| Background:A Congenital Pyriform Sinus Fistula (CPSF) is generally regarded as the remnant of the third and fourth branchial pouches and clefts or the result of a rupture of the interposed branchial plate. Over 90% of CPSF have been reported to occur on the left side of the neckl, which may be explained by the arch’s asymmetric pattern of growth, the diminished growth of an ultimobranchial body on the right side or the disturbed migration of C cells 13 during the early stages of embryonic development. Over 80% of patients are symptomatic during the first decade of life, without gender predominance.A fistula generally originates from the apex or the bottom of the pyriform fossa, penetrates the cricothyroid muscles or the inferior pharyngeal constrictor muscle and terminates in a lobe of the thyroid gland or passes through a lobe to the root of the neck. Common presentations include recurrent cervical swelling, pain or an external opening with purulent discharge at the anterior border of the middle or lower third of the sternocleidomastoid muscle, and these presentations were secondary to upper respiratory infections in most of the cases, with or without upper respiratory tract infections. A CPSF can be clinically classified as a sinus, i.e., a blind-ending tract that opens to either the pyriform fossa or the skin, a fistula, which is a tract connecting the pyriform fossa and the skin, or a cyst, which is open to neither. A sinus CPSF is the most commonly encountered, whereas a fistula may develop after the iatrogenic or spontaneous rupture of a cervical abscess.Further confirmation of an internal orifice in the pyriform fossa through suspension laryngoscope or esophagoscopy is the diagnostic gold standard for CPSF. But endoscopy procedure should be implemented under general anesthesia, the preliminary diagnosis of the disease by preoperative imaging studies are important. Ultrasound depicted the neck abscesses; BSX can reveal the existence of a sinus tract in the pyriform fossa, but the positive diagnostic rates was only 50～80%; Both MRI and CT can identify a tract between the internal orifice and the neck mass or infection. Although there were foreign studies to analyze the imaging signs of CPSF, there was little image study in mainland. This study will summary the image features (barium swallow X-ray, CT and MRI) and diagnostic value of CPSF.During the acute infection phase, intravenous antibiotics should be used, and incision and drainage procedure should be preform if necessary. Nicoucar et. had a study on 100 patients with CPSF neck abscess secretion culture and drug susceptibility test of bacteriology, bacteria spectrum infectious pathogens for hemolytic streptococcus, staphylococcus aureus, flu bloodthirsty bacillus coli, klebsiella pneumonia from oral and upper respiratory tract, which were sensitive to penicillin or B-lactam enzymes antibiotic resistance. Most studies describing CPSF have focused on the diagnosis and surgical treatment of these lesions, however, there’s little about the microbiology, and the sample size is relatively small. There’s no guideline of antibiotic treatment in mainland. In the present study, we collected the pus of CPSF, report our experience in the identification of pathogens responsible for these recurrent infections and discuss the clinical antibiotic treatment.Surgical excision of the anomalous tract is generally accepted to be the treatment of choice. But the lesion is close to the recurrent laryngeal nerve, the thyroid gland, and the carotid sheath,which is risky and difficult to completely remove a tract. The most frequent complication described in the literature was permanent vocal-cord paralysis, occurring in 3.71% to 33% of cases. The recurrence rate following traditional surgery ranges from 0% to 35.0%.Although many literatures have put forward the significant advantages of endoscopic surgery, but whether endoscopic surgery is suitable for all cases? For the recurrent cases, which kind of surgery should be choosing? The short term Endoscopic surgery in curative effect of ECLC is certain, but lack of prospective studies.Part Ⅰ Comparative Imaging study of congenital pyriform sinus fistula Objective:Investigate the image feature and diagnostic value of CPSF.Method:We retrospectively analyzed the clinical features and preoperative images of 100 patients with confirmed diagnosis of CPSF by surgical and pathological outcome in Guangdong General Hospital from January 2007 to December 2015. At least one of the following imaging examinations were perform for all the patients, including Barium Swallow X-ray (BSX), computed tomography (CT) and magnetic resonance imaging (MRI). Among them,63 patients were examined with BSX, while 42 patients underwent plain and enhanced CT scans, wherein forty of them were exanimated shortly after BSX. Thirty-two patients underwent plain and enhanced MR scans. Patients were grouped into young age (<14 years old) and older age (>14years old). Furthermore, they were grouped based on inflammatory or quiescent stage. The images of BSX, CT, and MRI from the patients were analyzed and the positive diagnostic rates (PDR) between groups were compared by using x2 tests.Result:For the patients examined with BSX, sinuses in 53 of 83 were depicted from pyriform and fistulas in 9 of 83 were depicted from the pyriform. The overall PDR of BSX was 74.7%(62/83),wherein 44.4% in young age group,95.7% in older age group,52.0% in inflammatory stage group,and 84.5% in quiescent stage group. The inter-group differences are statistically significant (x2:27.54,7.352. both P< 0.05).The PDR of CPSF with CT is 86.5%(45/52), BSX+CT is 96.0%(48/50), MRI is 84.4%(38/45). There was no statistical difference between CT and MRI groups. The courses of fistula or sinus were showed on CT and MRI in most of the cases. The fistula could be depicted more clearly in 48 cases which underwent CT shortly after BSX. The presence of air bubbles at the inferomedial edge of cricothyroid joints or around the upper lobe of the thyroid gland, the changes of the morphology of thyroid grand as well as the inflammation change along the fistula region were detected much clearly on CT and MRI.Conclusion:The diagnosis of image finding should depend on clinical features. We proposed that BSX could be a screening method for suspectable cases in quiescent stage. However, the PDR could be affected by many factors (e.g. age and inflammation). CT and MRI could primarily provide valid clues for diagnosis directly or indirectly, which can also be used in preoperative evaluation, operation guidance and postoperative follow-up. An examination combined BSX and CT is preferred to improve the PDR of CPSF.Part Ⅱ Clinical infectious bacterium spectrum of congenital pyriform sinus fistulaObjective:To identify the most common pathogens involved in infections of CPSF.Method:We collected from January 2010 to December 2015, who with deep neck infection, imaging finding depicted patients with suspected as CPSF. Specimens were collected from abscesses or other inflammatory lesions in all patients through a small incision or the external orifice on the skin of the neck. Microbiological specimens were obtained at the initial incision and drainage procedures. The samples were inoculated in blood agar, chocolate and Sabouraud flat plate, cultured for 24～ 48h in the incubator at 37 ℃ then observed, identification and testing the susceptibility. With VITEK-2 compact bacterial identification instrument (BioMerieux, France) and GN, GP, YST identification card to identify the bacteria species, and AST-GN13, AST-GP67 for susceptibility testing, fungal susceptibility test ATB FUNGUS 3 is detected. Determined resistance according to the CLSI (2014 edition) standard.Result:65 patients were confirmed as CPSF by endoscopic procedure. Among the bacteria recovered,35 samples were aerobic bacteria,9 samples were mixed bacteria, 21 samples were failed to cultivate bacteria. Among them, G+ coccus included Streptococcus (9/35,22.9%), Staphylococcus aureus (6/35,17.1%),1 case of Methicillin-resistant Staphylococcus aureus (MRSA), Streptococcus pneumoniae (4/35,11.4%); G-bacillus included Klebsiella pneumoniae (7/35,20.0%), Haemophilus influenzae (3/35,8.6%), Pseudomonas aeruginosa bacteria (3/35,8.6%), Proteus (2/35,5.7%), Escherichia coli (1/35,2.9%). Streptococcus mitis was the most common species isolated from pediatric patients, being found in 7 (7/37,18.9%) of the 37 pediatric patients whose bacteriological culture results could be retrieved; staphylococcus aureus was isolated from 4 patients (4/37,10.8%); streptococcus pneumoniae was isolated from 3 patients (3/37,8.1%)). klebsiella pneumoniae was the most common species isolated from non-pediatric patients, being found in 5 (5/28,17.9%) of the 28 pediatric patients; Streptococcus viridans, staphylococcus aureus, streptococcus pneumoniae respectively 7.1% (2/28) for each.Gram positive coccus was sensitive to Linezolid, Quinupristin/Dalfopristin Syncercid and vancomycin. Klebsiella pneumoniae was sensitive to Cefoperazone/sulbactam, Piperacillin/Tazobactam and imipenem.42 patients (42/65, 64.6%) used amoxicillin and clavulanate potassium,23 patients (23/65,35.4%) using a second-generation cephalosporin.21 patients (21/65,32.3%) used metronidazole. 48 cases (48/65,73.8%) patients used corticosteroids to strengthen anti-inflammatory treatment. Operation was arranged 1 to 2 months after the inflammation period.Conclusion:Deep neck infection may occured secondary to CPSF. Streptococcus mitis was the most common species isolated from pediatric patients; klebsiella pneumoniae was the most common species isolated from non-pediatric patients. Pure aerobes, such asstreptococci or staphylococci, were typically treated withβ-lactam antibiotics or with β-lactamase-resistant antibiotics or β-lactamase inhibitors. Klebsiella, Pseudomonas aeruginosa, Escherichia coli, or Haemophilus species were typically treated with second-or third-generation cephalosporins. Mixed cultures should treate with sensitive antibiotics in combination with clindamycin or metronidazole.Part III Endoscopic CO2 laser cauterization for treatment of congenital pyriform sinus fistulaObjective:To evaluate the feasibility, advantages and disadvantages of endoscopic CO2 laser cauterization (ECLC) as a treatment of congenital pyriform sinus fistula (CPSF).Method:26 patients who diagnosed as sinus type of CPSF were confirm by endoscopic procedure and then underwent ECLC between January 2011 to December 2015 at Department of Otorhinolaryngology Head and Neck Surgery, Guangdong General Hospital. The inclusion criteria were as follows:untreated patients who had not had open surgery previously were included. The exclusion criteria were as follows: patients who had previously undergone open neck surgery or had obvious neck scars were excluded. There were 11 males and 15 females; 24 lesions located in the left side and 2 located in the right, aging from 2 to 672 months (median62 months).11 patients presented as deep neck abscess,5 patients presented as neck cellulitis,10 patients presented as acute suppurative thyroiditis; 15 patients had an upper respiratory infection before the initial symptoms occurred. Preoperative examinations included a barium swallow X-ray (BSX), a computed tomography (CT) scan, magnetic resonance imaging (MRI) etc. During the acute infection phase, patients used antibiotics, and underwent the incision and drainage procedure if necessary. In the quiescent period, the internal openings of CPSF were confirmed by suspension laryngoscopy, and then ECLC on internal opening was routinely performed. Endoscopic procedure was carried out 3 months later in every patient, ECLC will be performed if the internal opening is not complete closed.Result:In five patients, incompletely closed orifices were identified and re-cauterized more than two times wherein one children and one adult felt plain and underwent the antibiotic treatment, and the other patient were without clinical symptoms. No complications such as hoarseness, coughing occurred with the endoscopic procedure. All the patients had no recurrence from 4 to 29 months (median 15 months).Conclusion:The ECLC is safe, minimally invasive effective, cosmetic, repeatable, and the recurrent rate will not higher than fistulectomy, which can be suggested a first-line treatment for sinus type of CPSF. |
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