Outcomes of endoscopic chemo- and laser-cauterizations and open fistulectomy for pyriform sinus fistula

Endoscopic Dyeing and Plasma Coblation-Assisted Open Neck Surgery for Pyriform Fossa Branchial Apparatus Anomalies in Adults

Objective: Pyriform fossa (PF) branchial apparatus anomalies (PFBAA) are rare congenital third or fourth branchial apparatus anomalies (TBAA or FBAA). This article summarizes our paradigm in managing this condition by combining endoscopic procedures and open neck surgery. Methods: A retrospective review was undertaken concerning PFBAA cases treated at our tertiary medical institution between July 2020 and November 2023. Data were collected from case records. Three sequential steps were implemented: (1) direct laryngoscopy to identify internal orifice (IO), with injection of methylene blue into it; (2) open neck surgery to resect all inflammatory tissues, focusing on the ligation of the sinus tract out of PF; and (3) plasma coblation of IO mucosa. Results: In total, 7 cases (4 men and 3 women) were included (28-67 years old, median age 53). Presenting symptoms were various, with 6 lesions on the left and 1 on the right side. Preoperative (PO) fiberoptic laryngoscopy identified IO in 6 patients, while PO barium esophageal study identified outflow from PF in 4 patients. A preliminary diagnosis of PFBAA could be established in all cases (2 TBAA and 5 FBAA cases). Direct laryngoscopy after general anesthesia identified IO in all cases (2 on the base of PF and 5 on the apex of PF). All the surgical procedures were successful, with uneventful recovery in all the patients. No postoperative complications were observed. All the patients resumed oral fluid intake after confirmation of no pharyngeal fistula by barium esophageal study on the seventh postoperative day. The duration of follow-up was between 6 and 40 months (with a median duration of 27 months). No recurrence was observed. Conclusion: Open neck surgery, assisted by endoscopic dyeing of sinus tracts and plasma coblation of IO mucosa, is a suitable treatment for PFBAA in adults. This paradigm is effective and safe for senior surgeons.

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.

Preferred diagnostic methods of pyriform sinus fistula in different situations: A systematic review

PURPOSE

Pyriform sinus fistula (PSF) diagnosis is often easily delayed and incorrect. Diagnostic values of modalities vary in different situations. The aim of this study was to recommend optimal schemes for diagnosing PSF at different ages and infection stages.

METHODS

A search of PubMed, Embase, Cochrane Library, and CBM databases was conducted to identify articles written in Chinese and English concerning PSF diagnosis using keywords: "pyriform sinus fistula", "diagnosis", and relevant synonymous terms. Quality assessment was performed using the Joanna Briggs Institute (JBI) levels of evidence and critical appraisal checklist tool.

RESULTS

111 studies describing 3692 patients were included. The highest true positive rate (TPR) of ultrasonography was 66.67 % in adult cases. Computed tomography (CT) yielded a good TPR (approximately 73 %) in both neonatal and adult patients, and contrast-enhanced CT (84.21 %) was better in adult patients. Most children cases could be accurately diagnosed by barium swallow (BS) examination which was significantly different in acute and non-infection stages (AIS, NIS). Magnetic resonance imaging (MRI) produced a nice TPR in fetal cases (69.23 %) and neonatal cases (54.44 %). Laryngoscopy was also affected by infection stages. TPR of gastroscopy (GS) was the highest in children (86.36 %) and adult cases (87.50 %).

CONCLUSION

For fetal cases suspected of PSF, an MRI is recommended. MRI or CT is preferred for neonatal cases regardless of infection stages. Children and adult patients are advised to undergo GS during NIS or AIS, while BS is suggested for NIS. Contrast-enhanced CT can also diagnose adults with PSF in AIS.

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.

A laser-assisted endoscopic approach to pyriform sinus fistula via fibrin glue cauterization

In the past, the general treatment method for pyriform sinus fistula was its removal by open surgery; however, in recent years, endoscopic surgery has become more common. We report two cases where laser surgery was performed using an endoscope and recurrence was prevented using fibrin glue. Both cases involved 3-year-old girls who underwent laser ablation of a pyriform sinus fistula under an endoscope, after which the site was closed with fibrin glue. No recurrence was observed in either case, and the postoperative course was uneventful. This approach is presented as a non-invasive and effective treatment for pyriform sinus fistula.