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Thyroid Abscess Associated With Pyriform Sinus Fistula

      A 24-year-old previously healthy man presented with a 3-day history of sore throat, dysphagia, and painful neck swelling. On physical examination, his left anterior neck was swollen and tender. Contrast-enhanced computed tomography of the neck revealed a cystic lesion with enhancing walls and tracheal compression (Figure 1). A diagnosis of thyroid abscess was made. The patient received parenteral antibiotic therapy as well as incision and drainage of the abscess. Pus cultures grew Streptococcus viridans and Prevotella buccae. He improved and was discharged home 10 days later. At 3 weeks after discharge, barium esophagogram was performed and revealed a left pyriform sinus fistula (Figure 2). To prevent recurrence, surgical removal or chemocauterization of the fistula was recommended to the patient, but he refused. At 5-year follow-up, there was no recurrence of the infection.
      Figure thumbnail gr1
      Figure 1Contrast-enhanced computed tomography of the neck revealed a thyroid abscess with tracheal compression (arrow).
      Figure thumbnail gr2
      Figure 2A frontal spot image from barium esophagogram revealed a left pyriform sinus fistula.
      Thyroid abscess is a rare but serious infectious disease. It usually occurs in patients with trauma, invasive procedures, immunosuppression, preexisting thyroid disease, or anatomical anomaly (such as pyriform sinus fistula).
      • Park S.W.
      • Han M.H.
      • Sung M.H.
      • et al.
      Neck infection associated with pyriform sinus fistula: imaging findings.
      • Falhammar H.
      • Wallin G.
      • Calissendorff J.
      Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes.
      • Cha W.
      • Cho S.W.
      • Hah J.H.
      • Kwon T.K.
      • Sung M.W.
      • Kim K.H.
      Chemocauterization of the internal opening with trichloroacetic acid as first-line treatment for pyriform sinus fistula.
      For this reason, a search for anatomical anomaly is required after controlling the acute infection in patients without the apparent causes.
      • Park S.W.
      • Han M.H.
      • Sung M.H.
      • et al.
      Neck infection associated with pyriform sinus fistula: imaging findings.
      ,
      • Falhammar H.
      • Wallin G.
      • Calissendorff J.
      Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes.
      Pyriform sinus fistula is a rare congenital branchial cleft anomaly, more frequent in the left side, and associated with recurrent neck or thyroid infection.
      • Park S.W.
      • Han M.H.
      • Sung M.H.
      • et al.
      Neck infection associated with pyriform sinus fistula: imaging findings.
      • Falhammar H.
      • Wallin G.
      • Calissendorff J.
      Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes.
      • Cha W.
      • Cho S.W.
      • Hah J.H.
      • Kwon T.K.
      • Sung M.W.
      • Kim K.H.
      Chemocauterization of the internal opening with trichloroacetic acid as first-line treatment for pyriform sinus fistula.
      Surgical removal or chemocauterization of the fistula is recommended to prevent recurrent infection.
      • Cha W.
      • Cho S.W.
      • Hah J.H.
      • Kwon T.K.
      • Sung M.W.
      • Kim K.H.
      Chemocauterization of the internal opening with trichloroacetic acid as first-line treatment for pyriform sinus fistula.

      References

        • Park S.W.
        • Han M.H.
        • Sung M.H.
        • et al.
        Neck infection associated with pyriform sinus fistula: imaging findings.
        AJNR Am J Neuroradiol. 2000; 21: 817-822
        • Falhammar H.
        • Wallin G.
        • Calissendorff J.
        Acute suppurative thyroiditis with thyroid abscess in adults: clinical presentation, treatment and outcomes.
        BMC Endocr Disord. 2019; 19: 130
        • Cha W.
        • Cho S.W.
        • Hah J.H.
        • Kwon T.K.
        • Sung M.W.
        • Kim K.H.
        Chemocauterization of the internal opening with trichloroacetic acid as first-line treatment for pyriform sinus fistula.
        Head Neck. 2013; 35: 431-435