Original Article
Recurrent deep neck abscess and piriform sinus tract: A 15-year review on the diagnosis and management

https://doi.org/10.1016/j.jpedsurg.2013.10.018Get rights and content

Abstract

Background

Piriform sinus tract (PST) is a rare congenital condition. A delay in diagnosis is common leading to recurrent inflammation.

Method

A retrospective review was performed on all cases of PST treated at a tertiary referral centre between May 1997 and May 2012.

Results

Eighteen patients were reviewed with a mean age of 5.4 years at presentation (ranged from 0 day to 14 years). Most patients presented as acute inflammation (88.9%) and 16 had a left sided lesion. 72.2% of the PST are identified by contrast swallow study. The diagnostic yield was significantly higher if the study was done after the initial acute inflammation settled. Ultrasonography and computer tomography are less sensitive. The median duration from presentation to diagnosis was 17.6 months (ranged 0–120 months). Ten patients (55.6%) experienced recurrent inflammation before confirming the diagnosis. Fistulectomy alone was performed in 15 patients while an additional en-bloc hemithyroidectomy was done in 2 patients.

Conclusion

PST should be suspected in children presenting with a left deep neck abscess. Contrast swallow study is very effective in making diagnosis but has to be postponed after the acute inflammation settles. The condition can be effectively treated by fistulectomy without hemithyroidectomy in majority of our cases.

Section snippets

Background/purpose

Piriform Sinus Tract (PST) is a very rare congenital condition presenting as a deep neck abscess or acute suppurative thyroiditis. Because of the rarity, the definitive diagnosis and hence the treatment are usually delayed. The purpose of this paper is to look into the possible factors leading to the delay in the diagnosis.

Materials and methods

All pediatric patients with a PST treated at the Prince of Wales Hospital between May 1997 and May 2012 were retrospectively reviewed. We investigated the demographic data, presentation, radiological investigations, surgical procedures, postoperative complications and outcome. In addition, the detailed information on those patients with delay in diagnosis including the number and timing of recurrence, and the interval between the inflammatory episode and contrast study was analyzed.

Results

Eighteen patients (13 girls and 5 boys) were diagnosed with PST during the 15-year period. The mean age at presentation was 5.4 years (ranged 2 days to 14 years). Sixteen patients (88.9%) presented with an acutely inflamed neck mass; two other patients – both neonate – presented with a non-inflamed neck lesion. Fourteen (77.8%) also had fever at presentation. Sixteen patients (88.9%) presented with a left-side lesion. Eleven (61.1%) had a preceding sore throat or evidence of an upper respiratory

Discussion

The thyroid gland has very high resistance against bacterial infection owing to its high iodine content, rich vascularity and the presence of a capsule that separates it from the neighboring source of infection [1], [2], [3]. Womack [4] demonstrated the ability of the thyroid gland to withstand infection by direct injection of bacteria into the superior thyroid artery of dog subjects. We should thus have high index of suspicion of an underlying abnormality whenever a case of acute suppurative

Conclusions

The diagnosis of piriform sinus tract is commonly delayed resulting in recurrent inflammation and potentially avoidable procedures. A high index of suspicion is therefore needed whenever children present with a left deep neck abscess or acute suppurative thyroiditis. A contrast swallow performed after the resolution of acute inflammation is the most useful investigation to identify a PST. In addition, US and CT may assist in making the diagnosis in selective cases. Managing neonates with a PST

References (12)

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