Left Pyriform Fossa Research Articles

Unusual Migration of Bullet from the Right Scalp to Left Pyriform Fossa.

Spontaneous migration of a retained bullet is rare. Foreign bodies like bullets will be found at the distant site from the region of wound of entry in case they migrate. We report a case of a 17-year-old female with spontaneous migration of bullet from right temporo- parietal scalp to the posterior wall of left pyriform fossa. Twelve years back she had received a gunshot in right temporal region, no exploration was done to remove the bullet. She started complaining of discomfort in the upper neck of two months duration. Rigid laryngoscopy revealed smooth bulge with thinning of overlying mucosa. Radiographs of the neck showed bullet along the posterior pharyngeal wall in the region of the pyriform fossa. CT scan of the head and neck region was done to exclude the presence of any other foreign bodies. Microlaryngoscopy suspension of the larynx was done and CO2 laser was used to incise the mucosa over the bullet and it was retrieved with the help of long artery forceps. Our case illustrates that bullets may take an unexpected course from the site of entry, probably by migration. Trans oral CO2 laser microsurgery is the recommended approach for removal of such foreign bodies.

Clinical efficacy of low-temperature plasma radiofrequency ablation in children with pyriform fossa fistula

ObjectiveTo evaluate clinical efficacy of low-temperature plasma radiofrequency ablation in children with pyriform fossa fistula. MethodsFrom June 2015 to August 2021, 80 children with pyriform fossa fistula who underwent low-temperature plasma radiofrequency ablation to occlude internal fistula in our hospital were included in this retrospective study. Antibiotics were routinely used for 3–5 days after operation. Indwelling gastric tube was given for 5–7 days, and nasal feeding was given. The curative effect, recurrence rate and incidence of postoperative complications were observed. ResultsThere were 67 cases of left pyriform fossa fistula and 13 cases of right pyriform fossa fistula. The average follow-up time was 16 months. During postoperative follow-up, 2 cases recurred, and the recurrence rate was 2.5%. The recurrence time was 10–21 months after operation. Temporary hoarseness occurred in 7 children after operation and recovered within 3 months after discharge. Children developed one or several clinical symptoms, such as choking cough, dysphagia, infection and esophageal injury. ConclusionLow-temperature plasma radiofrequency ablation has the advantages of low recurrence rate and incidence of postoperative complication rate for internal fistula closure in children with pyriform fossa fistula. It is a safe and effective treatment for children without surgical contraindications.

Lung cancer Detected as a Metachronous Second Primary Malignancy in a patient with Pyriform Sinus Carcinoma during 18F FDG PET-CT scan

Pyriform sinus squamous cell carcinoma is the most prevalent type of hypopharyngeal carcinoma. The presence of a second primary malignancy in pyriform sinus carcinoma is uncommon. We present a case of metachronous second primary lung cancer detected by whole-body 18F-FDG PET-CT imaging during the follow-up evaluation in a treated case of well-differentiated squamous cell carcinoma of the left pyriform fossa. Bangladesh J. Nuclear Med. 24(1&2): 64-67, 2021

A case report of anaplastic thyroid cancer and papillary thyroid cancer lymph node metastasis: an unusual presentation as an invasive hypopharyngeal mass

Anaplastic thyroid carcinoma is a rare undifferentiated tumour of the thyroid follicular epithelium. It almost always develops from a pre-existing well-differentiated thyroid cancer with a co-existent thyroid malignancy varying from 5 to 17% . The co-existence of papillary thyroid cancer (PTC) with anaplastic thyroid cancer is a rare occurrence in metastases outside the primary thyroid lesion. Traditionally, this has been regarded as an aggressive form of cancer associated with a dismal prognosis. Recently, the focus has shifted to the development of novel therapies based on the availability of comprehensive genomic profiling platforms (CGP) with a rapid turn-around to identify molecular aberrations in tumours which acts as potential therapeutic targets. In the United Kingdom, we report the case of a 60-year-old woman with an unusual presentation of (metastatic) anaplastic thyroid carcinoma and concomitant papillary thyroid cancer metastasis within a contralateral lymph node. This was initially perceived as a left pyriform fossa mass involving and compressing her left hemi-larynx on clinical and radiological examination. Following the identification of BRAF V600E mutation on CGP, she was started on targeted therapy with the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib and demonstrated excellent clinical and radiological response following 7 months of treatment. She has subsequently undergone total thyroidectomy alongside with bilateral neck dissection, and is due to start radioactive iodine treatment to reduce the risk of recurrence of disease.

A RARE CASE OF NEUROFIBROMATOSIS WITH SQUAMOUS CELL CARCINOMA OF EPIGLOTTIS

INTRODUCTION: The neurofibroma is a nonmalignant new growth of neuroectodermal origin. neurofibromas appear at the end of a nerve, often in the skin, producing small nonencapsulated nodules which may have pigmentation in the overlying skin. Neurofibromatosis with laryngeal involvement presents with dyspnea, followed by hoarseness, stridor, dysphagia, and voice change. most common sites involved in the larynx are the arytenoids and the aryepiglottic folds. CASE REPORT: 65-year-old female with previously diagnosed of neurofibromatosis since 10 years of age manifested by multiple cutaneous nodules The patient had symptoms of dysphagia, hoarseness of voice for past 2 months. Direct laryngeal examination using flexible endoscope showed a edematousulceroproliferative growth in the laryngeal surface of epiglottis and fullness in the left pyriform fossa. Hisopathological examination revealed squamous cell carcinoma from epiglottis and fibromatosis changes from pyriform fossa. CONCLUSION: All neurofibromatosis patient and their family members should under go regular oral and laryngeal examination to rule out complications at the earliest.

Case series: Endoscopic management of fourth branchial arch anomalies

IntroductionFourth branchial arch anomalies represent <1% of all branchial anomalies and present as recurrent neck infections or suppurative thyroiditis. Traditionally, management has consisted of treatment of the acute infection followed by hemithyroidectomy, surgical excision of the tract and obliteration of the opening in the pyriform fossa. Recently, it has been suggested that endoscopic obliteration of the sinus tract alone using laser, chemo or electrocautery is a viable alternative to open surgery. ObjectivesTo determine the results of endoscopic obliteration of fourth branchial arch fistulae in children in our institute. MethodsRetrospective case note review of all children undergoing endoscopic treatment of fourth branchial arch anomalies in the last 7 years at the Royal Manchester Children's Hospital. Patient demographics, presenting symptoms, investigations and surgical technique were analysed. The primary and secondary outcome measures were resolution of recurrent infections and incidence of surgical complications, respectively. ResultsIn total 5 cases were identified (4 females and 1 male) aged between 3 and 12 years. All presented with recurrent left sided neck abscesses. All children underwent a diagnostic laryngo-tracheo-bronchoscopy which identified a sinus in the apex of the left pyriform fossa. This was obliterated using electrocautery in 1 patient, CO2 laser/Silver Nitrate chemocautery in 2 patients and Silver Nitrate chemocautery in a further 2 patients. There were no complications and no recurrences over a mean follow-up period of 25 months (range 11–41 months). ConclusionEndoscopic obliteration of pyriform fossa sinus is a safe method for treating fourth branchial arch anomalies with no recurrence.

An 18FDG-PET/CT Finding of a Mediastinal Abscess

A 66-year-old man with left pyriform fossa squamous cell carcinoma (T2N0) was treated with chemoradiation. Nine months later, an emergency tracheostomy was performed for respiratory distress. Contrast-enhanced neck and thorax CT demonstrated a right pyriform mass. FDG-PET/CT showed linear increased uptake extending superiorly from the tracheostomy to the right Eustachian tube and inferiorly to the posterior mediastinum. Postmortem examination confirmed a 7 × 2.2 cm abscess extending from the right parapharyngeal, peritracheal, and prevertebral structures to the mediastinum.

Impacted Chicken Bone in the Laryngopharynx: A Case Report

Objective. To describe a rare case of an impacted large foreign body (chicken bone) in the laryngopharynx. Case Report. A 28-years-old man presented with pain in the neck of 5 days duration. The patient gave a history of severe choking sensation while eating chicken. Laryngoscopic examination revealed a linear whitish large chicken bone impacted in the left pyriform fossa. The bone was removed under local anesthesia with the guidance of telescopic laryngeal examination. Conclusion. This paper describes impaction of a large chicken bone in the hypopharynx in an adult male patient and its removal with guided telescopic laryngeal examination.

Use of intubating laryngeal mask airway for intubation in patient with massive goitrous thyroid

Sir, Large thyroid masses are a nightmare for the anaesthesiologist not only because of thyroid endocrinal abnormality but also because of difficult airway.[1] Fiberoptic bronchoscopy for tracheal intubation is considered the gold standard in such scenarios but may not be available sometimes.[23] We report a successful airway management in a patient with a large thyroid mass with distorted laryngeal anatomy using an intubating laryngeal mask airway (ILMA). A 65-year-old male was scheduled for total thyroidectomy for multinodular goitre. Patient complained of progressively increasing swelling over neck and difficulty in speaking, swallowing and breathing since last six months. The swelling extended superiorly up to the chin, laterally up to the posterior border of sternocleidomastoid and below up to the suprasternal notch (size, 30 × 20 cm) [Figure 1a and b]. There was prominence of veins over the mass and also over the anterior chest. Airway assessment revealed adequate mouth opening, modified mallampati class MMC II and neck movements were restricted. Investigations revealed normal haemogram, biochemical and thyroid profile. Indirect laryngoscopy revealed fixed left vocal cord and left pyriform fossa was not opening up. Soft tissue neck X-ray revealed compression and right deviation of trachea [Figure 2]. Contrast-enhanced computed tomography scan of neck and chest showed compression and right anterior displacement of the trachea. After overnight fasting, pantoprazole (40 mg) and glycopyrrolate (0.2 mg) was administered in the morning of surgery. In the operation room, routine monitors were attached. Lignocaine (4%) gargles were done. Left radial artery was cannulated. Anaesthesia was induced with sevoflurane (6%) in 100% oxygen. After lignocaine spray (10%), laryngoscopy revealed Cormack lehane CL Grade III. Even after manipulating the thyroid mass externally, the glottic chink could not be visualised. We could only appreciate a small hole in the left lateral aspect of the oral cavity and glottis was oedematous. We tried to negotiate the tube with a stylet but could not achieve tracheal intubation. Even bougie could not be negotiated. We attempted intubation using ILMA and optimal ventilation was achieved after adjusting the ILMA handle in different directions. This was achieved only when ILMA was rotated laterally and anteriorly. Stabilising the ILMA at this position of best ventilation and optimal capnograph, endotracheal tube was gently inserted and successful intubation was achieved. Thereafter the anaesthetic procedure was uneventful.Figure 1: (a, b). Patient with a larger thyroid massFigure 2: X-ray soft tissue neckWe predicted difficulty in tracheal intubation in our patient. Fiberoptic bronchoscope was not available with us for this patient. Tracheostomy as a definitive airway was not possible in our patient because of the large thyroid mass extending till the suprasternal notch and also due to airway distortion. So we planned to topicalize the airway and to secure the airway under sevoflurane induction. Since the endotracheal tube could not be negotiated in multiple attempts even after using bougie and stylet and manipulating the thyroid mass, ILMA was used as a rescue attempt. By manoeuvring the ILMA based on the predicted location of the glottic chink to achieve optimal ventilation helped us to adjust the ILMA cuff in line with the glottis and thereafter tracheal intubation was achieved in the first attempt. ILMA has been attempted earlier for tracheal intubation in patients with larger goitre but intubation was not successful though ventilation was easy.[4] They presumed that it could be because of distorted laryngeal anatomy and they performed standard manoeuvres for achieving the tracheal intubation. But we suggest that the manoeuvres need to be done on the basis of the predicted location of the glottic opening. We suggest that achieving optimal ventilation by ILMA could help in aligning the glottic chink and thus successful tracheal intubation could be done in a patient with a large goitrous thyroid with distorted laryngeal anatomy.

Complete Congenital Third Branchial Fistula: A Rare Case Report

Fistulae arising from the second branchial apparatus are the most common anomalies than those arising from the third and fourthbranchial apparatus. Third branchial fistula is extremely rare in occurrence.1 Complete fistulae are uncommon as in the majority of casesthe tracts end blindly. Here, we report a case of complete congenital third branchial fistula on left side of the neck with an internal openingnear left pyriform fossa in a 12-year-old male patient.

Obstructive neonatal respiratory distress: infected pyriform sinus cyst

Infected lateral cervical cysts in newborn are rare. We present the case of a baby born at 41 weeks of gestation. At day 3, persistent cyanosis was noted, and a mass appeared in the left cervical region next to the sternocleidomastoid muscle. No cutaneous sinus was visible. Ultrasound imaging showed no sign of blood flow within the mass and no septae. The mass extended down to the aortic arch and pushed the trachea to the right. A cervical lymphangioma was first suspected. Puncture of the mass evacuated 80 mL of pus, and a drain was put in place. Opacification through the drain showed a tract originating from the left pyriform fossa. Preoperative laryngoscopy and catheterization of the fistula tract confirmed the diagnosis. The cyst was totally excised up to the sinus with the assistance of a guidewire inserted orally through a rigid laryngoscope. This is a rare case of an infected pyriform sinus cyst in the neonatal period.

Multiple Sites of Impingement of a Tracheal Tube as it is Advanced over a Fibreoptic Bronchoscope or Tracheal Tube Introducer in Anaesthetized, Paralysed Patients

Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90 degree counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90 degree counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.

An Unusual Cause of Mechanical Dysphagia: An Agglomerate of Calculi in a Tonsillar Residue

We report the case of a 68-year-old man affected by severe oropharyngeal dysphagia for solid food, who had undergone tonsillectomy when he was 22 years old. Videolaryngoscopy revealed a smooth-surfaced, elongated overgrowth on the left lateral pharyngeal wall that protruded toward the left pyriform fossa and impeded the transit of solid boli. A computed tomography scan showed that the solid content of the lesion was markedly inhomogeneous and denser than the surrounding soft tissues. The mass was removed by means of direct pharyngoscopy under general anesthesia. It was found that it arose from the inferior pole of the left tonsillar fossa and had a central cavity filled with caseum and multiple calculi. Histopathologic examination showed that its soft tissue component consisted of lymphoid tonsillar tissue. The operation totally resolved the swallowing disturbance. This case report highlights that tonsilloliths in a tonsillar residue should be considered in the differential diagnosis of mechanical oropharyngeal dysphagia, even in tonsillectomized patients.

Fistula of the fourth branchial pouch

Most of the congenital anomalies of the branchial apparatus are from the second arch, pouch, and cleft; some are from the first and third arches. Fourth branchial pouch remnants are very rare. We present a rare case of fourth branchial fistula, with characteristic clinical features of recurrent left-sided neck abscess that burst spontaneously, forming a fistula. Diagnosis of fourth branchial pouch fistula was confirmed by contrast radiography (ie, fistulogram and barium swallow) revealing the internal opening in the apex of the left pyriform fossa.

Case report: Magnetic resonance imaging (MRI) appearances of benign schwannoma of the larynx

A 30-year-old Ghanaian woman presented with a history of hoarseness of voice since birth which had recently worsened. At laryngoscopy a soft, solid mass was seen filling the left ventricle and expanding into the left supraglonis. The tumour was biopsied and later debulked. Histological examination revealed fragments of a benign schwannoma (neurilemmoma). Immunohistochemistry confirmed the Schwann cell nature of the tumour. Nasendoscopy, 3 months later, showed recurrence of the tumour and MRI was performed before and after enhancement with gadolinium with a view to definitive surgery. MRI was performed on a 1.0T scanner (Siemens, Impact) with a Helmholtz neck coil. Contiguous Tl-weighted images (5mm) (TR 693 ms, TE 17 ms) demonstrated a 2 x 1.5 cm. ovoid nodule involving the left aryepiglottic fold and extending down to the level of the cords (Fig. 1). It is similar in intensity to muscle though a little inhomogeneous. The signal intensity of the lesion is higher than muscle on the proton density (TR 3549ms, TE 22ms) and T2-weighted images (TR 3549 ms, TE 90 ms) (Fig. 2). The edge of the lesion is well defined. The left pyriform fossa is compressed and the vestibule distorted. There is patchy enhancement after intravenous gadolinium (0.1 mmol/kg) given by hand injection (TR 658ms, TE 17ms) (Fig. 3).

An unusual presentation of squamous cell carcinoma of the pyriform fossa as a pedunculated polypoidal mass — a case report

A rare case of a squamous cell carcinoma of the left pyriform fossa is presented. It was found as a pedunculated polypoidal mass in a 17-year-old Hindu girl. A review of literature is included.

Use of a Lighted Stylet to Confirm Correct Endotracheal Tube Placement

Despite the fact that endotracheal intubation is a skill essential for clinicians of varied specialties, the procedure is not without risk, especially when practiced in an emergency setting, particularly the field environment. Of all complications, none is more serious than unrecognized esophageal intubation. Clinical experience with a method of guided orotracheal intubation using a rigid-wire lighted stylet prompted us to develop a technique to confirm correct intratracheal placement of an endotracheal tube using a new flexible lighted stylet designed for nasotracheal intubation. Endotracheal tubes were placed under direct vision at three sites in the upper airway of five unembalmed human cadavers: esophagus (20 cm from the teeth), trachea (20 cm from the teeth) and the right or left pyriform fossa. Thirty-five volunteer intubators were asked to identify tube placement using the transilluminated glow from the flexible nasotracheal lighted stylet. A total of 168 placements were made in 40 trials. Only one of 56 intratracheal placements was misidentified as esophageal. Of 112 extratracheal placements (esophagus or pyriform fossa), one was misidentified as intratracheal. The level of experience or training bore no relationship to the ability of the intubator to identify correct placement. We conclude from the study that this technique is a rapid and reliable method of confirming correct placement of endotracheal tubes. The use of this method could reduce, if not eliminate, unrecognized esophageal intubation in the field, emergency department, the critical care unit, and the operating room.

Total laryngectomy and cervical esophagectomy: Reconstruction employing a greater curvature gastric tube

A case is reported in which the finding of an additional primary carcinoma of the right pyriform fossa and one of the cervical esophagus at the time of left radical neck dissection and laryngectomy for carcinoma of the left pyriform fossa necessitated resection of the entire hypopharynx, cervical esophagus and a portion of the upper thoracic esophagus. Satisfactory primary reconstruction was effected by employing a reversed, greater curvature, gastric tube brought through a subcutaneous antethoracic tunnel and anastomosed to the base of the tongue, posterior pharyngeal wall and tonsillar pillars. A three-year follow-up of the patient who was free of recurrence is described. Various other methods of reconstruction following resection of the cervical esophagus, larynx and hypopharynx are reviewed briefly and reasons are cited for the preference of the method employed in this particular case.