Traitement endoscopique au laser des fistules de la 4e poche endobranchiale

Successful management of pyriform sinus cyst and fistula using endoscopic electrocauterization

OBJECTIVES

Pyriform sinus cyst (PSC) and pyriform sinus fistula (PSF) is a rare congenital malformation that arises from the third or fourth branchial structure. In our study, we describe the safety and the utility of endoscopic electrocauterization against PSC/PSF.

METHODS

We retrospectively reviewed the records of patients who underwent endoscopic electrocauterization for PSC/PSF at our hospital. The internal opening of the fistula was identified under general anesthesia using a flexible endoscope (XQ-260 or H-290; Olympus, Tokyo, Japan), and the DualKnifeJ (KD-655L; Olympus) was used to ablate the internal opening.

RESULTS

We experienced three PSF and three PSC patients. The postoperative course was uneventful in all cases. The patients declared no pain in the neck, and there were no cases showing recurrent nerve paralysis. Five in six cases (83%), the closure of fistula was archived in the first cauterization. One case (16.6%) required repeated cauterization. No recurrence was found during the follow-up period ( median: 1 year) in any cases.

CONCLUSIONS

Owing to its rarity in neonates, the diagnosis and treatment of PSC remains complicated and not clearly described. Complete removal of the fistula and the cyst with or without affected thyroid tissue was previously the most commonly used treatment. From our experience, we believe that endoscopic electrocauterization can be the first choice not only for PSF but also for neonatal PSC. In conclusion, endoscopic electrocauterization is feasible even for neonatal PSC. Further investigations including multicenter analyses are needed.

Surgical treatment of fourth branchial apparatus anomalies: a case series study

Background

Fourth branchial apparatus anomalies, are rare clinical entities, and present as complex cysts, sinuses and fistulae in the neck that can be difficult to manage.

Methods

This is a retrospective review of a series of consecutive patients with fourth branchial apparatus anomalies treated at Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, from Apr 2014 to Nov 2019.

Results

Ten patients with fourth branchial apparatus anomalies were identified, including 8 patients with fourth branchial fistula, and 2 patients with fourth branchial pouch sinus. There were 6 female patients and 4 male patients. Their age was from 6 years old to 39 years old (average age 20.4 years old, median age was 21 years old). All 8 fistulae were on the left side, while 2 pouch sinuses were both on the right side. Pre-operative examination with fiberoptic laryngoscope, barium swallow X-ray, CT or MRI identified internal orifice at pyriform fossa apex in 8 (80%) patients. All patients underwent challenging surgical resection by the senior author. Intra-operative direct laryngoscope confirmed or identified internal orifice in 9 (90%) patients. The tracts were all followed to the vicinity of inferior cornu of the thyroid cartilage and the cricothyroid space. Complete resection of cervical lesions and their attachment to hypopharynx were achieved in 9 cases. No complication occurred. One recurrence was detected, in the only patient whose internal orifice could not be located pre- or intra-operatively, and the hypopharyngeal attachment could not be removed.

Conclusions

Direct laryngoscopy under general anesthesia is a reliable method of diagnosis for the fourth branchial apparatus anomalies. Complete surgical removal of fourth branchial apparatus anomalies, including their hypopharyngeal attachment, is the treatment of choice, and the key to prevent recurrence.

Evaluation of endoscopic coblation treatment for obliteration of congenital pyriform sinus fistula

BACKGROUND

Congenital pyriform sinus fistula is a very rare branchial apparatus malformation. Conventional open surgery for fistulectomy might fail to excise the lesion completely, leading to continual recurrence. The aim of this study was to provide an innovative endoscopic coblation technique for patients with pyriform sinus fistula and evaluate its intermediate-term effectiveness.

METHODS

Retrospective case series with 112 patients (age range 3-36 years) between 2013 and 2016 and underwent endoscopic coblation of the sinus fistula. Data collected including patient demographics, presenting symptoms, diagnostic methods, prior and subsequent treatments, length of hospital stay, and recurrence were analyzed.

RESULTS

Of the 112 cases, there were no postoperative complications observed except temporary reddish swelling in three patients. Four cases were lost to follow-up. Of 108 patients, 106 experienced no recurrence after their first endoscopic coblation of the sinus tract. The remaining two patients with recurrence in the follow-up were ultimately treated with recoblation without complications or further recurrences. Also, Endoscopic coblation can be used to treat seven patients with recurrence who had experienced open resection. In our series, median follow-up period was 1.5 years.

CONCLUSION

Endoscopic coblation is an effective approach for most patients. We advocate using this minimally invasive technique as first line of treatment for pyriform sinus fistula.

Endoscopic Cauterization with Pneumatic Distension for Piriform Fossa Sinus Tracts

INTRODUCTION

Piriform fossa sinus tracts (PFSTs) are a cause of recurrent neck infections in the pediatric population. Conventional management required open resection, but over the last years minimally invasive approaches have been reported in an attempt to endoscopically obliterate the PFST, using different methods such as electrocautery, laser, trichloroacetic acid, or silver nitrate.

MATERIALS AND METHODS

We undertook a retrospective review of the medical records of 12 children (aged 4 months to 14 years) with PFSTs treated with endoscopic sclerosis with diathermy (ESD) between 2010 and 2016 at a tertiary care children's hospital. We also present a technical modification of ESD, using continuous infusion of airflow through the gastroscopy, to distend the piriform sinus and facilitate its recognition. PFST obliteration was performed using diathermy through a guide wire.

RESULTS

Clinical presentation of the 12 affected children included neck tumor (7 [58%]), neck abscesses (4 [33%]), and thyroiditis (5 [41%]). All lesions occurred on the left side. All patients underwent both ultrasonography and barium esophagography (the latter being positive only in 50%). Two patients were treated with ESD after the open approach had failed. There was no procedure-related morbidity. One patient had a recurrence (positive barium swallow without symptoms). The success rate of this procedure in our series was 91% with one attempt and 100% with two attempts.

CONCLUSION

In our experience, treatment of PFST with ESD is a reproducible, noninvasive, and an effective option. ESD could be considered a primary approach and also for revision after open surgery has failed in these patients.

Endoscopic chemocauterization for pyriform sinus fistula in children

BACKGROUND

Although complete excision is the standard treatment for pyriform sinus fistula (PSF), it has recently been suggested that chemocauterization via the internal orifice of the fistula could be an effective non-invasive treatment for the condition. The present report describes the details of our experience with and the efficacy of endoscopic chemocauterization for pediatric PSF.

METHOD

Between January 2010 and June 2015, four patients were diagnosed with PSF and scheduled to undergo endoscopic chemocauterization. Under general anesthesia, trichloroacetic acid (TCA) solution was endoscopically injected through the opening of the fistula using a fine plastic tube. Esophagogram was obtained at 3 weeks after the procedure to search for recurrence. Complete closure of the fistula was confirmed on endoscopy at 2-3 months after chemocauterization.

RESULTS

Two of the four patients were treated once, and the remaining patients required further chemocauterization procedures. No recurrence developed in any patient after it had been confirmed that the fistula's internal orifice had been obliterated. Some transient complications, such as sore throat, nausea or temporary vocal fold paresis, occurred.

CONCLUSION

Chemocauterization with TCA seems to be a useful first-choice treatment for PSF.

KTP laser assisted endoscopic tissue fibrin glue biocauterization for congenital pyriform sinus fistula in children

OBJECTIVE

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.

METHOD

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.

RESULTS

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.

CONCLUSIONS

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.

Intraoperative use of fibrin glue dyed with methylene blue in surgery for branchial cleft anomalies

OBJECTIVES/HYPOTHESIS

We present a new method of optimizing the results of surgery for branchial cleft anomalies based on the intraoperative injection of fibrin glue combined with methylene blue dye.

STUDY DESIGN

Retrospective single-center cohort study.

METHODS

The method was applied in 17 patients suffering from branchial anomalies. Six (35.29%) had a preauricular lesion; three (17.65%) had lesions derived from the first arch/pouch/groove (type I), four (23.53%) had lesions derived from the first (type II), one (5.88%) had lesions derived from the second, one (5.88%) had lesions derived from the third, and two (11.76%) had lesions derived from the fourth. The median and mean age at surgery were 10 and 10.6 years, respectively. All patients were followed by periodic clinical and ultrasonographic examination.

RESULTS

The combination of fibrin glue with methylene blue facilitated the correct assessment of the extension of the lesions and their intraoperative manipulation. After a mean follow-up of 47.8 months, all patients were free of disease.

CONCLUSIONS

Intraoperative injection of branchial fistulae and cysts by a mixture of fibrin glue and methylene blue is an effective, easy, and safe tool to track lesions and achieve radical resection. The technique requires a definitive validation on a large cohort with adequate stratification of patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:2147-2150, 2016.

Systematic Review of Endoscopic Obliteration Techniques for Managing Congenital Piriform Fossa Sinus Tracts in Children

BACKGROUND

Piriform fossa sinus tracts (PFSTs) are a recognized cause of recurrent deep neck infections in the pediatric population. Conventional management has historically required open resection, but over recent years minimally invasive endoscopic approaches to obliterate the pharyngeal opening of the sinus have been performed in many centers. However, there is a lack of clear evidence regarding the success rate and safety of these approaches.

OBJECTIVE

To determine the success rate of endoscopic management of PFST through a systematic review of the existing literature.

DATA SOURCES

MEDLINE (1964-2014) and bibliographies of identified papers.

REVIEW METHODS

Two authors independently reviewed 170 abstracts and identified relevant studies for full-text review. Data were independently extracted from those studies, and the Oxford Centre for Evidence-Based Medicine guidelines were used to classify the level of evidence.

RESULTS

Thirteen studies met the inclusion criteria, comprising a total of 84 patients. All included studies were evidence level 4 (case series). Various methods of obliterating the PFST were described: electrocautery (n = 39), laser (n = 19), trichloroacetic acid (n = 19), silver nitrate (n = 4), combination of silver nitrate and laser (n = 2), and fibrin glue (n = 1). The success rate for endoscopic management of PFST was 89.3% overall (90.5% in primary cases and 85.7% in revision cases). The only adverse event reported was temporary vocal cord immobility in 2.4% (n = 2) of cases.

CONCLUSION

Endoscopic management of pediatric PFST appears to be safe and effective, as a primary option and for revision after open surgery.

Surgery versus endoscopic cauterization in patients with third or fourth branchial pouch sinuses: A systematic review

OBJECTIVES

To systematically review the current literature on treatment of third and fourth branchial pouch sinuses with endoscopic cauterization, including chemocauterization and electrocauterization, in comparison to surgical treatment.

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

We conducted a systematic search. Studies reporting original study data were included. After assessing the directness of evidence and risk of bias, studies with a low directness of evidence or a high risk of bias were excluded from analysis. Cumulative success rates after initial and recurrent treatments were calculated for both methods. A meta-analysis was conducted comparing the success rate of electrocauterization and surgery.

RESULTS

A total of 2,263 articles were retrieved, of which seven retrospective and one prospective article were eligible for analysis. The cumulative success rate after primary treatment with cauterization ranged from 66.7% to 100%, and ranged from 77.8% to 100% after a second cauterization. The cumulative success rate after the first surgical treatment ranged from 50% to 100% and was 100% after the second surgical attempt. Meta-analysis on electrocauterization showed a nonsignificant risk ratio of 1.35 (95% confidence interval: 0.78-2.33).

CONCLUSIONS

The effectiveness of cauterization in preventing recurrence seems to be comparable to surgical treatment. However, we suggest endoscopic cauterization as the treatment of choice for third and fourth branchial pouch sinuses because of the lower morbidity rate.

Management of third branchial pouch anomalies - an evolution of a minimally invasive technique

OBJECTIVES

The management of third branchial pouch anomalies has evolved in recent times with the popularisation of the endoscopic diathermy technique to sclerose the pyriform fossa sinus opening. We present our experience in managing 3 children with third branchial pouch anomalies and propose a minimally invasive management algorithm avoiding open neck surgery.

METHODS

Retrospective case review of 3 patients including demographics, mode of presentation, investigations, management and complications.

RESULTS

Three children, two male and one female of mean age 9.6 years presented with painful left anterior neck swelling. Axial neck imaging showed a superficial abscess with air locules and a sinus tract leading towards the left pharynx. Diagnosis was confirmed by endoscopic examination of the pyriform fossa revealing a sinus opening. Two patients underwent open excision; one combined with diathermy to the sinus opening. The last patient was diagnosed at his initial presentation and managed with endoscopic diathermy of the sinus opening combined with percutaneous needle aspiration of the neck abscess at the same sitting. One patient had two recurrences, the first after initial open surgery and the second after the first cautery. Two patients developed temporary hoarseness after the procedure, which resolved within two weeks. All patients were free from recurrences at follow-up.

CONCLUSIONS

Introduction of the technique of endoscopic diathermy to the pyriform fossa sinus opening in children with third branchial pouch anomalies has revolutionised their management avoiding open and potentially morbid surgery. Our algorithm takes this further by advocating percutaneous needle aspiration of the infective component and performing diathermy to the sinus opening at the first presentation.

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.

Fourth branchial pouch sinus - an unusually late initial presentation

OBJECTIVE

Here we present an unusual case of a male patient with 4th branchial pouch sinus with an initial presentation of pseudothyroiditis at an unusually late age of 20 years.

METHOD

Case report and a review of the world literature concerning 4th branchial pouch sinus is presented.

RESULT

The patient was diagnosed by radiology and endoscopy and treated surgically. Histopathology revealed chronic inflammatory changes, which pointed towards recurrent sub clinical low-grade inflammations over the years keeping the condition occult till 20 years of age.

CONCLUSION

According to available literature it almost always presents in the first decade of life when it might be misdiagnosed. However our report shows it may also exist with sub clinical inflammations or infections and present at a much later stage in life, when the possibility of such a sinus shouldn't be ruled out on the basis of lack of history of recurrent neck inflammations.

Suppurative thyroiditis in children: a management algorithm

OBJECTIVE

To elucidate the etiology of suppurative thyroiditis in children and recommend a management algorithm.

METHODS

Case series of 5 pediatric patients with a diagnosis of suppurative thyroiditis seen between January 1999 and April 2007.

RESULTS

All 5 patients primarily presented with left-sided intrathyroidal abscesses. The number of infections from first presentation to the time of definitive diagnosis ranged from 1 to 5. Three patients underwent incision and drainage of the abscess once, and 2 had the procedure performed 3 times. Barium swallows identified a piriform sinus tract on the left side in 2 of the 5 patients. Telescopic hypopharyngoscopy identified the internal opening in all 5. Three were managed with complete excision of their tracts and 2 with cauterization of the internal opening with silver nitrate. All 5 are currently asymptomatic.

CONCLUSIONS

Suppurative thyroiditis is a very rare infection in children. A left-sided intrathyroidal abscess should immediately arouse suspicion of a piriform sinus tract. Barium swallows may identify the etiology in some cases. Definitive diagnosis requires a hypopharyngoscopy, with detailed telescopic examination of the left piriform fossa apex. Endoscopic chemical cautery of the internal opening is a safe and effective technique, with very low morbidity, and has the potential for cure.

Endoscopic chemical cautery of piriform sinus tracts: a safe new technique

Piriform sinus tracts are thought to be of branchial origin and typically present with suppurative thyroiditis or a lateral neck mass. Endoscopic examination with direct visualization of the internal opening usually confirms the diagnosis. Complex external surgery with complete excision of the tract is the current standard of care. We report two cases of piriform sinus tracts which were managed with silver nitrate cautery of the internal opening. Post-operative closure of the opening was confirmed in one patient. This appears to be a safe and effective technique that eliminates the need for surgery and has not been previously reported.

Treatment of piriform fossa sinuses with monopolar diathermy

Introduction:

Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition.

Materials and methods:

A retrospective, case report review was performed.

Results:

Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months.

Discussion:

Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.