[size=20px]A seven-year old female is referred to you with a recurrent lower left anterolateral neck infection previously treated with drainage and a course of antibiotics. Other than the small drainage site which is now closed there are no other skin openings. A computerized tomography (CT) scan suggests an abscess in the left upper pole of the thyroid gland. An esophagram shows a fistula tract to the pyriform sinus.

 

The next best step in management of this patient with recurrent neck infections is

 

A endoscopic injection of fibrin glue into the fistula tract.

 

B left neck exploration, fistula resection and partial thyroidectomy.

 

C small lower neck incision with step ladder fistulectomy.

 

D prolonged course of intravenous antibiotics.

 

E chemical cauterization.[/size]

D

think again my dear

B

C

(Untitled)

 

C

C

C

C, branchial fistula

B

correct

 

Pyriform sinus fistula infections frequently present as swelling and recurrent infections - particularly on the left side of the neck. The fistula typically arises in the apex of the pyriform sinus and courses anteroinferiorly, either beside or through the thyroid gland, into the perithyroid space and is frequently associated with thyroiditis.

 

The embryologic origin of the pyriform sinus remains controversial. The third and fourth pharyngeal pouches form the pyriform sinus. Persistent ducts from either of these pharyngeal pouch sinuses may drain into the pyriform sinus. Barium esophagram is a reasonable initial imaging approach although it may be positive only 50% of the time. Cervical computerized tomography scan and magnetic resonance imaging are often definitive. Hypopharyngoscopy is confirmatory at the time of planned drainage of an abscess or wide neck exploration and fistula excision. Resection of the involved thyroid is appropriate if abscess or significant infection is found. The other treatment options listed will not result in definitive eradication although cautery has been attempted frequently as a first line therapy.

B

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Correct Answer

B left neck exploration, fistula resection and partial thyroidectomy.

 

Pyriform sinus fistula infections frequently present as swelling and recurrent infections - particularly on the left side of the neck. The fistula typically arises in the apex of the pyriform sinus and courses anteroinferiorly, either beside or through the thyroid gland, into the perithyroid space and is frequently associated with thyroiditis.

 

The embryologic origin of the pyriform sinus remains controversial. The third and fourth pharyngeal pouches form the pyriform sinus. Persistent ducts from either of these pharyngeal pouch sinuses may drain into the pyriform sinus. Barium esophagram is a reasonable initial imaging approach although it may be positive only 50% of the time. Cervical computerized tomography scan and magnetic resonance imaging are often definitive. Hypopharyngoscopy is confirmatory at the time of planned drainage of an abscess or wide neck exploration and fistula excision. Resection of the involved thyroid is appropriate if abscess or significant infection is found. The other treatment options listed will not result in definitive eradication although cautery has been attempted frequently as a first line therapy.