Congenital pyriform sinus fistula: a cause of acute left-sided suppurative thyroiditis and neck abscess in children

Optimal Timing of the First Barium Swallow Examination for Diagnosis of Pyriform Sinus Fistula

OBJECTIVE

Observation of a sinus tract during a barium swallow examination is important for the diagnosis of pyriform sinus fistula; however, to our knowledge, no reports have existed regarding the optimal timing of the examination in relation to the onset of symptoms. The purpose of this study was to compare the timing of the examination, patient age, the number of inflammatory episodes that occurred before the examination, and the barium concentration used for examinations with true-positive results versus those with false-negative results for the diagnosis of pyriform sinus fistula.

MATERIALS AND METHODS

Twenty-three children with pyriform sinus fistula were included. The timing of the examination, patient age, the number of the inflammatory episodes that occurred before examination, and the barium concentration used were compared between examinations with true-positive results and examinations with false-negative results, by use of the Mann-Whitney U test.

RESULTS

The examination had true-positive results for 60.9% (14/23) of patients and false-negative results for 39.1% (9/23) of patients. The mean (± SD) interval since the onset of symptoms was significantly shorter for patients with false-negative examination results than for those with true-positive examination results (26.33 ± 21.17 days vs 48.57 ± 17.67 days; p = 0.020). By 6 weeks after the onset of symptoms, more than half of the examinations had false-negative results. No significant difference in patient age (p = 0.238) or number of previous inflammatory episodes (p = 0.431) existed between examinations with true-positive and false-negative results; however, a significant difference was noted in the mean barium concentration used (88.57% ± 31.53% vs 52.86% ± 18.68% weight/volume, respectively; p = 0.014).

CONCLUSION

Barium swallow examinations with false-negative results were significantly more likely when the examination was performed soon after the onset of symptoms. Therefore, early first examinations would not be recommended for the diagnosis of pyriform sinus fistula, especially in terms of radiation exposure. A higher barium concentration may be useful.

Statement and Recommendations on Interventional Ultrasound as a Thyroid Diagnostic and Treatment Procedure

The recently published guidelines of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on interventional ultrasound (INVUS)-guided procedures summarize the intended interdisciplinary and multiprofessional approach. Herewith, we report on recommendations for interventional procedures for diagnosis and treatment of the thyroid gland.

Successful endoscopic ablation of a pyriform sinus fistula in a child: case report and literature review

Recurrent thyroid infections are rare in children. When present, patients should be evaluated for anatomic anomalies such as pyriform sinus fistulae. We describe a 12-year-old girl with history of recurrent thyroid abscesses secondary to a pyriform sinus fistula and managed with concurrent endoscopic ablation and incision and drainage.

Open and Endoscopic Management of Fourth Branchial Pouch Sinus - Our Experience

Introduction Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common and usually present with recurrent left thyroid lobe abscesses.

Objectives The authors present their experience in treating such cases that were observed exclusively in children.

Methods The study involved performing a retrospective review of five cases in PSG Institute of Medical Sciences & Research. All cases were evaluated radiologically and with Direct Rigid hypopharyngoscopy. Definitive surgery was performed, including hemithyroidectomy.

Results The patients consisted of five children, two boys and three girls. All of them presented with recurrent episodes of neck infection. Investigations performed included computed tomography (CT) fistulography, rigid hypopharyngoscopy and ultrasound, which were useful in preoperatively delineating pyriform sinus fistulous tract. All patients underwent neck exploration with excision of the fistulous tract and hemithyroidectomy. Upon follow-up, all patients are asymptomatic.

Conclusions Recurrent neck abscesses in a child should alert the clinician to the possibility of a fourth branchial arch anomaly; therefore, children with this condition require a complete evaluation so the anomaly can be ruled out.

Acute suppurative thyroiditis following fine-needle aspiration biopsy in an immunocompetent patient

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine-needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50-year-old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

Branchial fistula arising from pyriform fossa: CT diagnosis of a case and discussion of radiological features

Anomalies of third or fourth branchial apparatus origin are very uncommon and present as recurrent neck infections or thyroiditis with a predominant left-sided involvement. Radiological diagnosis requires a high index of suspicion and is critical for initiation of proper treatment. We describe a case of branchial sinus of pyriform fossa with external fistulization that presented in adulthood and was diagnosed on computed tomographic scan. The radiological features of this rare anomaly are revisited.

Management of Congenital Third Branchial Arch Anomalies: A Systematic Review

OBJECTIVE: To systematically review the existing literature on third branchial arch anomalies and suggest guidelines for their management.

DATA SOURCES: We searched PubMed, Medline, and Embase using Scopus, and collected additional publications cited in bibliographies. We included all English-language articles and all foreign-language articles with an English abstract.

REVIEW METHODS: Two investigators reviewed all cases explicitly identified as third arch anomalies or meeting anatomical criteria for third arch anomalies; they assessed presentation, diagnostic methods, intervention, and outcome.

RESULTS: We found 202 cases of third arch anomalies; they presented primarily on the left side (89%), usually as neck abscess (39%) or acute suppurative thyroiditis (33%). Barium swallow, direct laryngoscopy, and magnetic resonance imaging were the most useful diagnostic tools. The recurrence rate varied among the treatment options: incision and drainage, 94 percent; endoscopic cauterization of the sinus tract opening, 18 percent; open-neck surgery and tract excision, 15 percent; and partial thyroidectomy during open-neck surgery, 14 percent. Complications after surgery appeared somewhat more frequently in children eight years of age or younger.

CONCLUSION: Third arch anomalies are more common than previously reported. They appear to be best treated by complete excision of the cyst, sinus, or fistula during a quiescent period. Repeated incision and drainage yields high rates of recurrence and should be avoided. Complications might be minimized by first initiating antibiotic treatment, delaying surgical treatment until the inflammatory process is maximally resolved, and by using endoscopic cauterization.

Revisiting imaging features and the embryologic basis of third and fourth branchial anomalies

BACKGROUND AND PURPOSE

There is wide discrepancy between common clinical and radiologic presentations of branchial sinuses arising from the pyriform fossa and the theoretic course of third and fourth branchial arch anomalies. The purpose of this study was to revisit the clinical presentations and imaging features of such anomalies in children.

MATERIALS AND METHODS

A retrospective review of institutional and diagnostic imaging data bases from 1998 to 2008 for reported cases of third and fourth branchial cleft anomalies was conducted. Clinical presentation, pharyngoscopy results, and imaging features in all the patients were evaluated. Surgical and histopathology correlation in patients who underwent excision of the tract was also obtained.

RESULTS

Twenty reported cases described as third or fourth branchial apparatus anomalies were identified. There were 12 females and 8 males with a mean age of 84.6 months. The most common presentation was an inflammatory neck mass (18/20, 90%) almost always involving the thyroid gland. Most lesions were on the left side (16/20, 80%). Pharyngoscopy showed a sinus opening at the piriform fossa in 18/20 (90%) cases. None of the cases followed the classic theoretic pathway of third and fourth arch remnants. Histopathology showed tracts lined with pseudostratified squamous epithelium or ciliated columnar epithelium often associated with inflammatory changes in 17 surgically resected cases.

CONCLUSIONS

Branchial sinuses arising from the pyriform fossa often present with an inflammatory neck mass involving the thyroid lobe, most often on the left side. Imaging and surgical findings suggest that they arise from the embryonal thymopharyngeal duct of the third branchial pouch, because they do not follow the hypothetic course of third or fourth arch fistulas.

Sonography of the pediatric thyroid: a pictorial essay

The purpose of this article is to review the various pediatric thyroid diseases using sonographic images. These diseases included congenital hypothyroidism (dysgenesis [aplasia; ectopy; hypoplasia], dyshormonogenesis, transient hypothyroidism), thyroglossal duct cyst, Graves' disease, Hashimoto's thyroiditis, suppurative thyroiditis, nodular hyperplasia (goiter) and thyroid mass. Thyroid sonogram is the primary method used for thyroid disease and can be used for guiding of fine needle aspiration to obtain a more accurate diagnosis for suspected thyroid lesions.

Klebsiella pneumoniae pulmonary infection with thyroid abscess: report of a case

Thyroid abscess is a rare clinical entity, usually associated with a pyriform sinus fistula. A prompt diagnosis is important because it may progress rapidly into a life-threatening condition. We report a very unusual case of thyroid abscess associated with a lung infection, both caused by Klebsiella pneumoniae. The patient was treated successfully with a culture-appropriate antibiotic and an uneventful thyroid lobectomy. A delay in diagnosis of morbidities associated with a thyroid abscess may result in rapid exacerbation of this condition; therefore, prompt and appropriate treatment is mandatory for a successful outcome.

Branchial Sinus of the Piriform Fossa: Reappraisal of Third and Fourth Branchial Anomalies

OBJECTIVE

The objective of this study was to review clinical and embryologic aspects of third and fourth branchial anomalies.

STUDY DESIGN

Retrospective study.

METHODS

We reviewed the institutional and departmental databases at our institution to identify all cases of third and fourth branchial anomalies encountered from 1992 to 2006. All patient records were examined with respect to demographics, clinical history, and radiologic and pathologic reports.

RESULTS

We identified 17 cases of third and fourth branchial anomalies, the largest series of its kind reported to date. The lesions were predominantly left sided, all presenting with neck infection. Fistula formation was iatrogenic, secondary to incision and drainage. Preoperative direct laryngoscopy always revealed a pit within the apex of the piriform fossa. Surgical excision involved ipsilateral thyroidectomy as the lesion passed through the thyroid gland. No lesions following the classical course of a either a third or fourth branchial anomaly were identified.

CONCLUSIONS

The clinical presentation of branchial sinuses arising from the piriform fossa is more in keeping with derivation from the thymopharyngeal duct (of the third pouch) than the hypothetical course of third and fourth branchial fistulae.

Thyroid Abscess: Case Report and Review of the Literature

A thyroid abscess is an infrequently encountered condition with a rarity that is attributable to anatomic and physiologic characteristics of the gland that impart a unique quality of infection resistance. The differential diagnoses for a painful thyroid is limited, with subacute and chronic thyroiditis being the most often-encountered processes. Acute suppurative thyroiditis with abscess formation, although rare, is a formidable clinical scenario with morbid complications. Because the diagnosis of a thyroid abscess is often delayed in lieu of investigating other more common etiologies of thyroiditis, this disease entity may portend to a dismal clinical outcome. The authors report the case of a 53-year-old woman with a thyroid abscess yielding a single microbial isolate believed to be resultant from a urinary tract bacteremia. They also review the literature for discussion of abscess etiologies, presentations, and management strategies.

Nonsurgical management of thyroid abscess with sonographically guided fine needle aspiration

Treatment of thyroid abscess commonly includes the surgical drainage along with systemic antibiotic therapy. Alternatives for open surgical intervention may be the conservative management with use needle aspiration or catheter drainage. We report here two cases of thyroid abscess treatment with 21-gauge needle aspiration under ultrasound guidance. In each case needle drainage was performed twice, at the 1st and 5th day of admission. Antibiotics were administered in pills and injected into the abscess cavity followed the pus aspiration and lavage. Both patients were cured. Follow-up has not revealed recurrence during 6 month and 5 years.

[Diagnostic imaging of piriform sinus fistulas]

OBJECTIVES

To establish the usefulness of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and barium contrast swallow studies in the diagnosis of piriform sinus fistulas (PSF).

MATERIAL AND METHODS

We reviewed the clinical histories and imaging studies of four pediatric patients diagnosed with PSF. Cervical ultrasound was the first imaging study performed in all cases. Three patients subsequently underwent intravenous contrast-enhanced CT examination and one underwent MRI. Barium contrast swallow studies were performed in all patients at a later time. All cases were confirmed at surgery.

RESULTS

Ultrasound enabled the lesions to be located on the left side and showed the existence of heterogeneous collections in and around the thyroid glands in all four patients. Posterior CT and MRI studies determined the exact size of the abscessed lesions. Barium contrast swallow studies demonstrated the existence of the PSF in all four cases.

CONCLUSIONS

The presence of a recurrent inflammatory process and acute suppurating thyroiditis located on the left side should raise suspicions of PSF. Both CT and MRI are useful in the study of PSF; however, in our experience, ultrasound examination is the technique of choice for initial evaluation and follow-up. After the acute process, barium swallow studies continue to be the main method for diagnosing the trajectory of the fistulous tract.

Thyroid disease in the pediatric patient: emphasizing imaging with sonography

Thyroid disease does occur in the pediatric patient, and imaging plays an important role in its evaluation. A review is presented of normal development of the thyroid gland, the technique and indications for thyroid sonography, and key imaging features of congenital thyroid disorders (ectopic or absent thyroid, infantile goiter, thyroglossal duct remnants), benign thyroid masses (follicular adenoma, degenerative nodules, colloid and thyroid cysts), malignant masses (follicular, papillary and medullary carcinoma) and diffuse thyroid disease (acute bacterial thyroiditis, Hashimoto's thyroiditis, Grave's disease).

Simultaneous branchial cleft and thyroid disorders may present a management challenge

BACKGROUND

Cysts, sinuses or abscesses arising from second, third or fourth branchial cleft remnants may lie either within the body of, or in close proximity to the thyroid gland. Given their infrequent nature they may pose both diagnostic and management challenges for the treating surgeon when they occur in association with thyroid disorders.

METHODS

This is a case series. All patients with concomitant thyroid disorders and a branchial cleft anomaly treated in the University of Sydney Endocrine Surgical Unit in the 10-year period 1994-2003 comprised the study group. Patient demographics, clinical presentation, imaging, surgical management, definitive histology and outcomes were documented.

RESULTS

Six patients were identified with an age range of 3-76 years and a male : female ratio of 1:5. Five branchial cleft anomalies were left sided, one was right sided. Two patients had second cleft anomalies, both of which were initially thought to represent metastatic lymph nodes in association with thyroid cancer. A further two patients had third cleft abnormalities presenting as suppurative thyroiditis. The final two patients had fourth cleft abnormalities causing intraoperative management problems.

CONCLUSIONS

Branchial cleft remnants and anomalies are rare but may occur in association with thyroid disease. They may pose a diagnostic and management dilemma either preoperatively, when mistaken for metastatic thyroid cancer, or intraoperatively when mistaken for a thyroid nodule.

Congenital piriform fossa sinus tract presenting as an asymptomatic neck mass in an infant

BACKGROUND

A 5-month-old girl with an asymptomatic left-sided neck mass was demonstrated by ultrasound and upper gastrointestinal series (UGI), and confirmed at surgery, to have a congenital piriform fossa sinus tract (CPFST) that communicated with an intrathyroidal cyst.

OBJECTIVE

To demonstrate a case of CPFST presenting as an asymptomatic neck mass. Nearly all cases of CPFST present with infection or pain, making this case unique.

MATERIALS AND METHODS

Case report and review of the literature.

CONCLUSIONS

CPFST with an associated cyst should be added to the differential diagnosis of asymptomatic cystic neck masses in infants, especially if the cyst is intrathyroidal by ultrasound.

Imaging studies of pyriform sinus fistula

BACKGROUND

Pyriform sinus fistula (PSF) refers to a persistent embryologic third or fourth pharyngeal pouch, which typically presents as a congenital sinus tract that originates from the pyriform sinus. The sinus tract is often diagnosed by a barium study or direct endoscopic inspection. Utilization of advanced imaging studies, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), may aid in the diagnosis of this disease entity.

OBJECTIVES

To review the imaging findings of PSF and demonstrate the value of various cross-sectional imaging (US, CT, and MRI) in the diagnosis of PSF.

MATERIALS AND METHODS

PSF in five children was verified surgically. Preoperative barium esophagography, US, CT, and MRI were performed selectively in these patients. The clinical and imaging findings are reviewed retrospectively.

RESULTS

Barium studies demonstrated the sinus tract in all five patients. US, CT, and MRI demonstrated an associated inflammatory process. By utilizing the trumpet maneuver, the presence of sinus tract was evident in two patients during US. The sinus tract is also demonstrated by CT in another patient.

CONCLUSIONS

Although barium esophagography is advantageous in demonstration of the sinus tract in PSF, US and CT are also capable of showing the sinus tract. The extent of inflammatory process related to PSF is better delineated by US, CT, and MRI.

Thyroid abscess due to Acinetobacter calcoaceticus: case report and review of the causes of and current management strategies for thyroid abscesses

Thyroid abscess was a common condition in the era before antibiotics. In the current medical environment, however, it is a clinical entity that is seldom encountered. We report the case of a unique cause of thyroid abscess, the environmental Gram-negative bacterium Acinetobacter calcoaceticus. Review of the published causes of thyroid abscess since 1980 demonstrated that although Gram-positive bacteria (Staphylococcus and Streptococcus species) remain the most common causes, there has been a marked decrease in the number of cases caused by mycobacteria, Salmonella species, and anaerobes when compared with the early part of the 20th century. Patients infected with the human immunodeficiency virus, however, still develop mycobacterial and fungal thyroid infections with some regularity. Reported modes of management of thyroid abscess vary, but drainage remains an integral component of therapy for resolution of the infection.

Ten years of experience with third and fourth branchial remnants

BACKGROUND

Third and fourth branchial remnants may result in cysts and abscesses that are in close contact with the thyroid gland. These anomalies are rare and often present diagnostic and therapeutic challenges.

METHODS

The charts of patients diagnosed with a branchial anomaly between July 1991 and July 2001 at the Montreal Children's Hospital were reviewed. All cases of third and fourth branchial remnants or pyriform sinus fistulae were identified. Clinical presentation, imaging, treatment, and outcome were recorded.

RESULTS

Eight patients with a third or fourth branchial anomaly were identified and ranged in age from birth to 13 years. All anomalies were left sided. Presenting symptoms consisted of an asymptomatic cervical mass (n = 1), an infected mass (n = 5), neonatal respiratory distress (n = 1), and 1 incidental cyst found on magnetic resonance imaging. Ultrasonography was useful in suggesting the diagnosis in 7 cases. Barium swallow was performed in 3 patients with 2 positive results. Pharyngoscopy results showed the internal opening in 2 of 7 patients. A portion of the thyroid gland was resected in 6 patients. One patient has not yet undergone a definitive procedure. There was 1 recurrence in a patient whose pathology did not confirm a branchial remnant.

CONCLUSIONS

The diagnosis and management of pyriform sinus anomalies are challenging. Ultrasound scan, computed tomography scan, barium swallow, and pharyngoscopy are all useful. The portion of thyroid involved in the fistula must be excised en bloc with the inflammatory mass, and the tract should be ligated at the level of the pharynx to minimize recurrence.

Acute suppurative thyroiditis in children

BACKGROUND

Acute suppurative thyroiditis in children is rare and is often related to a pyriform sinus fistula or thyroglossal duct remnant, especially when it is recurrent.

METHODS

From January, 1985, through December, 2000, 15 children with acute suppurative thyroiditis were treated. Their clinical, laboratory and radiologic findings were reviewed and analyzed.

RESULTS

There were 8 girls and 7 boys, with a mean age at diagnosis of 6.1+/-2.9 years (range, 1.5 to 9.8). A thyroid mass was present on the left in 13 and on the right in 2 (P < 0.05). Fever, neck pain and swelling were the most common symptoms and signs. Seven patients (46.7%) had recurrent disease. Needle aspiration for Gram stain and bacterial cultures were done, and pathogenic organisms were identified on culture in 8 patients but were found only on Gram stain in 2 patients. In one-half of the patients with positive cultures, mixed pathogens were found. The most common organisms isolated were streptococcal species (50%). Barium esophagography was performed in all patients, and 5 (33.3%) had a pyriform sinus fistula on the left. Only 1 of the recurrent patients had a fistula. Thyroid scans were performed in 13 patients, of whom 12 (92.3%) had decreased radioactive uptake. Thyroid function tests were normal in all 15.

CONCLUSIONS

Acute suppurative thyroiditis is usually caused by oropharyngeal flora, resulting in mixed pathogens on culture. Broad spectrum antibiotics should be given once cultures have been obtained. Imaging studies might be helpful in the diagnosis of acute suppurative thyroiditis.

A new role for computed tomography in the diagnosis and treatment of pyriform sinus fistula

Neck abscess located in or around the thyroid gland should raise the suspicion of acute suppurative thyroiditis, pyriform sinus fistula, a 3rd or 4th branchial cleft anomaly. Differentiating between these entities on a clinical basis is difficult. After treating the initial infection, computed tomography, barium esophagography, ultrasound, and endoscopy can be used in search of the fistulous tract that can be associated with a pyriform sinus fistula or a 3rd or 4th branchial anomaly. We present a case of a pyriform sinus fistula involving the use of oral contrast, combined with computed tomography, to delineate the tract and its surrounding structures. This method, in combination with endoscopy, aided in the removal of this branchial anomaly.

Acute suppurative thyroiditis due to foreign body-induced retropharyngeal abscess presented as thyrotoxicosis

Acute suppurative thyroiditis is an uncommon condition. Most patients have preexisting oropharyngeal fistulae. Penetrating oropharyngeal injuries resulting from swallowed foreign bodies provide an acquired channel of infection spreading into the relatively resistant thyroid gland. The authors describe a patient with infective thyroiditis complicating retropharyngeal abscess caused by a chicken bone that perforated the upper esophagus. Transient thyrotoxicosis complicating acute suppurative thyroiditis is very rare. Pertechnetate and Ga-67 scans confirmed extensive inflammation of the thyroid gland and the release of hormones as the cause, as distinct from concurrent Graves' disease. Awareness of this unusual complication is important to avoid inappropriate treatment for hyperthyroid disease.

Imaging the thyroid

Thyroid imaging has historically relied heavily on scintigraphy, although, not surprisingly in view of the superficial position of the gland, ultrasound has assumed an increasingly prominent role in recent years. The other cross-sectional imaging modalities can also be useful, and the emergence of new radiopharmaceuticals and the increasingly central role of fine needle aspiration cytology have further added to the range of diagnostic techniques available. This review attempts to summarize the current state of knowledge, and makes some suggestions for the most efficient use of imaging resources in the investigation of thyroid disease.

The role of ultrasound and oesophagography in the management of acute suppurative thyroiditis in children associated with congenital pyriform fossa sinus

The thyroid is remarkably resistant to infection. Hence, when an infection does occur, the presence of a pyriform fossa sinus must be considered, particularly if it is recurrent and left sided. The aim of this paper is to alert radiologists to the existence, clinical presentation, and ultrasonographic and oesophagographic appearances of a pyriform fossa sinus. We present the role of ultrasound and oesophagography in five children with pyriform fossa sinus associated with suppurative thyroiditis. In four children the abnormality was on the left and on the right in one.

Recurrent suppurative thyroiditis due to pyriform sinus fistula: a case report

Acute suppurative thyroiditis is a rare disease, particularly in childhood. We present a case with recurrent acute suppurative thyroiditis due to a pyriform sinus fistula originating from the fourth branchial pouch. The typical symptoms of a pyriform sinus fistula are recurrent left-sided pain and swelling of the neck with signs of acute bacterial inflammation. Diagnosis should be made by high resolution ultrasound, barium meal studies and endoscopic examination. During acute exacerbations treatment with antibiotics is indicated, but permanent cure can only be attained by complete fistulectomy.

Thyroid abscess complicating subacute thyroiditis: a consequence of steroid therapy?

A patient with subacute thyroiditis developed a thyroid abscess after drainage of a pilonidal abscess. An infective focus in a patient with subacute thyroiditis on steroids should be treated aggressively with adequate antibiotic cover.

Branchial fistula: CT manifestations

A patient with a recurrent left neck abscess was found to have a branchial fistula from the pyriform sinus. This uncommon anomaly was demonstrated by CT and barium swallow. The embryology, pathology and clinical features of this lesion are discussed and contrasted with those of the branchial cyst.