Recurrent pyriform sinus fistula successfully treated by endoscopic Glubran 2 sealing: A rare case and literature review

A safe and effective surgical method for complex pyriform sinus fistula

Objective

This article aims to propose a new surgical method for the treatment of pyriform fistula, especially for the complex pyriform fistula.

Methods

A total of 36 patients with pyriform fistula underwent the procedure between August 2017 to October 2020. Surgery was performed by the senior authors using the same technique at the same clinical center for all patients. The median follow-up time was 33 months. Meantime, we collected information on patients with pyriform fistula using traditional surgical methods in our hospital from April 2015 to November 2018 for comparison.

Results

The surgery was successfully completed in 36 patients. In all, 32 patients had a history of multiple incisions and drainage, 16 patients had a history of surgical resections, and two patients had a history of cauterization of the internal fistula. Compared with traditional surgical methods, our new surgical method greatly shortens the length of the surgical incision (4.3 vs. 5.5, p < 0.0001), reduces the operation time (8.1 vs. 27.1, p < 0.0001), and reduces the blood loss (103.2 vs. 196.8, p < 0.0001). None of the 36 patients in this study had complications such as pharyngeal fistula, recurrent laryngeal nerve paralysis, or hypothyroidism. The mean follow-up duration after the excision of the lesion was 34.1 months. To date, no patients have relapsed.

Conclusion

Our experience showed that this surgical technique could be used to completely remove the fistula, and it was easier to perform than the conventional strategies. These treatment options result in less trauma and reliable results, especially for complex pyriform fistulas.

Level of evidence

IV.

Surgical approach and treatment for the orifice of a pyriform sinus fistula: a case report and literature review

A 4-year-old girl underwent an open-neck surgical procedure for a recurrent pyriform sinus fistula (PSF). A catheter could not be inserted through the endoscope into the opening of the fistula. An open-neck surgical procedure with coring out of the fistula stained with a dye revealed that the fistula was missed near the upper lobe of the left thyroid. A guide wire was successfully inserted via the endoscope into the fistula, and the wire was gripped with forceps under fluoroscopic guidance and removed. As a modification of the surgical approach and treatment for the orifice of the PSF, a catheter was exchanged through the guide wire, and a nylon thread was passed into the catheter. The tip of the nylon thread from the oral side was fastened and fixed to a gauze ball. After removing the nylon thread, the orifice of the sinus fistula was recognized and sutured. She was discharged uneventfully and has done well without a postoperative recurrence for 12 months.

Spontaneous closure of branchial sinus of the pyriform fossa

Management of third and fourth branchial cleft anomalies are similar. These anomalies should be suspected in a child with recurrent low-anterior neck abscess. Investigations in the form of cross-sectional studies and examination of the pharynx under anaesthesia will facilitate diagnosis and resolution of abscess. Spontaneous closure of the pyriform sinus can occur following conservative management with antibiotic treatment and abscess drainage. This emphasise the role of second-look prior to implementing endoscopic cauterisation or surgery.

Bilateral Piriform sinus fistulas: a case study and review of management options

BACKGROUND

Piriform sinus fistulas occur due to developmental abnormalities of the third and fourth branchial arches, and almost always occur unilaterally. They generally present as recurrent abscesses in the anterior-inferior neck, with concurrent thyroiditis. They have conventionally been managed with complete removal of the sinus tract, and thyroidectomy if required; however, endoscopic approaches have been increasingly favored. Herein we describe a case of bilateral piriform sinus fistulas, and present a review of the literature concerning their endoscopic management.

CASE PRESENTATION

Our patient was determined to have bilateral piriform sinus fistulas based on computer tomography, magnetic resonance imaging and microlaryngoscopy. We performed electrocauterization of the proximal fistula tracts, followed by injection of fibrin sealent. Our patient has not had a recurrence in the ten months since his procedure. There were no complications. Twenty-three articles describing an endoscopic approach to these fistulas were identified through PubMed, and a search through the references of related articles was completed.

CONCLUSION

Of one hundred and ninety-five patient cases we reviewed, an endoscopic procedure success rate of 82% and complication rate of 5.6% was determined. Piriform sinus fistulas that occur bilaterally are a rare congenital abnormality of the neck. Endoscopic approaches are an acceptable alternative option to open procedures, with similar success and a lower rate of complications.