Pyriform Sinus Fistula in the Fetus and Neonate: A Systematic Review of Published Cases

Prenatal tomography ultrasound imaging diagnosis of fetal pyriform sinus cysts (third or fourth branchial cleft cyst): A case report

This case report describes a fetal piriform sinus cyst identified via tomographic ultrasound imaging and discusses its prenatal sonographic characteristics. We employed the tomographic ultrasound imaging function of the GE Voluson Ultrasound E10 to visualize multilevel transverse sections of the cyst. Specifically, we propose for the first time that the cross-sectional shape of a piriform sinus cyst composed of aryepiglottic folds approximates a triangle. This special shape facilitates the precise localization of the piriform sinus, providing valuable insights for timely diagnosis and appropriate postnatal management.

A novel and efficient surgical procedure for pyriform sinus fistulas in children

Objective

This study aims to evaluate the efficacy of a novel surgical procedure for pyriform sinus fistulas in children via the external cervical approach through the hypopharynx.

Methods

A retrospective analysis was conducted on 71 pediatric patients with pyriform sinus fistula (PSF) who underwent treatment at the Department of Otolaryngology Head and Neck Surgery, Shanghai Children's Hospital, from 2012 July to 2022 July. Surgical treatment of PSF was performed via the external cervical approach through the hypopharynx, with dye instilled through the internal opening to serve as a guide for tract identification.

Results

All the internal orifices were found in the pyriform sinus by direct laryngoscopy in all 71 patients under general anesthesia. Two patients had a postoperative temporary hoarseness that resolved after 3 months. The other patients had no complications such as parapharyngeal abscess and incision infection. All patients were followed up for 23 months-70 months, and no recurrence was found.

Conclusion

The novel surgical procedure of PSF performed via the hypopharynx has advantages such as a short operation path, quick recovery, fewer complications, and a low recurrence rate. This method is a better choice for managing recurrence cases after repeated cauterization endoscopic surgeries, as well as for patients with visible cervical surgical scars or masses.

Hoarseness as the first symptom in a patient with acute suppurative thyroiditis secondary to a pyriform sinus fistula: a case report

BACKGROUND

Pyriform sinus fistulas (PSFs) are rare congenital anomalies of the third or fourth brachial pouch. Dyspnea is reportedly secondary to compression by a neck mass. However, hoarseness, as the first symptom of PSF, has not yet been reported.

CASE PRESENTATION

This report describes an 11-year-old girl presenting with hoarseness as the first symptom of PSF. Hoarseness occurred 2 days prior to admission. On admission, she had fever, hoarseness, and an elastic soft mass on her left anterior neck. Contrast-enhanced computed tomography of the cervical region demonstrated an abscess partially infiltrating the thyroid gland and an air pocket near the pyriform sinus. Pharyngoscopy revealed swelling of the left arytenoid region, with purulent retention. The left vocal cord was swollen but not paralyzed. Additionally, the laboratory data indicated thyrotoxicosis. Suspecting a PSF infection, parenteral treatment with cefotaxime and dexamethasone was initiated. On the following day, the hoarseness disappeared, and the fever resolved. Four weeks after onset, the thyroid hormone levels returned to the normal range, and a barium esophagogram revealed residual contrast in the left pyriform sinus, leading to a diagnosis of PSF.

CONCLUSION

PSF presenting with hoarseness as the first symptom in patients should be considered.

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.

Multimodal imaging of congenital pyriform fossa fistula in children

Objective

Our aim was to explore the clinical value of multimodal imaging examinations in the diagnosis of congenital pyriform fossa fistula in children, so as to provide clues for the early diagnosis and treatment of congenital pyriform fossa fistula.

Methods

The clinical and imaging data of 55 children with pyriform fossa fistula diagnosed surgically in our hospital from 2015 to 2018 were analyzed retrospectively. All 55 patients underwent a CT scan. Of those patients, contrast enhancement CT was performed in 47 cases, MRI was performed in 2 cases, and barium esophagography was performed in 41 cases.

Results

Among the 55 cases, there were 24 male patients and 31 female patients. The age ranged from 11 months to 13 years old, and the median age was 3.8 years old. The lesions of 49 cases (89.1%) were located on the left side, and the imaging of CT showed soft tissue mass in the anterior cervical region blurred boundary. There was ipsilateral thyroid involvement in 50 cases (90.9%), trachea and/or carotid sheath extension in 43 cases (78.2%), abscess formation in 39 cases (70.9%), and pneumatosis in 25 cases (45.5%). The CT examination of 22 children after treatment showed a linear or tubular low-density shadow in the thyroid gland, gas accumulation in the anterior cervical region or thyroid, and residual contrast medium, partly. A total of 24 cases underwent barium esophagography during the acute phase, and 15 cases (62.5%) showed sinus formation from the pyriform fossa downward or punctate high-density shadow in the anterior cervical region. The 2 cases where MRI was performed showed abscess formation in one side of the neck and thyroid involvement.

Conclusion

Pyriform fossa fistula is most common in the left anterior cervical region, and it is closely related to the thyroid gland. The plain and enhanced-contrast CT scan can be used as the first choice during the infection stage. It helps to understand the location, extent, and structure of the surrounding tissue. The preliminary diagnosis of pyriform sinus fistula was according to the imaging features. It provided an important basis for clinical diagnosis and reduced the pain caused by repeated infection or surgical incision and drainage.

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.

[Clinical analysis of treatment and postoperative efficacy in neonatal congenital pyriform sinus fistula]

Objective:To discuss the diagnosis and treatment of congenital pyriform sinus fistula（CPSF） in newborn. Methods:Clinical data of 5 patients with CPSF innewborn were reviewed and the clinical symptoms, auxiliary examinations, surgical methods were analyzed after the operation, patients were followed up closely at different stages. Results:All the 5 neonates successfully completed the surgery without pharyngeal fistula, dysphagia, perifistula and distal fistula infection. Follow-up survey ranged from 3 months to 2 years and no one recurred. Conclusion:Neonatal CPSF is a rare disease with a short course of disease and rapid progression. In severe cases, it may threaten life and should be treated in time.

Pyriform Sinus Fistula in Children: Preferred Imaging Modality and Risk Factors for Diagnostic Delay

Background: Diagnostic delay of pyriform sinus fistula (PSF) continues to challenge clinicians, and the preferred imaging modality is yet to be verified. The purpose of this study was to investigate the preferred imaging modality for PSF and the possible risk factors for a longer diagnostic delay. Methods: Medical records of patients with a surgically confirmed PSF from 2014 to 2018 were retrospectively evaluated. A comparison of the first esophagography timing with a true-positive (TP) result and that with a false-negative (FN) result was made. Data of computed tomography (CT) performed immediately after esophagography were also analyzed. In addition, the factors related to diagnostic delay were analyzed using multivariate regression models. Results: A total of 147 patients ranging in age from 0 to 16 years (median: 5.2 years) were included. The mean time since the symptom onset of the first esophagography with TP result was significantly longer than that of the examination with FN result (95.18 ± 79.12 vs. 52.59 ± 42.40 days, P = 0.032). When the time since the symptom onset was less than 12 weeks, the false-negative rate (FNR) of the first esophagography was declining dramatically with a longer time interval. Among 18 cases with an FN result of the first esophagography, the fistulous tract was finally identified in seven cases using an immediate CT. The mean of diagnostic delay was 12.28 months. Besides, rural residency was an independent risk factor for a longer diagnostic delay. Conclusion: Joint examination of esophagography and an immediate CT is the preferred imaging modality for the diagnosis of PSF in children. It is inadvisable to perform the first esophagography when the time since the symptom onset is less than 12 weeks. Besides, the rural residency is an independent risk factor for a longer diagnostic delay.