Endoscopic Cauterization Research Articles

Endoscopic diagnostic and therapeutic management of branchial cleft fistula type III & IV: a single tertiary centre experience.

To date, recurrent neck abscesses associated with branchial anomalies are treated using a variety of techniques. Management strategies may include various imaging modalities and surgical methods. Endoscopic assessment and electrocauterization are the preferred diagnostic modalities and treatment strategies that have recently gained widespread acceptance and popularity. This was a retrospective review on patients' medical record from 2016 to 2023. Seven patients underwent endoscopic cauterization at our centre, a tertiary academic institution. Five of the patients (71.5%) achieved complete remission. Two patients experienced recurrence within 6 months that necessitated re-cauterization once but subsequently recovered completely. Currently, endoscopic management is the preferred approach compared to the typical open neck excision surgery as it is significantly less invasive, resulting in lesser morbidity and similar success rates. At presentation, all of them had ultrasound neck that suggestive of neck abscess. Computed tomography or magnetic resonance imaging unable to provide adequate information about the side of internal opening of fistula where only 3 out of 7 patients demonstrated tract up to the ipsilateral region of pyriform fossa. Management outcomes of this limited case series showed the potential benefits of endoscopic cauterization as the minimally invasive therapeutic method for recurrent neck abscesses caused by third and fourth branchial cleft fistulas but also to suggest the possibility as the first diagnostic tool prior to imaging studies.

Epistaxis and its management: A prospective study in a Teritiary Care Centre

Background: Epistaxis ( nose bleed) is one of the most common ear, nose and throat (ENT) emergencies that present to the tertiary care center. Management of Epistaxis is challenging and most are managed conservatively and some by surgical intervention. There is always a need to find the prevalence of Epistaxis and to identify the etiological factors in management of Epistaxis, by different methods such as medical treatment, anterior and posterior nasal packing, and surgical intervention that includes endoscopic cauterization, endoscopic arterial ligation, SMR and Nasal bone reduction. In our study we will determine the various etiologies of epistaxis and its management options. Methodology: A prospective study was done in the Department of ENT, for duration of 18 months, total of 70 patients of both genders in age group of 18 - 60 years with clinical features of nasal bleed were enrolled in the study, and were subjected to clinical examination and history regarding onset and predisposing factors. Patients who are willing to undergo investigations to identify the cause and treatment are enrolled for the study after obtaining the written informed consent. Results: A total of 70 patients were examined in this study. Males were affected more than females. The patients distribution across different age groups shows maximum at age of 46-60 years followed by 36-45 years. The most common cause was found to be trauma followed by hypertension, rhinosinusitis, deviated nasal septum and idiopathic. In most cases, anterior nasal bleeding was observed.Majority of the cases managed conservatively 71.5% while 28.5% patients required surgical intervention. Conclusion: The study on epistaxis and its management provides valuable insights into effective strategies for addressing this common medical condition. This study emphasizes the importance of a medical and surgical approaches based on the severity and underlying causes of epistaxis. Anterior epistaxis is more common than posterior bleeds. Majority of cases of epistaxis are manageable by conservative measures and only few require surgical intervention. Overall, this study contributes to the ongoing efforts to enhance our understanding of epistaxis and refine therapeutic approaches for better patient outcomes.

Management of a recurrent third branchial arch fistula using combined endoscopic and open approach

Branchial cleft anomalies are rare, congenital lesions, that occur due to the maldevelopment of the branchial apparatus, during fetal maturation. Anomalies of the third and fourth arch contribute to a very small proportion of these. Most cases are detected in childhood, either as a cyst, sinus or fistula in the neck. Some of the common treatment approaches to third branchial cleft fistulas include endoscopic cauterization, open cervical fistulectomy and, in cases of recurrence, selective neck dissection. Here, we present a case of recurrent branchial fistula of the third arch, wherein we used a combined cervical and intraoral approach, conserving the thyroid cartilage, to achieve a complete excision of the fistula tract.

Isolated tracheo-esophageal fistula in children: Analysis of a large multicentric series and proposal of a comprehensive treatment algorithm

BackgroundIsolated tracheo-esophageal fistulas (TEF) are rare and challenging, possibly leading to severe complications. We evaluated the outcomes in a large series of patients treated in 9 referral Centers for airway surgery, and suggested an ideal management algorithm. MethodsA multicentric retrospective study on TEF was performed. Results186 cases were collected. Among 101 patients with recurrent TEF after EA repair, 1 was treated successfully with thoracoscopy, 23 with open surgery with TEF division and tissue interposition, with 15 complete resolution (65 %), 2 TEF recurrence (9 %) and 6 other complications (26 %), and 77 received TCA endoscopic cauterization, with complete resolution in 61 (79 %). Among 54 patients with congenital H-type fistula, 1 received conservative treatment with resolution; 4 underwent thoracoscopy (50 % resolution); 6 had endoscopic cauterization (33 % resolution); 44 received open surgery, with 43 (98 %) successes. In the last group, the majority of TEF was ligated and divided with tissue interposition. Among 26 post-traumatic fistulas (mechanical trauma, battery or caustic ingestion), 6 patients received endoscopic procedure and 5 of them (83 %) reached complete resolution. The other 19 received open surgery (trans-tracheal direct FTE closure with tracheal resection), and 12 had complete resolution (63 %). Two patients eventually died and complication rate was 23 %. Other 5 cases (3 Bronchial-Esophageal Fistulas and 2 TEF after cleft repair) were treated endoscopically or with open approach. ConclusionEndoscopic cauterization can be the preferred treatment for recurrent TEF after EA, while for the congenital H-type and post-traumatic TEF the open approach remains our first choice.

Endoscopic Suture With Chemocauterization: An Effective Treatment of Congenital Pyriform Sinus Fistula.

Endoscopic cauterization is an effective method for treating pyriform sinus fistula (PSF). However, these approaches sometimes result in a higher failure rate. We present an effective technique utilizing suture combined with chemocauterization as first-line treatment in patients with PSF and evaluate the safety and efficacy of its use in 126 patients. Retrospective study. Tertiary referral center. Retrospective case review of patients treated between March 2012 and June 2021 at our institution with descriptive statistical analysis. A total of 126 patients with PSF were included in this study with a mean age of 14.7 years. There was no sex predilection. The majority of patients presented with a left-sided neck lesion (89.7%). Ten patients presented following prior attempts at the surgery of the PSF at another institution; 8 via open surgery and 2 following endoscopic CO2 laser cauterization; other patients only had a history of repeat incision and drainageor antibiotic treatment. The success rate of obliteration of the internal opening was 96.83% after a single treatment without complications. Following reoperation, a successful outcome was achieved in the remaining 4 patients. Length of stay ranged from 10 to 14 days. No recurrences occurred within 12 to 120 months followed-up. Endoscopic suture combined with chemocauterization is a safe and effective treatment of PSF. Surgery can be performed during the acute cervical inflammatory period without increased risk of complication or recurrence, however, patients found to have acute changes affecting the pyriform sinus should be treated with a staged surgery strategy.

Endoscopic Sphenopalatine Artery Cauterization in the Management of Recurrent Posterior Epistaxis.

Background and Objectives: Endoscopic sphenopalatine artery cauterization (ESPAC) has become a reliable and effective surgical procedure for managing posterior epistaxis. The objectives of our study were to evaluate the effectiveness of ESPAC in the management of posterior epistaxis and the possible factors that lead to the failure of the procedure. Materials and Methods: We performed a retrospective analysis of all patients who underwent ESPAC between 2018 and 2022. We retrospectively reviewed the demographic data, patients' co-morbidities, medical treatment conditions, whether other surgical procedures were performed in addition to the ESPAC, and the success rate of ESPAC. Results: 28 patients were included in our study. After ESPAC, epistaxis was successfully managed in 25 patients (89.28%). Of all patients undergoing ESPAC, three (10.7%) presented re-bleeding. In two patients, we performed an endoscopic revision surgery with re-cauterization of the sphenopalatine foramen area, together with anterior and posterior ethmoidectomy, followed by fat occlusion/obliteration of these sinuses. In one patient, fat obliteration of the anterior and posterior ethmoid was also unsuccessful, and we performed an external carotid artery ligation at the level of the neck with no recurrence afterwards. Conclusions: Endoscopic cauterization of the sphenopalatine artery remains a safe, effective, and reliable surgical procedure in the management of recurrent posterior epistaxis. The use of anticoagulant drugs and the association of hypertension and other heart and liver diseases do not materialize as factors influencing surgical failure.

Management of Recurrent and Refractory Posterior Epistaxis by Transnasal Endoscopic Sphenopalatine Artery Cauterization: a Prospective Cohort Study.

Transnasal endoscopic sphenopalatine artery occlusion procedures are becoming the standard of care for intractable posterior epistaxis. Improved endoscopic anatomical features of the lateral nasal wall and endoscopic skill with high-resolution cameras result in a higher success rate of endoscopic intervention. To evaluate the safety and effectiveness of endoscopic cauterization of the sphenopalatine artery (ESPAC) in controlling intractable posterior nasal bleeding. This prospective cohort study enrolled patients with refractory posterior epistaxis from August 2016 to December 2019. The trial recruited patients between 18 and 65years of age with a history of recurrent and refractory posterior epistaxis receiving endoscopic arterial cauterization due to conservative treatment failure. All of the cases involved bipolar cauterization. Recurrent nosebleeds must pause for at least three months for a procedure to be considered successful. In the first 30days following surgery, complications are recorded. 415 patients with epistaxis received both inpatient and outpatient care. Transnasal ESPAC was necessary for 36 patients (11.5%). The most common comorbidity was hypertension accounting for 9 (23%) cases. Thus, 26 of 36 (72%) cases had a unilateral ESPAC, while 10 (28%) had a bilateral ESPAC. Twenty-two (61%) and ten (28%) patients had single and two branching patterns of the sphenopalatine artery, respectively. Septal correction and middle meatus antrostomy (44%) were the most performed additional procedures. During the three-month follow-up period, 35 patients in this study had epistaxis control; the success rate of ESPAC was 97.2%. There were no significant postoperative complications found. Endoscopic sphenopalatine artery cauterization is successful in controlling 97.2% of posterior epistaxis. It is safe and effective without any significant complications.

Angioembolism for the Management of Refractory Epistaxis

A majority of the population will experience epistaxis at some time in their life. Most cases will be from an anterior source and can be treated with pressure, anterior nasal packing, or cautery. Intractable epistaxis is generally posterior in origin and may require endoscopic cauterization, posterior packing, ligation of external carotid artery or embolization. Here we report a case of bilateral posterior epistaxis in a 41 year old male patient with c/o spontaneous epistaxis from bilateral nostril. Digital Subtraction Angiography followed by Angioembolisation was done.

Exploration of the thoracoscopic treatment of esophageal atresia under high-frequency ventilation.

Explore the feasibility and safety of thoracoscopy in the treatment of esophageal atresia under high-frequency oscillatory ventilation (HFOV) mode. This was a single-center retrospective analysis. A total of 24 children were divided into the HFOV and the No-HFOV group. The demographic information, surgical results and relevant experience were analyzed. All patients in the HFOV group underwent thoracoscopic esophageal atreplasty with a mean operation duration of 165.8 ± 33.9 min. Two patients had postoperative anastomotic leakage, which was cured after conservative treatment. One child had a recurrent tracheoesophageal fistula, which was closed after endoscopic cauterization. The mean postoperative mechanical ventilation time was 8.83 ± 8.02 days. There was no return of anastomotic leakage or r-TEF after oral feeding. Furthermore, there was no significant difference between the NO-HFOV and the HFOV groups except for the operation time where the HFOV group was shorter than that of the NO-HFOV group. Thoracoscopic esophageal atresia anastomosis under HFOV ventilation is feasible for patients with severe pulmonary infection, heart malformation, such as patent ductus arteriosus, ventricular septal defect, and poor anesthesia tolerance, but the long-term prognosis still needs further study in a large sample size.

ENDOSCOPIC SURGERY OF THE ANTERIOR ETHMOIDAL ARTERY IN EPISTAXIS: DESCRIPTION OF THE TECHNIQUE AND RESULTS

Epistaxis is one of the most common otorhinolaryngological emergencies. Most cases are self-limiting and do not require medical support. While some bleeds require simple local compression to stop the bleeding, others require a more invasive approach, such as ligation or cauterization of the anterior ethmoidal artery or sphenopalatine artery. Anterior ethmoidal artery surgery by external access has been extensively described and studied in the literature. The advent of the endoscope for this procedure has offered the possibility of providing patients and surgeons with an alternative way to perform the surgery. In the present study, patients with epistaxis who underwent endoscopic cauterization of the anterior ethmoidal artery or sphenopalatine artery were selected, and the postoperative results, complications, and recurrence of bleeding were evaluated. In addition, the surgical technique used was described. From these data, it was concluded that endoscopic cauterization surgery of the anterior ethmoidal artery or sphenopalatine artery is effective in the treatment of epistaxis.

Piriform fossa sinus tract - a 15-year retrospective review with a focus on atypical neonatal presentations.

Third and fourth branchial anomalies are rare, accounting for less than 10% of all branchial anomalies. The piriform fossa sinus tract (PFST) typically presents with left-side suppurative thyroiditis, although it can present earlier in neonates as a non-inflamed cystic neck mass. PFST poses a considerable diagnostic challenge with variable clinical and imaging features, leading to long delays to definitive diagnosis and appropriate management. To analyse the patterns of presentation and imaging findings in children with PFST, with a particular focus on neonatal presentation. This was a retrospective review of the clinical presentation, imaging findings and management in 16 cases of PFST presenting to our tertiary children's hospital between 2003 and 2018. Cases were identified by medical records and picture archiving and communication system (PACS) search using relevant International Classification of Diseases (ICD)-10 coding. Age at presentation ranged from prenatal to 16years, with a male-to-female ratio of 2:1. All patients presented with neck swelling. Thirteen patients (81%) had suppurative thyroiditis at initial presentation. Two patients had severe thyroiditis/mediastinitis that required intensive care unit admission. Three neonates presented with noninfected, asymptomatic large cystic neck masses; two of these were detected prenatally and misdiagnosed as lymphatic malformations with subsequent spontaneous clinical resolution that later represented with evidence of PFST. The PFST was on the left side in 15/16 (94%) patients. All patients had neck imaging before definitive diagnosis. Imaging studies included radiographs, ultrasound, computed tomography, magnetic resonance imaging and barium esophagram studies. No single modality was diagnostic of PFST in all patients. Seventy-five percent of patients had multimodal imaging before diagnosis. All PFSTs were confirmed by endoscopic visualisation. Management of PFST was by endoscopic cauterisation in 13 patients and open surgery in 2. One patient did not require surgical correction. Our study highlights the complex nature of PFST. The anomaly is uncommon, has variable clinical and imaging features and may have a lengthy, complicated course if not considered at initial presentation. An episode of suppurative thyroiditis in a child should prompt investigation for PFST. We describe atypical presentations with cystic masses in neonates that appear to resolve but represent later as typical clinical features of PFST.

Endoscopic cauterisation and injection of Voicegel for treatment of congenital pyriform fossa sinus tracts.

SUMMARYObjectiveTo demonstrate our experience in treating pyriform fossa sinus tracts (PFST) using a novel technique of endoscopic cauterisation of the pyriform fossa sinus opening combined with injection of sodium carboxymethylcellulose gel (VoiceGel) lateral to the tract to encourage tight closure.MethodsOver a 48-month period, we used this technique on 11 patients who were diagnosed with PFST at BC Children’s Hospital, a tertiary paediatric centre in Vancouver, BC, Canada.ResultsThe 11 patients included 8 males and 3 females, and mean age at presentation was 69 months (range 22-108 months). Mean time from beginning of symptoms till diagnosis was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one on the right. Nine patients presented with recurrent neck infections and two had suppurative thyroiditis. All patients had endoscopic cauterisation of their PFST opening combined with injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence at the last follow-up visit. No post-operative complications were reported.ConclusionsEndoscopic management of paediatric PFST combined with the injection of sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effective treatment option for PFST.

Endoscopic Management of Branchial Fistula: Diagnostic and Therapeutic.

Recurrent neck abscess is a typical feature of branchial anomaly. Open surgical excision has been the primary treatment modality for past decades however several alternative treatment modalities such as endoscopic electrocauterization has recently gained popularity and acceptance universally. This series aims to introduce endoscopic assessment as the first line diagnostic and therapeutic management for branchial fistula.
 5 patients underwent examination under general anesthesia via direct laryngoscopy, endoscopic assessment and cauterization in our centre from 2016 to 2019. They were then followed up at our clinic to assess disease progression.
 Comparison between open neck surgery and endoscopic cauterization of internal sinus tract opening as the primary treatment has reported similar recurrence rate.
 Proposal of endoscopic assessment as the first line investigation and diagnostic tool with the aim of therapeutic cauterization at the same setting. MRI may be needed in scenarios such as failed endoscopic treatment or when open surgery is required.

Intraoperative variations of the sphenopalatine artery between epistaxis and non-epistaxis cases: a comparative endoscopic analysis

BackgroundSevere epistaxis is one of the most common emergencies in rhinology practices. The commonly used endoscopic cauterization of the sphenopalatine artery (SPA), alone or with the anterior ethmoidal artery (AEA), has a high success rate for controlling severe epistaxis. The current study was conducted to evaluate the endoscopic intra-operative variations of SPA between epistaxis and non-epistaxis cases. Forty consecutive patients who underwent exploration of SPA were included in the study. They were distributed into two groups depending upon the indication of SPA exploration; the epistaxis group (group A, n=25 patients, n=26 sides) and the non-epistaxis group (group B, n=15 patients, n=25 sides). Criteria of the main SPA in the two groups were compared regarding four parameters; arterial diameter, arterial adherence to the mucosa of the lower part of the basal lamella, sphenopalatine nerve bundle, and crista ethmoidalis erosion.ResultsA significant difference was found regarding the diameter of SPA between the two groups; a mean diameter of 4.2±0.64 mm was compared to 3.2±0.35 mm for group A and B, respectively (p=0.043). Moreover, a highly significant tendency was observed regarding the arterial adherence to the mucosa of the lower part of the basal lamella and sphenopalatine nerve bundle in the epistaxis group; (p≤0.01).ConclusionThese data clearly signify the importance of intraoperative identification of SPA criteria during surgical management of severe epistaxis. These criteria may help in altering the surgical decision between solely SPA and concomitant SPA/AEA cauterization.

Endoscopic treatment of ectopic teeth in the maxillary sinus.

BackgroundEctopic teeth in maxillary sinus is rare and are usually removed via sub-labial trans-canine fossa approach (SLCFA). The aim of our study was to present our experience with extraction of ectopic teeth in the maxillary sinus via transnasal endoscopic approach (TEA). Material and Methods Rhinologists were asked to share their experience in the management of ectopic teeth in the maxillary sinus. Data were reviewed retrospectively. Results Eleven cases were reported in 10 patients from 2010 to 2019, six males and four females with a mean age of 33.5 +/-17 years (range 16 to 61). Seven patients complained of sinonasal symptoms, two were diagnosed incidentally during routine dental work-up, and one had oro-antral fistula. In eight patients, a cyst coexisted within the maxillary sinus. Teeth were located arbitrarily within the sinus. All cases were operated by TEA. One patient had self-limited periorbital emphysema, one had transient cheek numbness, and one had early post-operative bleeding that stopped after endoscopic cauterization. Long-term follow-up revealed good clinical outcomes. ConclusionsTransnasal endoscopic removal of ectopic teeth from the maxillary sinus is a feasible and rational approach when SLCFA is contraindicated. Key words:Ectopic teeth, dentigerous cyst, endoscopic sinus surgery, Caldwell-Luc.

Selective Neuroendoscopic Resection of the Choroid Plexus as an Alternative Technique for Optimizing the Standard Endoscopic Approach to Hydrocephalus

In the past four decades, enormous advances have been made in the neuroendoscopic techniques, along with improvement of illumination, and the development of effective instruments. As a result, endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) have become consolidated techniques for the treatment of hydrocephalus. In particular, endoscopic cauterization of the choroid plexus has increased the effectiveness of hydrocephalus treatment in combination with ETV. In the past decade, the use of flexible endoscopes has enabled surgeons to resect even the temporal segment of the choroid plexus at the lateral ventricles, which has increased the success of treatment. In this technical note, we describe CPC with the use of a rigid endoscope, which we used to selectively disconnect the glomus of the choroid plexus, in addition to choroid plexus coagulation, as an alternative way to facilitate ETV. This new procedure optimized the visualization of the choroid plexus and the temporal horn and prevented additional difficulties in coagulation of this mobile region of the choroid plexus in selected patients. To achieve the best outcome, avoid bleeding, and optimize the standard technique, it was important to recognize both the classical anatomic structure of the choroid plexus and some variations, and previous expertise in ETV and CPC were necessary. We demonstrate that resection of the glomus of the choroid plexus in selected patients is safe and feasible.

Combination Surgical Procedure for Fourth Branchial Anomalies: Operative Technique and Outcomes.

Branchial apparatus anomalies of the fourth cleft are the rarest subtype of anomaly and occasionally present with suppurative thyroiditis or thyroid abscess due to their relationship with the thyroid gland. Surgical approaches vary and some surgeons favor cauterization of associated pyriform sinus tracts alone versus complete surgical excision. Currently, the literature is scarce and there is limited data on surgical outcomes and procedural steps. Here we describe a combination surgical technique for fourth branchial anomalies including: (1) surgical excision of the cyst and any external pit, (2) hemithyroidectomy, and (3) direct laryngoscopy with cauterization of pyriform apex tract, if present. A retrospective review was performed on all patients who underwent surgical excision of fourth branchial apparatus lesions (including fistulae, cysts, and sinus tracts) at an urban pediatric university hospital from 2000 to 2019. Data regarding demographics, medical history, surgical methods, complications, and surgical cure rates were collected. A total of 16 patients (9 female, 7 male) underwent a combination surgical procedure for fourth branchial apparatus lesions. Success rate after primary surgery was 94%. One patient had residual disease requiring re-operation. Two patients had post-operative complications: 1 transient vocal fold paresis and 1 seroma, both managed conservatively. A consensus surgical algorithm was created based on operative steps present in the majority of cases. A combination approach to fourth branchial apparatus lesions-including endoscopic cauterization, external excision, and hemithyroidectomy-is safe and provides a high rate of primary cure. Although less invasive options exist, remnants of the branchial lesion, especially in the thyroid, may remain and cause recurrent issues. Therefore, we advocate for complete surgical excision of this rare developmental anomaly, especially when obvious thyroid involvement exists.

Endoscopic diathermy cauterization of piriform fossa sinus tract (PFST)

Introduction A congenital piriform fossa sinus tract is thought to be caused by a developmental abnormality of the third or fourth pharyngeal arches. This condition is traditionally managed by an open approach, external excision of sinus tract with hemi-thyroidectomy. However, endoscopic cauterization of PFST is now recognized as a minimally invasive definitive first line therapeutic option. Objective To evaluate the success of endoscopic cauterization of the PFST as a definitive first line therapeutic option. Method Retrospective analysis was done on medical records of ten patients (aged 1-12y), who were diagnosed with PFST and underwent endoscopic diathermy cauterization of PFST during one-year period (2015/2016) at LRH. Data including demography, presentation, management and response to treatment were analyzed. Results Median age of our case series was 8.23 years and eight out of ten patients (80%) were males. The most common presentation was recurrent thyroid abscess 60% (6/10) and the side of the disease was left in 90% (9/10). Eight out of ten (80%) patients had complete closure of the PFST after one session of endoscopic diathermy cauterization. Two out of ten (20%) patients had to undergo two sessions. Average follow up period was 17 months. Conclusion We propose the endoscopic diathermy cauterization as a safe and definitive first line therapeutic option in the management of the PFST.

Resection of recurrent third branchial cleft fistulas assisted by flexible pharyngotomy.

BACKGROUNDTreatment of fistulas arising from the third branchial cleft includes endoscopic cauterization or open cervical fistulectomy. Both approaches are associated with recurrence rates of 14%-18%, and possibly greater rates when the fistula has been treated operatively beforehand. Treatment of fistulas arising from the third branchial cleft is associated with an inordinate recurrence rate. Recurrence may be multifactorial and related to incomplete resection of all of the anatomical elements of the fistula.AIMTo present a new approach that involves complete resection of the recurrent fistula by a combined therapeutic approach.METHODSHere, 12 adult patients diagnosed with recurrent third branchial cleft fistulas underwent a combined therapy assisted by flexible fiber-optic pharyngoscopy to identify and resect the entry site of the fistula into the pyriform sinus. The fistulous opening into the pyriform sinus was identified by flexible fiber-optic pharyngoscopy. The application of intubation with a guidewire by pharyngoscopy, in addition to the removal of the partial excision of the thyroid cartilage, allowed complete resection of the opening and all parts of the fistula tract.RESULTSAll of the internal openings of the fistulas in the pharynx were found and easily identified by flexible fiber-optic pharyngoscopy. All of the 12 patients underwent complete resection of the recurrent fistula by the combined therapeutic approach. There were no postoperative complications such as parapharyngeal abscess or wound infection, injury or dysfunction of the recurrent laryngeal or superior laryngeal nerves. The pharyngeal edema had degraded, and the pharyngeal wound healed postoperatively within 1 wk. Laryngeal endoscopy and voice analysis were performed on the 14th d post-operatively. Vocal cord movements did not change. The characters of voice for jitter, shimmer, and normalized noise energy were all within normal limits. In addition, no recurrences were observed during the 13-60 mo follow-up period.CONCLUSIONIt can be concluded that the proposed combined therapy is associated with excellent results, minimal morbidity, and no recurrence.

Acquired Hemophilia A with Gastrointestinal Bleeding

Peptic ulcer disease is the most common cause of acute gastrointestinal bleeding, followed by variceal bleeding, Mallory–Weiss syndrome, and malignancy. On the contrary, acquired hemophilia A is a very rare hemorrhagic disease, which usually manifests with musculocutaneous bleeding, caused by autoantibodies against coagulation factor VIII.A 78-year-old man presented to the Emergency Department with melena. Dieulafoy’s lesions were observed on, and endoscopic cauterization was performed. However, the patient complained of back pain and symptoms indicative of upper gastrointestinal bleeding. Abdominopelvic computed tomography was performed, and hematoma in the psoas muscle was detected. Antibodies against coagulation factor VIII were confirmed with a blood test, and the diagnosis of acquired hemophilia A was made. Here, we report a case of acquired hemophilia A presenting with upper gastrointestinal bleeding symptoms and present a brief review of literature.