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.

A pain in the neck: Salmonella spp. as an unusual cause of a thyroid abscess. A case report and review of the literature.

BACKGROUND: Thyroid gland infections are rare. Their incidence is estimated to be less than 1% in immunocompromised hosts. Most common pathogens isolated are Gram positive aerobic cocci. Infections with Gram negative facultative aerobes such as Salmonella are rare. CASE PRESENTATION: A 55-year-old female with type II diabetes mellitus and a history of a colloid right thyroid lobe nodule presented with neck pain and fever. She was found to have a thyroid abscess 2 weeks following a non-specific diarrheal illness. A needle aspiration for symptomatic and diagnostic purposes was performed. Cultures grew Salmonella enterica serotype Heidelberg. She was treated with a 12-week course of oral antibiotics and serial aspiration. CONCLUSION: A thyroid abscess is a rare occurrence; however, a high index of suspicion is required to make the diagnosis. The management is directed at minimizing morbidity. The mainstay treatment is medical, but surgery is sometimes necessary to achieve adequate source control, particularly when complications arise.

Congenital Pyriform Sinus Fistula: Management of an Extra-Delayed and Atypical Case.

Clinical presentations of pyriform sinus fistulas vary, and this sometimes leads to a delay in diagnosis and treatment. Recently, we experienced a case of recurrent cervical abscesses occurring after thyroidectomy in an adult affected by a bifidus pyriform sinus fistula. The diagnostic dilemma was related to the timing of events, with a single episode of acute suppurative thyroiditis having occurred 16 years before the onset of the more recent clinical scenario. An endoscopic approach allowed effective management of this clinical case.

Endoscopic electrocauterization of pyriform sinus fistula.

To determine the efficacy of endoscopic electrocauterization for pyriform sinus fistula (PSF) using a flexible Bugbee cautery electrode. From 2009 to 2016, a total of eight patients with acute suppurative thyroiditis or cervical abscess secondary to PSF were retrospectively registered in our study (three males, five females; median age 6.5 years). All patients underwent endoscopic electrocauterization as treatment for PSF. Six of eight patients had no recurrence after the initial endoscopic electrocauterization of PSF. One patient with recurrence developed symptoms 9 days after cauterization and another experienced recurrence after 2 years. Mean follow-up for the eight patients was 50 months (range 5-96 months). No post-operative complication was reported. Endoscopic electrocauterization appears to be a less-invasive, safe, and effective method for the treatment of PSF.

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.

Acute suppurative thyroiditis following fine-needle aspiration biopsy in an immunocompetent patient.

The thyroid gland is remarkably resistant to infectious agents owing to several protective mechanisms. Acute suppurative thyroiditis after fine-needle aspiration (FNA) in an immunocompetent patient is very rare. We report the case of a 50-year-old immunocompetent male patient who presented with painful cervical swelling, fever, and chills after an FNA of the thyroid. His physical and laboratory examination suggested an acute suppurative thyroiditis. Repeat FNA results were consistent with thyroid abscess. Physicians should be aware of the probability of acute bacterial thyroiditis after FNA.

[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.

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 Due to Acute Suppurative Thyroiditis in a Pediatric Patient: A Case Report.

Acute suppurative thyroiditis is a rare and potentially life-threatening cause of thyroid inflammation requiring prompt recognition and management. There are few reported cases of thyrotoxicosis due to acute suppurative thyroiditis. We are reporting the case of a 9-year-old boy who presented to the emergency room with fevers, neck pain and swelling, night terrors, and emotional lability. He was hemodynamically stable with initial lab work remarkable for neutrophilia without leukocytosis, elevated inflammatory markers, and hyperthyroidism. Imaging of the neck revealed a heterogenous collection in the region of the left thyroid concerning for suppurative thyroiditis and adenitis. He was admitted to the hospital and initiated on intravenous antibiotics. Given lack of significant improvement in pain, he was taken to the operating room for drainage on hospital day 4 with remarkable clinical improvement in pain. He was discharged on oral antibiotics. Lab work obtained on postoperative day 15 showed resolution of hyperthyroidism and decreasing inflammatory markers. Subsequent imaging following resolution of the acute illness did not reveal any anatomic abnormality that may have predisposed him to developing acute suppurative thyroiditis. Thyrotoxicosis as a complication of acute suppurative thyroiditis is a rare occurrence, and is thought to be due to the release of preformed thyroid hormone from damaged thyroid follicles. The thyrotoxic state is often transient and resolves with appropriate management of acute suppurative thyroiditis. This complication is important to recognize, as failure to appropriately diagnose and treat acute suppurative thyroiditis can lead to poor outcomes, such as airway compromise and death.

Acute suppurative thyroiditis due to pyriform sinus fistula: a case report.

Congenital pyriform sinus fistula is an unusual developmental abnormality, but it is the most common cause of acute suppurative thyroiditis or recurrent lateral neck infection in pediatric group. It is often overlooked because of poor diagnostic roles. Further investigations are important for diagnosis and evaluation. The authors herein present a case of pyriform sinus fistula and diagnostic roles to confirm the diagnosis.

Acute suppurative thyroiditis with thyroid metastasis from oesophageal cancer.

Not required for Clinical Vignette.

Aspiration with or without lavage in the treatment of acute suppurative thyroiditis secondary to pyriform sinus fistula.

Objective There is currently no consensus regarding the optimal management of acute suppurative thyroiditis (AST) secondary to pyriform sinus fistula (PSF). To investigate the benefits and adverse events of aspiration with or without lavage for the treatment of AST secondary to PSF. Subjects and methods This was a retrospective analysis of consecutive patients with AST secondary to PSF who were admitted at the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University between August 2012 and December 2018. Clinical information, procedural data, and imaging data were analyzed. Results Seven patients (five women; mean age, 16.9 ± 6.3 years; range, 8-26 years) were included. The patients most presented with anterior neck pain and swelling (n = 7), fever (n = 7), or odynophagia (n = 5). Six cases of AST occurred on the left side of the thyroid and 1 on the right. All patients had thyroid abscess. AST was diagnosed by ultrasound-guided needle aspiration cytology in all cases. PSF was diagnosed during the inflammatory stage in five patients and during the quiescent stage in two. All patients were treated with empiric antibiotics. Needle aspiration without lavage was performed in three cases. Needle aspiration with lavage was performed in four cases. Repeat aspiration was performed in three cases. All patients recovered completely, with no procedure-related complications. During 18.3 ± 7.8 months of follow-up, AST recurred in one case. Excision of the PSF was performed in another case. Conclusion Ultrasound-guided aspiration with or without lavage had a good treatment effect and without adverse events for the management of AST secondary to PSF.

Acute suppurative klebsiella thyroiditis: a case report.

Acute suppurative thyroiditis and thyroid abscess are extremely rare disorders. The most common pathogens causing acute suppurative thyroiditis are Gram-positive bacteria, including staphylococcal and streptococcal species. Thyroid abscess is mostly located in the left thyroid lobe. We report the case of a 75-year-old female patient with acute suppurative thyroiditis and right lobe thyroid abscess caused by Klebsiella spp. The patient had a firm, livid, hardly mobile cervical swelling. Axial computed tomography image showed soft-tissue swelling, an abscess in the right thyroid lobe and swelling of the thyroid gland. The diagnosis was established on a smear culture result. The patient was diabetic and had been operated on for goitre fifty years before. On indirect laryngoscopic examination, the patient was found to have right vocal cord paralysis. Infection and abscess resolved following surgical drainage and treatment with intravenous antibiotics, while the vocal cord paralysis persisted. Diabetes mellitus and previous thyroid surgery, in which sutures were used with unresorptive material, might have been the precipitating factors for the patient to acquire this unusual infection.

Suppurative thyroiditis in children: a management algorithm.

OBJECTIVE: To elucidate the etiology of suppurative thyroiditis in children and recommend a management algorithm. METHODS: Case series of 5 pediatric patients with a diagnosis of suppurative thyroiditis seen between January 1999 and April 2007. RESULTS: All 5 patients primarily presented with left-sided intrathyroidal abscesses. The number of infections from first presentation to the time of definitive diagnosis ranged from 1 to 5. Three patients underwent incision and drainage of the abscess once, and 2 had the procedure performed 3 times. Barium swallows identified a piriform sinus tract on the left side in 2 of the 5 patients. Telescopic hypopharyngoscopy identified the internal opening in all 5. Three were managed with complete excision of their tracts and 2 with cauterization of the internal opening with silver nitrate. All 5 are currently asymptomatic. CONCLUSIONS: Suppurative thyroiditis is a very rare infection in children. A left-sided intrathyroidal abscess should immediately arouse suspicion of a piriform sinus tract. Barium swallows may identify the etiology in some cases. Definitive diagnosis requires a hypopharyngoscopy, with detailed telescopic examination of the left piriform fossa apex. Endoscopic chemical cautery of the internal opening is a safe and effective technique, with very low morbidity, and has the potential for cure.

[A toddler with a rare complication of scarlet fever]. / Een peuter met een zeldzame complicatie van roodvonk.

BACKGROUND: Haemolytic group A streptococci (GAS) are the most common bacterial cause of infection in the Netherlands. These bacteria can cause many different non-invasive infections, including scarlet fever. CASE DESCRIPTION: A two-year-old girl presented with fever, tachycardia, exanthema and swelling in the neck. On suspicion of scarlet fever with neck phlegmon we treated her with antibiotics and supportive therapy. Blood and throat cultures revealed growth of haemolytic GAS. Lab tests revealed mild hyperthyroidism and neck ultrasound revealed an inhomogeneous appearance of the thyroid. We diagnosed her with 'infectious thyroiditis', a rare complication of infection with haemolytic GAS. A fistula from the pyriform sinus could not be demonstrated. CONCLUSION: Although GAS infections are common, complications such as thyroiditis are rare. When a paediatric patient is diagnosed with infectious thyroiditis, a fistula from the pyriform sinus should be considered. Patients with such a congenital malformation have an increased risk of recurrent infectious thyroiditis and thyroid abscess formation.

Papillary thyroid carcinoma presenting as acute suppurative thyroiditis: A case report and review of the literature.

Acute suppurative thyroiditis is a rare, potentially life-threatening condition. We report the case of a 17-year-old male who initially presented with a thyroid abscess. Due to persistent symptoms and lack of evidence for underlying predisposing factors, he was followed closely and subsequently diagnosed with papillary thyroid cancer. He was successfully managed with surgery. His clinical course, radiological evaluation, and pathology reports are presented here along with a review of the literature. This case of papillary thyroid cancer highlights the need for close follow-up of patients presenting with a thyroid abscess, when other predisposing risk factors are not evident.

Acute suppurative thyroiditis with deep neck infection: a case report.

Thyroid gland suppuration is a rare condition with nonspecific features. For this reason, diagnosis is often delayed, which may lead to a life-threatening situation. Causative agents are often gram-positive bacteria, such as Staphylococcus aureus and Streptococcus pneumoniae. With appropriate antibiotics and drainage of the abscess, the prognosis is usually excellent. Herein, we describe a unique case of acute suppurative thyroiditis in an adult male presenting with nonspecific sore throat after a fish bone injury to the throat. The patient had a history of essential hypertension and gouty arthritis. In the emergency room, fever, chills, and neck swelling were noted. Thyroid echo and computed tomography of the neck revealed the thyroid abscess with deep neck infection. The culture of the abscess showed Streptococcus viridans. He recovered gradually after parenteral antibiotics and surgical intervention.

Citrobacter freundii as a cause of acute suppurative thyroiditis in an immunocompetent adult female.

Acute suppurative thyroiditis (AST) is an uncommon condition, in the patients with preexisting thyroid disease or immunosuppression. The most common cause of AST is bacterial, and the most common bacteria are Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, and Klebsiella species. Due to various complications such as septicemia, septic thrombophlebitis, necrotizing mediastinitis, or pericarditis, prompt diagnosis and treatment are the keys to reduce mortality and morbidity. Here, we describe a case of a 40-year-old female with AST caused by Citrobacter freundii. This is the first case report of isolation of this bacterium from AST in the world. It is important to differentiate AST from subacute thyroiditis, which is far more frequent and runs a more prolonged course. Various risk factors which predispose to this condition include structural abnormality in the thyroid gland or thyroid disease and immunocompromised state. The route of infection may be either hematogenous or lymphatic seeding. With the increase in number of immunocompromised patients, the cases of AST will increase.