Branchial fistula arising from pyriform sinus: positive esophagogram despite active infection

Abstract

We read with interest the article Branchial fistula arising from pyriform sinus: CT diagnosis of a case and discussion of radiological features by Chauhan et al. [1]. The authors have reviewed the literature well and presented the classic computed tomography findings of a rarely encountered condition. In their patient, the barium swallow study did not visualize the fistulous tract. We would like to share a similar case and highlight the barium study findings. A 21-year-old male presented with history of repeated neck infections since the age of 3 years. He had been treated multiple times with antibiotics and repeated incisions and drainage. On examination, he had extensive scar tissue in the left anterior neck; along with multiple cutaneous openings (Fig. 1). There was a soft fluctuant swelling at the local site. The patient underwent needle aspiration, which drained approximately 20 ml of pus. Subsequently, on the same day, a barium study was performed. The barium examination revealed a blind-ending tract extending from the tip of left pyriform sinus coursing anteroinferiorly, with increased pretracheal soft tissue (Figs. 2, 3). The contrast enhanced MRI performed 3 days later revealed a rim enhancing air-filled cavity in the soft tissue in the anterior neck (Fig. 4), which might have formed following the aspiration of pus. There was no intrathoracic extension; however, we need to be wary of it because of multiple pathways of spread of infections between cervical and thoracic regions [2]. We concluded the diagnosis of pyriform sinus fistula because of the clinical features and the characteristic radiological findings. It has been suggested that barium studies should be performed after clearing the acute infection to decrease the rate of false–negative results [3,4]. In an article published by J Bar Ziv et al. [3], they reported two patients with negative initial esophagograms during the acute phase. Subsequent esophagogram following treatment was successful in filling up the tract in both the patients. Gan et al. [5] also reported a case in which the barium examination was negative despite it being performed 2 weeks following the