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

doi:10.1016/j.ijporl.2007.10.007

International Journal of Pediatric Otorhinolaryngology

Volume 72, Issue 2, February 2008, Pages 185-188

https://doi.org/10.1016/j.ijporl.2007.10.007 Get rights and content

Summary

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.

Introduction

Piriform sinus tracts are unusual anomalies thought to be of branchial pouch origin. Most literature suggests that they are remnants of the third and fourth branchial pouches [1], [2], [3]. These tracts are generally left sided and tend to present with suppurative thyroiditis. The pouch of origin is determined by the relationship of the tract to the superior laryngeal nerve. If it passes superior to the nerve a third pouch is suspected, whereas if it lies between the superior and recurrent laryngeal nerves a fourth pouch is implied [3]. Although the presentation and methods of investigating piriform sinus tracts have been well described and agreed upon, their treatment remains controversial. The recent recognition of the fact that some of them could be asymptomatic makes it even harder to make strong recommendations regarding surgical therapy [1]. Complete surgical excision, endoscopic cautery and observation have all been recommended depending on the clinical presentation [1], [2], [4].

Endoscopic electro-cautery of piriform sinus tracts was first reported in 1998 with a follow up report from the same institution in 2004 [2]. The patients were contacted by telephone and the absence of a neck mass after cauterization of the tract was considered a successful outcome. Whether or not the tract had indeed been obliterated could not be confirmed other than by the caregivers report of non-recurrence of symptoms. In our previous reports we have highlighted the fact that some of these anomalies can lie dormant for many years before presentation and hence absence of symptoms cannot definitely rule out patency of the tract [1], [4]. We present our initial experience with endoscopic chemical cautery of two piriform sinus tracts along with direct and radiologic confirmation of closure of one of them. This appears to be a safe and effective technique with excellent results. To the best our knowledge the technique along with post-operative confirmation of complete closure of the tract has not been previously described in literature.

Section snippets

Surgical technique

A direct endoscopic examination of the hypopharynx with a zero degree optical telescope is performed to identify the internal opening of the piriform sinus tract. The tip of a silver nitrate stick is carefully cut off and grasped with an optical forceps. Using video guidance the tip of the stick is inserted into the internal opening of the tract and held there for about 3–4 s. Blanching indicates successful cautery.

Case 1

A 2-year-old male presented to the emergency room of the Children's hospital with a history of fever and a painful left sided neck swelling. A CT scan of the neck revealed an intrathyroidal abscess. He underwent an incision and drainage of the abscess after failure of antibiotic therapy. A barium swallow performed subsequently did not reveal any sinus tract. However, due to a high index of suspicion a direct endoscopic examination of the hypopharynx with optical telescopes was performed which

Discussion

Suppurative thyroiditis and recurrent lateral neck infections are uncommon conditions in the pediatric age group and should arouse suspicion of a piriform sinus tract [4]. Literature suggests that some of them can remain asymptomatic for many years, often leading to misdiagnosis at initial presentation. Previous studies from our institution have emphasized the need for direct visualization of the internal opening of the tract to confirm the diagnosis [1], [4]. Barium swallows are part of the

Conclusions

The ease of the endoscopic chemical cautery of piriform sinus tracts combined with the low associated morbidity make it relatively easy to recommend. Based on our limited preliminary experience, this appears to be a very safe and effective way of dealing with these anomalous tracts of the piriform fossa.

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Li et al. previously identified the fistulous orifice, then injected methylene blue to facilitate the identification of the fistula before its removal [7]. Other therapeutic modalities have been described, particularly by Watson, who found conclusive results in 5 patients treated by coagulation (thermal by electrocoagulation, or chemical with silver nitrate, or with CO2 laser) of the fistulous orifice by endoscopic route [5,11,13–20]. Kim, Verret and Leboulanger have the largest series of patients treated with endoscopic cauterization, with 11, 10 and 19 children respectfully [5,17,20].
Branchial cleft anomalies represent approximately 17% of all pediatric neck masses (Tong et al., 2016) [1] in which fourth branchial arch anomalies represent less than 1%.
We report the case of a 3 years old male, presenting with a left neck inflammatory mass of 4cm associated with fever and anorexia. Ultrasound reveals an abscess of the left thyroid lobe. Contrast enhanced CT scan revealed a left thyroid hypodense area, with disappearance of the cleavage area with the SCM muscle. In late time, after Valsalva's maneuver, the appearance of a left intra-thyroid air bubble was noticed. This surgery consisted on a prior laryngoscopy followed by a cervicotomy. The orifice of the sinus was found in the left piriform fossa. The cervicotomy revealed a sinus of 5cm, located between the common carotid artery and the internal jugular vein, descending to the thoracic orifice. It's resection was done and 3.0 resorbable sutures were done at each sinus extremity. The interposition of a fragment of sternocleidomastoid muscle was done to ensure the total closure of the sinus. No suppurative event or neck infections were noticed 9 months after surgery.
Open surgical treatment gives good results and represent a good alternative in a poorly equipped environment.
Endoscopic electrocauterization for congenital pyriform sinus fistula treatment in paediatrics. Case series
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Las fístulas del seno piriforme son anomalías infrecuentes de los arcos branquiales. La mayoría se localizan en el lado izquierdo y se extienden desde el ápex del seno piriforme de la hipofaringe hasta la glándula tiroides o el espacio peritiroideo.
El diagnóstico se sospecha ante la presencia de tiroiditis aguda supurada o abscesos cervicales laterales recurrentes, y se confirma mediante la visualización endoscópica del orificio de la fístula. El tratamiento clásico consiste en la exéresis del trayecto fistuloso por vía cervical, con o sin lobectomía tiroidea. Sin embargo, se han desarrollado alternativas menos invasivas y con menos riesgos de complicaciones que obliteran el trayecto de la fístula, como la electrocauterización endoscópica.
Describimos nuestra experiencia con 7 pacientes que presentaban esta afección, tratados con cauterización endoscópica utilizando electrobisturí de radiofrecuencia, y evaluamos la eficacia y la seguridad del tratamiento realizado.
Pyriform sinus fistulas are rare anomalies of the branchial arches. Most of them are located on the left side. They extend from the apex of the pyriform sinus of the hypopharynx to the thyroid gland or adjacent tissues.
The diagnosis is suspected in the presence of acute suppurative thyroiditis or recurrent cervical abscesses, and is confirmed by endoscopic visualization of the fistula hole. The traditional treatment consists of excision of the fistulous tract, with or without thyroid lobectomy, by cervical approach. However, less invasive alternatives that obliterate the path of the fistula have been developed, such as endoscopic electrocautery.
We describe our experience with 7 patients with this condition, who were treated with endoscopic cauterization using radiofrequency electrocautery, and we evaluate the effectiveness and safety of the treatment performed.
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Then the verification of the tract should be confirmed by histopathology. Recently, endoscopic obliteration of the sinus alone using laser, chemo (trichloroacetic acid, silver nitrate, or fibrin) or electrocautery represents a minimally invasive technique [17–22]. Although vocal fold immobility and recurrence have been noted in patients after chemocauterizaton [23,24], this new approach is a viable alternative to open excision.
Pyriform sinus fistula (PSF) is often overlooked, and presents diagnostic and management challenge. The aim of this study was to highlight the value of intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide in searching for the fistula.
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PSF should be considered in any children with repeated neck or thyroid infection/mass. The combination of barium esophagography, CT scan and ultrasound is useful to establish the diagnosis. Intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide can facilitate identification of the tract during dissection.
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Endoscopic techniques to seal the pyriform fossa sinus opening has shown promising outcomes avoiding open neck surgery and the risk associated with it [5,6]. Several modalities of endoscopic treatment in congenital head and neck lesions have been described including electrocautery [5,6], chemocautery using trichloroacetic acid [7–9] or silver nitrate sticks [10], low power diode laser [11] and fibrin glue [12]. Chemocautery provides good distal penetration but there is a risk of leakage of the acid into the oesophagus potentially resulting in oesophageal stricture.
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Endoscopic chemical cautery of piriform sinus tracts: A safe new technique

Summary

Introduction

Section snippets

Surgical technique

Case 1

Discussion

Conclusions

Otolaryngol. Clin. N. Am.

J. Pediatr. Surg.

Am. J. Otolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Ann. Otolaryngol. Chir. Cervicofac.

Piriform sinus tracts in children

Arch. Otolaryngol. Head Neck Surg.