title: Endoscopic-assisted surgery for pyriform sinus fistula in children: experience of 165 cases from a single institution.
abstract: BACKGROUND
  Congenital pyriform sinus fistula (PSF) is relatively rare, but often presents diagnostic and therapeutic challenges. Herein, we report our experience of endoscopic-assisted surgery of PSF in children.
  
  
  METHODS
  Since 1999, 165 children (100 males, 65 females) with PSF had been enrolled. Their clinical manifestations were recurrent lateral neck infection, cervical mass and respiratory distress. Preoperative investigations included barium swallow, ultrasound, computed tomography, and thyroid scan. After resolution of the infection, the fistulas were identified by the endoscopic-assisted technique at operation. The fistula tract was completely excised just at the apex of the pyriform sinus. More recently, the anatomic point where the fistula tract penetrated into the pharynx was specified and recorded.
  
  
  RESULTS
  Of the 165 cases, the male to female ratio was 1.54:1, the median age of onset was 3.2 years (range, 1 day to 13.8 years), and median age at operation was 5.0 years (range, 17 days to 15.0 years). One hundred fifty-six (94.6%) fistulas located on the left side, 7 right, and 2 bilateral. Twelve neonates and young infants (younger than 3 months) presented with a large cervical cyst. The fistulas were completely excised in all but 2 (98.8%) with intraoperative gastroscopy successfully conducted in 160 cases (97.0%). In 77 cases the points where fistulas penetrated into the pharynx were specified intraoperatively, which were classified into 3 types according to their anatomic relationship with the inferior cornu of the thyroid cartilage (ICTC): type I (anterior to ICTC), 22 cases (28.5%); type II (inferior to ICTC), 18 cases (23.4%); and type III (posterior to ICTC), 37 cases (48.1%). Postoperatively, 160 cases recovered well without complications. PSF recurred in 5 cases, 2 of whom were cured by fistula re-excision and 3 remained asymptomatic. Esophageal perforation was found and repaired uneventfully in 1 neonate and 1 young infant. Transient postoperative hoarseness happened in 1 neonate. All the latter 3 cases had cervical cysts.
  
  
  CONCLUSIONS
  To our knowledge, this series is the largest report of PSF in children. Our results suggested that PSF is more common in males. With the help of endoscopy and a better understanding of the anatomic relationship between ICTC and the points where the fistulas penetrated into the pharynx, PSF excision can be done successfully with minimized complications. For neonates and young infants with a cervical cyst, however, the management of PSF continues to be a challenge.
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China. Electronic address: xmxiao@shmu.edu.cn.
authors.forename: Xianmin
authors.initials: X
authors.lastname: Xiao
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Shan
authors.initials: S
authors.lastname: Zheng
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Jicui
authors.initials: J
authors.lastname: Zheng
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Linlin
authors.initials: L
authors.lastname: Zhu
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Kuiran
authors.initials: K
authors.lastname: Dong
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Chun
authors.initials: C
authors.lastname: Shen
authors.affiliation: Department of Surgery of Children's Hospital, Fudan University, Shanghai, People's Republic of China.
authors.forename: Kai
authors.initials: K
authors.lastname: Li
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010608:Pharyngeal Diseases / Q000151:congenital / Q000601:surgery*; D011183:Postoperative Complications; D056144:Pyriform Sinus / Q000002:abnormalities / Q000601:surgery*; D016156:Respiratory Tract Fistula / Q000151:congenital / Q000601:surgery*; D016896:Treatment Outcome
keywords: Branchial remnant; Children; Endoscopic-assisted surgery; Pyriform sinus fistula