10.14639/0392-100X-N1433
Objective. To 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.Methods. Over 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.Results. The 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.Conclusions. Endoscopic 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.
text/xml
1827-675X
1433
en
Neil K. Chadha
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
carboxymethylcellulose
Endoscopic cauterisation and injection of Voicegel for treatment of congenital pyriform fossa sinus tracts
Text.Serial.Journal
https://www.actaitalica.it/
41
Laryngology
2021-11-05
2021-01-31
2021-11-02
2021-11-02
432-435
1
Neil K. Chadha
2021/11/05
10.14639/0392-100X-N1433
432
2 Division of Pediatric Otolaryngology-Head and Neck Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada
1827-675X
carboxymethylcellulose
435
Endoscopic cauterisation and injection of Voicegel for treatment of congenital pyriform fossa sinus tracts
https://www.actaitalica.it/article/download/1433/678
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:432-435; doi: 10.14639/0392-100X-N1433




Laryngology


Endoscopic cauterisation and injection of Voicegel
for treatment of congenital pyriform fossa sinus tracts
Trattamento delle fistole congenite del seno piriforme mediante cauterizzazione
endoscopica e iniezione di Voicegel
Roy Hod1,2, Sophie Lachance2,3, Neil K. Chadha2,4
1
  Department of Pediatric Otolaryngology, Schneider Children’s Medical Center of Israel, Petach Tiqwa, Israel; 2 Division of Pediatric
Otolaryngology-Head and Neck Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada; 3 Département d’Oto-rhino-
laryngologie et chirurgie cervico-faciale, CHUL, CHU de Québec, Québec, Canada; 4 University of British Columbia, Vancouver,
British Columbia, Canada


SUMMARY
Objective. To 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.
Methods. Over 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.
Results. The 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                   Received: January 31, 2021
was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one                 Accepted: April 15, 2021
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             Correspondence
injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean           Roy R. Hod
follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence               Department of Pediatric Otolaryngology-Head and
at the last follow-up visit. No post-operative complications were reported.                            Neck Surgery, Schneider Children’s Medical Center
                                                                                                       of Israel, 16 Kaplan Street, Petach Tiqwa, 49300
Conclusions. Endoscopic management of paediatric PFST combined with the injection of
                                                                                                       Israel
sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effec-           Tel. +97 239253367
tive treatment option for PFST.                                                                        E-mail: royhod@gmail.com
KEY WORDS: piriform fossa sinus tract, endoscopy, cauterisation, carboxymethylcellulose
                                                                                                       Funding
                                                                                                       None.
RIASSUNTO
Obiettivo. Descrivere la nostra esperienza nel trattamento delle fistole congenite del seno piri-      Conflict of interest
forme (PFST) utilizzando una nuova tecnica di cauterizzazione endoscopica del seno piriforme           The Authors declare no conflict of interest.
ed iniezione di gel di sodio carbossimetilcellulosa (VoiceGel) per favorire la chiusura del tramite.
Metodi. Per un periodo di 48 mesi, abbiamo utilizzato questa tecnica su undici bambini a                 How to cite this article: Hod R, Lachance S,
cui è stata diagnosticata la PFST al BC Children’s Hospital, un centro pediatrico terziario              Chadha NK. Endoscopic cauterisation and in-
di Vancouver, BC, Canada.                                                                                jection of Voicegel for treatment of congeni-
Risultati. Il gruppo di bambini includeva 8 maschi e 3 femmine, l’età media era di 69 mesi               tal pyriform fossa sinus tracts. Acta Otorhi-
(range 22-108 mesi). Il tempo medio dall’inizio dei sintomi fino alla diagnosi è stato di                nolaryngol Ital 2021;41:432-435. https://doi.
15 mesi (range 12-22 mesi). Dieci PFST erano sul lato sinistro del collo e uno a destra. 9               org/10.14639/0392-100X-N1433
pazienti soffrivano di infezioni ricorrenti del collo e due avevano tiroidite suppurativa. Tutti
i pazienti sono stati trattati mediante cauterizzazione endoscopica ed iniezione di carbos-            © Società Italiana di Otorinolaringoiatria
                                                                                                       e Chirurgia Cervico-Facciale
simetilcellulosa per cicatrizzare il tratto fistoloso. Il follow-up medio è stato di 15,8 mesi
(range 8-24). Tutti i pazienti sono asintomatici, senza recidive al follow-up. Non sono state
                                                                                                                      OPEN ACCESS
riportate complicanze postoperatorie.
Conclusioni. Il trattamento endoscopico della PFST pediatrica combinata con l’iniezione                This is an open access article distributed in accordance with
                                                                                                       the CC-BY-NC-ND (Creative Commons Attribution-Non-
di gel di carbossimetilcellulosa di sodio sembra essere un’opzione terapeutica sicura ed               Commercial-NoDerivatives 4.0 International) license. The
efficace per le PFST.                                                                                  article can be used by giving appropriate credit and mentio-
                                                                                                       ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: seno piriforme, fistole del seno piriforme, endoscopia, cauterizzazione,                only in the original version. For further information: https://
carbossimetilcellulosa                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




432
                                                                                Endoscopic treatment for branchial clefts - a novel technique




Introduction                                                       tract in the piriform fossa via an endoscopic approach. It is
                                                                   thought that by closing the opening in the piriform fossa,
Piriform Fossa Sinus Tracts (PFST) are unusual anomalies
                                                                   the source of infection will effectively be cut off. This per-
thought to be of branchial pouch origin. They were first           mits avoiding the need for an open procedure altogether 10.
described in 1972 by Sandborn and Shafer 1. They account           Our aim was to present our initial experience of eleven
for less than 2% of all branchial arch defects 2. Most of          patients with PFST who were treated by endoscopic elec-
the literature suggests that they are remnants of the third        tro-cautery combined with injection of sodium carboxym-
and fourth branchial pouches 3-5. The pouch of origin is           ethylcellulose gel (Voicegel) lateral to the sinus tract. This
determined by the relationship of the tract to the superior        appears to be a safe and effective technique with excellent
laryngeal nerve: if it passes superior to the nerve a third        results. To the best of our knowledge, this technique has not
pouch is suspected, whereas if it lies between the superior        been previously described in the literature.
and recurrent laryngeal nerves a fourth pouch is implied 3.
It is difficult to clinically differentiate between third and
fourth branchial pouch remnants, even on surgical explora-         Materials and methods
tion. An internal opening, usually in the left piriform fossa,     Between 2013-2017 we diagnosed and treated 11 patients
is a fairly constant feature of both; thus, the term piriform      with PFST using the described surgical technique. For all
fossa sinus tract is preferred 6. It usually presents as recur-    11 patients this was the primary treatment. There were 8
rent deep neck infections or suppurative thyroiditis, as the       males and three females. Mean age at presentation was 69
tract often ends in one of the thyroid lobes. It is thought that   months (range 22-108 months). Mean time from beginning
seepage of pharyngeal content into the tract is what leads to      of symptoms until diagnosis was 15 months (12-22). Ten
suppuration in the neck.                                           PFST were on the left side of the neck and one on the right.
PFST present most commonly in the paediatric population            Nine patients had presented with recurrent neck infections,
and are overwhelmingly more prevalent on the left than on          and the remaining two had suppurative thyroiditis. All pa-
the right 4. Patients will often have had multiple infective       tients underwent the described endoscopic cauterisation
exacerbations and/or emergency incision and drainage pro-          of their PFST opening combined with injection of sodium
cedures before a definitive diagnosis is made.                     carboxymethycellulose lateral to the sinus tract to cause
Computed tomography (CT) and magnetic resonance im-                its collapse. Mean follow-up was 15.8 months (8-24), all
aging (MRI) showing an inflammatory neck mass closely              patients are asymptomatic at last follow up visit. No post-
associated with the thyroid can aid in diagnosis and de-           operative complications were reported.
termining the extent of the lesion. Barium contrast swal-          The study protocol was approved by the Ethics Committee
low study can also give information regarding a diagnosis          of BC Children’s hospital and was carried out in accord-
of PFST with a positive predictive value of 100%. Direct           ance with the principles of the Declaration of Helsinki (ap-
laryngoscopy of the pyriform fossa plays an integral role          proval process: 12876).
in conclusive diagnosis and should always be conducted
when a PFST is suspected.                                          Surgical technique
Although the presentation and methods of investigating             All surgical procedures were performed under general an-
PFST have been well described, their treatment remains             aesthesia and after informed consent was obtained. The pa-
controversial. Traditionally, complete open excision of the        tient was taken to the operating room and was placed in the
sinus tract with or without hemithyroidectomy has been             supine position for intravenous induction of general, spon-
advocated in order to prevent recurrence 7-9. This can be          taneous ventilation anaesthesia by the anesthesiologist.
technically challenging, however, with a significant risk of       Topical lidocaine 2% was then sprayed (according to the
damage to neurovascular structures, especially in a neck           patient’s weight) on the larynx via a Miller laryngoscope
previously exposed to multiple inflammatory episodes as            in order to prevent laryngospasm. Dental protection was
a consequence of repeated infection and/or drainage pro-           used. Once adequate depth of anaesthesia was obtained, a
cedures. Moreover, recurrent suppuration may still occur           direct laryngoscopy and examination of the hypopharynx
even after extensive surgery 10.                                   with a 0°, 4-mm, Hopkins-rod telescope (Karl Storz En-
With time, it has became apparent that recognising and             doskope, Tuttlingen, Germany) was performed to try and
addressing the internal opening helped in successful open          identify the internal opening of the piriform sinus tract.
surgical management and guiding the dissection 1. An alter-        If the sinus opening was confirmed (Fig. 1), suspension
native approach to management, originally reported by Jor-         laryngoscopy with an appropriate-sized Parsons laryngo-
dan et al. 11 is ablation of the internal opening of the sinus     scope was performed (Karl Storz Endoskope, Tuttlingen,



                                                                                                                                       433
R. Hod et al.




Figure 1. Piriform fossa sinus opening before cauterisation.    Figure 2. Piriform fossa sinus opening post cauterisation.


Germany). A 3 French Bugbee monopolar cautery (Richard
Wolf, Vernon Hills, Illinois, USA) is then advanced into
the opening and tract to try and measure its depth. After
measuring the depth, the same tip is again advanced into
the opening and coagulation starts on 5 W and increased if
necessary. Cauterisation is performed starting from deep to
superficial finishing by cauterising the opening of the sinus
itself (Fig. 2). Subsequently, 0.5-1 CC of sodium carboxy-
methylcellulose aqueous gel (Radiesse Voice Gel; Bioform
Medical Inc, San Mateo, California, USA) is injected using
the provided laryngeal syringe and needle, just lateral and
anterior to the PFST opening in order to make the tract col-
lapse (Fig. 3). The injection is performed to pull the tissue   Figure 3. Piriform fossa sinus opening post cauterisation and injection.
around the piriform opening causing the tract to collapse,
so the newly de-epithelialised tract is more likely to scar
                                                                weeks after initial presentation prior to getting the study.
closed, as opposed to remaining as a tubular opening al-
                                                                Although a positive barium swallow study will confirm the
lowing gradual re-epithelialisation. At the end of the injec-
                                                                diagnosis, a negative one will not rule it out and requires
tion, a neuropatty with epinephrine is temporarily placed
                                                                direct endoscopic examination of the hypopharynx if the
on the PFST opening for haemostasis, and once achieved
                                                                index of suspicion is high 5. CT and MRI scans can depict
removed before the patient is awakened. The patient can be
                                                                inflammatory infiltration or an abscess along the course of
discharged on the same day with a prescription of one week
of oral antibiotic therapy, a recommendation of a soft diet     the sinus tract from the piriform fossa to the thyroid gland,
and avoidance of the Valsalva manoeuver.                        but are not used as a standard diagnostic tool 6. Complete
                                                                surgical excision of the tract has been the standard treat-
                                                                ment in the literature. Intraoperative rigid hypopharyngos-
Discussion                                                      copy can facilitate ligation of the tract in the pharynx. Thy-
Suppurative thyroiditis and recurrent lateral neck infections   roid lobectomy with isthmectomy is controversial, but is
are uncommon conditions in the paediatric age group and         recommended to assist with preservation of the recurrent
should arouse suspicion of a piriform fossa sinus tract 4.      laryngeal nerve and to reduce the risk of recurrence when
The literature suggests that some patients can remain           involved thyroid tissue is removed 7-9. Care must be taken
asymptomatic for many years, often leading to misdiagno-        to avoid injury to the recurrent laryngeal nerve, which may
sis at initial presentation.                                    be difficult to identify due to scarring from prior infections
Previous studies have emphasised the need for direct visu-      and operative procedures 4. Other surgical modalities, such
alisation of the internal opening of the tract to confirm the   as aspiration or incision and drainage, have been shown to
diagnosis 1-4. Barium swallows are part of the diagnostic       have increased risk of recurrence and complications such
work-up, but are unlikely to show the tract until the acute     as haemorrhage, wound infection, cranial nerve injury and
event has subsided. Most authors recommend waiting 4-6          airway obstruction. A study by Jordan suggested that the



434
                                                                                   Endoscopic treatment for branchial clefts - a novel technique




piriform sinus tract partially obliterates itself following an    ease of this endoscopic management of piriform fossa sinus
acute infection 10. In their series and subsequent follow-up      tracts combined with the low associated morbidity make it
evaluation, it was found that endoscopic electro-cauteri-         relatively easy to recommend. As with open excision, re-
sation was an effective alternative to open excision, with        currence can occur.
no patients having a recurrence of a neck mass 10,11. Other       There are a few limitations to our study, the study popula-
endoscopic methods of tract closure have been described,          tion is small and the follow-up period is short (mean 15
such as chemical cautery using trichloroacetic acid, sealing      months), although we would expect recurrence to occur
with fibrin glue and laser coagulation 8-10.                      shortly after the surgical procedure.
Endoscopic approaches offer many advantages over open             Based on our limited preliminary experience, this appears
procedures, including decreased risk to the laryngeal             to be a very safe and effective way of dealing with these
nerves, oesophagus, trachea and large vessels (internal jug-      anomalous tracts of the piriform fossa.
ular vein and carotid artery).
Although the results after endoscopic cauterisation appear
to be promising, complete closure of the tract after the pro-     References
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