Hoarseness as the first symptom in a patient with acute suppurative thyroiditis secondary to a pyriform sinus fistula: a case report.

BACKGROUND: Pyriform sinus fistulas (PSFs) are rare congenital anomalies of the third or fourth brachial pouch. Dyspnea is reportedly secondary to compression by a neck mass. However, hoarseness, as the first symptom of PSF, has not yet been reported. CASE PRESENTATION: This report describes an 11-year-old girl presenting with hoarseness as the first symptom of PSF. Hoarseness occurred 2 days prior to admission. On admission, she had fever, hoarseness, and an elastic soft mass on her left anterior neck. Contrast-enhanced computed tomography of the cervical region demonstrated an abscess partially infiltrating the thyroid gland and an air pocket near the pyriform sinus. Pharyngoscopy revealed swelling of the left arytenoid region, with purulent retention. The left vocal cord was swollen but not paralyzed. Additionally, the laboratory data indicated thyrotoxicosis. Suspecting a PSF infection, parenteral treatment with cefotaxime and dexamethasone was initiated. On the following day, the hoarseness disappeared, and the fever resolved. Four weeks after onset, the thyroid hormone levels returned to the normal range, and a barium esophagogram revealed residual contrast in the left pyriform sinus, leading to a diagnosis of PSF. CONCLUSION: PSF presenting with hoarseness as the first symptom in patients should be considered.

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

BACKGROUND: 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. OBJECTIVE: To analyse the patterns of presentation and imaging findings in children with PFST, with a particular focus on neonatal presentation. MATERIALS AND METHODS: 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. RESULTS: Age at presentation ranged from prenatal to 16 years, 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. CONCLUSION: 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.

Suppurative thyroiditis caused by ingested fish bone in the thyroid gland: a case report on its diagnostics and surgical therapy.

BACKGROUND: Accidental ingestion of fish bone is a common cause of otolaryngological emergency. Migration of the ingested bone into the thyroid gland, however, occurs very rarely. The associated clinical presentation, symptoms and duration of discomfort are also highly variable between patients and can be diagnostically challenging. CASE PRESENTATION: Here, we report the case of a 71-year-old female patient presenting with an ingested fish bone that migrated into the right thyroid lobe as a rare cause of suppurative thyroiditis with the clinical features of sepsis. We outline the diagnostic approach, peri- and intraoperative management as well as complications. It is proposed that besides endoscopy, imaging methods such as ultrasound or computed tomography may be necessary to verify the diagnosis and location of an ingested fish bone. Prompt surgical removal of the foreign body and resection of the infectious focus is recommended to minimize the risk of local inflammation, recurrent nerve lesions and septic complications arising from the spread of infection. CONCLUSION: Fish bone migration into the thyroid gland is an extremely rare event, the successful detection and surgical management of which can be achieved through a careful interdisciplinary approach.

Suppurative thyroiditis: Systematic review and clinical guidance.

OBJECTIVE: Acute suppurative thyroiditis (AST) is a rare but potentially fatal condition which can initially be difficult to distinguish from the more common subacute thyroiditis (SAT). We aim to update understanding of this medical emergency. DESIGN: A systematic review over the past 20 years was performed on the epidemiology, clinical features, investigations, management and outcomes of AST. All full-text cases of microscopy or culture- proven AST in the English literature were included. RESULTS: 200 cases of AST have been described in 148 articles from January 2000 - January 2020. Bacterial AST is most common, often presenting with neck pain (89%) and fever (82%). Immunosuppression and pyriform sinus fistula are the most common causes, most often due to gram-positive aerobes. Transient hyperthyroidism is common (42%). Aspiration and antibiotics are becoming a more common treatment. Overall mortality was 7.8%. Tuberculous and fungal AST are less likely to present with fever and neck pain. Fungal AST is more common in immunosuppressed individuals (31%) and has a high overall mortality (33%). Tuberculous AST is more common in TB endemic areas. CONCLUSION: The symptoms and signs of AST commonly overlap with SAT and initially can be hard to diagnose. AST can be rapidly morbid or even fatal. Clinicians need to consider AST when they assess patients with thyroiditis who are systemically unwell, have high fever, high white cell count and c-reactive protein, tender neck and abnormal neck imaging. An investigative and treatment strategy is described based on a systematic review of the literature.

Suppurative Thyroiditis: A Management Paradigm Based on Microbiology.

OBJECTIVE: The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis. DESIGN: This study is a retrospective case series set in 2 tertiary care academic hospitals. METHODS: The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study. RESULTS: Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile. CONCLUSIONS: The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.

Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes.

BACKGROUND: Abscess in the thyroid gland is a rare but severe infectious disease. The condition can have anatomic or iatrogenic underlying causes. If untreated it could be fatal. Pathogens vary considerably. Treatment is intravenous antibiotics, drainage, and sometimes surgery. METHODS: The electronic medical records of all adult patients with acute thyroiditis 2003-2017 treated at the Karolinska University Hospital (catchment area 2 million) in Sweden were systematically reviewed. RESULTS: Five patients were found in the catchment area. One patient from another region but known to us was also included. Thus, six patients (aged 28-73 years) were included in the study. Median length of hospital stay was 7.5 days (4-79 days). All were treated with antibiotics (intravenous n = 5, oral n = 1). Total antibiotic treatment duration was 13.5 days (10-41 days). Blood cultures were positive in three (streptococcus pneumonia, streptococci sanguineous, pepto streptococci), deep tissue culture in three (Escherichia coli, Candida, Hemophilic influenza) and no positive culture at all in two. Drainage was used in three patients. All patients recovered without recurrences. Surgery was performed twice in the acute phase in one. There was no recurrence during 7 years (3-12) of follow-up, but one patient died after three years (severe heart failure and pneumonia). CONCLUSION: Thyroid abscess in adults is extremely rare nowadays in the developed world. With prompt antibiotic therapy, drainage and in some cases thyroidectomy the prognosis seems favourable.

[Thyroid abscess due to Salmonella enteritidis in an immunocompetent patient]. / Le cas clinique du mois. Abcès thyroïdien à Salmonella enteritidis chez un patient immunocompétent.

The thyroid gland is usually resistant to infections due to its anatomy. However, suppurative thyroiditis could be found in immunocompromised patients or those with previous thyroid diseases. We report a case of thyroid abscess secondary to Salmonella enteritidis infection in an immunocompetent patient. We were not able to establish the source of infection. Clinical improvement was achieved under antibiotic treatment without complications. Early diagnosis is important as thyroid abcess may be a life threatening condition.

La thyroïde est une glande endocrine généralement résistante aux infections en raison de sa localisation et présentation anatomique. Cependant, une thyroïdite suppurée est susceptible de survenir chez des patients immunodéprimés ou ayant déjà présenté un dysfonctionnement thyroïdien. Nous rapportons un cas d'abcès thyroïdien consécutif à une infection à Salmonella enteritidis chez un patient immunocompétent. Nous n'avons pas pu établir la source de l'infection. Une amélioration clinique a été obtenue sous traitement antibiotique sans complications. Un diagnostic précoce est essentiel afin d'éviter toutes complications graves mettant en jeu le pronostic vital.

A suppurative thyroiditis and perineal subcutaneous abscess related with aspergillus fumigatus: a case report and literature review.

BACKGROUND: Invasive aspergillosis is a complication in immunocompromised patients and commonly detected in patients with hematological malignancies, which mostly affect the lungs. Because of its high iodine content, rich blood supply and capsule, the thyroid is considered to be less prone to microbial invasion thus most infectious thyroiditis cases are caused by bacteria. However, a few case reports have described thyroid gland aspergilloses, most of which were due to disseminated invasive aspergillosis. CASE PRESENTATION: We first report a case of thyroid gland and subcutaneous labium majus aspergillosis in a Chinese patient who received long-term glucocorticoid treatment for systemic lupus erythematosus (SLE) and lupus nephritis, and then we reviewed 36 articles describing similar aspergillus infections in 41 patients. CONCLUSION: We included 29 cases of diagnosed aspergillus thyroiditis and analyzed clinical findings, treatments and outcomes to provide clinical information for diagnosis and prognosis of thyroiditis caused by Aspergillus fumigatus.

Successful Antifungal Combination Therapy and Surgical Approach for Aspergillus fumigatus Suppurative Thyroiditis Associated with Thyrotoxicosis and Review of Published Reports.

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.

Recurrent neck lesions secondary to pyriform sinus fistula.

Recurrent neck lesions associated with third or fourth branchial arch fistula are much less common than those of second arch and usually present with acute suppurative thyroiditis or neck abscess. Our aim is to describe clinical features, management and treatment outcomes of 64 cases of congenital pyriform sinus fistula (PSF). Medical record of these 64 patients (33 males, 31 females) treated at the First Affiliated Hospital of Zhengzhou University from 2011 to 2014 were reviewed. The patients comprised 33 males and 31 females, and their ages ranged from 18 months to 47 years (median 10 years, mean 12.7 years). Neck abscess and recurrent infection was the mode of presentation in 37 cases (57.8 %), 4 patients (6.3 %) presented with acute suppurative thyroiditis, neck mass was the mode of presentation in 17 cases (26.6 %), 2 patients (3.1 %) presented with neck mass with respiratory distress, and cutaneous discharging fistula was the mode of presentation in 1 cases (1.6 %). The remaining 3 patients (4.7 %) presented with cutaneous discharging fistula with neck infection. Investigations performed include barium swallow, CT scan, and ultrasound which were useful in delineating PSF tract preoperatively. Barium swallow was taken as the gold standard for diagnosis. Our patients were treated by fistulectomy with hemithyroidectomy, fistulectomy, fistulectomy with endoscopic electric cauterization, endoscopic electric cauterization or endoscopic coblation cauterization, respectively. Histopathologic examination of the surgical specimens revealed that they were lined with ciliated epithelium, stratified cuboid epithelium with chronic inflammatory cell infiltration and fibrosis. Voice hoarseness occurred after operation in seven patients, but disappeared 1 week later. PSF recurred in 6 patients, 4 of them were cured by a successful re-excision. One patient was cured by successful endoscopic electric cauterization. The other 1 has remained asymptomatic for 5 months. In our series, mean follow-up period was 13.3 months and median follow-up period was 12.5 months (range 2-40 months). Presence of congenital PSF should be suspected when intra-thyroidal abscess formation occurs as the gland is resistant to infection. Strong clinical suspicion, barium swallow study, CT scan and ultrasound are the key to diagnosis. Both fistulectomy with hemithyroidectomy and endoscopic treatment have comparable success rate. Endoscopic coblation cauterization may prove a useful and equally effective method of treatment for PSF in future.

[Non-autoimmune thyroiditis]. / Tiroiditis no-autoinmunes.

The term thyroiditis comprises a group of thyroid diseases characterized by the presence of inflammation, including autoimmune and non-autoimmune entities. It may manifest as an acute illness with severe thyroid pain (subacute thyroiditis and infectious thyroiditis), and conditions in which the inflammation is not clinically evident evolving without pain and presenting primarily thyroid dysfunction and/or goiter (drug-induced thyroiditis and Riedel thyroiditis). The aim of this review is to provide an updated approach on non-autoimmune thyroiditis and its clinical, diagnostic and therapeutic aspects.

Salmonella thyroiditis: a case report and review of the literature.

Thyroid abscesses are rare, and Staphylococcus aureus is the main causative organism. Abscesses caused by other organisms are even rarer. This report describes a case of salmonella thyroiditis in an HIV-positive patient. Fine-needle aspiration cytology was performed and Salmonella sp. were cultured. The patient was successfully treated with antibiotics and incision and drainage.

[Thyroiditis]. / Thyroïdites.

The diagnosis of thyroiditis encompasses a broad spectrum of thyroid disorders. Analysis of signs and symptoms, biochemical changes, neck ultrasound characteristics and radioactive iodine uptake values allows an accurate diagnosis. Recent studies of the whole genome have helped to identify many susceptibility genes for autoimmune thyroiditis. However, none of these genes contribute to a significant increase in risk of developing this thyroiditis. Clinical awareness of the characteristic presentations of exceptional thyroiditis (acute suppurative thyroiditis, Riedel's thyroiditis) is an important issue. Selenium administration seems to be beneficial for reducing the incidence of thyroiditis. Finally, certain drug-induced thyroiditis remains a therapeutic challenge for the physician.

Acute Suppurative Thyroiditis in Children: Clinical Decision-Making.

Acute suppurative thyroiditis are infrequent infections, although their early and proper management are needed to reduce complications and recurrences. We review the clinical presentation, etiology, clinical outcome and management of 9 cases of thyroid infections diagnosed in children, and analyze the existence of predisposing factors for these infections.

A case report of acute suppurative thyroiditis caused by Clostridium perfringens.

A 42-year-old woman inadvertently discovered a neck mass, which caused pain. Initially, she was treated with antibiotics at a local clinic; however, this treatment did not alleviate the symptoms. She visited the authors' outpatient clinic for further treatment and underwent thyroid ultrasonography, which revealed a mixed echo nodule. On day 4 after admission, surgery was performed to remove the diseased thyroid tissue and levofloxacin (0.4 g/day) was infused. Bacterial culture confirmed infection with Clostridium perfringens. Subsequently, the treatment was switched to ceftriaxone sodium (2 g/day) according to the results of the drug sensitivity test. Following treatment, the patient recovered fully and was discharged. She was then followed up with after discharge. Ultrasonography, laboratory testing and clinical manifestations did not indicate obvious abnormalities.

Thyrotoxicosis as a rare presentation in acute suppurative thyroiditis: a case report.

BACKGROUND: Acute suppurative thyroiditis is a rare and potentially life-threatening disease. A few cases of acute suppurative thyroiditis associated with thyrotoxicosis have been reported in adults. We report a case of acute suppurative thyroiditis that was associated with thyrotoxicosis. CASE PRESENTATION: We report the case of a 49-year-old Iranian female presented with a painful neck swelling for a week. Computed tomography showed a well-defined gas-filled collection in the left thyroid lobe with an enhancing margin. The patient underwent two-phase surgery, first left thyroid abscess drainage and then total thyroidectomy. The result of histopathology examination was multinodular goiter with abscess formation without malignancy. CONCLUSION: Abscess formation and thyrotoxicosis is a very rare condition that occurs at the same time in acute suppurative thyroiditis. Despite antibiotic therapy being the first line of treatment, surgery is also required when antibiotic therapy fails.

[Acute suppurative thyroiditis in a patient with a piriform sinus fistula: A case report]. / Tiroiditis aguda supurada en una paciente con fístula del seno piriforme: presentación de un caso.

Acute suppurative thyroiditis is an infectious disease, uncommon in children, caused by various microorganisms, being bacteria the most frequently involved. The typical presentation includes the appearance of a tumor in combination with signs of swelling in the anterior aspect of the neck, which is painful on palpation and is associated with warmth and erythema. It usually moves with swallowing and the patient can suffer fever, dysphagia or dhysfonia. In children, congenital anomalies can lead to the gland's infection, and the surgical excision of them is important to prevent recurrency. A quick diagnosis, based on clinical manifestations and imaging studies, is necessary to install an adequate antibiotic treatment. We present the case of a 3-year-old patient, who was previously healthy, with a painful left cervical tumor associated with fever. During the hospitalization, we reached the diagnosis of acute suppurative thyroiditis caused by an underlying pyriform sinus fistula.

La tiroiditis aguda supurada es una entidad poco frecuente en pediatría; de origen infeccioso, cuya etiología más frecuente es bacteriana. Su presentación típica en niños es la aparición de una tumoración en la cara anterior del cuello, con signos de flogosis, dolorosa, caliente y eritematosa, que excursiona con la deglución, y puede o no estar acompañada de fiebre, disfagia o disfonía. En niños, las anomalías congénitas, principalmente la fístula del seno piriforme, predisponen a la infección de la glándula, por lo que es importante la resolución quirúrgica del defecto anatómico para prevenir las recurrencias. El diagnóstico rápido, basado en la clínica y los estudios por imágenes, es importante para comenzar en forma temprana con un tratamiento antibiótico adecuado. Se presenta una paciente de 3 años, previamente sana, con tumoración cervical izquierda dolorosa y asociada a fiebre. Durante la internación, se arribó al diagnóstico de tiroiditis aguda supurada secundaria a fístula de seno piriforme.

Management of pediatric head and neck infections in the emergency department.

Head and neck infections can spread to nearby structures, compromising the airway and progressing to life-threatening events. Pediatric head and neck infections can be difficult to recognize; emergency clinicians must know the signs and symptoms of head and neck infections for early diagnosis and urgent management in order to prevent complications and decrease hospitalization rates. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.