Branchial Sinus of the Piriform Fossa: Reappraisal of Third and Fourth Branchial Anomalies

James, Adrian L.; Stewart, Craig; Warrick, Paul; Tzifa, Constance; Forte, Vito

doi:10.1097/mlg.0b013e31813437fc

Cited by 94 publications

(151 citation statements)

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“…Complete congenital third and fourth branchial fistulae are rare, with most presenting originally as sinus tracts before becoming secondary iatrogenic fistulae [5]. These lesions are most commonly observed in children and young adults.…”

Section: Discussionmentioning

confidence: 99%

“…These tracts then loop over the hypoglossal nerve, inferior to the glossopharyngeal nerve and posterior to the internal carotid artery [5]. Alternatively, classically described fourth pouch fistulae follow a more indirect route, coursing from the pyriform apex or proximal esophagus [1] below the superior laryngeal nerve, above the carotid bifurcation.…”

Section: Discussionmentioning

confidence: 99%

“…These descriptions are infrequently seen in case reports, and no one has ever reported a lesion following the classical pathway of a fourth branchial fistula. This led James et al [5]. to propose an alternative theory for the embryologic origin of third and fourth branchial fistulae, suggesting that they may actually be derivations of the embryologic thymopharyngeal duct, which forms as the thymus descends during fetal development.…”

Section: Discussionmentioning

confidence: 99%

“…A recurrent lateral neck abscess (42%) and suppurative thyroiditis (45%) are the most common presentations [6], although upper respiratory infections, recurrent retropharyngeal abscess and cellulitis, odynophagia, stridor, and mediastinitis as presenting features have also been reported [1,[7][8][9][10]. Approximately 93-97% of fourth pouch anomalies are left sided [2,3,5,6,11] which may be related to the absence or involution of the ultimobranchial body on the right side, in addition to asymmetric vascular agenesis during fourth arch development [6,9,10]. Females are slightly more prone, and age at diagnosis ranges from birth to adulthood [1,11].…”

Section: Discussionmentioning

confidence: 99%

“…Alternatively, classically described fourth pouch fistulae follow a more indirect route, coursing from the pyriform apex or proximal esophagus [1] below the superior laryngeal nerve, above the carotid bifurcation. They then descend in the tracheoesophageal groove parallel to the recurrent laryngeal nerve into the mediastinum, loop under the aortic arch on the left side and subclavian artery on the right side, and ascend posterior to the common carotid artery until exiting at the skin surface [1,4,5]. As with branchial anomalies of the second pharyngeal pouch, the external opening of both third and fourth pouch remnants arises at the same location in the skin overlying the anterior border of the sternomastoid muscle, which is the location of the embryologic cervical sinus.…”

Section: Discussionmentioning

confidence: 99%

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Right‐Sided Pyriform Sinus Fistula: A Case Report and Review of the Literature

2011

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Objectives. Pyriform sinus fistulae arise from disturbances in the development of the fetal third and fourth branchial pouches and are predominantly found on the left side. We report the rare case of a right-sided pyriform sinus fistula presenting as a lateral neck abscess. Study Design. Case report. Methods. A 24-year-old woman presented with a two-week history of right-sided neck abscess. A fluoroscopic sinogram revealed a fistulous tract extending from the abscess to the apex of the right pyriform sinus. It was determined that the fistula was likely a third or fourth branchial remnant, a rare right-sided finding. Chemocauterization of the fistulous tract with 40% trichloroacetic acid was used to successfully treat the patient. Results. Approximately 93-97% of branchial pouch anomalies are left sided. Treatment options include surgical excision and cauterization. Conclusions. Branchial cleft cyst and pyriform sinus fistula must be considered in the diagnosis of cervical abscess in either side of the neck.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Right‐Sided Pyriform Sinus Fistula: A Case Report and Review of the Literature

2011

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Neonatal vs Delayed-Onset Fourth Branchial Pouch Anomalies

Leboulanger¹,

Ruellan²,

Nevoux³

et al. 2010

Arch Otolaryngol Head Neck Surg

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Third and fourth branchial pouch anomalies can present in 2 distinct forms: a neonatal form and a childhood form. The endoscopic technique should be the favored approach for both forms: whenever possible, in view of its simplicity, rapidity, and the lack of serious postoperative complications. Recurrences can be treated by repeated cauterization using the same technique, with good long-term outcomes. An age-based management algorithm has been developed.

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Endoscopic Cauterization of Congenital Pyriform Fossa Sinus Tracts

Sun

Berg

McClay

2014

JAMA Otolaryngol Head Neck Surg

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ranchial arch abnormalities opening into the pyriform fossa are an important congenital cause of recurrent neck abscesses in children. The classification and naming of these anomalies is controversial because of the complex embryological development of the region involved. In 1972, Sandborn and Shafer 1 first described a neck mass caused by a sinus tract traveling from the left pyriform fossa to the superior pole of the left lobe of the thyroid. The lesion was classified as a fourth branchial pouch derivative, which became the widely used term for such structures. 1 Theoretically, a complete fourth branchial pouch fistula tract would begin at the pyriform fossa, exit the larynx near the cricothyroid joint, and pass between the superior and recurrent laryngeal nerves behind the body of the thyroid gland. The fistula would then make a convoluted journey toward the mediastinum before looping back and exiting anterior to the sternocleidomastoid muscle on the lower neck. 2 To our knowledge, a complete fistula tract naturally opening onto the neck has never been reported. To complicate matters, fistula tracts arising from the third branchial pouch theoretically would also start at the pyriform fossa. However, the tract would pass cranial instead of caudal to the superior laryngeal nerve. 2Because of the difficulty of distinguishing third and fourth pouch tracts, some authors have chosen to consider them a single entity. More recently, the thymopharyngeal duct, a third pouch derivative independent of the third and fourth fistula tracts, has been alternatively proposed as the cause of these lesions. 3 The thymopharyngeal duct is formed when the thymus descends from the third pouch through the fourth arch to fuse with its contralateral counterpart during fetal development. Failure of thymopharyngeal duct involution should lead to a sinus tract containing thymus-derived tissue starting at the pyriform fossa and descending in close association with the thyroid. OBJECTIVE To evaluate the long-term effectiveness of endoscopic cauterization as definitive treatment for pyriform fossa sinus tracts. DESIGN, SETTING, AND PATIENTSRetrospective review of the medical records of 23 children (aged 7 months to 14 years) with pyriform fossa sinus tracts treated with endoscopic cauterization between 1995 and 2013 at a tertiary care children's hospital.INTERVENTION Endoscopic electrocauterization of pyriform fossa sinus tract opening. MAIN OUTCOMES AND MEASURESRecurrence of symptoms after endoscopic treatment.RESULTS Twenty-one of 23 patients experienced no recurrence after their first endoscopic electrocauterization of the sinus tract. The 2 patients with recurrence experienced symptoms within 1 month of cauterization and were treated with either open excision or recauterization. Endoscopic cauterization was able to definitively treat 9 patients whose treatments with incision and drainage or open excision had failed. Mean (range) follow-up for the 15 patients with follow-up was 7.4 (0.10-14.2) years. No procedure-related morbidity was re...

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Branchial Sinus of the Piriform Fossa: Reappraisal of Third and Fourth Branchial Anomalies

Abstract: The clinical presentation of branchial sinuses arising from the piriform fossa is more in keeping with derivation from the thymopharyngeal duct (of the third pouch) than the hypothetical course of third and fourth branchial fistulae.

Cited by 94 publications

References 11 publications

Right‐Sided Pyriform Sinus Fistula: A Case Report and Review of the Literature

Right‐Sided Pyriform Sinus Fistula: A Case Report and Review of the Literature

Neonatal vs Delayed-Onset Fourth Branchial Pouch Anomalies

Endoscopic Cauterization of Congenital Pyriform Fossa Sinus Tracts

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