Bilateral Piriform sinus fistulas: a case study and review of management options

Abstract

Background: Piriform sinus fistulas occur due to developmental abnormalities of the third and fourth branchial arches, and almost always occur unilaterally. They generally present as recurrent abscesses in the anterior-inferior neck, with concurrent thyroiditis. They have conventionally been managed with complete removal of the sinus tract, and thyroidectomy if required; however, endoscopic approaches have been increasingly favored. Herein we describe a case of bilateral piriform sinus fistulas, and present a review of the literature concerning their endoscopic management.

Case presentation: Our patient was determined to have bilateral piriform sinus fistulas based on computer tomography, magnetic resonance imaging and microlaryngoscopy. We performed electrocauterization of the proximal fistula tracts, followed by injection of fibrin sealent. Our patient has not had a recurrence in the ten months since his procedure. There were no complications. Twenty-three articles describing an endoscopic approach to these fistulas were identified through PubMed, and a search through the references of related articles was completed.

Conclusion: Of one hundred and ninety-five patient cases we reviewed, an endoscopic procedure success rate of 82% and complication rate of 5.6% was determined. Piriform sinus fistulas that occur bilaterally are a rare congenital abnormality of the neck. Endoscopic approaches are an acceptable alternative option to open procedures, with similar success and a lower rate of complications.

Keywords: Branchial arch abnormality; Endoscopic repair; Fourth Branchial fistula; Piriform sinus fistula; Suppurative Thyroiditis; Third Branchial fistula.

Fig. 1

Axial enhanced CT showing involvement of the thyroid gland with surrounding multiloculated abscess

Fig. 2

Axial enhanced CT illustrating involvement of the abscess with the right lobe of the thyroid gland

Fig. 3

Coronal MRI identifying bilateral tracts from the piriform sinus to the thyroid gland

Fig. 4

Left piriform sinus fistula seen in (a); cannulated in (b); Right piriform sinus fistula seen in (c); cannulated in (d)

Fig. 5

Right piriform sinus fistula following electrocauterization (left) and fibrin sealant into the fistula tract (right)