[size=20px]A seven-year old female presents with a recurrent left lower anterolateral neck infection, previously treated with drainage and antibiotics. On exam, there is a small scar from the drainage but no other skin openings. A computerized tomography (CT) scan suggests an abscess in the left thyroid gland. An esophagram shows a fistula tract to the pyriform sinus. The best next step in management of this patient with recurrent neck infections is

 

A a 2-week course of clarithromycin.

 

B prolonged course of intravenous antibiotics.

 

C endoscopic injection of fibrin glue into the fistula tract.

 

D left neck exploration, fistula resection and partial thyroidectomy.

 

E small lower neck incision with step ladder fistulectomy.[/size]

D: Justification: To prevent recurrence of neck infection and to allow complete excision of the fistula

D

correct answer

D 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 (>85% of cases). 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. Suppurative thyroiditis is very rare in children and a pyriform sinus fistula should be considered.

 

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 positive only 50% of the time. Cervical computerized tomography scan with thin cuts and magnetic resonance imaging are often definitive. Direct laryngoscopy of the pyriform sinus is confirmatory at the time of 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.

 

A recent large series (n=191 children) from Shanghai, China reported excellent results with either radiofrequency ablation of the inner orifice of the tract (n=48) or endoscopic assisted surgical excision (n=143), with only 2 recurrences. 94% were on the left side.

 

Clarithromycin can be used in treatment of atypical mycobacterium.