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Radiology Quiz Case 2: Diagnosis

Radiology Quiz Case 2: Diagnosis Diagnosis: Pyriform sinus fistula The patient underwent a fistulectomy. During the operation, the thyroid-cricoid joint was dislocated, a fistula opening was noted at the inner aspect of the thyroid cartilage, and a tract going into pyriform sinus was seen and ligated (Figure 3). Some sclerotic thyroid tissue of the left superior pole due to previous inflammation was also removed. The pathologic findings showed a sinus tract lined with squamous epithelium (Figure 4). View LargeDownload Figure 3. View LargeDownload Figure 4. Branchial cleft anomalies are the second most common congenital head and neck lesions found in children and young adults. There are 4 well-defined pairs of branchial arches by the end of the fourth week of gestation. The first branchial cleft develops into the external auditory canal. The second, third, and fourth branchial clefts merge and become involuted. Failure of the branchial apparatus to obliterate results in vestigial structures in the head and neck area. Among them, the second branchial cleft accounts for 95% of branchial anomalies, and fourth branchial cleft cysts are extremely rare. The fourth pouch will become the superior parathyroid gland and the ultimobranchial body. On the right side, it loops around the subclavian artery, ascends to the level of the hypoglossal nerve, descends along the anterior border of the sternocleidomastoid muscle, and enters the pharynx at the level of the pyriform apex. On the left, the tract loops over the anterior aortic arch and completes a course similar to that described on the right, whereas tracts of third arch anomalies enter the thyroid membrane above the internal branch of the superior laryngeal nerve and then the pharynx at the pyriform sinus.1 Therefore, the sinus tract in relation to the apex of the pyriform sinus is likely to be of fourth branchial pouch origin, as in the present case. Most of the cases of fourth branchial cleft anomalies present with acute thyroiditis or a recurrent lateral neck abscess.2 Acute suppurative thyroiditis is the less common form of the inflammatory disorders of the gland. The presence of abundant blood supply and a thick fibrous capsule make it inherently resistant to infection.3 Therefore, the finding of acute thyroiditis, particularly recurrent, should raise the suspicion of an underlying pyriform fossa sinus. In conclusion, a pyriform sinus fistula, especially the fourth one, is uncommon. A patient who presents with a recurrent anterior neck abscess should undergo thorough clinical and radiologic assessment to rule out the possibility of a congenital fistula or sinus. Various imaging modalities, such as ultrasonography, computed tomography, barium esophagography, and direct laryngoscopy, may be used alone or in combination to aid clinical diagnosis.4 The sensitivity of barium esophagography was only 50% in some series, most likely because of occlusion of the tract opening due to inflammation and tissue compression.5 Early diagnosis and excision of the tract are necessary to prevent recurrent neck infections in such cases. Return to Quiz Case. References 1. Waldhausen JH. Branchial cleft and arch anomalies in children. Semin Pediatr Surg. 2006;15(2):64-6916616308PubMedGoogle ScholarCrossref 2. Garrel R, Jouzdani E, Gardiner Q, et al. Fourth branchial pouch sinus: from diagnosis to treatment. Otolaryngol Head Neck Surg. 2006;134(1):157-16316399198PubMedGoogle ScholarCrossref 3. Tovi F, Gatot A, Bar-Ziv J, Yanay I. Recurrent suppurative thyroiditis due to fourth branchial pouch sinus. Int J Pediatr Otorhinolaryngol. 1985;9(1):89-964030234PubMedGoogle ScholarCrossref 4. Mukerji SS, Parmar H, Ibrahim M, Bradford C. An unusual cause of recurrent pediatric neck abscess: pyriform sinus fistula. Clin Imaging. 2007;31(5):349-35117825745PubMedGoogle ScholarCrossref 5. Neff L, Kirse D, Pranikoff T. An unusual presentation of a fourth pharyngeal arch (branchial cleft) sinus. J Pediatr Surg. 2009;44(3):626-62919302871PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 2: Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 138 (5) – May 1, 2012

Radiology Quiz Case 2: Diagnosis

Abstract

Diagnosis: Pyriform sinus fistula The patient underwent a fistulectomy. During the operation, the thyroid-cricoid joint was dislocated, a fistula opening was noted at the inner aspect of the thyroid cartilage, and a tract going into pyriform sinus was seen and ligated (Figure 3). Some sclerotic thyroid tissue of the left superior pole due to previous inflammation was also removed. The pathologic findings showed a sinus tract lined with squamous epithelium (Figure 4). View LargeDownload Figure...
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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archoto.2012.445b
Publisher site
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Abstract

Diagnosis: Pyriform sinus fistula The patient underwent a fistulectomy. During the operation, the thyroid-cricoid joint was dislocated, a fistula opening was noted at the inner aspect of the thyroid cartilage, and a tract going into pyriform sinus was seen and ligated (Figure 3). Some sclerotic thyroid tissue of the left superior pole due to previous inflammation was also removed. The pathologic findings showed a sinus tract lined with squamous epithelium (Figure 4). View LargeDownload Figure 3. View LargeDownload Figure 4. Branchial cleft anomalies are the second most common congenital head and neck lesions found in children and young adults. There are 4 well-defined pairs of branchial arches by the end of the fourth week of gestation. The first branchial cleft develops into the external auditory canal. The second, third, and fourth branchial clefts merge and become involuted. Failure of the branchial apparatus to obliterate results in vestigial structures in the head and neck area. Among them, the second branchial cleft accounts for 95% of branchial anomalies, and fourth branchial cleft cysts are extremely rare. The fourth pouch will become the superior parathyroid gland and the ultimobranchial body. On the right side, it loops around the subclavian artery, ascends to the level of the hypoglossal nerve, descends along the anterior border of the sternocleidomastoid muscle, and enters the pharynx at the level of the pyriform apex. On the left, the tract loops over the anterior aortic arch and completes a course similar to that described on the right, whereas tracts of third arch anomalies enter the thyroid membrane above the internal branch of the superior laryngeal nerve and then the pharynx at the pyriform sinus.1 Therefore, the sinus tract in relation to the apex of the pyriform sinus is likely to be of fourth branchial pouch origin, as in the present case. Most of the cases of fourth branchial cleft anomalies present with acute thyroiditis or a recurrent lateral neck abscess.2 Acute suppurative thyroiditis is the less common form of the inflammatory disorders of the gland. The presence of abundant blood supply and a thick fibrous capsule make it inherently resistant to infection.3 Therefore, the finding of acute thyroiditis, particularly recurrent, should raise the suspicion of an underlying pyriform fossa sinus. In conclusion, a pyriform sinus fistula, especially the fourth one, is uncommon. A patient who presents with a recurrent anterior neck abscess should undergo thorough clinical and radiologic assessment to rule out the possibility of a congenital fistula or sinus. Various imaging modalities, such as ultrasonography, computed tomography, barium esophagography, and direct laryngoscopy, may be used alone or in combination to aid clinical diagnosis.4 The sensitivity of barium esophagography was only 50% in some series, most likely because of occlusion of the tract opening due to inflammation and tissue compression.5 Early diagnosis and excision of the tract are necessary to prevent recurrent neck infections in such cases. Return to Quiz Case. References 1. Waldhausen JH. Branchial cleft and arch anomalies in children. Semin Pediatr Surg. 2006;15(2):64-6916616308PubMedGoogle ScholarCrossref 2. Garrel R, Jouzdani E, Gardiner Q, et al. Fourth branchial pouch sinus: from diagnosis to treatment. Otolaryngol Head Neck Surg. 2006;134(1):157-16316399198PubMedGoogle ScholarCrossref 3. Tovi F, Gatot A, Bar-Ziv J, Yanay I. Recurrent suppurative thyroiditis due to fourth branchial pouch sinus. Int J Pediatr Otorhinolaryngol. 1985;9(1):89-964030234PubMedGoogle ScholarCrossref 4. Mukerji SS, Parmar H, Ibrahim M, Bradford C. An unusual cause of recurrent pediatric neck abscess: pyriform sinus fistula. Clin Imaging. 2007;31(5):349-35117825745PubMedGoogle ScholarCrossref 5. Neff L, Kirse D, Pranikoff T. An unusual presentation of a fourth pharyngeal arch (branchial cleft) sinus. J Pediatr Surg. 2009;44(3):626-62919302871PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: May 1, 2012

Keywords: radiology specialty

References