Abstract
Pyriform sinus fistula is a rare branchial anomaly that manifests as recurrent cervical infection resulting from contamination of the fistula internal orifice in the pyriform sinus. Although open neck surgery to resect the fistula has been recommended as a definitive treatment, identifying the fistula within the scar is difficult and occasionally results in recurrence. Here, we describe a novel transoral surgical technique for pyriform sinus fistula using transoral videolaryngoscopic surgery (TOVS) as a definitive treatment to resect and close the fistula without skin incision. Needle cautery enables fine excision and delicate dissection of the fistula tract. TOVS is a safe, easy, and reliable treatment and is a suitable first line treatment.
1
Introduction
Pyriform sinus fistula (PSF) is a rare branchial anomaly derived from the congenital remnants of the third or fourth branchial cleft . The chief clinical manifestations are recurrent cervical abscessation and suppurative thyroiditis that are predominantly left sided . Although PSF is usually diagnosed at a young age, most patients have already undergone several rounds of treatment in an attempt to eliminate the cervical abscesses of unknown origin, and as a result, accurate diagnosis tends to be delayed . Recurrent cervical infection is caused by fistula internal orifice, usually at the apex of the left pyriform sinus. The fistula tract descends through the inferior edge of the thyroid cartilage or cricothyroid muscle and terminates at the superior pole of thyroid gland; it rarely terminates at the external opening at skin. The primary treatment for PSF accompanied by acute cervical infection is antibiotics with or without surgical abscess drainage. Further definitive treatment is recommended in patients experiencing recurrent infection caused by residual PSF, namely radical resection of the fistula tract by open neck surgery, sometimes including resection of the terminal portion of the fistula tract at the thyroid gland. However, as most surgeons have experienced, identification of the fistula tract is difficult due to the altered fascial planes and extensive scarring caused by previous abscesses. Consequently, there is a high risk of surgical complication, and failure to close the internal opening at the pyriform sinus ultimately results in recurrence of infection . In contrast, general otolaryngologists are able to easily identify the fistula orifice in the pyriform sinus using direct laryngoscopy. If the PSF can be properly removed and completely closed by transoral surgery, then this surgical strategy may be an ideal minimally invasive treatment with a low risk of complications and cosmetic advantages.
Transoral videolaryngoscopic surgery (TOVS) was originally developed by Shiotani et al. as a minimally invasive transoral surgery for laryngeal and pharyngeal cancer . This technique offers a wide surgical view and working space in the apex of pyriform sinus using rigid videolaryngoscopy combined with distending laryngoscopy and enables free bimanual manipulation of laparoscopic surgical instruments such as needle electrocautery, suction coagulator, and a variety of forceps. These instruments are fine enough for mucosal cutting and dissection of submucosal tissue in hypopharynx.
In this report, we present a novel transoral surgical technique using TOVS to resect and close a PSF.
2
Case report
A 20-year-old woman was referred to our hospital primarily complaining of recurrent cervical infections since 6 years of age. On presentation, she had an abscess in the left neck, and an endoscopic examination and video fluorography revealed a fistula opening at the apex of the left pyriform sinus ( Fig. 1 ). She was diagnosed with an acute infection secondary to PSF and was treated with surgical drainage and antibiotics. Several months after the infection subsided, we recommended definitive treatment of the PSF. Two treatment options were offered: open neck surgery alone or transoral surgery as a primary treatment, with open neck surgery performed only if the transoral surgery proved impossible. The patient chose the latter option; therefore, we planned for a TOVS of the pyriform sinus fistula.
Surgery was performed under general anesthesia with endotracheal intubation. A commercially available endotracheal electromyography (EMG) tube and surface EMG electrodes were placed adjacent to the true vocal cord so that the recurrent laryngeal nerve could be monitored by electrostimulation of the probe (NIM response III; Medtronic Inc.). The patient was placed in a supine position, and a Weerda distending laryngoscope (8588BV; Karl Storz) was inserted to expose the pyriform sinus ( Fig. 2 A ). A surgical assistant held the rigid laryngeal video endoscope, which was connected to a high definition camera set (12067AA and IMAGE 1; Karl Storz; Fig. 2 B), to obtain the surgical view, and the surgeon manipulated the laparoscopic surgical instruments (30710MD, 26870UF and 26167ND; Karl Storz; Fig. 2 C) bimanually while watching the endoscopic view on a monitor. The fistula orifice was clearly visible with the videolaryngoscope ( Fig. 3 A ). The internal fistula orifice was cannulated with an 8-Fr flexible catheter, and the approximate depth of the fistula tract was estimated to be 1 cm. Blue dye (crystal violet solution) was injected as a landmark so that the PSF wall could be easily identified during the procedure ( Fig. 3 B). A circumferential incision was made around the PSF internal orifice using an electrocautery needle (26167ND; Karl Storz; Fig. 3 C), and the fistula wall was dissected away from the submucosal tissue using the blue-stained wall for guidance. Proper dissection layer was confirmed by gently cutting loose connective tissue without charring. Lateral edge of thyroid cartilage was identified by endoscopic vision and palpation. The caudal end of the fistula was pursued to the hypopharyngeal constrictor muscle posterior to the inferior cornu of the thyroid cartilage ( Fig. 3 D). The recurrent laryngeal nerve was monitored through the procedure by NIM response, and the nerve was not observed in the surgical field in this case. The PSF was resected en bloc, and the remaining proximal mucosa was sutured with 5-0 PDS (PDP8251; Ethicon) using a needle holder and knot tier (8660N and 8596T; Karl Storz; Fig. 3 E, F).
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