SPR Unknown # 58 -- FINAL

Hamilton Reavey, M.D.

Kiery Braithwaite, M.D.

Bradley Wyly, M.D.

Emory Department of Radiology and Imaging Sciences and Children’s Healthcare of Atlanta, Egleston Hospital


SPR Unknown # 58, pyriform sinus fistula, branchial apparatus anomaly

Publication Date: 2011-09-21


10 year old with recurrent neck abscesses


CT: There is a mildly enhancing heterogeneous mass with a hypodense center and a thick rim of peripheral enhancement posterior and medial to the left thyroid lobe. Inflammatory changes are seen within the adjacent subcutaneous fat. On coronal images, a line of enhancement extends inferiorly from the left pyriform sinus and connects to this mass.

Barium Esophogram: There is a linear accumulation of contrast communicating with the inferior aspect of the left pyriform sinus and extending inferiorly.


Left pyriform sinus fistula


Pyriform sinus fistula

Thyroglossal duct cyst

A nodule arising from the left thyroid lobe

Suppurative bacterial thyroiditis


Recurrent neck abscess in the superior pole of the thyroid should raise the possibility of a pyriform sinus fistula. A pyriform sinus fistula is a congenital lesion that occurs during embryogenesis along the spectrum of a Branchial cleft anomaly. Branchial anomalies arise from incomplete evolution of the branchial apparatus or from buried epithelial rests. They are classified according to the cleft or pouch of origin. A pyriform sinus fistula is extremely rare and is thought to occur embryologically from a 4th branchial anomaly. A 4th branchial sinus arises from the lowest point of the pyriform sinus and occurs much more commonly on the left side. Some have postulated that this represents a persistent pharyngobrachial duct.

Acute suppurative neck infections associated with branchial fistulas are frequently recurrent unless the fistula is ligated. Ultrasound with color Doppler imaging or a contrast enhanced CT are frequently used imaging modalities for evaluation of neck pathology. A barium esophagram after treatment with antibiotics is more successful in trying to demonstrate the presence of the fistula. Active inflammation or reactive edema may result in closure of the tract. If the study is to be successful, the existing infection must be cleared by appropriate antibiotics.

Treatment involves surgical resection of the fistula, adjacent scar tissue, and a portion of the thyroid gland when the fistula is attached.


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4 images