The diagnosis and management of pyriform sinus fistulae in infants and young children

Acute suppurative thyroiditis is rare in childhood. It presented in two clinically euthyroid children over a 2-year period. Repeated drainage for recurrent abscesses was necessary in one child. Thyroiditis without abscess was present in the second. After treatment and resolution of the infection, contrast studies with barium demonstrated an internal fistula extending from the left pyriform sinus to the ipsilateral thyroid lobe. Thyroid scans showed decreased uptake in the left lobe. Thyroid-function tests were normal. A third infant developed acute respiratory distress at 2 weeks of age from an enlarging left neck mass without evidence of infection. Exploration revealed an intrathyroid cyst with fistulous communication to the left pyriform sinus. Fistulas arise from the third pharyngeal pouch as a branchial remnant which is exclusively left-sided. Administration of antibiotics, which are effective against oral flora, combined with initial drainage of suppuration control infection. Only then can the diagnosis be made by contrast study of the hypopharynx and upper esophagus. Operative excision of the entire epithelial tract and adjacent thyroid tissue is essential to prevent recurrent thyroiditis and abscess.