Misdiagnosis of asymptomatic intrathyroidal pyriform sinus fistula: a case report

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

Download Full-text

A Case of Pyriform Sinus Fistula Infection with Double Tracts

Case Reports in Otolaryngology ◽

10.1155/2014/126840 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Masato Shino ◽

Yoshihito Yasuoka ◽

Kyoko Nakajima ◽

Kazuaki Chikamatsu

Keyword(s):

Deep Infection ◽

Left Lobe ◽

Pyriform Sinus ◽

Deep Neck Infection ◽

Rare Clinical Entity ◽

Suppurative Thyroiditis ◽

Neck Infection ◽

Pyriform Sinus Fistula ◽

Tract Involvement ◽

Acute Suppurative Thyroiditis

Pyriform sinus fistula is a rare clinical entity and the precise origin remains controversial. The fistula is discovered among patients with acute suppurative thyroiditis or deep neck infection of the left side of the neck and is usually located in the left pyriform sinus. To the best of our knowledge, only a single tract has been reported to be responsible for pyriform sinus fistula infection. We present a case of a 13-year-old female patient with a pyriform sinus fistula that caused a deep infection of the left side of the neck and showed double-tract involvement discovered during surgical resection of the entire fistula. Both tracts arose around the pyriform sinus and terminated at the upper portion of the left lobe of the thyroid.

Download Full-text

Outcomes of endoscopic chemo- and laser-cauterizations and open fistulectomy for pyriform sinus fistula

Journal of Otolaryngology - Head and Neck Surgery ◽

10.1186/s40463-021-00537-7 ◽

2021 ◽

Vol 50 (1) ◽

Author(s):

Hiroo Masuoka ◽

Akira Miyauchi ◽

Takahiro Sasaki ◽

Tsutomu Sano ◽

Akihiro Miya

Keyword(s):

Mouth Opening ◽

Pyriform Sinus ◽

Barium Swallow ◽

Success Rates ◽

Suppurative Thyroiditis ◽

Endoscopic Procedures ◽

Pyriform Sinus Fistula ◽

Lower Blood ◽

Acute Suppurative Thyroiditis ◽

The Individual

Abstract Background Acute suppurative thyroiditis through the congenital pyriform sinus fistula (PSF) often recurs if the fistula is not resected. Although endoscopic chemo-cauterization (ECC) to obliterate the orifice of the fistula is less invasive than open fistulectomy, it may require repeated treatments. We recently adopted an endoscopic diode laser-cauterization (ELC) system with the intention of improving treatment outcomes in PSF. Here, we describe ELC and compare the outcomes of these three modalities. Methods We evaluated 83 patients with PSF who underwent treatment between 2007 and 2018 at Kuma Hospital, a tertiary thyroid treatment hospital. ECC and ELC were implemented in 2007 and 2015, respectively. Patients who were ineligible for the endoscopic procedures underwent open fistulectomy. Barium swallow studies and computed tomography scan under a trumpet maneuver were performed after treatment to evaluate obliteration or removal of the fistula. Results In total, 70 of the 81 (86%) patients who underwent barium swallow studies after the first treatment achieved obliteration or removal of the fistula. The success rates for open fistulectomy, ECC, and ELC were 100% (9/9), 83% (49/59), and 100% (13/13), respectively. ECC and ELC had significantly shorter operative times and lower blood loss than open fistulectomy. Insufficient opening of the mouth was the major reason for converting endoscopic procedures to open fistulectomy. Conclusions ELC may yield superior outcomes and is therefore the optimal treatment modality for PSF. However, it is still associated with certain limitations. Thus, treatment selection remains dependent on the shape and size of the PSF and the mouth opening of the individual patient.

Download Full-text

Pyriform Sinus Fistula

Philippine Journal of Otolaryngology Head and Neck Surgery ◽

10.32412/pjohns.v29i1.463 ◽

2014 ◽

Vol 29 (1) ◽

pp. 33-34

Author(s):

Ian C. Bickle

Keyword(s):

Thyroid Gland ◽

Pyriform Sinus ◽

Alternative Methods ◽

Definitive Treatment ◽

Diagnostic Process ◽

Barium Swallow ◽

Branchial Cyst ◽

Neck Infection ◽

Pyriform Sinus Fistula ◽

Anterior Aspect

This 17-year-old young man attended the oromaxillofacial (OMF) department of a tertiary surgical center. He had attended both local and overseas ENT departments since the age of 5 years. Previous, but unspecified surgery had been performed as a child, with ongoing problems, since with a discharging sinus on the anterior aspect of the lower left side of the neck. On clinical examination, several scars were present on the anterior aspect of the neck, and a skin opening was evident in the left para-midline of the lower neck. Following clinico-radiological discussion a barium swallow was undertaken (Figures 1 and 2). Discussion A pyriform sinus fistula is an uncommon, but well documented condition. It is most commonly observed in the pediatric community, usually presenting with an acute neck infection. The vast majority occur on the left side of the neck, with reports documenting fistula on this side accounting for between 83 and 100%.1, 2 It is highly associated with an underlying congenital 3rd or 4th branchial cyst. Various imaging modalities have been employed in the identification and characterization of a pyriform sinus fistula. Barium swallow has been traditionally used and may elegantly illustrate the fistula in a dynamic fashion. However, the tract is not always well demonstrated. Use of a cross sectional modality (ideally MRI) is essential in identifying; the fistula and its course, any underlying branchial cyst, an associated acute neck infection and whether the thyroid gland is involved.3 Thyroid gland involvement is frequently encountered given the typical course of the fistula.4 Fiberoptic endoscopy is also employed to identify the origin of the fistula in the pyriform sinus and is an important part of the diagnostic process. Definitive treatment is complete excision of the fistula and any underlying cystic focus. Alternative methods have been employed with success, including chemo-cauterization and the use of fibrin to close the fistulous tract.5

Download Full-text

Acute suppurative thyroiditis secondary to pyriform sinus fistula

The Lancet Infectious Diseases ◽

10.1016/s1473-3099(18)30657-1 ◽

2019 ◽

Vol 19 (4) ◽

pp. 447 ◽

Cited By ~ 1

Author(s):

Takeshi Kondo

Keyword(s):

Pyriform Sinus ◽

Suppurative Thyroiditis ◽

Pyriform Sinus Fistula ◽

Acute Suppurative Thyroiditis

Download Full-text

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 ◽

10.1017/s0022215112000898 ◽

2012 ◽

Vol 126 (7) ◽

pp. 737-742 ◽

Cited By ~ 13

Author(s):

D Yolmo ◽

J Madana ◽

R Kalaiarasi ◽

S Gopalakrishnan ◽

M Kiruba Shankar ◽

...

Keyword(s):

Fistulous Tract ◽

Branchial Arch ◽

Pyriform Sinus ◽

Barium Swallow ◽

Case Review ◽

Retrospective Case ◽

Suppurative Thyroiditis ◽

Ultrasound Computed Tomography ◽

Acute Suppurative Thyroiditis ◽

Operative Ultrasound

AbstractObjective: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.

Download Full-text

Pyriform Sinus Fistula: An Unusual Cause of Recurrent Retropharyngeal Abscess and Cellulitis

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348948609500411 ◽

1986 ◽

Vol 95 (4) ◽

pp. 377-382 ◽

Cited By ~ 38

Author(s):

Howard L. DeLozier ◽

Robert A. Sofferman

Keyword(s):

Thyroid Gland ◽

Surgical Approach ◽

Pyriform Sinus ◽

Retropharyngeal Abscess ◽

Barium Swallow ◽

Suppurative Thyroiditis ◽

Common Cause ◽

Surgical Exploration ◽

Swallow Study ◽

Congenital Fistula

Recurrent retropharyngeal cellulitis and recurrent suppurative thyroiditis are rare entities that share a common cause. A congenital fistula from the pyriform sinus apex to the thyroid gland has been identified in approximately 23 cases of suppurative thyroiditis and now has been implicated in a case of retropharyngeal abscess and repeated episodes of cellulitis. Virtually all reported cases have been on the left side, and the fistula is usually identified with a barium swallow study. When the esophagogram fails to demonstrate a fistula, a careful endoscopic search in the area of the left pyriform sinus should be actively pursued. An external surgical approach, which includes resection of the entire tract and involved area of the left thyroid, has been curative in all reported cases subjected to definitive surgical exploration.

Download Full-text

Transient hyperthyroidism secondary to acute suppurative thyroiditis caused by pyriform sinus fistula

International Journal of Pediatric Otorhinolaryngology ◽

10.1016/j.ijporl.2010.09.028 ◽

2011 ◽

Vol 75 (11) ◽

pp. 1470

Keyword(s):

Pyriform Sinus ◽

Suppurative Thyroiditis ◽

Pyriform Sinus Fistula ◽

Acute Suppurative Thyroiditis

Download Full-text

Complete Pyriform Sinus Fistulas: Case Series and Review of Literature

International Journal of Head and Neck Surgery ◽

10.5005/jp-journals-10001-1068 ◽

2011 ◽

Vol 2 (3) ◽

pp. 134-137

Author(s):

Sandeep Bansal ◽

Abhishek Jaswal

Keyword(s):

Case Series ◽

Pyriform Sinus ◽

Suppurative Thyroiditis ◽

Upper Respiratory Infection ◽

Pyriform Sinus Fistula ◽

Fourth Arch ◽

Acute Suppurative Thyroiditis ◽

Neonates And Infants ◽

Painful Neck ◽

Branchial Anomalies

ABSTRACT Pyriform sinus fistula belongs to the rarest group of cervical fistulae accounting for 3 to 10% of all branchial anomalies.1 The first clinical and embryological studies were described in the early seventies by Sandborn and Tucker, but embryological knowledge in this field remains incomplete. Children and adults usually complaint of painful neck swelling accompanied by fever that is preceded by upper respiratory infection, otalgia and odynophagia. Neonates and infants may have respiratory distress, sometimes with stridor, due to tracheal compression by the abscess.1,5,6 However, the most common mode of presentation is the recurrent episodes of acute thyroiditis. Eighty percent of patients with recurrent acute suppurative thyroiditis due to persistent pyriform sinus fistula present during the first decade of life. Making the distinction between third and fourth arch fistulas is difficult on clinical grounds alone and hence they are often collectively termed pyriform sinus fistula. Owing to the rarity of the condition and varied clinical presentation, diagnosis and ultimate management is often delayed leading to undue morbidity to the patient and professional frustration for the treating surgeon. We, hereby, present a case series of three classical cases of complete pyriform sinus fistulas with review of available literature in an attempt to clarify issues regarding presentation, diagnosis and management of this condition.

Download Full-text