Acute suppurative thyroiditis with bilateral piriform sinus fistulae

Bilateral Piriform sinus fistulas: a case study and review of management options

BACKGROUND

Piriform sinus fistulas occur due to developmental abnormalities of the third and fourth branchial arches, and almost always occur unilaterally. They generally present as recurrent abscesses in the anterior-inferior neck, with concurrent thyroiditis. They have conventionally been managed with complete removal of the sinus tract, and thyroidectomy if required; however, endoscopic approaches have been increasingly favored. Herein we describe a case of bilateral piriform sinus fistulas, and present a review of the literature concerning their endoscopic management.

CASE PRESENTATION

Our patient was determined to have bilateral piriform sinus fistulas based on computer tomography, magnetic resonance imaging and microlaryngoscopy. We performed electrocauterization of the proximal fistula tracts, followed by injection of fibrin sealent. Our patient has not had a recurrence in the ten months since his procedure. There were no complications. Twenty-three articles describing an endoscopic approach to these fistulas were identified through PubMed, and a search through the references of related articles was completed.

CONCLUSION

Of one hundred and ninety-five patient cases we reviewed, an endoscopic procedure success rate of 82% and complication rate of 5.6% was determined. Piriform sinus fistulas that occur bilaterally are a rare congenital abnormality of the neck. Endoscopic approaches are an acceptable alternative option to open procedures, with similar success and a lower rate of complications.

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

OBJECTIVES

To describe a new method of treatment of the fourth branchial pouch sinuses by laser endoscopic coagulation of the fistula.

MATERIAL AND METHODS

Retrospective study of two children aged 3 and 12 years with fourth branchial pouch sinuses. Both children presented recurrent cervical abscesses. The diagnosis was established on results of ultrasound, barium study, CT scan and pharyngoscopy. After recovering from infection, the definitive treatment was a laser diode cauterization of the fistulous route and its pharyngeal opening.

RESULTS

Outcome was rapidly favorable in both children without complications or recurrence.

DISCUSSION

These two cases and other reports in the literature confirm the role of endoscopic management for the treatment of the fourth branchial pouch sinus. Laser treatment is especially useful because of its convenience, its harmlessness and its reliability.

CONCLUSION

Fourth branchial pouch sinuses are rare. Surgery, which can be difficult and not without risks, is the generally accepted treatment. This new laser method combines ease of treatment and efficacy.

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.

Occult congenital pyriform sinus fistula causing recurrent left lower neck abscess

BACKGROUND

Congenital pyriform sinus fistula (CPSF) is a rare branchial pouch anomaly; it has the characteristic of left-sided predominance and is not always detected until complications such as neck abscess or acute suppurative thyroiditis resulted.

METHOD

Seven sequential cases of CPSF, including five adults and two children, causing recurrent left lower neck abscess were reported. All of these patients had past histories of misdiagnosis: the intervals from the onset of symptoms to correct diagnosis ranged from 3 years to 34 years with an average of 20 years.

RESULTS

After barium swallow study and direct laryngoscopic examination in the quiescent stage of infection, the CPSFs of these seven patients were successfully excised with or without catheter guide.

CONCLUSION

The key to diagnosis of CPSF is a high index of suspicion by the clinician. CPSF should be considered in the differential diagnosis of a neck abscess, especially if it is recurrent and left-sided.