Congenital fistula of the fourth branchial pouch

Pyriform sinus fistula in children: A comparison of endoscopic-assisted surgery and endoscopic radiofrequency ablation

BACKGROUND

Pyriform sinus fistula (PSF) is a rare congenital anomaly, and the preferred definitive treatment is yet to be verified. In this study, we investigated the treatment outcomes of PSF specifically comparing endoscopic-assisted surgery and endoscopic radiofrequency ablation (RA).

METHODS

The medical records of patients treated for PSF at the Shanghai Children's Hospital between October 2016 and September 2019 were retrospectively evaluated.

RESULTS

There were 93 girls and 98 boys. The median age at onset and operation was 3 years and 5 years, respectively. Endoscopic-assisted surgery was performed in 143 patients. During the same period, RA was performed in 48 patients, and 10 of them concurrently underwent incision and drainage of neck abscesses. Longer hospital stay was found in the endoscopic-assisted surgery group than in the RA group (10.50 ± 3.93 vs. 5.02 ± 3.30 days, P < 0.001). Postoperative complications were not significantly different between the two groups, except for neck infection (0 vs. 8.3%, P = 0.004). After a median follow-up period of 21 months, no significant difference was found between the two groups in terms of recurrence (1.4% vs. 0, P = 0.560).

CONCLUSION

Patients treated with RA had a significantly shorter hospital stay than those treated with endoscopic-assisted surgery. Outcomes of endoscopic-assisted surgery and RA were not significantly different for the management of PSF and treatment method should be tailored to the patient.

LEVEL OF EVIDENCE

IV.

The treatment of congenital pyriform sinus fistula: a single-center experience

PURPOSE

Congenital pyriform sinus fistula (CPSF) often presents diagnosis and treatment challenges. This study aimed to explore the treatment principles and to evaluate the effectiveness of the hypothermia plasma cauterization with suspension laryngoscopy for CPSF.

METHODS

The medical records of 56 patients with CPSF from January 2000 to December 2019 were retrospectively reviewed.

RESULTS

Of the 56 cases, the lesions were predominantly located on the left side (95%), and the accuracy of the first diagnosis was 30%. Ultrasound showed an abnormal rate of 86%, while CT or MRI displayed an abnormal anatomic lesion of 92%. The 3D visual reconstruction enabled the analysis of morphological characteristics of CPSF. The positive predictive value of barium esophagography was 89%, whereas the positive rate of the internal opening in CPSF under local anesthesia laryngoscopy was 33%. Nine cases of sinus type underwent open resection, and the recurrence rate was 33%. Interestingly, ten patients with sinus type underwent hypothermia plasma cauterization with suspension laryngoscopy, leading to a success rate of 100% without apparent complications.

CONCLUSIONS

Hypothermia plasma cauterization with suspension laryngoscopy alongside 3D imaging is both minimally invasive and repeatable with neglectable complications, which has the potential to serve as the first-line treatment for CPSF in the future.

Fourth branchial pouch sinus: A report of 7 cases and review of the literature

A fourth branchial pouch sinus often manifests quite late in life as a recurrent neck abscess, suppurative thyroiditis, or pseudothyroiditis. Demonstration of the sinus opening in the piriform fossa by hypopharyngoscopy in combination with ultrasonography of the neck provides adequate information to justify proceeding to surgery. The sinus tract usually courses through the thyroid cartilage. The most effective treatment is surgical excision of the tract up to the piriform fossa through the cartilage. This procedure is associated with very low complication and recurrence rates. A fourth branchial pouch sinus is an uncommon condition. Even so, it is still underdiagnosed as a result of poor awareness of its existence by medical practitioners, including otolaryngologists. Part of the reason is a lack of adequate coverage of this topic in otolaryngology and surgery textbooks. In this article, we add to the literature by describing our experience with 7 patients-4 males and 3 females, aged 5 to 45 years (mean: 25.6)-who were diagnosed with a fourth branchial pouch sinus over a 6-year period. The diagnosis was confirmed by identifying the sinus opening at the apex of the piriform sinus during hypopharyngoscopy. Definitive treatment consisted of surgical exploration of the neck and excision of the tract.

Accessory submandibular duct sialolithiasis identified during sialendoscopy

We describe a unique case of a 62-year-old patient with recurrent right submandibular sialadenitis. He initially appeared to have extensive sialolithiasis of the right submandibular duct on computed tomography imaging and examination, but sialendoscopy demonstrated a normal-appearing right submandibular duct. An accessory duct posterior and parallel to the normal duct was identified at the time of sialendoscopy and was found to have extensive sialolithiasis, which required removal by both an endoscopic and intraoral technique. To the best of our knowledge, this is the first report of sialolithiasis of an accessory submandibular duct identified at the time of sialendoscopy; the other few reported cases in the literature are based primarily on findings from traditional sialography or magnetic resonance sialography. Identification of accessory salivary ducts requires intraoperative consideration of this entity during sialendoscopy. Open approaches to sialolithiasis, however, may be aided by appropriate preoperative imaging.

A fatal case of severe neck abscess due to a third branchial cleft fistula: morphologic and immunohistochemical analyses

Background

Branchial cleft anomalies constitute a frequently encountered and commonly non-lethal disease in otolaryngology, and result from aberrant embryonic development. The third branchial cleft fistula is one of the four known specific types of branchial cleft anomalies, and always presents as recurrent neck abscess and suppurative thyroiditis. Here, we report an unexpected death due to severe neck infection following a third branchial cleft fistula.

Case presentation

A 19-year-old man was sent to the hospital with a 1-week history of recurrent left-sided neck abscess, and was scheduled for incision and drainage of the abscess. However, before the surgery was performed, the man’s condition deteriorated and he died. A review of his medical history showed that he had undergone a previous incision and drainage for a neck abscess 2 years ago. Postmortem examination revealed that the fatal neck abscess was induced by a third branchial cleft fistula.

Conclusions

We conclude that a histopathological examination of neck tissue combined with a detailed review of medical history and examination of ultrasonographic and CT images can provide a rapid and accurate diagnosis of third branchial cleft fistula. This common, non-lethal disease can potentially lead to death if the neck infection is not properly diagnosed and treated. In medico-legal practice, medical examiners should be aware of this condition, as this knowledge would be important in the diagnosis of the cause of death.

Fourth Branchial Pouch Sinus: From Diagnosis to Treatment

BACKGROUND: Fourth branchial pouch sinus (FBPS) is rare and frequently unknown to clinicians. Misdiagnosis is common and definitive surgery is often made difficult by previous episodes of infection and failed attempts at excision. The purpose of this paper is to clarify the diagnostic criteria and the methods used for the surgical management of FBPS.

MATERIALS AND METHOD: From a series of 265 head and neck cysts and fistulae, 7 cases of FBPS were retrospectively reviewed. The surgical technique is detailed.

RESULTS: Six cases were located on the left side and one on the right. CT scanning showed an air-filled structure on both sides of the lesser horn of the thyroid cartilage in 2 cases out of 4, and barium swallow found a FBPS in 1 case out of 3. Direct pharyngoscopy allowed confirmation of the diagnosis in all cases and permitted catheterization of the tract with the spring guidewire of a vascular catheter which helped surgical location and subsequent dissection. The recurrent laryngeal nerve was systematically dissected to avoid inadvertent damage. A hemi-thyroidectomy was performed in one case. A transient laryngeal paralysis (lasting 9 months) was noted in a 3-week-old newborn operated on. None of the 7 cases had a recurrence after complete resection of the FBPS (3.7 years average follow-up).

CONCLUSION: Symptoms on the right side do not exclude the diagnosis of a FBPS. Endoscopy is the key investigation. It allows confirmation of the diagnosis and catheterization of the tract, which aids the surgical dissection. Total removal of the sinus tract tissue with dissection and preservation of the recurrent laryngeal nerve is recommended.

EBM rating: A-1

Case series: Endoscopic management of fourth branchial arch anomalies

INTRODUCTION

Fourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery.

OBJECTIVES

To determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute.

METHODS

Retrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively.

RESULTS

In total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO₂ laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11-41 months).

CONCLUSION

Endoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.

Right-sided pyriform sinus fistula: a case report and review of the literature

Objectives. Pyriform sinus fistulae arise from disturbances in the development of the fetal third and fourth branchial pouches and are predominantly found on the left side. We report the rare case of a right-sided pyriform sinus fistula presenting as a lateral neck abscess. Study Design. Case report. Methods. A 24-year-old woman presented with a two-week history of right-sided neck abscess. A fluoroscopic sinogram revealed a fistulous tract extending from the abscess to the apex of the right pyriform sinus. It was determined that the fistula was likely a third or fourth branchial remnant, a rare right-sided finding. Chemocauterization of the fistulous tract with 40% trichloroacetic acid was used to successfully treat the patient. Results. Approximately 93–97% of branchial pouch anomalies are left sided. Treatment options include surgical excision and cauterization. Conclusions. Branchial cleft cyst and pyriform sinus fistula must be considered in the diagnosis of cervical abscess in either side of the neck.

Stridor as a presentation of fourth branchial pouch sinus

Background:

Anomalies of the fourth arch are the rarest of all the branchial anomalies. They arise as a result of failure of involution of the cleft during embryogenesis, and manifest clinically as sinuses, cysts or abscesses in the neck, commonly presenting in childhood.

Methods:

This article describes a case of a neonate presenting with stridor which was secondary to a fourth branchial pouch sinus. The presentation, investigations, operative findings and treatment are discussed.

Results:

Microlaryngobronchoscopy was done to evaluate the stridor. A swelling in the posterolateral pharyngeal wall and a sinus opening in the pyriform fossa on the left side were identified. There were no external neck swellings. Magnetic resonance imaging confirmed a swelling in the expected region filled with air and fluid. After the diagnosis was confirmed, the swelling was aspirated and the fourth arch pouch treated. Microlaryngobronchoscopy was repeated six weeks later, showing complete resolution of the pharyngeal swelling. At this stage, the child had no airway symptoms and was feeding normally.

Conclusion:

This is an interesting case of a fourth branchial cleft pouch presenting with stridor. The child was treated without any complications and recovered well.

Lateral Congenital Anomalies of the Pharyngeal Apparatus: Part II. Anatomy of the Abnormal for the Surgeon

“Anatomy of the abnormal”—a branch of surgical anatomy—deals with relations of an anomaly to surrounding entities. Here, lateral congenital anomalies of the pharyngeal apparatus are examined; their relations to entities of the neck can be explained embryologically. Location of embryonic pharyngeal arches, clefts, and pouches in the adult is presented and terminology of these anomalies (fistulas, sinuses, cysts) is defined. First “cleft and pouch” anomalies relate with the parotid and facial nerve. Second cleft and pouch anomalies course deeply to second arch structures and superficially to third arch structures. Consequently, they relate with hypoglossal and glossopharyngeal nerves and internal and external carotid arteries. Third cleft and pouch anomalies pass deep to third arch entities and superficial to those of the fourth arch and relate with glossopharyngeal, hypoglossal, superior and recurrent laryngeal nerves, and the internal carotid artery. The complicated course of fourth cleft and pouch anomalies brings them into relationship with glossopharyngeal, hypoglossal, superior and recurrent nerves, internal carotid, aorta, and subclavian arteries. Found superficially are veins (external and anterior jugular, common facial, communicating), nerves (transverse cervical, great auricular, mandibular, cervical branches of facial), and relevant spinal nerves (e.g., accessory). Knowledge of these anatomical relations helps prevent anatomical complications.

Branchial anomalies in children

BACKGROUND

Branchial cleft anomalies are the second most common head and neck congenital lesions seen in children. Amongst the branchial cleft malformations, second cleft lesions account for 95% of the branchial anomalies. This article analyzes all the cases of branchial cleft anomalies operated on at Great Ormond Street Hospital over the past 10 years.

METHODS

All children who underwent surgery for branchial cleft sinus or fistula from January 2000 to December 2010 were included in this study.

RESULTS

In this series, we had 80 patients (38 female and 42 male). The age at the time of operation varied from 1 year to 14 years. Amongst this group, 15 patients had first branchial cleft anomaly, 62 had second branchial cleft anomaly and 3 had fourth branchial pouch anomaly. All the first cleft cases were operated on by a superficial parotidectomy approach with facial nerve identification. Complete excision was achieved in all these first cleft cases. In this series of first cleft anomalies, we had one complication (temporary marginal mandibular nerve weakness. In the 62 children with second branchial cleft anomalies, 50 were unilateral and 12 were bilateral. In the vast majority, the tract extended through the carotid bifurcation and extended up to pharyngeal constrictor muscles. Majority of these cases were operated on through an elliptical incision around the external opening. Complete excision was achieved in all second cleft cases except one who required a repeat excision. In this subgroup, we had two complications one patient developed a seroma and one had incomplete excision. The three patients with fourth pouch anomaly were treated with endoscopic assisted monopolar diathermy to the sinus opening with good outcome.

CONCLUSION

Branchial anomalies are relatively common in children. There are three distinct types, first cleft, second cleft and fourth pouch anomaly. Correct diagnosis is essential to avoid inadequate surgery and multiple procedures. The surgical approach needs to be tailored to the type of anomaly of origin of the anomaly. Complete excision is essential for good outcomes.

Magnetic resonance imaging of branchial cleft abnormalities: illustrated cases and literature review

Objective:

We report two cases of branchial cleft abnormalities investigated using magnetic resonance imaging.

Background:

There appears to be no clear imaging technique that is universally recommended for imaging branchial cleft abnormalities. Options include fistulography, computed tomography, magnetic resonance imaging and ultrasonography.

Method:

Case reports and literature review.

Case reports:

Two cases, although not unusual in themselves, are described to illustrate the use of magnetic resonance imaging to define the anatomy and to assist surgical planning.

Conclusion:

Magnetic resonance imaging is able to accurately depict the extent and course of branchial cleft abnormalities, and in the current cases could have been relied upon to determine the necessary surgical procedure. Branchial cleft abnormalities are sufficiently rare for magnetic resonance imaging to be recommended as the first-line imaging modality.

[Clinical evaluation of patients with pyriform sinus fistula]

Thirteen patients with pyriform sinus fistula treated surgically at our department were clinically evaluated. Twelve (92%) fistulae occurred in the left pyriform sinus, and one (8%) in the right. There were a mean of 4 infectious episodes before the final diagnosis. The median age at the first infection was 5 years, and the median age at surgery was 13 years, although there were 2 elderly patients (over 60 years old) in this series. Association with pharyngeal foreign body was suspected in the case with onset at 81 years of age. There was a history of previous surgery for cervical disease in 54% of the patients. The final diagnosis was based on delineation of the fistula by hypopharyngography, although coronal section of CT and MRI were also useful for understanding the morphopathology. The surgical procedure consisted of identification and staining of the fistula under direct hypopharyngoscopy, followed by identification and extirpation of the fistula until the distal end via a cervical approach. There was no recurrence of infections, although resection of the thyroid gland and identification of the recurrent laryngeal nerve were not always performed. The most important surgical principle is considered to be complete disconnection of the lesion from the hypopharynx, and complete identification and extirpation of the fistula by the procedure used at our department is considered to be a useful surgical strategy.

Retrospective review of 13 cases of pyriform sinus fistula

PURPOSE

To review 13 cases of pyriform sinus fistula (PSF) and to summarize the clinical and histologic features.

MATERIALS AND METHODS

A retrospective review and immunohistochemical analysis of 13 cases of PSF treated in Sapporo Medical University Hospital from 1985 to 2005. This study includes 13 patients with PSF diagnosed by the existence of fistulous tract radiologically and/or pathologically. Fistulectomy was performed in all cases. Surgically obtained specimens were processed for immunohistochemistry with commercial anticalcitonin antibody.

RESULTS

The patients consisted of 4 males and 9 females, and the ages ranged from 4 to 55 years. The fistula was detected by barium study in 12 cases (92.3 %), and all cases were on the left side. Pathologic detection of the fistula was achieved in only 8 cases (69.2 %). Immunohistochemistry showed abnormal distribution of calcitonin-positive cells in 12 cases (92.3 %). No recurrence has occurred in any of the patients.

CONCLUSIONS

Surgical removal of the inflammatory tissue is worthy of consideration in suspected PSF cases as in patients who exhibit similar manifestations without preoperative detection of the tract.

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.