Pyriform Sinus Fistula

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

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Misdiagnosis of asymptomatic intrathyroidal pyriform sinus fistula: a case report

Journal of International Medical Research ◽

10.1177/03000605211031430 ◽

2021 ◽

Vol 49 (7) ◽

pp. 030006052110314

Author(s):

Zengfang Hao ◽

Yuqi Hou ◽

Xiaoyu Li ◽

Juan Wang ◽

Ying Wang ◽

...

Keyword(s):

Sinus Tract ◽

Pyriform Sinus ◽

Lymphoid Cells ◽

Barium Swallow ◽

Deep Neck Infection ◽

Suppurative Thyroiditis ◽

Neck Infection ◽

Pyriform Sinus Fistula ◽

Neck Masses ◽

Cancer Pathology

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.

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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.

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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.

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Distribution of C cells in the thyroid gland with pyriform sinus fistula

Otolaryngology ◽

10.1016/s0194-5998(95)70249-0 ◽

1995 ◽

Vol 112 (2) ◽

pp. 268-273 ◽

Cited By ~ 13

Author(s):

T HIMI ◽

A KATAURA

Keyword(s):

Thyroid Gland ◽

Pyriform Sinus ◽

C Cells ◽

Pyriform Sinus Fistula

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Contrast‐Enhanced Ultrasound Diagnosed a Pyriform Sinus Fistula That Failed to Be Diagnosed by a Barium Swallow Examination: Case Report and Review of Choices for the Imaging Examination

Journal of Ultrasound in Medicine ◽

10.1002/jum.15239 ◽

2020 ◽

Vol 39 (8) ◽

pp. 1669-1673

Author(s):

Tiantong Zhu ◽

Ying Huang

Keyword(s):

Case Report ◽

Pyriform Sinus ◽

Barium Swallow ◽

Contrast Enhanced Ultrasound ◽

Pyriform Sinus Fistula ◽

Imaging Examination ◽

Contrast Enhanced

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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.

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Computed tomography and acute neck infection associated with pyriform sinus fistula

Otolaryngology ◽

10.1016/s0194-5998(03)00969-0 ◽

2003 ◽

Vol 129 (2) ◽

pp. P239

Author(s):

M Nakahira

Keyword(s):

Computed Tomography ◽

Pyriform Sinus ◽

Neck Infection ◽

Pyriform Sinus Fistula

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

Scientific Reports ◽

10.1038/s41598-019-55050-9 ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Qingfeng Sheng ◽

Zhibao Lv ◽

Weijue Xu ◽

Jiangbin Liu

Keyword(s):

Neck Mass ◽

Pyriform Sinus ◽

Diagnosis And Treatment ◽

Common Finding ◽

Older Children ◽

Thyroid Lesion ◽

Cervical Mass ◽

Neck Infection ◽

Pyriform Sinus Fistula ◽

Initial Symptoms

AbstractPyriform 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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Pyriform Sinus Fistula: Management with Chemocauterization of the Internal Opening

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348940010900503 ◽

2000 ◽

Vol 109 (5) ◽

pp. 452-456 ◽

Cited By ~ 82

Author(s):

Kwang Hyun Kim ◽

Myung-Whun Sung ◽

Seung Ha Oh ◽

Tae-Yong Koh ◽

In-Sang Kim

Keyword(s):

Computed Tomography ◽

Pyriform Sinus ◽

Fistula Tract ◽

Barium Swallow ◽

Internal Opening ◽

Pyriform Sinus Fistula ◽

Recurrent Fistula ◽

Swallow Study ◽

Barium Esophagography ◽

Operative Findings

A branchial remnant originating in the pyriform sinus causes a recurrent fistula or abscess in the neck. In spite of excision, recurrence may result from inadequate removal of the fistula tract. We attempted chemocauterization of the internal opening of the fistula tract with trichloroacetic acid (TCA) on direct endoscopy. This is a 6-year review of 18 patients with pyriform sinus fistula. Medical history, barium esophagography, computed tomography scans, operative findings, and treatment results were analyzed. By direct endoscopy, all patients were found to have a fistula opening in the pyriform sinus, exclusively on the left side. In only 9 patients, the fistula tract was identified by barium esophagography before operation. Computed tomography revealed a suspicious fistula tract originating from the pyriform sinus in 8 of 10 patients. Sixteen patients were initially managed by TCA chemocauterization. There were no serious intraoperative or postoperative complications. Four patients had recurrent masses, which were managed by simple excision in 2 patients and repeated TCA cauterization in the other 2 patients with unobliterated internal openings. We recommend barium swallow study and direct endoscopy for all patients presenting with a recurrent lateral neck abscess, especially on the left side. Our results suggest that initial chemocauterization of the internal opening can be a reasonable alternative procedure for the management of pyriform sinus fistula.

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