Endoscopic-Assisted Surgery for Pyriform Sinus Fistula in Chinese Children: A 73-Consecutive-Case Study

Open surgical excision vs. endoscopic radiofrequency ablation in managing congenital pyriform sinus fistula-a comprehensive analysis of 166 cases

Background

Congenital pyriform sinus fistula (CPSF) is uncommon congenital abnormality, and the optimal definitive treatment has not yet been established. The aim of the present study was to comparatively evaluate patients with CPSF regarding the indications and outcomes of treatment with open surgical excision (OSE) vs. endoscopic Radiofrequency Ablation (RA), and the advantages of both therapeutic procedures were also analyzed.

Methods

An observational, longitudinal, retrospective, analytical and comparative study was conducted on 166 consecutive pediatric patients with CPSF treated at Shanghai Children's Hospital between December 2018 and September 2023.

Results

In this study, there were 79 males and 87 females. The median age at operation was 4.8 years (8 days to 15 years). OSE and Endoscopic RA were respectively performed in 48 and 118 children. The gastric tube retention time after RA was longer (3 days vs. 14 days) than after OSE. Patients with a history of incision and drainage (I&D) tended to choose OSE (75.0% vs. 39.0%, P < 0.01). There were no significant differences in postoperative complications and recurrence rates between these two groups (P > 0.05), but the hospitalization duration was shorter for RA group compared to OSE group [2 (2-3) vs. 4 (3-5), P < 0.01].

Conclusions

Both OSE and RA are recognized as first-line treatment options for CPSF, which show no significant differences in prognosis, except hospitalization duration and the gastric tube retention time. Nevertheless, the indications for OSE and RA differ, which are influenced by factors such as the inflammatory stage, specific typing, previous treatments, and the surgeon's expertise. The selection of surgical approach should be carefully determined based on individual circumstances.

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.

Retrospective review of 70 cases of pyriform sinus fistula

BACKGROUND

Pyriform sinus fistula (PSF) is a rare branchial pouch anomaly of the neck that presents a diagnostic and management challenge. The objective of this study is to highlight the value of intraoperative suspension laryngoscope-assisted methylene blue injection through the internal opening as a guide for locating the fistula.

METHODS

A retrospective study of 70 cases of PSF in children from 2009 to 2017 was managed, and an intraoperative suspension laryngoscope-assisted method combined with neck exploration and excision of the tract were performed in all cases.

RESULTS

The patients comprised 36 males and 34 females ranging in age from 7 days to 15 years. Sixty-four cases were predominantly left-sided (64/70, 91.4%), and 6 cases (6/70, 8.6%) occurred on the right side. Four cases exhibited temporary postoperative hoarseness (4/70, 5.7%), which disappeared after one week. There were no instances of recurrence during follow-up ranging from two to nine years, and the median follow-up period was four years.

CONCLUSION

The use of our surgical approaches can facilitate the localization of the fistula during dissection in open neck surgery, and reduce recurrence.

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.

Reoperation for Pyriform Sinus Fistula in Pediatric Patients

Introduction: The aim of this study was to analyze the authors' experience in re-operative surgery for children with pyriform sinus fistula (PSF) who were subjected to attempted but failed operations. Methods: We retrospectively analyzed the medical records of 30 patients with PSF who underwent reoperation (i.e., a revision of the primary performed definitive procedure) from January 2010 to December 2018. Results: There were 19 boys and 11 girls. Twenty-nine cases were left-sided. The median age of the patients when they underwent the primary operation was 5.5 years (range, 15 days-14 years). Five children received two definitive procedures from outside hospitals. The primary operations included traditional open-neck surgery (n = 30), endoscopic-assisted open-neck surgery (n = 4), and endoscopic laser cauterization (n = 1). The median time from primary operation to recurrence was 4 months (range, 1 month-4 years). The reasons for recurrence were incomplete resolution of infection (n = 7), incomplete resection of the fistula (n = 23), cauterization of PSF inner orifice (n = 1), only cyst excision in neonates (n = 2), and unknown (n = 2). All 30 children underwent endoscopy-assisted open-neck surgery. The median age of the children when they underwent reoperation was 8 years (range, 2-17 years). The fistula was detected in 29 cases (96.7%). After reoperation, good outcome was achieved in 27 patients (90%). Wound infection developed in one case. PSF recurred in two cases (6.7%). Conclusion: Most of the recurrences observed by us are preventable. Complete resolution of infection, clear verification, and exact resection of the fistula at a high level are essential for preventing recurrence. Endoscopy-assisted surgery is effective for PSF reoperation.

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.

Differences in the diagnosis and management of pyriform sinus fistula between newborns and children

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.

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.

Branchial anomalies in children: A report of 105 surgical cases

BACKGROUND

Branchial anomalies (BAs) account for 20% of all congenital masses in children. We sought to review the incidence of involvement of individual anomalies, diagnostic methods, surgical treatment, and complications of BAs in children. In addition, we also classified our study and analyzed a congenital lower neck cutaneous fistula near the sternoclavicular joint that was thought to be the skin-side remnant of the fourth BAs.

METHODS

We conducted a retrospective analysis of 105 children who were referred to our hospital from June 2009 to December 2016 for the treatment of BAs.

RESULTS

In this series, there were 51 males and 54 females. The age at the time of operation varied from 19 days to 13 years, and the mean age was 4.5 years. A total of 33 (31.4%) cases presented with first BAs, 13 (12.4%) presented with second BAs, and 59 (56.2%) presented with third and fourth BAs, including 6 cases of congenital lower neck cutaneous fistula. Fistulectomy under general anesthesia was performed on all of them. For postoperative complications, 2 cases had temporary facial paralysis, 1 case had permanent facial paralysis, 4 cases had temporary recurrent laryngeal nerve injury. Recurrence occurred in 2 patients with first BAs after medium follow-up time of 3.6 years (6 months-8 years).

CONCLUSIONS

BAs are common congenital head and neck lesions in children, and there are four distinct types (first, second, third and fourth anomalies). The incidence of third and fourth BAs in Asia maybe higher when compared with literature reports, second BAs seem rare in this population, but more research is needed to confirm this perspective. Diagnosis is not difficult with a proper knowledge of the anatomy of the BAs. The surgical procedures should be tailored depending on the various types, and complete excision of the fistula is the key to prevent recurrence.