 2021; 8:748351. [PMID: 34651012 PMCID: PMC8505890 DOI: 10.3389/fsurg.2021.748351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Annelien Boonen
- Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hens
- Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Robert Hermans
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Pierre Delaere
- Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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Maksimoski M, Maurrasse SE, Purkey M, Maddalozzo J. Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes. Ann Otol Rhinol Laryngol 2020; 130:738-744. [PMID: 33158383 DOI: 10.1177/0003489420971674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. METHODS A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. RESULTS A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. CONCLUSION A combination approach to fourth branchial apparatus lesions-including endoscopic cauterization, external excision, and hemithyroidectomy-is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.
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Affiliation(s)
- Matthew Maksimoski
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah E Maurrasse
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Matthew Purkey
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Maddalozzo
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Xia L, Lin Z, Lin X, Wang Y, Zhu L, Lin J, Zhao Y, Li Z. The treatment of congenital pyriform sinus fistula: a single-center experience. Pediatr Surg Int 2020; 36:779-788. [PMID: 32424498 DOI: 10.1007/s00383-020-04676-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Congenital pyriform sinus fistula (CPSF) often presents diagnosis and treatment challenges. This study aimed to explore the treatment principles and to evaluate the effectiveness of the hypothermia plasma cauterization with suspension laryngoscopy for CPSF. METHODS The medical records of 56 patients with CPSF from January 2000 to December 2019 were retrospectively reviewed. RESULTS Of the 56 cases, the lesions were predominantly located on the left side (95%), and the accuracy of the first diagnosis was 30%. Ultrasound showed an abnormal rate of 86%, while CT or MRI displayed an abnormal anatomic lesion of 92%. The 3D visual reconstruction enabled the analysis of morphological characteristics of CPSF. The positive predictive value of barium esophagography was 89%, whereas the positive rate of the internal opening in CPSF under local anesthesia laryngoscopy was 33%. Nine cases of sinus type underwent open resection, and the recurrence rate was 33%. Interestingly, ten patients with sinus type underwent hypothermia plasma cauterization with suspension laryngoscopy, leading to a success rate of 100% without apparent complications. CONCLUSIONS Hypothermia plasma cauterization with suspension laryngoscopy alongside 3D imaging is both minimally invasive and repeatable with neglectable complications, which has the potential to serve as the first-line treatment for CPSF in the future.
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Affiliation(s)
- Liguang Xia
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China.
| | - Zhengxiu Lin
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Xiaokun Lin
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Yongbiao Wang
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Libin Zhu
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Jinhan Lin
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Yiming Zhao
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China
| | - Zhongrong Li
- Department of Pediatric Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China.
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Bi J, Chen X, Zhou Z, Xu B, Fu Y. Diagnosis and treatment of deep neck abscess due to congenital piriform sinus fistula in children. Braz J Otorhinolaryngol 2020; 87:655-660. [PMID: 32165104 PMCID: PMC9422700 DOI: 10.1016/j.bjorl.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/08/2019] [Accepted: 12/14/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Congenital piriform sinus fistula is a relatively rare type of disease in clinical practice, most occurring during childhood, but doctors have insufficient knowledge regarding this disease, easily misdiagnosing it. OBJECTIVES This study aimed to identify the characteristics of deep neck abscess due to congenital piriform sinus fistula in children. METHODS We performed a retrospective study of 21 cases from January 2016 to August 2018 in our hospital. The onset age, clinical characteristics, auxiliary examination and clinical treatment of the patients was summarized to analyze the diagnosis, treatment characteristics and prognosis. RESULTS Children from 11 days to 12 years-old were enrolled, with an average age of 3.5 years. Twenty patients had left congenital piriform sinus fistula and 1 had right congenital piriform sinus fistula. Cervical enhanced computed tomography imaging showed gas-liquid equilibrium or air-shadow in the abscesses in 18 cases, and neck ultrasound demonstrated gas echo in the thyroid region in 10 cases. All patients underwent low temperature plasma to seal the internal fistula and returned to the hospital for electronic laryngoscope and neck ultrasound examination at 3 months, 6 months and 1year after the surgery. No recurrence occurred in any patient. CONCLUSION Congenital piriform sinus fistula is an important cause of deep neck abscess in children. The presence of purulent gas-liquid equilibrium or air shadow in cervical-enhanced computed tomography or ultrasound suggests a high possibility of the presence of an internal fistula, and endoscopic low temperature ablation can be done at the same time as the diagnostic endoscopy.
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Affiliation(s)
- Jing Bi
- Children's Hospital of Zhejiang University School of Medicine, Department of Otolaryngology Head and Neck Surgery, Hangzhou, China
| | - Xiaowei Chen
- Children's Hospital of Zhejiang University School of Medicine, Department of Otolaryngology Head and Neck Surgery, Hangzhou, China
| | - Zhiying Zhou
- Children's Hospital of Zhejiang University School of Medicine, Department of Otolaryngology Head and Neck Surgery, Hangzhou, China
| | - Bin Xu
- Children's Hospital of Zhejiang University School of Medicine, Department of Otolaryngology Head and Neck Surgery, Hangzhou, China
| | - Yong Fu
- Children's Hospital of Zhejiang University School of Medicine, Department of Otolaryngology Head and Neck Surgery, Hangzhou, China.
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Sheng Q, Lv Z, Xu W, Liu J. Differences in the diagnosis and management of pyriform sinus fistula between newborns and children. Sci Rep 2019; 9:18497. [PMID: 31811210 PMCID: PMC6898025 DOI: 10.1038/s41598-019-55050-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/20/2019] [Indexed: 12/14/2022] Open
Abstract
Pyriform sinus fistula (PSF) is a rare congenital entity. We hypothesized that clinical features, diagnosis and treatment may differ between newborns and children. 190 patients diagnosed with PSF were divided into two groups: neonatal (n = 15) and childhood (n = 175). The medical records including demographic and clinical data were retrospectively analyzed. There were 102 boys and 88 girls in this study. Most patients presented as a left-sided neck lesion. A neck mass, with or without infection and respiratory distress, was the common finding in newborn patients. Prenatal diagnosis was made in three cases. However, in childhood group, initial symptoms were neck abscess (78.8%), acute thyroiditis (11.4%), neck mass (6.9%), and thyroid lesion (2.8%). The presence of a cervical mass with air pocket showed on CT image was thought to be the pathognomonic finding of neonatal PSF. The diagnosis was usually established by barium esophagography in older children. Delayed accurate diagnosis was detected in both groups. The median time from onset to diagnosis was 22 months and 1 year respectively. Endoscopic-assisted open surgery was performed successfully in all patients, with good outcomes in majority cases of both groups (93.3% and 95.4%). Recurrence was developed in 5 patients. PSF should be suspected in newborns with cervical mass and in children with recurrent neck infection, especially on the left side. Early diagnosis and treatment might avoid repeated surgical procedures. Complete resection of the cyst and fistula in non-infected state is essential for good outcomes.
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Affiliation(s)
- Qingfeng Sheng
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Zhibao Lv
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China.
| | - Weijue Xu
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Jiangbin Liu
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
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11
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Li Y, Lyu K, Wen Y, Xu Y, Wei F, Tang H, Chen S, Wang Z, Zhu X, Wen W, Lei W. Third or fourth branchial pouch sinus lesions: a case series and management algorithm. J Otolaryngol Head Neck Surg 2019; 48:61. [PMID: 31711544 PMCID: PMC6849311 DOI: 10.1186/s40463-019-0371-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 09/09/2019] [Indexed: 01/06/2023] Open
Abstract
Background The purpose of this study was to develop an effective management algorithm for lesions of third or fourth branchial sinuses. Study design Case series with chart review. Methods Data from patients who were identified as having third or fourth branchial pouch sinus lesions in a single institution between January 2014 and December 2018 were retrospectively collected. Results All 67 patients underwent fistulectomy. First, we classified the patients into five types based on their anatomic features. Then, we considered four optimized surgical methods and adopted the appropriate method with full consideration of the patient’s clinical characteristics. The great majority of cases occurred on the left side of the neck (68.7%) and most commonly presented as either a recurrent low-neck abscess or cutaneous discharging fistula with neck infection. Effective preoperative examination included administering contrast agent prior to a computed tomography (CT) scan and in-office laryngoscopy during the quiescent period of inflammation. Ultrasound was also very helpful in determining the presence of thyroiditis. The mean follow-up duration after excision of the lesion was 25.8 months. To date, only 1 (1.5%) recurrence and no obvious complications have been observed. Conclusion Refining fistula subtypes and adopting corresponding treatment measures can reduce the recurrence rate and improve curative effects. We propose and advocate this treatment algorithm for all third and fourth branchial pouch lesions.
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Affiliation(s)
- Yun Li
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kexing Lyu
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yihui Wen
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yang Xu
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fanqin Wei
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Haocheng Tang
- Department of Otolaryngology-Head and Neck Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Siyu Chen
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhangfeng Wang
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaolin Zhu
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weiping Wen
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenbin Lei
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Li L, Liu J, Lv D, Shen T, Deng D, Wang J, Chen F. The utilization of selective neck dissection in the treatment of recurrent branchial cleft anomalies. Medicine (Baltimore) 2019; 98:e16799. [PMID: 31415388 PMCID: PMC6831353 DOI: 10.1097/md.0000000000016799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To investigate the characteristics of recurrent branchial cleft anomalies (BCAs) and to evaluate the surgical technique and outcomes of patients undergoing reoperation.From January 2005 to August 2018, the clinical data of 216 patients with recurrent second, third, and fourth BCAs were retrospectively analyzed. According to the embryological and anatomical features of the cleft palate and recurrence site, selective neck dissection techniques were used for surgical treatment.Among all 216 patients, 203 healed by primary healing. Twelve patients with local infections and 1 patient with a pharyngeal fistula healed after dressing changes. Eleven patients experienced transient hoarseness and recovered after a few months. Three patients developed permanent hoarseness, and 5 patients developed coughing after eating and drinking. Three patients underwent internal jugular vein ligation. Only 4 recurrences occurred during a follow-up period of more than 1 year. The total cure rate was 98.15%.Selective neck dissection is an effective and safe surgical treatment for recurrent second, third, and fourth branchial cleft anomalies.
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Rossi ME, Moreddu E, Leboulanger N, Akkari M, Triglia JM, Mondain M, Nicollas R, Denoyelle F. Fourth branchial anomalies: Predictive factors of therapeutic success. J Pediatr Surg 2019; 54:1702-1707. [PMID: 30981424 DOI: 10.1016/j.jpedsurg.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this work was to determine the epidemiology and the predictive factors of success of the surgical management of fourth branchial anomalies. METHODS This is a multicentric retrospective review from 1998 to 2016 of patients who presented with an endoscopically-confirmed fourth branchial pouch anomaly. Data were analyzed according to sex, age, clinical features, number of recurrences, treatment modalities (endoscopic and/or cervicotomy), post-operative complications and follow-up. RESULTS Fifty-two children have been included. The average age at diagnosis was 4.5 years. Among them, 73.1% were female, 11.4% were neonatal forms; 94.2% of lesions were left-sided; 75% of patients presented a cervical abscess as first symptom, and 7.7% of children presented with dyspnea. Average time between first symptoms and management was 9.5 months. Management was endoscopic in 73.1% of patients (laser in 84.2%, coagulation in 15.8%) with about a third of recurrence after one procedure. Overall success of endoscopic procedures reached 84.2%. A cervical open surgery was performed in 26.9% as first line treatment. Overall success of cervicotomy reached 85.7%. No complications of endoscopic surgery have been identified. There were 35.7% complications of cervicotomy (2 recurrent nerve palsy, 2 keloid scars, 1 pharyngostoma). An association was proved between recurrences and initial abscess (OR = 2.44), and with age between 3 and 5 (OR = 4). CONCLUSION Endoscopic treatments appear to be effective in first line approach in the management of fourth branchial anomalies, offering an excellent efficiency with rare complications. We identified two risk factors of recurrence: age between 3 and 5 years old and history of cervical abscesses. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marie-Eva Rossi
- ENT department, Hôpital d'enfants La Timone, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France.
| | - Eric Moreddu
- ENT department, Hôpital d'enfants La Timone, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Nicolas Leboulanger
- ENT department, Hôpital d'enfants Necker, Assistance Publique - Hôpitaux de Paris, Paris V Université, Marseille, France
| | - Mohamed Akkari
- ENT department, Hôpital Gui de Chauliac, Assistance Publique - Hôpitaux de Montpellier, Montpellier Université, Montpellier, France
| | - Jean-Michel Triglia
- ENT department, Hôpital d'enfants La Timone, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Michel Mondain
- ENT department, Hôpital Gui de Chauliac, Assistance Publique - Hôpitaux de Montpellier, Montpellier Université, Montpellier, France
| | - Richard Nicollas
- ENT department, Hôpital d'enfants La Timone, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Françoise Denoyelle
- ENT department, Hôpital d'enfants Necker, Assistance Publique - Hôpitaux de Paris, Paris V Université, Marseille, France
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Lachance S, Chadha NK. Systematic Review of Endoscopic Obliteration Techniques for Managing Congenital Piriform Fossa Sinus Tracts in Children. Otolaryngol Head Neck Surg 2015; 154:241-6. [PMID: 26527612 DOI: 10.1177/0194599815613286] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 10/01/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Piriform fossa sinus tracts (PFSTs) are a recognized cause of recurrent deep neck infections in the pediatric population. Conventional management has historically required open resection, but over recent years minimally invasive endoscopic approaches to obliterate the pharyngeal opening of the sinus have been performed in many centers. However, there is a lack of clear evidence regarding the success rate and safety of these approaches. OBJECTIVE To determine the success rate of endoscopic management of PFST through a systematic review of the existing literature. DATA SOURCES MEDLINE (1964-2014) and bibliographies of identified papers. REVIEW METHODS Two authors independently reviewed 170 abstracts and identified relevant studies for full-text review. Data were independently extracted from those studies, and the Oxford Centre for Evidence-Based Medicine guidelines were used to classify the level of evidence. RESULTS Thirteen studies met the inclusion criteria, comprising a total of 84 patients. All included studies were evidence level 4 (case series). Various methods of obliterating the PFST were described: electrocautery (n = 39), laser (n = 19), trichloroacetic acid (n = 19), silver nitrate (n = 4), combination of silver nitrate and laser (n = 2), and fibrin glue (n = 1). The success rate for endoscopic management of PFST was 89.3% overall (90.5% in primary cases and 85.7% in revision cases). The only adverse event reported was temporary vocal cord immobility in 2.4% (n = 2) of cases. CONCLUSION Endoscopic management of pediatric PFST appears to be safe and effective, as a primary option and for revision after open surgery.
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Affiliation(s)
- Sophie Lachance
- Département d'Oto-rhino-laryngologie et chirurgie cervico-faciale, CHUL, CHU de Québec, Québec, Canada Division of Pediatric Otolaryngology-Head and Neck Surgery, BC Children's Hospital, Vancouver, Canada
| | - Neil K Chadha
- Division of Pediatric Otolaryngology-Head and Neck Surgery, BC Children's Hospital, Vancouver, Canada University of British Columbia, Vancouver, Canada
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Derks LSM, Veenstra HJ, Oomen KPQ, Speleman L, Stegeman I. Surgery versus endoscopic cauterization in patients with third or fourth branchial pouch sinuses: A systematic review. Laryngoscope 2015; 126:212-7. [PMID: 26372400 DOI: 10.1002/lary.25321] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To systematically review the current literature on treatment of third and fourth branchial pouch sinuses with endoscopic cauterization, including chemocauterization and electrocauterization, in comparison to surgical treatment. DATA SOURCES PubMed, Embase, and the Cochrane Library. REVIEW METHODS We conducted a systematic search. Studies reporting original study data were included. After assessing the directness of evidence and risk of bias, studies with a low directness of evidence or a high risk of bias were excluded from analysis. Cumulative success rates after initial and recurrent treatments were calculated for both methods. A meta-analysis was conducted comparing the success rate of electrocauterization and surgery. RESULTS A total of 2,263 articles were retrieved, of which seven retrospective and one prospective article were eligible for analysis. The cumulative success rate after primary treatment with cauterization ranged from 66.7% to 100%, and ranged from 77.8% to 100% after a second cauterization. The cumulative success rate after the first surgical treatment ranged from 50% to 100% and was 100% after the second surgical attempt. Meta-analysis on electrocauterization showed a nonsignificant risk ratio of 1.35 (95% confidence interval: 0.78-2.33). CONCLUSIONS The effectiveness of cauterization in preventing recurrence seems to be comparable to surgical treatment. However, we suggest endoscopic cauterization as the treatment of choice for third and fourth branchial pouch sinuses because of the lower morbidity rate.
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Affiliation(s)
- Laura S M Derks
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Utrecht, the Netherlands
| | - Hidde J Veenstra
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Utrecht, the Netherlands
| | - Karin P Q Oomen
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Utrecht, the Netherlands
| | - Lucienne Speleman
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Utrecht, the Netherlands
| | - Inge Stegeman
- Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Utrecht, the Netherlands.,Brain Center Rudolph Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
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Givens DJ, Buchmann LO, Park AH. A novel surgical management of hypopharyngeal branchial anomalies. Int J Pediatr Otorhinolaryngol 2015; 79:579-83. [PMID: 25726018 DOI: 10.1016/j.ijporl.2015.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To review our experience treating hypopharyngeal branchial anomalies utilizing an open transcervical approach that: (1) includes recurrent laryngeal nerve (RLN) monitoring and identification if needed; (2) resection of tract if present; and (3) a superiorly based sternothyroid muscle flap for closure. METHODS A retrospective chart review was performed to identify all patients at a tertiary level children's hospital with branchial anomalies from 2005 to 2014. The clinical presentation, evaluation, treatment and outcome were analyzed for those patients with hypopharyngeal branchial anomalies. RESULTS Forty-seven patients who underwent excision of branchial anomalies with a known origin were identified. Thirteen patients had hypopharyngeal branchial anomalies. Six of these patients were treated by the authors of this study and are the focus of this analysis. All six underwent an open transcervical procedure with a sternothyroid muscle flap closure of a piriform sinus opening over a nine year period. Definitive surgery included a microlaryngoscopy and an open transcervical approach to close a fistula between the piriform sinus and neck with recurrent laryngeal nerve monitoring or dissection. A superiorly based sternothyroid muscle flap was used to close the sinus opening. There were no recurrences, recurrent laryngeal nerve injuries or other complications from these procedures. CONCLUSIONS This study supports complete surgical extirpation of the fistula tract using an open cervical approach, recurrent laryngeal nerve monitoring or identification, and rotational muscle flap closure to treat patients with hypopharyngeal branchial anomalies.
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Affiliation(s)
| | - Luke O Buchmann
- Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA
| | - Albert H Park
- Department of Surgery, Division of Otolaryngology, University of Utah, Salt Lake City, UT, USA.
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Parida PK, Gopalakrishnan S, Saxena SK. Pediatric recurrent acute suppurative thyroiditis of third branchial arch origin--our experience in 17 cases. Int J Pediatr Otorhinolaryngol 2014; 78:1953-7. [PMID: 25219934 DOI: 10.1016/j.ijporl.2014.08.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 07/29/2014] [Accepted: 08/24/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe clinical presentations, management and treatment outcomes of 17 cases of congenital pyriform sinus fistula (PSF) of third branchial arch origin presenting as left recurrent acute suppurative thyroiditis with cervical abscess. METHOD Medical record of these 17 cases (5-males, 12-females) presented during 2009-2013 were reviewed. RESULTS Average age was 9.6 years (range 3-15 years). Fistulous opening in neck was present in 10 cases (58.8%). Average number of episode of infection from first presentation to definitive diagnosis was 3 (range 2-5). All patient had history of incision and drainage (ID) of abscess (average 2, range 1-3). All cases had barium swallow and CT scan. Sixteen cases had telescopic hypopharyngoscopy. Barium swallow and telescopic hypopharyngoscopy detected PSF in 88.23% (15/17) and 100% (16/16) cases respectively. Fourteen cases were treated by transcervical excision (TE) (fistulectomy with left hemithyroidectomy), two cases were treated by endoscopic chemical cauterization (ECC) of internal opening at pyriform sinus using silver nitrate and only ID of abscess was done in one case. Success rate of TE and ECC was 93% and 100% respectively. Recurrence in one case initially treated by TE was managed successfully by ECC. CONCLUSION Presence of congenital PFS should be suspected when left-sided intra-thyroidal abscess formation occurs as gland is resistant to infection. Strong clinical suspicion, barium swallow study, telescopic pharyngoscopy and CT scan are the key to diagnosis. Both TE and ECC has comparable success rate. ECC may prove a useful and equally effective method of treatment for congenital PFS in future.
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Affiliation(s)
| | | | - Sunil Kumar Saxena
- Department of Otorhinolaryngology and Head-Neck Surgery, JIPMER, Puducherry, India
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Carta F, Sionis S, Mascia L, Puxeddu R. Fourth branchial cleft anomaly: management strategy in acute presentation. Int J Pediatr Otorhinolaryngol 2014; 78:1480-4. [PMID: 25012196 DOI: 10.1016/j.ijporl.2014.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/16/2014] [Accepted: 06/11/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician's decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the "ultima ratio" treatment to avoid recurrence. METHODS We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus. RESULTS A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis. CONCLUSION Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.
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Affiliation(s)
- Filippo Carta
- Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy.
| | - Sara Sionis
- Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy
| | - Luigi Mascia
- Department of Pediatric Surgery, ASL 8, P.O. SS Trinità, Via Is Mirrionis 92, 09121 Cagliari, Italy
| | - Roberto Puxeddu
- Department of Otorhinolaryngology, AOU, P.O. S Giovanni di Dio, University of Cagliari, Via Ospedale 54, 09124 Cagliari, Italy
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Sheng Q, Lv Z, Xiao X, Zheng S, Huang Y, Huang X, Li H, Wu Y, Dong K, Liu J. Diagnosis and management of pyriform sinus fistula: experience in 48 cases. J Pediatr Surg 2014; 49:455-9. [PMID: 24650477 DOI: 10.1016/j.jpedsurg.2013.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/01/2013] [Accepted: 07/20/2013] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Qingfeng Sheng
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China
| | - Zhibao Lv
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China.
| | - Xianmin Xiao
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Shan Zheng
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Yimin Huang
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China
| | - Xiong Huang
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China
| | - Hui Li
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China
| | - Yibo Wu
- Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China
| | - Kuiran Dong
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Jiangbin Liu
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
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Parker KL, Clary MS, Courey MS. The endoscopic approach to a fourth branchial pouch sinus presenting in an adult. Laryngoscope 2013; 123:2798-800. [DOI: 10.1002/lary.24185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 04/07/2013] [Accepted: 04/15/2013] [Indexed: 11/09/2022]
Affiliation(s)
| | - Matthew S. Clary
- Department of Otolaryngology-Head & Neck Surgery; University of Colorado School of Medicine; Denver Colorado
| | - Mark S. Courey
- Department of Otolaryngology-Head & Neck Surgery; University of California San Francisco; San Francisco California U.S.A
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Retrospective case review of pyriform sinus fistulae of third branchial arch origin commonly presenting as acute suppurative thyroiditis in children. The Journal of Laryngology & Otology 2012; 126:737-42. [PMID: 22624855 DOI: 10.1017/s0022215112000898] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Abnormalities of the third branchial arch are less common than those of the second arch and usually present with left thyroid lobe inflammation. This paper describes 15 cases of pyriform sinus fistulae of third branchial arch origin usually presenting as recurrent thyroid abscess on the left side. METHOD A retrospective review of 15 cases of third arch fistulae managed 2000 and 2008, diagnosed based on histopathology and radiological evidence of a fistulous tract, and treated with fistulectomy with left hemithyroidectomy. RESULTS All patients (six boys and nine girls, aged three to 15 years) presented with recurrent low neck inflammation. Pre-operative ultrasound, computed tomography fistulography and barium swallow demonstrated a third arch fistulous tract, left-sided in all cases. The fistula was detected intra-operatively and pathologically in all cases. Surgery (successful in all cases) emphasised complete recurrent laryngeal nerve and ipsilateral pyriform sinus exposure, to facilitate tract excision, with left hemithyroidectomy. There was no recurrence over three to five years' follow up. CONCLUSION Paediatric recurrent low neck inflammatory episodes, due to thyroidal abscess, especially left-sided, should raise suspicion of pyriform sinus fistulae.
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Nagato T, Otaka R, Wada T, Kanai N, Harabuchi Y. Right-sided pyriform sinus fistula. Intern Med J 2011; 41:798. [PMID: 22077946 DOI: 10.1111/j.1445-5994.2011.02594.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T Nagato
- Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical College, Asahikawa, Japan
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Sioka E, Efthimiou M, Skoulakis C, Zacharoulis D. Thyroid abscess requiring emergency intervention. J Emerg Med 2011; 43:e455-6. [PMID: 22018983 DOI: 10.1016/j.jemermed.2011.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 03/28/2011] [Accepted: 06/04/2011] [Indexed: 10/16/2022]
Affiliation(s)
- Eleni Sioka
- Surgical Department, University Hospital of Larissa, Larissa, Greece
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Madana J, Yolmo D, Kalaiarasi R, Gopalakrishnan S, Saxena SK, Krishnapriya S. Recurrent neck infection with branchial arch fistula in children. Int J Pediatr Otorhinolaryngol 2011; 75:1181-5. [PMID: 21763006 DOI: 10.1016/j.ijporl.2011.06.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 06/14/2011] [Accepted: 06/18/2011] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. METHODS A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. RESULTS The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence. CONCLUSION Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.
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Affiliation(s)
- J Madana
- Department of Otorhinolaryngology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605 006, India.
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Nour YA, Hassan MH, Gaafar A, Eldaly A. Deep Neck Infections of Congenital Causes. Otolaryngol Head Neck Surg 2010; 144:365-71. [DOI: 10.1177/0194599810391629] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives. To review cases of deep neck infections with underlying congenital etiology with special emphasis on their clinical presentations and the computed tomographic findings and to discuss the various therapeutic modalities employed for such lesions. Study Design. Case series with chart review. Settings. Alexandria University Hospital, Egypt. Subjects and Methods. The authors retrospectively reviewed the clinical, imaging, and operative records of deep neck infection cases presented to their department in the past 10 years. Deep neck infection cases due to congenital causes were included in the study. Results. Of the 249 cases of deep neck infections admitted to the authors’ department in the past 10 years, 39 patients were diagnosed with deep neck infections due to congenital causes. Patients were classified into 2 groups. In group 1 (29 patients), computed tomography revealed the presence of infected cystic swelling in the neck that was classified as second branchial cyst (16 patients), third and fourth branchial cysts (8 patients), and thyroglossal cyst (5 patients). Group 2 (10 patients) presented with recurrent attacks of deep neck infection with a history of incision and drainage several times. Radiological and operative findings revealed the presence of congenital pyriform fossa sinus. Conclusion. Computed tomography is helpful in diagnosing infected congenital cysts and its types. Infected congenital cysts could be excised completely under an umbrella of antibiotics. Recurrence of deep neck infections should alert the physician to the possibility of underlying congenital lesions. Thorough clinical and radiological assessment is mandatory to rule out the possibility of a congenital pyriform fossa sinus.
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Affiliation(s)
- Yasser Ahmed Nour
- Department of Otorhinolaryngology, Alexandria University, Alexandria, Egypt
| | | | - Alaa Gaafar
- Department of Otorhinolaryngology, Alexandria University, Alexandria, Egypt
| | - Ahmed Eldaly
- Department of Otorhinolaryngology, Alexandria University, Alexandria, Egypt
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Richer SL, Yelken K, Cunningham MJ, Randolph GW, Franco RA. Hypopharyngeal pharyngoplasty for the management of piriform fossa sinus. Laryngoscope 2010; 120:500-3. [DOI: 10.1002/lary.20786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis. The Journal of Laryngology & Otology 2010; 124:1025-9. [PMID: 20156371 DOI: 10.1017/s0022215110000034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy. METHOD A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented. RESULTS A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence. CONCLUSION To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.
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Pahlavan S, Haque W, Pereira K, Larrier D, Valdez TA. Microbiology of third and fourth branchial pouch cysts. Laryngoscope 2009; 120:458-62. [DOI: 10.1002/lary.20724] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Madana J, Yolmo D, Gopalakrishnan S, Saxena SK. Cervical infection secondary to pyriform sinus fistula of branchial origin. Congenit Anom (Kyoto) 2009; 49:276-8. [PMID: 20021489 DOI: 10.1111/j.1741-4520.2009.00249.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Complete third branchial arch anomalies are rare and have been described only in case reports, affecting mainly children and typically presenting as a cervical inflammatory process. Anomalies of the third and fourth branchial apparatus, though rare, usually present as sinuses/incomplete fistulas of pyriform sinus or recurrent suppurative thyroiditis. A 6-year-old girl presented with a small opening on the left side of her anterior neck, which had been present since birth and was associated with recurrent infection. She had no history of incision and drainage of swelling. Computed tomography with contrast injection into the cervical opening revealed a fistulous tract extending from the cervical neck skin to the pyriform fossa. Complete excision of the fistulous tract and left hemithyroidectomy were performed. There was no recurrence at 22 months of follow-up.
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Affiliation(s)
- J Madana
- Department of Otorhinolaryngology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India.
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Chen EY, Inglis AF, Ou H, Perkins JA, Sie KCY, Chiara J, Manning SC. Endoscopic electrocauterization of pyriform fossa sinus tracts as definitive treatment. Int J Pediatr Otorhinolaryngol 2009; 73:1151-6. [PMID: 19481267 DOI: 10.1016/j.ijporl.2009.04.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 04/30/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To (1) update the technique of endoscopic electrocauterization of patients with pyriform fossa sinus tracts and (2) evaluate its effectiveness as a definitive treatment. METHODS Retrospective case series with nine patients (age range, 3.3-16.1 years) who were diagnosed with pyriform fossa sinus tracts between 2000 and 2007 at a single tertiary care children's hospital and underwent endoscopic electrocauterization of the sinus tract. Data collected including age of diagnosis, presenting symptoms, time from presentation to diagnosis, diagnostic studies, prior and subsequent treatments, length of hospital stay, and recurrence, were reviewed and analyzed with descriptive statistics. RESULTS All nine patients presented with recurrent left or midline neck masses or abscesses. Seven patients (78%) had at least one previous incision and drainage procedures for abscess treatment. All patients had a computed tomography scan with findings suspicious for left-sided pyriform fossa sinus tract. The diagnosis was confirmed with laryngoscopy. For seven patients (78%), endoscopic electrocauterization was definitive treatment with no recurrences to date. Two patients (22%) had recurrent left neck abscesses after endoscopic treatment; these patients ultimately underwent excision of sinus tract with left thyroid lobectomy without complications or further recurrences. CONCLUSIONS Endoscopic electrocauterization of pyriform fossa sinus tracts is a safe and definitive treatment for most patients. We advocate this minimally invasive procedure as first line of treatment for pyriform fossa sinus tracts, reserving open excision with or without thyroid lobectomy for failures.
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Affiliation(s)
- Eunice Y Chen
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Neff L, Kirse D, Pranikoff T. An unusual presentation of a fourth pharyngeal arch (branchial cleft) sinus. J Pediatr Surg 2009; 44:626-9. [PMID: 19302871 DOI: 10.1016/j.jpedsurg.2008.10.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 10/09/2008] [Accepted: 10/11/2008] [Indexed: 10/21/2022]
Abstract
Fourth pharyngeal arch (branchial cleft) sinuses and fistulas are a rare cause of recurrent neck abscesses presenting in the first 2 decades of life. Because they are uncommon, the diagnosis and subsequent treatment can be delayed, even with proper radiographic imaging and clinical evaluation. This case illustrates a life-threatening presentation of a ruptured fourth branchial cleft sinus with extravasation into the mediastinum, chest, and abdomen.
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Affiliation(s)
- Lucas Neff
- Department of Pediatric Surgery, Wake Forest University Baptist Medical Center, NC, USA
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Abstract
OBJECTIVE To elucidate the etiology of suppurative thyroiditis in children and recommend a management algorithm. METHODS Case series of 5 pediatric patients with a diagnosis of suppurative thyroiditis seen between January 1999 and April 2007. RESULTS All 5 patients primarily presented with left-sided intrathyroidal abscesses. The number of infections from first presentation to the time of definitive diagnosis ranged from 1 to 5. Three patients underwent incision and drainage of the abscess once, and 2 had the procedure performed 3 times. Barium swallows identified a piriform sinus tract on the left side in 2 of the 5 patients. Telescopic hypopharyngoscopy identified the internal opening in all 5. Three were managed with complete excision of their tracts and 2 with cauterization of the internal opening with silver nitrate. All 5 are currently asymptomatic. CONCLUSIONS Suppurative thyroiditis is a very rare infection in children. A left-sided intrathyroidal abscess should immediately arouse suspicion of a piriform sinus tract. Barium swallows may identify the etiology in some cases. Definitive diagnosis requires a hypopharyngoscopy, with detailed telescopic examination of the left piriform fossa apex. Endoscopic chemical cautery of the internal opening is a safe and effective technique, with very low morbidity, and has the potential for cure.
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Mantle BA, Otteson TD, Chi DH. Fourth branchial cleft sinus: relationship to superior and recurrent laryngeal nerves. Am J Otolaryngol 2008; 29:198-200. [PMID: 18439956 DOI: 10.1016/j.amjoto.2007.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Accepted: 05/01/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES 1) Demonstrate the surgical anatomy of a fourth branchial cleft sinus relative to the superior and recurrent laryngeal nerves. 2) Review the diagnosis and management of a fourth branchial cleft sinus. DESIGN Case Study. SETTING Tertiary Children's Hospital. PATIENT Three year old female who presented with a fever and painful right neck mass. CT scan demonstrated a right neck abscess containing air adjacent to the thyroid. INTERVENTION Two months after initial drainage, the patient underwent enbloc excision of the sinus including the thyroid lobe with closure of the piriform sinus defect. MAIN OUTCOME MEASURE Intraoperative photo documentation of the anatomic relationship between the fourth branchial sinus and surrounding neural structures. RESULTS The sinus tract was shown to terminate in the piriform sinus inferior to the superior laryngeal nerve.
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