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

Prenatal tomography ultrasound imaging diagnosis of fetal pyriform sinus cysts (third or fourth branchial cleft cyst): A case report

This case report describes a fetal piriform sinus cyst identified via tomographic ultrasound imaging and discusses its prenatal sonographic characteristics. We employed the tomographic ultrasound imaging function of the GE Voluson Ultrasound E10 to visualize multilevel transverse sections of the cyst. Specifically, we propose for the first time that the cross-sectional shape of a piriform sinus cyst composed of aryepiglottic folds approximates a triangle. This special shape facilitates the precise localization of the piriform sinus, providing valuable insights for timely diagnosis and appropriate postnatal management.

Multimodal imaging of congenital pyriform fossa fistula in children

Objective

Our aim was to explore the clinical value of multimodal imaging examinations in the diagnosis of congenital pyriform fossa fistula in children, so as to provide clues for the early diagnosis and treatment of congenital pyriform fossa fistula.

Methods

The clinical and imaging data of 55 children with pyriform fossa fistula diagnosed surgically in our hospital from 2015 to 2018 were analyzed retrospectively. All 55 patients underwent a CT scan. Of those patients, contrast enhancement CT was performed in 47 cases, MRI was performed in 2 cases, and barium esophagography was performed in 41 cases.

Results

Among the 55 cases, there were 24 male patients and 31 female patients. The age ranged from 11 months to 13 years old, and the median age was 3.8 years old. The lesions of 49 cases (89.1%) were located on the left side, and the imaging of CT showed soft tissue mass in the anterior cervical region blurred boundary. There was ipsilateral thyroid involvement in 50 cases (90.9%), trachea and/or carotid sheath extension in 43 cases (78.2%), abscess formation in 39 cases (70.9%), and pneumatosis in 25 cases (45.5%). The CT examination of 22 children after treatment showed a linear or tubular low-density shadow in the thyroid gland, gas accumulation in the anterior cervical region or thyroid, and residual contrast medium, partly. A total of 24 cases underwent barium esophagography during the acute phase, and 15 cases (62.5%) showed sinus formation from the pyriform fossa downward or punctate high-density shadow in the anterior cervical region. The 2 cases where MRI was performed showed abscess formation in one side of the neck and thyroid involvement.

Conclusion

Pyriform fossa fistula is most common in the left anterior cervical region, and it is closely related to the thyroid gland. The plain and enhanced-contrast CT scan can be used as the first choice during the infection stage. It helps to understand the location, extent, and structure of the surrounding tissue. The preliminary diagnosis of pyriform sinus fistula was according to the imaging features. It provided an important basis for clinical diagnosis and reduced the pain caused by repeated infection or surgical incision and drainage.

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.

Neonatal respiratory distress due to a third or fourth branchial pouch sinus: A systematic review

OBJECTIVES

Third and fourth branchial pouch sinuses can be rare causes of respiratory distress in neonates. An overview of this distinct clinical entity is missing in literature. To aid clinicians in recognizing and adequately treating this unique entity, we conducted a systematic review to discuss patient characteristics, diagnostic considerations and treatment strategy.

METHODS

MEDLINE and EMBASE were searched from inception to December 29th^, 2020. Original studies concerning patients with respiratory symptoms as a result of a third or fourth branchial pouch sinus, as confirmed with rigid endoscopy, videofluoroscopy or during surgery.

RESULTS

Thirty-nine studies describing 56 patients (66% male, aged 0-30 days) were analyzed. Symptoms included cervical mass (76.8%), stridor (55.4%), dyspnea (35.7%) and cyanosis (17.9%) due to a third (39.3%) or fourth (60.7%) branchial pouch sinus. Intubation was performed before treatment in 31.3%. The piriform sinus opening was identified with rigid endoscopy in 81.1%. Surgery was the treatment of choice in the majority of patients (85.7%), with a success rate of 100% and a complication rate of 10.7%. Endoscopic cauterization was successful in 40% and endoscopic cauterization followed by sclerotherapy was successful 100%, with no complications.

CONCLUSION

Third or fourth branchial pouch sinuses can lead to respiratory distress in neonates. It is important to recognize this distinct clinical picture for adequate diagnosis and treatment. Rigid endoscopy is indicated to demonstrate an opening in the piriform sinus and provides the opportunity to directly perform treatment with endoscopic cauterization. If this is insufficient to relief respiratory symptoms due to a persistent cyst, sclerotherapy or surgical excision should be considered.

Application of Gastroscopy in the Diagnosis of Congenital Pyriform Sinus Fistula in Children

Objective: The aim of this study was to explore the diagnostic value of gastroscopy under local anesthesia for congenital pyriform sinus fistula (CPSF). Methods: This research was a diagnostic study. Patients received gastroscopy under local anesthesia to diagnose CPSF, and suspension laryngoscopy under general anesthesia was performed 2 days after gastroscopy. Various conditions of the internal opening of CPSF were then recorded. Patients were grouped according to lesion sides, age, time after the inflammation subsided, and history of previous surgery. The sensitivity, specificity, area under the receiver operating characteristic curve (AUC), accuracy, and positive and negative predictive values of gastroscopy were compared between the groups. Results: A total of 48 patients were recruited in this study, and no patients had severe gastroscopy-related complications. The diagnostic values of gastroscopy in 41 cases (85.4%) were consistent with suspension laryngoscopy. The sensitivity of gastroscopy was 86.4%, the specificity was 75%, the AUC was 0.807, the positive prediction rate was 97.4%, the negative prediction rate was 33.3%, the accuracy rate was 85.4%, and the diagnostic odds ratio (DOR) was 2.1. The kappa consistency test results had statistical significance (P = 0.0026, kappa = 0.3913). The diagnostic value of gastroscopy was better for the patients with inflammation subsiding for more than 4 weeks (P < 0.0001). Conclusion: Gastroscopy under local anesthesia is a safe, effective, reliable and novel diagnostic method for CPSF, and it is especially recommended as a diagnostic method for the patients with inflammation subsiding for more than 4 weeks.