Diagnosis of pyriform sinus fistula in children via ultrasonography

doi:10.1016/j.amjoto.2013.01.010

American Journal of Otolaryngology

Volume 34, Issue 5, September–October 2013, Pages 579-581

https://doi.org/10.1016/j.amjoto.2013.01.010 Get rights and content

Abstract

A pyriform sinus fistula is a rare congenital abnormality of the third or fourth branchial pouch that usually affects children. We report one case of the condition; ultrasound (US) imaged a heterogeneous mass with a hypoechoic area and air bubbles representing an abscess. Although these manifestations are rare, prominent and characteristic findings on US may facilitate the diagnosis of pyriform sinus fistula.

Introduction

A pyriform sinus fistula is uncommon and typically presents as a congenital sinus tract; it usually occurs in children [[1], [4]]. A left-sided fistula is more common than a right-sided fistula [[5], [6]]. Pyriform sinus fistulas often cause recurrent cervical suppurative infections or neck abscesses with swelling and tenderness in children [[2], [6]]. An early diagnosis, as well as incision and drainage of the fistula, prevents recurrence of cervical infections. As a simple and non-invasive examination, US plays a significant and useful role on the diagnosis of a pyriform sinus fistula. To emphasize the US characteristics, we present one case of pyriform sinus fistula that was treated in our hospital. Barium Swallow can confirm the disease.

Section snippets

Case report

A four-year-old boy was admitted to our hospital with a mass in the left side of the neck, which appeared two days earlier, and a fever of seven days’ duration. The white blood cell count was 11.92×10⁹/L. Physical examination revealed tenderness and a palpable mass in the left lobe of the thyroid gland. Thyroid function tests and thyroid antibody titers were normal.

Cervical US exam was requested. On cervical US, an ill-defined, heterogeneous mass measuring 3.2 × 1.8 cm was found with hypoechoic

Discussion

A pyriform sinus fistula was first described by Raven in 1933 [[5], [7]]. It is a developmental abnormality of the third or fourth branchial pouch [[1], [4]]. There is a sinus tract that originates from the apex of the pyriform sinus, courses the inferior border of the thyroid cartilage, and descends along the trachea. It is either adjacent to or within the thyroid gland, and commonly terminates at the superior pole of the thyroid gland [3]. Children with pyriform sinus fistulas often present

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Imaging studies of pyriform sinus fistula
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Cited by (16)

Retrospective review of 70 cases of pyriform sinus fistula
2021, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
The presence of an air pocket in the upper left pole of the thyroid gland is considered characteristic of PSF [11]. Meanwhile, ultrasound examination can be used repeatedly to diagnose inflammatory lesions because it is not radioactive or traumatic and will not aggravate the deterioration of the PSF or cause other blood diseases [12]. CT examination will show a cervical inflammatory soft tissue mass; an inflammatory mass often surrounds one side of the thyroid gland.
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.
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.
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.
The use of our surgical approaches can facilitate the localization of the fistula during dissection in open neck surgery, and reduce recurrence.
Diagnosis and treatment of deep neck abscess due to congenital piriform sinus fistula in children
2021, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
CTs and ultrasound examinations of the neck are frequently used in children. Typical signs in CT images showed abnormal density of the skin in piriform fossa-thyroid region or anterior cervical region, with a possibility of air-containing cavities, thyroid morphology changes or ring-gap enlargement.11 Ultrasound is a common examination method for diagnosing neck abscess in children due to its simple, non-invasive features and children’s easier cooperation.
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.
This study aimed to identify the characteristics of deep neck abscess due to congenital piriform sinus fistula in children.
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.
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 1 year after the surgery. No recurrence occurred in any patient.
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.
CO<inf>2</inf> laser cauterization approach to congenital pyriform sinus fistula
2018, Journal of Pediatric Surgery
Citation Excerpt :
In our series, we effectively utilized ultrasound evaluation as our preferred modality of assessment. Ultrasound diagnosis of a CPSF is accurate and has no associated radiation hazards [8,10–12]. The diagnosis rate of preoperative ultrasound examination was 74.1%, which is higher than the previous literatures [4,13].
To evaluate the efficacy of CO₂ laser cauterization with suspension microlaryngoscopy as a definitive surgical treatment for pediatric Congenital Pyriform Sinus Fistula (CPSF).
This is a cohort retrospective study. Thyroid function and cervical ultrasonography examinations were performed before operation. Enhanced magnetic resonance imaging (MRI) was performed on patients with a repeated infection (≥ 2 times) and/or if they had a prior open surgery. Patients were divided into two groups: the < 8-year-old group and the ≥ 8-year-old group. The differences in the number of cauterization procedures between the two age groups and between the initial treatment and the retreatment groups were analyzed.
CO₂ laser cauterizations with suspension microlaryngoscopy were performed for 104 CPSF patients. No complications occurred. Three patients had a recurrence in the follow-up. The number of surgical cauterization operations was fewer than 3 in 85.1% of the patients. There was no significant difference in the number of cauterizations among the different age groups or between the initial treatment and retreatment groups (P > 0.05).
CO₂ laser cauterization with suspension microlaryngoscopy is a safe, effective, and minimally invasive approach to CPSF with optimal patient outcomes.
Treatment Study.
Level III.
Branchial Cysts
2017, Maxillofacial Surgery, 3rd Edition: Volume 1-2
KTP laser assisted endoscopic tissue fibrin glue biocauterization for congenital pyriform sinus fistula in children
2016, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
The first step to diagnose CPSF is to keep the clinical suspicion in mind, especially in children with acute, recurrent suppurative thyroiditis or neck infections. In terms of image study of 349 cases reviewed from the literature, 233 cases received a CT scan, 289 cases received a barium study, including a barium swallow study or X-ray fistulogram, 105 cases received head and neck ultrasonagraphy, and 3 cases received a MRI image [2,4,5,7,17–28]. The CT scan definitely revealed the sinus tract in only 25 cases (25/233, 11%) and most of them were performed right after the barium study [19,20,29], whereas the sinus tract was detected in 255 cases who receive the barium swallow study or X-ray fistulogram (255/289, 88%) [21,24,26–29].
This study aims to assess the efficacy of a novel endoscopic management for congenital pyriform sinus fistula (CPSF) using potassium titanyl phosphate (KTP) laser assisted endoscopic tissue fibrin glue biocauterization in children.
From 2010 to 2014, a total of 5 children with recurrent or acute suppurative thyroiditis or neck abscess secondary to CPSF were enrolled retrospectively in this study.
Mean age at the first time of endoscopic biocauterization was 6.2 ± 0.7 (5–7) years. The barium swallow study detected a fistula in four cases. Endoscopy identified an internal opening at the pyriform sinus in all cases with four on the left side and one on the right side. All patients underwent KTP laser assisted endoscopic tissue fibrin glue biocauterization as treatment for CPSF. Only one case required the second endoscopic procedure due to fluctuation of symptoms. Post-endoscopic follow-up duration of these patients was 24.6 ± 11.6 (7–36) months. Neither complications nor recurrences were noted during follow-up in all patients.
For children presenting with repeated acute suppurative thyroiditis or neck infections, clinicians should highly suspect the possibility of CPSF. Endoscopy should be performed not only to confirm the diagnosis but also could be served as an initial treatment modality of biocauterization by KTP laser and tissue fibrin glue, which was demonstrated as a less invasive, safe, and effective method in children.
Imaging Findings in Neonates With Congenital Pyriform Sinus Fistula: A Retrospective Study of 45 Cases
2021, Frontiers in Pediatrics

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Case reportDiagnosis of pyriform sinus fistula in children via ultrasonography

Abstract

Introduction

Section snippets

Case report

Discussion

Clin Imaging

Imaging studies of pyriform sinus fistula

Pediatr Radiol

Pyriform sinus fistula: diagnosis and management

Clin Pediatr

Imaging findings in acute neck infection due to pyriform sinus fistula

Annals Academy of Medicine

Case report
Diagnosis of pyriform sinus fistula in children via ultrasonography