Endoscopic Cauterization of Congenital Pyriform Fossa Sinus Tracts

Abstract

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...

Surgery versus endoscopic cauterization in patients with third or fourth branchial pouch sinuses: A systematic review

“…Treatment with silver nitrate showed a success rate of 100% after the first treatment . Electrocauterization showed a success rate ranging from 66.7% to 100%, and a cumulative success rate of 77.8% to 100% . The success rate after primary surgical treatment ranged from 50% to 100%.…”

“…This might be due to selection bias, because several articles included their patients on the basis of the diagnosis pyriform sinus fistula and treatment with cauterization. 10,13,15 The cumulative success rate after the second treatment increases for both treatment methods. However, this is based on a very low number of patients.…”

“…The relatively low surgical success rates in this study may be explained by the low number of patients receiving surgical treatment in the analyzed articles. This might be due to selection bias, because several articles included their patients on the basis of the diagnosis pyriform sinus fistula and treatment with cauterization …”

“…12 Electrocauterization showed a success rate ranging from 66.7% to 100%, and a cumulative success rate of 77.8% to 100%. [13][14][15][16] The success rate after pri-mary surgical treatment ranged from 50% to 100%. In two studies, a second surgical treatment was performed after failure of the previous treatment with a cumulative success rate of 100% in both articles.…”

Endoscopic chemocauterization for pyriform sinus fistula in children

“…TCA and silver nitrate are useful for chemocauterization . In contrast, electric cautery, laser coagulation, and the endoscopic injection of fibrin glue have been suggested to be useful surgical modalities for endoscopic cauterization . Previous cases of endoscopic cauterization or chemocauterization are listed in Table .…”