Sheng Qingfeng, Lv Zhibao, Xiao Xianmin, Zheng Shan, Huang Yimin, Huang Xiong, Li Hui, Wu Yibo, Dong Kuiran, Liu Jiangbin
Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China.
Department of General Surgery, Children's Hospital of Shanghai, Shanghai Jiao Tong University, Shanghai 200040, P.R. China.
J Pediatr Surg. 2014 Mar;49(3):455-9. doi: 10.1016/j.jpedsurg.2013.07.008.
Pyriform sinus fistula (PSF) is often overlooked, and presents diagnostic and management challenge. The aim of this study was to highlight the value of intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide in searching for the fistula.
The charts of 48 patients diagnosed with PSF during January 1990 until January 2013 were retrospectively reviewed. The records were analyzed for sex, side of lesion, age at onset/diagnosis, initial presentations, diagnostic methods, microbiologic cultures, pathologic findings, treatments and outcomes.
There were 22 males and 26 females, with a median age at onset and diagnosis of 2 years (range, 8 months to 9 years) and 4 years (range, 12 months to 13 years), respectively. The lesions were predominantly left sided (93.7%). The most common presentation was neck abscess (62.5%). Other presentations were acute suppurative thyroiditis/thyroid abscess (7), neck mass with or without dyspnea (9), and thyroid nodule (2). Barium esophagography showed the sinus tract in 100% cases. The positive predictive value of other modalities was oral-contrast CT 88.9%, intravenous contrast-enhanced CT 53.8%, noncontrast CT 33.3%, and sonography 7.9%. Thyroid function were reported normal in most tested cases (14/15, 93.3%). The fistula tract was lined with pseudostratified squamous epithelium or ciliated columnar epithelium, often associated with inflammatory changes. Bacteria cultured from the discharge were found to be oral flora. Partial thyroidectomy was operated on 11 cases. Two patients (2/8, 25%) who underwent open surgery without endoscopic assistance exhibited recurrence, while no recurrence was noted in children with the help of intraoperative endoscopy. Postoperative results were good in majority (93.7%).
PSF should be considered in any children with repeated neck or thyroid infection/mass. The combination of barium esophagography, CT scan and ultrasound is useful to establish the diagnosis. Intraoperative endoscopy-assisted intubation or methylene blue injection through the internal opening as a guide can facilitate identification of the tract during dissection.
梨状窝瘘（PSF）常被忽视，在诊断和治疗方面存在挑战。本研究的目的是强调术中内镜辅助插管或通过内口注射亚甲蓝作为寻找瘘管的引导的价值。
回顾性分析1990年1月至2013年1月期间48例诊断为PSF的患者的病历。分析记录的性别、病变侧、发病/诊断年龄、初始表现、诊断方法、微生物培养、病理结果、治疗方法和结果。
男性22例，女性26例，发病和诊断的中位年龄分别为2岁（范围8个月至9岁）和4岁（范围12个月至13岁）。病变主要位于左侧（93.7%）。最常见的表现是颈部脓肿（62.5%）。其他表现包括急性化脓性甲状腺炎/甲状腺脓肿（7例）、伴有或不伴有呼吸困难的颈部肿块（9例）和甲状腺结节（2例）。食管钡餐造影在100%的病例中显示了窦道。其他检查方法的阳性预测值分别为：口服对比剂CT 88.9%、静脉对比增强CT 53.8%、非增强CT 33.3%、超声7.9%。大多数检测病例（14/15，93.3%）的甲状腺功能报告正常。瘘管内衬假复层鳞状上皮或纤毛柱状上皮，常伴有炎症改变。从分泌物中培养出的细菌为口腔菌群。11例患者接受了部分甲状腺切除术。2例（2/8，25%）在没有内镜辅助的情况下接受开放手术的患者出现复发，而在术中内镜辅助下的儿童未发现复发。大多数患者（93.7%）术后结果良好。
任何反复出现颈部或甲状腺感染/肿块的儿童都应考虑PSF。食管钡餐造影、CT扫描和超声检查相结合有助于确诊。术中内镜辅助插管或通过内口注射亚甲蓝作为引导可便于在解剖过程中识别瘘管。
