Recurrent Neck Infection Research Articles

Diagnosis and treatment of pediatric cervical bronchogenic cyst

Objective:To investigate the clinical characteristics and surgical treatment outcomes of children with cervical bronchogenic cysts. Methods:A retrospective study of 6 pediatric patients with bronchogenic cysts in the neck region treated in our hospital during 2014 to 2020 was performed. All children underwent complete resection of cervical mass under general anesthesia. Results:There were 6 children, aged from 1 to 5 years, with a median of 2.25 years. There were 3 males and 3 females. The lesions were located on the left neck in 3 cases, the midline neck in 2 cases and the right neck in 1 case. The clinical manifestations were painless mass in 5 cases and recurrent neck infection in 1 case. The size of the mass ranged from 2.1 to 7.5 cm. There was no characteristic clinical or imaging features of bronchogenic cysts. Misdiagnosed as lymphangioma in 3 cases, thyroglossal cyst in 2 cases and piriform fistula in 1 case. The follow-up ranged from 1.50 to 7.75 years, with a median of 4.13 years. All 6 children had no recurrence or complications. Conclusion:Although rare, bronchogenic cysts should be considered in the differential diagnosis of cervical cystic masses in children. Surgery is the most effective way to treat cervical bronchogenic cyst, and histopathological examination is the gold standard for diagnosis.

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.

Fourth Branchial Anomalies: Diagnosis, Treatment, and Long-Term Outcome.

Introduction: Fourth branchial anomalies, the rarest among anomalies of the branchial apparatus, often present diagnostic and therapeutic challenges. We evaluated the clinical presentation and radiographic features, the treatment and the long-term outcome of patients in this setting.Patients and Methods: Of 12 patients treated in the University Hospitals Leuven from 2004 until 2020, 12 variables were collected: date of birth, gender, age of onset of the symptoms, age at final diagnosis, presentation, laterality, previous procedures, diagnostic tools, treatment (open neck surgery, endoscopic laser excision, or combination), complications, recurrence, and period of follow-up. Descriptive statistics were calculated and results were compared to the existing literature.Results: The most common clinical manifestations were recurrent neck infections with and without abcedation. Definitive diagnosis using direct laryngoscopy, visualizing the internal sinus opening, was possible in all patients. A CT study revealed the typical features of fourth branchial anomalies in seven patients out of nine, an ultrasound study in five out of nine patients. All patients underwent open neck surgery. If this was insufficient, secondary endoscopic laser resection of the ostium at the apex of the piriform sinus was performed (n = 4). In eight patients a thyroid lobectomy was needed for safe complete resection. Postoperative complications were minimal and at long-term, none of the patients showed further recurrence. Average time of follow-up was 8.6 years.Conclusions: Direct laryngoscopy and CT are the most accurate diagnostic tools. Our recommended treatment schedule consists of complete excision of the sinus tract by open neck surgery as the primary treatment because this ensures the best results. In case of recurrence afterwards, endoscopic laser resection of the pharyngeal ostium solved the problem.

Differences in the diagnosis and management of pyriform sinus fistula between newborns and children

Pyriform sinus fistula (PSF) is a rare congenital entity. We hypothesized that clinical features, diagnosis and treatment may differ between newborns and children. 190 patients diagnosed with PSF were divided into two groups: neonatal (n = 15) and childhood (n = 175). The medical records including demographic and clinical data were retrospectively analyzed. There were 102 boys and 88 girls in this study. Most patients presented as a left-sided neck lesion. A neck mass, with or without infection and respiratory distress, was the common finding in newborn patients. Prenatal diagnosis was made in three cases. However, in childhood group, initial symptoms were neck abscess (78.8%), acute thyroiditis (11.4%), neck mass (6.9%), and thyroid lesion (2.8%). The presence of a cervical mass with air pocket showed on CT image was thought to be the pathognomonic finding of neonatal PSF. The diagnosis was usually established by barium esophagography in older children. Delayed accurate diagnosis was detected in both groups. The median time from onset to diagnosis was 22 months and 1 year respectively. Endoscopic-assisted open surgery was performed successfully in all patients, with good outcomes in majority cases of both groups (93.3% and 95.4%). Recurrence was developed in 5 patients. PSF should be suspected in newborns with cervical mass and in children with recurrent neck infection, especially on the left side. Early diagnosis and treatment might avoid repeated surgical procedures. Complete resection of the cyst and fistula in non-infected state is essential for good outcomes.

Endoscopic Cauterization with Pneumatic Distension for Piriform Fossa Sinus Tracts.

Piriform fossa sinus tracts (PFSTs) are a cause of recurrent neck infections in the pediatric population. Conventional management required open resection, but over the last years minimally invasive approaches have been reported in an attempt to endoscopically obliterate the PFST, using different methods such as electrocautery, laser, trichloroacetic acid, or silver nitrate. We undertook a retrospective review of the medical records of 12 children (aged 4 months to 14 years) with PFSTs treated with endoscopic sclerosis with diathermy (ESD) between 2010 and 2016 at a tertiary care children's hospital. We also present a technical modification of ESD, using continuous infusion of airflow through the gastroscopy, to distend the piriform sinus and facilitate its recognition. PFST obliteration was performed using diathermy through a guide wire. Clinical presentation of the 12 affected children included neck tumor (7 [58%]), neck abscesses (4 [33%]), and thyroiditis (5 [41%]). All lesions occurred on the left side. All patients underwent both ultrasonography and barium esophagography (the latter being positive only in 50%). Two patients were treated with ESD after the open approach had failed. There was no procedure-related morbidity. One patient had a recurrence (positive barium swallow without symptoms). The success rate of this procedure in our series was 91% with one attempt and 100% with two attempts. In our experience, treatment of PFST with ESD is a reproducible, noninvasive, and an effective option. ESD could be considered a primary approach and also for revision after open surgery has failed in these patients.

The diagnosis and treatment for pyriform sinus fistula in children

Objective: To discuss the diagnosis and management for pyriform sinus fistula in children. Methods: Eight cases of pyriform sinus fistula admitted in Guangzhou Women and Children's Medical Center from May 2013 to August 2015 were retrospectively analyzed. The median age at onset was 54 months (range from 11 months to 12 years). All 8 cases presented recurrent neck infection (typical of redness, swelling, heat and pain) and 2 accompanied with acute suppurative thyroiditis. The diagnosis was confirmed by the preoperative barium esophagography combined with neck computed tomography scan (plain scan, enhancement and reconstruction). All the patients underwent laryngeal endoscopic-assisted surgery. Results: Preoperative imaging findings identified seven left-side cases and one bilateral (the symptom only manifested on left side). All 8 cases underwent left fistulectomy. There was no esophageal injury nor nerve injury during the operation. Postoperatively, all cases recovered well without complications (such as sound hoarse and coughing) and reoccurrence within the follow-up period (range from 7 months to 34 months). Conclusions: Preoperative barium esophagogram combined with neck computed tomography scan facilitates proper diagnosis and appropriate treatment. Laryngeal endoscopic-assisted technique at operation provides a better understanding of the anatomic relationship and the points where the fistulas penetrated into the pharynx, and essentially improves the operation outcome.

Recurrent neck abscess in a 2-year-old child

Pyriform sinus fistula is a rare congenital anomaly affecting the third or fourth branchial arches. It is often overlooked, and poses a diagnostic and management challenge. We report the case of an infant with recurrent neck infections despite appropriate treatment that was finally diagnosed as pyriform sinus fistula.

A Review Over the Past 15 Years of the Management of the Internal Piriform Apex Sinus Tract of a Branchial Pouch Anomaly and Case Description

Literature review of treating the piriform apex sinus tract through microlaryngoscopy and a case description. Fourteen papers were identified in PubMed using the search criteria of piriform sinus fistula, microlaryngoscopic repair, and endoscopy. Institutional Review Board approval was obtained. One hundred forty-five cases including ours were available for review, with 182 procedures. Sixty-two cases were male, 73 female, and 10 genders were not reported. Multiple treatment options were used, including electrocautery, chemocautery, mass excision, fibrin glue, lasers, suture closure, or combination of stated modalities. Of the 182 procedures, 147 procedures were performed endoscopically. There were 37 recurrences (25%). These patients either underwent a repeat endoscopic procedure or an open excision. One hundred and ten (75%) endoscopic procedures were successful. Piriform sinus tract anomalies often present as a mass and recurrent neck infections. This review reveals that treating the internal piriform sinus opening alone can be successful. This procedure has low morbidity, short operative time, and high success. We advocate this approach first with a combined open/laryngoscopic approach for failed cases. To our knowledge, our technique of CO₂laser ablation of the tract followed by suture closure has not been previously described. We believe this to be the first comprehensive review of this topic and the largest series of cases included in a single report.

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.

Branchial fistula arising from pyriform fossa: CT diagnosis of a case and discussion of radiological features

Anomalies of third or fourth branchial apparatus origin are very uncommon and present as recurrent neck infections or thyroiditis with a predominant left-sided involvement. Radiological diagnosis requires a high index of suspicion and is critical for initiation of proper treatment. We describe a case of branchial sinus of pyriform fossa with external fistulization that presented in adulthood and was diagnosed on computed tomographic scan. The radiological features of this rare anomaly are revisited.

Recurrent neck infection with branchial arch fistula in children

Objective Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. Methods A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. Results The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1–3 years showed no recurrence. Conclusion Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.

Hypopharyngeal pharyngoplasty for the management of piriform fossa sinus

Hypopharyngeal pharyngoplasty for the management of piriform fossa sinus

Imaging Findings in Acute Neck Infection due to Pyriform Sinus Fistula

Introduction: Pyriform sinus fistula is a congenital branchial pouch abnormality that is often overlooked as a cause of acute neck infection in children. Our aim is to demonstrate the value of various imaging modalities (ultrasound, computed tomography [CT], barium oesophagraphy) in its diagnosis. Materials and Methods: The preoperative imaging findings of 5 patients with surgically proven pyriform sinus fistula who presented with acute neck infection between September 2001 and March 2003 were retrospectively reviewed. CT was performed in all patients, 4 patients had barium oesophagraphy and 3 had an ultrasound scan. Results: All 5 patients suffered from upper respiratory tract infection within a week of developing a tender swelling on the left side of the neck. Four patients had a history of recurrent neck infections. CT depicted inflammation of the left perithyroid soft tissue and adjacent left thyroid lobe in every case. In 2 cases, CT demonstrated the presence of a pyriform sinus fistula. Ultrasound, performed in 3 patients, correlated strongly with the CT findings. It also showed gas within a fistula in 1 case. Barium oesophagraphy clearly delineated the fistula in 3 out of 4 cases. Conclusion: Ultrasound and CT accurately showed the presence of acute neck infection and could demonstrate the pyriform sinus fistula. Barium oesophagraphy most clearly depicted the presence and course of the fistula. Recurrent left-sided neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula and imaging should be performed to confirm its presence.

Fourth branchial complex anomalies: a case series

Objective: Anomalies of the fourth branchial arch complex are exceedingly rare, with approximately forty cases reported in the literature since 1972. The authors report experience with six fourth arch anomalies. Methods: Retrospective chart review of six consecutive patients presenting to the pediatric otolaryngology service at a tertiary care center with anomalies referable to the fourth branchial arch. Results: All six patients presented within the first or second decade of life. All six had left-sided disease. Four patients presented with recurrent neck infection, one with asymptomatic cervical masses, and one with a neck mass and respiratory compromise. One patient had prior surgery presented with a recurrence. Diagnosis of fourth arch anomalies was suggested or confirmed by computed tomography and flexible laryngoscopy. Treatment was surgical in five patients; one patient is awaiting surgery. Surgical procedures included resection of the mass and endoscopic cauterization of the inner opening of the cyst. Conclusions: The presentation of a cervical mass, especially with recurrent infections and especially on the left side, in a child in the first or second decade of life heightens suspicion for an anomaly of the fourth branchial arch. Diagnosis can be difficult, but is aided by the use of flexible laryngoscopy, Computed tomography (CT) scanning and ultrasonography. Surgical resection of the cyst and cauterization of its pyriform sinus opening should be undertaken to minimize recurrence.