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To demonstrate our experience in treating pyriform fossa sinus tracts (PFST) using a novel technique of endoscopic cauterisation of the pyriform fossa sinus opening combined with injection of sodium carboxymethylcellulose gel (VoiceGel) lateral to the tract to encourage tight closure.Over a 48-month period, we used this technique on 11 patients who were diagnosed with PFST at BC Children's Hospital, a tertiary paediatric centre in Vancouver, BC, Canada.The 11 patients included 8 males and 3 females, and mean age at presentation was 69 months (range 22-108 months). Mean time from beginning of symptoms till diagnosis was 15 months (range 12-22 months). Ten PFST were on the left side of the neck and one on the right. Nine patients presented with recurrent neck infections and two had suppurative thyroiditis. All patients had endoscopic cauterisation of their PFST opening combined with injection of carboxymethylcellulose lateral to the sinus tract to cause tract collapse. Mean follow up was 15.8 months (range 8-24). All patients are asymptomatic without recurrence at the last follow-up visit. No post-operative complications were reported.Endoscopic management of paediatric PFST combined with the injection of sodium carboxymethylcellulose gel lateral to the sinus tract appears to be a safe and effective treatment option for PFST.Trattamento delle fistole congenite del seno piriforme mediante cauterizzazione endoscopica e iniezione di Voicegel.Descrivere la nostra esperienza nel trattamento delle fistole congenite del seno piriforme (PFST) utilizzando una nuova tecnica di cauterizzazione endoscopica del seno piriforme ed iniezione di gel di sodio carbossimetilcellulosa (VoiceGel) per favorire la chiusura del tramite.Per un periodo di 48 mesi, abbiamo utilizzato questa tecnica su undici bambini a cui è stata diagnosticata la PFST al BC Children’s Hospital, un centro pediatrico terziario di Vancouver, BC, Canada.Il gruppo di bambini includeva 8 maschi e 3 femmine, l’età media era di 69 mesi (range 22-108 mesi). Il tempo medio dall’inizio dei sintomi fino alla diagnosi è stato di 15 mesi (range 12-22 mesi). Dieci PFST erano sul lato sinistro del collo e uno a destra. 9 pazienti soffrivano di infezioni ricorrenti del collo e due avevano tiroidite suppurativa. Tutti i pazienti sono stati trattati mediante cauterizzazione endoscopica ed iniezione di carbossimetilcellulosa per cicatrizzare il tratto fistoloso. Il follow-up medio è stato di 15,8 mesi (range 8-24). Tutti i pazienti sono asintomatici, senza recidive al follow-up. Non sono state riportate complicanze postoperatorie.Il trattamento endoscopico della PFST pediatrica combinata con l’iniezione di gel di carbossimetilcellulosa di sodio sembra essere un’opzione terapeutica sicura ed efficace per le PFST.

Acute suppurative thyroiditis is a rare and potentially life-threatening cause of thyroid inflammation requiring prompt recognition and management. There are few reported cases of thyrotoxicosis due to acute suppurative thyroiditis. We are reporting the case of a 9-year-old boy who presented to the emergency room with fevers, neck pain and swelling, night terrors, and emotional lability. He was hemodynamically stable with initial lab work remarkable for neutrophilia without leukocytosis, elevated inflammatory markers, and hyperthyroidism. Imaging of the neck revealed a heterogenous collection in the region of the left thyroid concerning for suppurative thyroiditis and adenitis. He was admitted to the hospital and initiated on intravenous antibiotics. Given lack of significant improvement in pain, he was taken to the operating room for drainage on hospital day 4 with remarkable clinical improvement in pain. He was discharged on oral antibiotics. Lab work obtained on postoperative day 15 showed resolution of hyperthyroidism and decreasing inflammatory markers. Subsequent imaging following resolution of the acute illness did not reveal any anatomic abnormality that may have predisposed him to developing acute suppurative thyroiditis. Thyrotoxicosis as a complication of acute suppurative thyroiditis is a rare occurrence, and is thought to be due to the release of preformed thyroid hormone from damaged thyroid follicles. The thyrotoxic state is often transient and resolves with appropriate management of acute suppurative thyroiditis. This complication is important to recognize, as failure to appropriately diagnose and treat acute suppurative thyroiditis can lead to poor outcomes, such as airway compromise and death.

急性化脓性甲状腺炎较罕见，特点是起病急骤、病情多变，若治疗不及时可导致纵隔脓肿、气管或食管瘘，死亡风险高。在早期甲状腺脓肿未形成时易误诊为亚急性甲状腺炎。本例患者梨状窝瘘导致的急性化脓性甲状腺炎误诊为亚急性甲状腺炎，在应用糖皮质激素治疗后疾病进展伴颈部脓肿形成，需行脓肿切开引流及术后短暂呼吸机持续辅助呼吸。感染控制后行第三鰓裂瘘管探查切除，术后随访无复发。.

BackgroundThyroid gland infections are rare. Their incidence is estimated to be less than 1% in immunocompromised hosts. Most common pathogens isolated are Gram positive aerobic cocci. Infections with Gram negative facultative aerobes such asSalmonellaare rare.Case presentationA 55-year-old female with type II diabetes mellitus and a history of a colloid right thyroid lobe nodule presented with neck pain and fever. She was found to have a thyroid abscess 2 weeks following a non-specific diarrheal illness. A needle aspiration for symptomatic and diagnostic purposes was performed. Cultures grewSalmonella enterica serotype Heidelberg. She was treated with a 12-week course of oral antibiotics and serial aspiration.ConclusionA thyroid abscess is a rare occurrence; however, a high index of suspicion is required to make the diagnosis. The management is directed at minimizing morbidity. The mainstay treatment is medical, but surgery is sometimes necessary to achieve adequate source control, particularly when complications arise.

Objective The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis. Design This study is a retrospective case series set in 2 tertiary care academic hospitals. Methods The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study. Results Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile. Conclusions The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.

Background Acute suppurative thyroiditis through the congenital pyriform sinus fistula (PSF) often recurs if the fistula is not resected. Although endoscopic chemo-cauterization (ECC) to obliterate the orifice of the fistula is less invasive than open fistulectomy, it may require repeated treatments. We recently adopted an endoscopic diode laser-cauterization (ELC) system with the intention of improving treatment outcomes in PSF. Here, we describe ELC and compare the outcomes of these three modalities. Methods We evaluated 83 patients with PSF who underwent treatment between 2007 and 2018 at Kuma Hospital, a tertiary thyroid treatment hospital. ECC and ELC were implemented in 2007 and 2015, respectively. Patients who were ineligible for the endoscopic procedures underwent open fistulectomy. Barium swallow studies and computed tomography scan under a trumpet maneuver were performed after treatment to evaluate obliteration or removal of the fistula. Results In total, 70 of the 81 (86%) patients who underwent barium swallow studies after the first treatment achieved obliteration or removal of the fistula. The success rates for open fistulectomy, ECC, and ELC were 100% (9/9), 83% (49/59), and 100% (13/13), respectively. ECC and ELC had significantly shorter operative times and lower blood loss than open fistulectomy. Insufficient opening of the mouth was the major reason for converting endoscopic procedures to open fistulectomy. Conclusions ELC may yield superior outcomes and is therefore the optimal treatment modality for PSF. However, it is still associated with certain limitations. Thus, treatment selection remains dependent on the shape and size of the PSF and the mouth opening of the individual patient. Graphical Abstract

Background Accidental ingestion of fish bone is a common cause of otolaryngological emergency. Migration of the ingested bone into the thyroid gland, however, occurs very rarely. The associated clinical presentation, symptoms and duration of discomfort are also highly variable between patients and can be diagnostically challenging. Case presentation Here, we report the case of a 71-year-old female patient presenting with an ingested fish bone that migrated into the right thyroid lobe as a rare cause of suppurative thyroiditis with the clinical features of sepsis. We outline the diagnostic approach, peri- and intraoperative management as well as complications. It is proposed that besides endoscopy, imaging methods such as ultrasound or computed tomography may be necessary to verify the diagnosis and location of an ingested fish bone. Prompt surgical removal of the foreign body and resection of the infectious focus is recommended to minimize the risk of local inflammation, recurrent nerve lesions and septic complications arising from the spread of infection. Conclusion Fish bone migration into the thyroid gland is an extremely rare event, the successful detection and surgical management of which can be achieved through a careful interdisciplinary approach.

Third and fourth branchial anomalies are rare, accounting for less than 10% of all branchial anomalies. The piriform fossa sinus tract (PFST) typically presents with left-side suppurative thyroiditis, although it can present earlier in neonates as a non-inflamed cystic neck mass. PFST poses a considerable diagnostic challenge with variable clinical and imaging features, leading to long delays to definitive diagnosis and appropriate management.To analyse the patterns of presentation and imaging findings in children with PFST, with a particular focus on neonatal presentation.This was a retrospective review of the clinical presentation, imaging findings and management in 16 cases of PFST presenting to our tertiary children's hospital between 2003 and 2018. Cases were identified by medical records and picture archiving and communication system (PACS) search using relevant International Classification of Diseases (ICD)-10 coding.Age at presentation ranged from prenatal to 16 years, with a male-to-female ratio of 2:1. All patients presented with neck swelling. Thirteen patients (81%) had suppurative thyroiditis at initial presentation. Two patients had severe thyroiditis/mediastinitis that required intensive care unit admission. Three neonates presented with noninfected, asymptomatic large cystic neck masses; two of these were detected prenatally and misdiagnosed as lymphatic malformations with subsequent spontaneous clinical resolution that later represented with evidence of PFST. The PFST was on the left side in 15/16 (94%) patients. All patients had neck imaging before definitive diagnosis. Imaging studies included radiographs, ultrasound, computed tomography, magnetic resonance imaging and barium esophagram studies. No single modality was diagnostic of PFST in all patients. Seventy-five percent of patients had multimodal imaging before diagnosis. All PFSTs were confirmed by endoscopic visualisation. Management of PFST was by endoscopic cauterisation in 13 patients and open surgery in 2. One patient did not require surgical correction.Our study highlights the complex nature of PFST. The anomaly is uncommon, has variable clinical and imaging features and may have a lengthy, complicated course if not considered at initial presentation. An episode of suppurative thyroiditis in a child should prompt investigation for PFST. We describe atypical presentations with cystic masses in neonates that appear to resolve but represent later as typical clinical features of PFST.

Objective Acute suppurative thyroiditis (AST) is a rare but potentially fatal condition which can initially be difficult to distinguish from the more common subacute thyroiditis (SAT). We aim to update understanding of this medical emergency. Design A systematic review over the past 20 years was performed on the epidemiology, clinical features, investigations, management and outcomes of AST. All full-text cases of microscopy or culture- proven AST in the English literature were included. Results 200 cases of AST have been described in 148 articles from January 2000 - January 2020. Bacterial AST is most common, often presenting with neck pain (89%) and fever (82%). Immunosuppression and pyriform sinus fistula are the most common causes, most often due to gram-positive aerobes. Transient hyperthyroidism is common (42%). Aspiration and antibiotics are becoming a more common treatment. Overall mortality was 7.8%. Tuberculous and fungal AST are less likely to present with fever and neck pain. Fungal AST is more common in immunosuppressed individuals (31%) and has a high overall mortality (33%). Tuberculous AST is more common in TB endemic areas. Conclusion The symptoms and signs of AST commonly overlap with SAT and initially can be hard to diagnose. AST can be rapidly morbid or even fatal. Clinicians need to consider AST when they assess patients with thyroiditis who are systemically unwell, have high fever, high white cell count and c-reactive protein, tender neck and abnormal neck imaging. An investigative and treatment strategy is described based on a systematic review of the literature.

Objective There is currently no consensus regarding the optimal management of acute suppurative thyroiditis (AST) secondary to pyriform sinus fistula (PSF). To investigate the benefits and adverse events of aspiration with or without lavage for the treatment of AST secondary to PSF. Subjects and methods This was a retrospective analysis of consecutive patients with AST secondary to PSF who were admitted at the Affiliated Changzhou No. 2 People’s Hospital of Nanjing Medical University between August 2012 and December 2018. Clinical information, procedural data, and imaging data were analyzed. Results Seven patients (five women; mean age, 16.9 ± 6.3 years; range, 8-26 years) were included. The patients most presented with anterior neck pain and swelling (n = 7), fever (n = 7), or odynophagia (n = 5). Six cases of AST occurred on the left side of the thyroid and 1 on the right. All patients had thyroid abscess. AST was diagnosed by ultrasound-guided needle aspiration cytology in all cases. PSF was diagnosed during the inflammatory stage in five patients and during the quiescent stage in two. All patients were treated with empiric antibiotics. Needle aspiration without lavage was performed in three cases. Needle aspiration with lavage was performed in four cases. Repeat aspiration was performed in three cases. All patients recovered completely, with no procedure-related complications. During 18.3 ± 7.8 months of follow-up, AST recurred in one case. Excision of the PSF was performed in another case. Conclusion Ultrasound-guided aspiration with or without lavage had a good treatment effect and without adverse events for the management of AST secondary to PSF.

Suppurative thyroiditis is uncommon in the pediatric population and particularly rare to be caused by fungi. We present a case of Candida tropicalis thyroiditis in an adolescent male with acute lymphocytic leukemia that led to disseminated candidiasis, thyroid storm and eventual total thyroidectomy for source control.

Acute suppurative thyroiditis is a rare, potentially life-threatening condition. We report the case of a 17-year-old male who initially presented with a thyroid abscess. Due to persistent symptoms and lack of evidence for underlying predisposing factors, he was followed closely and subsequently diagnosed with papillary thyroid cancer. He was successfully managed with surgery. His clinical course, radiological evaluation, and pathology reports are presented here along with a review of the literature. This case of papillary thyroid cancer highlights the need for close follow-up of patients presenting with a thyroid abscess, when other predisposing risk factors are not evident.

To determine the efficacy of endoscopic electrocauterization for pyriform sinus fistula (PSF) using a flexible Bugbee cautery electrode. From 2009 to 2016, a total of eight patients with acute suppurative thyroiditis or cervical abscess secondary to PSF were retrospectively registered in our study (three males, five females; median age 6.5 years). All patients underwent endoscopic electrocauterization as treatment for PSF. Six of eight patients had no recurrence after the initial endoscopic electrocauterization of PSF. One patient with recurrence developed symptoms 9 days after cauterization and another experienced recurrence after 2 years. Mean follow-up for the eight patients was 50 months (range 5-96 months). No post-operative complication was reported. Endoscopic electrocauterization appears to be a less-invasive, safe, and effective method for the treatment of PSF.

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.

Background Abscess in the thyroid gland is a rare but severe infectious disease. The condition can have anatomic or iatrogenic underlying causes. If untreated it could be fatal. Pathogens vary considerably. Treatment is intravenous antibiotics, drainage, and sometimes surgery. Methods The electronic medical records of all adult patients with acute thyroiditis 2003–2017 treated at the Karolinska University Hospital (catchment area 2 million) in Sweden were systematically reviewed. Results Five patients were found in the catchment area. One patient from another region but known to us was also included. Thus, six patients (aged 28–73 years) were included in the study. Median length of hospital stay was 7.5 days (4–79 days). All were treated with antibiotics (intravenous n = 5, oral n = 1). Total antibiotic treatment duration was 13.5 days (10–41 days). Blood cultures were positive in three (streptococcus pneumonia, streptococci sanguineous, pepto streptococci), deep tissue culture in three (Escherichia coli, Candida, Hemophilic influenza) and no positive culture at all in two. Drainage was used in three patients. All patients recovered without recurrences. Surgery was performed twice in the acute phase in one. There was no recurrence during 7 years (3–12) of follow-up, but one patient died after three years (severe heart failure and pneumonia). Conclusion Thyroid abscess in adults is extremely rare nowadays in the developed world. With prompt antibiotic therapy, drainage and in some cases thyroidectomy the prognosis seems favourable.

The thyroid gland is usually resistant to infections due to its anatomy. However, suppurative thyroiditis could be found in immunocompromised patients or those with previous thyroid diseases. We report a case of thyroid abscess secondary to Salmonella enteritidis infection in an immunocompetent patient. We were not able to establish the source of infection. Clinical improvement was achieved under antibiotic treatment without complications. Early diagnosis is important as thyroid abcess may be a life threatening condition.La thyroïde est une glande endocrine généralement résistante aux infections en raison de sa localisation et présentation anatomique. Cependant, une thyroïdite suppurée est susceptible de survenir chez des patients immunodéprimés ou ayant déjà présenté un dysfonctionnement thyroïdien. Nous rapportons un cas d’abcès thyroïdien consécutif à une infection à Salmonella enteritidis chez un patient immunocompétent. Nous n’avons pas pu établir la source de l’infection. Une amélioration clinique a été obtenue sous traitement antibiotique sans complications. Un diagnostic précoce est essentiel afin d’éviter toutes complications graves mettant en jeu le pronostic vital.

Pyriform sinus fistula is uncommon and easily misdiagnosed. Most reported cases occur in children and are associated with either acute suppurative thyroiditis or deep neck infection. Asymptomatic pyriform sinus fistula is difficult to diagnose because it can manifest as an incidental thyroid nodule with highly suspicious malignant features on ultrasonography. The patient was a 41-year-old man with asymptomatic thyroid nodules incidentally detected on ultrasonography. Surgery was performed under the suspicion of thyroid cancer. Pathology findings revealed multiple cystic walls lined by ciliated columnar cells with stratified squamous epithelial cysts in a background of inflammatory and lymphoid cells. Barium swallow examination performed 2 weeks later revealed a sinus tract measuring 1.8 cm that arose from the apex of the left pyriform sinus. The diagnosis and management of pyriform sinus anomalies are challenging. The majority of physicians, including some otolaryngologists, lack an understanding of the disease, which should be considered one of the important differential diagnoses of neck masses. Barium swallow examination, ultrasonography, computed tomography, and laryngoscopy are useful to diagnose this condition.

Not required for Clinical Vignette.

Background Invasive aspergillosis is a complication in immunocompromised patients and commonly detected in patients with hematological malignancies, which mostly affect the lungs. Because of its high iodine content, rich blood supply and capsule, the thyroid is considered to be less prone to microbial invasion thus most infectious thyroiditis cases are caused by bacteria. However, a few case reports have described thyroid gland aspergilloses, most of which were due to disseminated invasive aspergillosis. Case presentation We first report a case of thyroid gland and subcutaneous labium majus aspergillosis in a Chinese patient who received long-term glucocorticoid treatment for systemic lupus erythematosus (SLE) and lupus nephritis, and then we reviewed 36 articles describing similar aspergillus infections in 41 patients. Conclusion We included 29 cases of diagnosed aspergillus thyroiditis and analyzed clinical findings, treatments and outcomes to provide clinical information for diagnosis and prognosis of thyroiditis caused by Aspergillus fumigatus.

Haemolytic group A streptococci (GAS) are the most common bacterial cause of infection in the Netherlands. These bacteria can cause many different non-invasive infections, including scarlet fever.A two-year-old girl presented with fever, tachycardia, exanthema and swelling in the neck. On suspicion of scarlet fever with neck phlegmon we treated her with antibiotics and supportive therapy. Blood and throat cultures revealed growth of haemolytic GAS. Lab tests revealed mild hyperthyroidism and neck ultrasound revealed an inhomogeneous appearance of the thyroid. We diagnosed her with 'infectious thyroiditis', a rare complication of infection with haemolytic GAS. A fistula from the pyriform sinus could not be demonstrated.Although GAS infections are common, complications such as thyroiditis are rare. When a paediatric patient is diagnosed with infectious thyroiditis, a fistula from the pyriform sinus should be considered. Patients with such a congenital malformation have an increased risk of recurrent infectious thyroiditis and thyroid abscess formation.

A 59-year-old man was admitted with 3 weeks of worsening shortness of breath 18 months after receiving a bilateral lung transplant for idiopathic pulmonary fibrosis. His immunosuppression included tacrolimus, everolimus and low-dose prednisone with no antifungal prophylaxis at the time of admission. CT chest revealed multiple, bilateral pulmonary nodules (figure 1—red arrows). CT-guided biopsy revealed fungal hyphae (figure 2). The initial CT and ultrasound of the neck at the onset of sore throat was negative; however, repeat CT neck for evolving neck pain and dysphasia during hospital course showed a mass-like lesion in the …

Our study aimed to identify more accurate results about the diagnostic role of shear-wave elastography (SWE) for thyroid malignant nodules through a meta-analysis. Potential articles were searched in PubMed, Embase, and the Cochrane Library databases. Overall sensitivity and specificity with 95% confidence intervals (CIs) was used to represent the diagnostic accuracy of SWE. Summary receiver operating characteristic (ROC) curve was constructed to illustrate the results. In addition, χ² and I² tests were performed to assess heterogeneity. A value of p≤0.05 indicated significant heterogeneity. All the analysis was conducted in Meta-DiSc version 1.4 software. Twenty studies were included in the analysis. There were a total of 2,907 patients and 3,397 thyroid nodules included in the meta-analysis. Overall sensitivity and specificity were 0.68 (95% CI: 0.66-0.70) and 0.85 (95% CI: 0.84-0.87), respectively. The results showed the area under curve (AUC) was 0.9041, suggesting high accuracy of SWE for differentiating benign and malignant thyroid nodules. SWE showed high accuracy in identifying thyroid malignant nodules, suggesting it could serve as a diagnostic biomarker in thyroid nodules.

BACKGROUND Iodine intake is related to thyroid disease. This study investigated the effect of the amount of iodine intake on p14ARF and p16INK4a expression of thyroid papillary carcinoma in rats. MATERIAL AND METHODS A cohort of 240 SD rats were randomly divided into control group, low iodine, normal iodine, and high iodine groups (n=60 per group). We inoculated 2 × 10(5) papillary thyroid carcinoma (PTC) cells on the left side of the thyroid gland. After 6 and 12 weeks, serum thyroid hormone level and urine iodine level were measured in addition to morphological observations of tumor tissues. Expression of p14ARF, p16INK4a was detected by immunohistochemical staining. RESULTS The expression of p14ARF, p16INK4a, FT3, and FT4 levels in all iodine-treated animals were significantly lower than in the control group, while TSH level was significantly higher (P

Clinical presentations of pyriform sinus fistulas vary, and this sometimes leads to a delay in diagnosis and treatment. Recently, we experienced a case of recurrent cervical abscesses occurring after thyroidectomy in an adult affected by a bifidus pyriform sinus fistula. The diagnostic dilemma was related to the timing of events, with a single episode of acute suppurative thyroiditis having occurred 16 years before the onset of the more recent clinical scenario. An endoscopic approach allowed effective management of this clinical case.

Pyriform sinus fistula is a rare clinical disease, often with recurrent acute suppurative thyroiditis or neck infection in children.The traditional method treatment is complete resection of the fistula with or without hemithyroidectomy in external cervical surgical approach, but in recent years, minimally invasive endoscopic occlusion of the internal opening for the treatment of pyriform sinus fistula is performed in many hospitals, including electrocautery, chemocautery, laser cauterization, biocauterization, and suture closure. Literatures about endoscopic management of pyriform sinus fistula in children are reviewed and various surgical methods, complications and success rate are evaluated.梨状窝瘘是一种临床上罕见的疾病，常表现为反复急性化脓性甲状腺炎或颈部感染。过去传统的手术方法是颈外径路完整切除瘘管，伴或者不伴有患侧甲状腺切除，但近年来许多医院开展微创内镜下闭塞内瘘口方法来治疗梨状窝瘘，其中包括电烧灼、化学烧灼、激光烧灼、生物胶治疗、缝合技术等。因此，本文收集国内外内镜下治疗儿童梨状窝瘘的相关文献，并综述各类手术方法、并发症及治疗有效率。.

Granulomatous disease in the thyroid gland has been linked to viral, bacterial and autoimmune etiologies. The most common granulomatous disease of the thyroid is subacute granulomatous thyroiditis, which is presumed to have a viral or post-viral inflammatory cause. Bacterial etiologies include tuberculosis, actinomycosis, and nocardiosis, but are extremely rare. Disseminated actinomycosis and nocardiosis more commonly affect organ-transplant patients with the highest susceptibility within the first year after transplant surgery.A 45-year-old African American male, who received his third kidney transplant for renal failure secondary to Alport Syndrome, presented with numerous subcutaneous nodules and diffuse muscle pain in the neck. Further workup revealed bilateral nodularity of the thyroid. Fine needle aspiration of these nodules demonstrated suppurative granulomatous thyroiditis. Subsequent right thyroid lobectomy showed granulomatous thyroiditis with filamentous micro-organisms, morphologically resembling Nocardia or Actinomyces.Disseminated granulomatous disease presenting in the thyroid is very rare, and typically afflicts immune-compromised patients. The overall clinical, cytologic and histologic picture of this patient strongly points to an infectious etiology, likely Nocardia, in the setting of recent organ transplantation within the last year.

Background Thyroid abscess or acute suppurative thyroiditis is an unusual clinical condition. We present our experience with cases attended over 41 years. Materials and methods A retrospective study was performed on these patients reviewing their epidemiological characteristics and the diagnostic and therapeutic manoeuvres chosen for them all, as well as their clinical outcome. A group of 9 males and 5 females was studied, with ages ranging from 19 to 68 (mean of 40.6 ± 15.4). These patients suffered 22 acute episodes, and 2 patients each had 4 episodes. Results Suppurative thyroiditis comprised 0.29% of the neck abscesses. Fine needle aspiration was performed in 13 cases to evacuate the collection and isolate the aetiological agent. Mycobacterium tuberculosis and Staphylococcus aureus were the most frequently identified. Nine patients underwent ultrasound and 7 computed tomography imaging studies. Surgery was the option for 10 patients, including drainage for 7, thyroidectomy for 4 and hemithyroidectomy for the remaining 2. Systemic or intralesional antibiotics and sclerosis of the gland were also carried out. Although one case presented with hyperthyroidism and thyrotoxicosis in the acute phase, definitive hypothyroidism was observed in 5 patients at 6 months following discharge. The rate of success was 100%. Conclusion Thyroid gland suppuration is a very infrequent circumstance in neck pathology, and the options for its treatment are varied, from conservative to invasive techniques according to the microbial and radiologic findings.

Acute suppurative thyroiditis (AST) leading to thyroid abscess is a rare clinical entity. The aim of this article is to demonstrate a case of severe bilateral pneumonia which originated from a thyroid abscess. The authors report the case of a 57-year-old woman with severe bilateral pneumonia of thyroid origin. The patient had a painful throat and dysphagia for 2 or 3 days. She also had a history of mild fever and hard breathing with a discreet cough 7 days prior to hospital admission. In the past few months, the patient had frequent pneumonias. The patient was treated with a culture-appropriate antibiotic and total thyroidectomy. Primary recommendations for treatment of complicated infections of thyroid origin consider a multidisciplinary approach. Recurrent pneumonia in patients with thyroid nodules may be the result of thyroid inflammation, and, in such patients, neck ultrasound should be conducted as part of the diagnostic workup.

Objective To describe clinical presentations, management and treatment outcomes of 17 cases of congenital pyriform sinus fistula (PSF) of third branchial arch origin presenting as left recurrent acute suppurative thyroiditis with cervical abscess. Method Medical record of these 17 cases (5-males, 12-females) presented during 2009–2013 were reviewed. Results Average age was 9.6 years (range 3–15 years). Fistulous opening in neck was present in 10 cases (58.8%). Average number of episode of infection from first presentation to definitive diagnosis was 3 (range 2–5). All patient had history of incision and drainage (ID) of abscess (average 2, range 1–3). All cases had barium swallow and CT scan. Sixteen cases had telescopic hypopharyngoscopy. Barium swallow and telescopic hypopharyngoscopy detected PSF in 88.23% (15/17) and 100% (16/16) cases respectively. Fourteen cases were treated by transcervical excision (TE) (fistulectomy with left hemithyroidectomy), two cases were treated by endoscopic chemical cauterization (ECC) of internal opening at pyriform sinus using silver nitrate and only ID of abscess was done in one case. Success rate of TE and ECC was 93% and 100% respectively. Recurrence in one case initially treated by TE was managed successfully by ECC. Conclusion Presence of congenital PFS should be suspected when left-sided intra-thyroidal abscess formation occurs as gland is resistant to infection. Strong clinical suspicion, barium swallow study, telescopic pharyngoscopy and CT scan are the key to diagnosis. Both TE and ECC has comparable success rate. ECC may prove a useful and equally effective method of treatment for congenital PFS in future.

Background Piriform sinus tract (PST) is a rare congenital condition. A delay in diagnosis is common leading to recurrent inflammation. Method A retrospective review was performed on all cases of PST treated at a tertiary referral centre between May 1997 and May 2012. Results Eighteen patients were reviewed with a mean age of 5.4years at presentation (ranged from 0day to 14years). Most patients presented as acute inflammation (88.9%) and 16 had a left sided lesion. 72.2% of the PST are identified by contrast swallow study. The diagnostic yield was significantly higher if the study was done after the initial acute inflammation settled. Ultrasonography and computer tomography are less sensitive. The median duration from presentation to diagnosis was 17.6months (ranged 0–120months). Ten patients (55.6%) experienced recurrent inflammation before confirming the diagnosis. Fistulectomy alone was performed in 15 patients while an additional en-bloc hemithyroidectomy was done in 2 patients. Conclusion PST should be suspected in children presenting with a left deep neck abscess. Contrast swallow study is very effective in making diagnosis but has to be postponed after the acute inflammation settles. The condition can be effectively treated by fistulectomy without hemithyroidectomy in majority of our cases.

Acute infectious thyroiditis, particularly fungal thyroiditis, is rare and typically presents in immunocompromised individuals. Here we report the first case of coccidiomycosis thyroiditis occurring in an organ recipient as a consequence of likely allograft contamination and discuss the management strategies for thyroid masses in the setting of disseminated infection.In this clinical case seminar, we summarize the previously published cases of coccidiomycosis thyroiditis based on a MEDLINE search of all peer-reviewed publications (original articles and reviews) on this topic. We identified six other cases, five of which also occurred in immunocompromised hosts, although none occurred in organ recipients.A case of coccidiomycosis thyroiditis occurring in a post-liver transplant immunocompromised host is reported. Analysis of donor serum revealed the liver allograft as the likely infectious source, resulting in hematological spread to the thyroid. Although our patient's thyroid gland was lacking gross structural abnormalities at presentation, new-onset thyroid masses developed after relative immune restoration and initiation of antifungal therapies. The differential diagnosis of new-onset thyroid masses in immunocompromised hosts is discussed, with a focus on immune reconstitution inflammatory syndrome. The role of thyroidectomy in the management of fungal thyroiditis is also discussed.

1. Miranda Broadney, MD, MPH* 2. Rajan Senguttuvan, MD† 3. Priti G. Patel, MD‡ 1. *National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD. 2. †Section of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, The University of Arizona, Tucson, AZ. 3. ‡Pediatric Endocrinology, Texas Tech University Health Sciences Center, El Paso, TX. A previously healthy 3-year-old boy presents to the emergency department with a 5-day history of fever, sore throat, and progressive neck swelling despite treatment with antibiotics. Two days ago, he had presented to a community hospital emergency department for these symptoms and was prescribed azithromycin for presumed bacterial pharyngitis (no throat culture was obtained). Despite treatment, he now experiences a choking sensation and worsening pain in his neck. His vital signs are notable for a temperature of 98.2°F (36.8°C), blood pressure of 140/103 mm Hg, heart rate of 170 beats per minute, and respiratory rate of 20 breaths per minute. His physical examination reveals a teary boy because of pain with normal work of breathing. His oropharynx has no erythema, and the tonsils are normal in appearance. He has marked erythema of the anterior lower neck with an exquisitely tender, indurated area that measures 6 cm in diameter and extends laterally from midline to the left. There is no fluctuation. Respiratory examination reveals a hoarse voice without stridor and clear lung fields on auscultation. Cardiovascular examination findings are notable for moderate tachycardia. The remainder of the examination findings are unremarkable. Laboratory evaluation reveals a leukocyte count of …

Objective:Abnormalities of the third branchial arch are less common than those of the second arch and usually present with left thyroid lobe inflammation. This paper describes 15 cases of pyriform sinus fistulae of third branchial arch origin usually presenting as recurrent thyroid abscess on the left side.Method:A retrospective review of 15 cases of third arch fistulae managed 2000 and 2008, diagnosed based on histopathology and radiological evidence of a fistulous tract, and treated with fistulectomy with left hemithyroidectomy.Results:All patients (six boys and nine girls, aged three to 15 years) presented with recurrent low neck inflammation. Pre-operative ultrasound, computed tomography fistulography and barium swallow demonstrated a third arch fistulous tract, left-sided in all cases. The fistula was detected intra-operatively and pathologically in all cases. Surgery (successful in all cases) emphasised complete recurrent laryngeal nerve and ipsilateral pyriform sinus exposure, to facilitate tract excision, with left hemithyroidectomy. There was no recurrence over three to five years' follow up.Conclusion:Paediatric recurrent low neck inflammatory episodes, due to thyroidal abscess, especially left-sided, should raise suspicion of pyriform sinus fistulae.

Subacute, silent, and postpartum thyroiditis are temporary forms of thyroid dysfunction caused by thyroid gland inflammation. They classically present with a triphasic course: a brief period of thyrotoxicosis due to release of preformed thyroid hormone that lasts for 1 to 3 months, followed by a more prolonged hypothyroid phase lasting up to 6 months, and eventual return to a euthyroid state. However, the types and degree of thyroid dysfunction are variable in these disorders, and individual patients may present with mild or more severe cases of thyrotoxicosis alone, hypothyroidism alone, or both types of thyroid dysfunction.

1. Raghu Varier, DO* 2. Laura Plencner, MD* 3. Douglas Rivard, DO† 4. Angela L. Myers, MD, MPH* 1. *Department of Pediatrics, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. 2. †Department of Radiology, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. A previously healthy 13-year-old girl presents to the emergency department with a 2-week history of worsening sore throat and a 4-day history of left neck swelling, pain, and fever. Results of evaluation by a prior clinician at the onset of symptoms included a negative rapid streptococcal antigen test and a positive heterophile antibody test, prompting treatment with oral corticosteroids for 5 days as an anti-inflammatory medication. The girl now reports pain with swallowing, decreased oral intake, and left-sided head tilt for the past 24 hours. On physical examination, the girl has a temperature of 38.4°C and appears to be in no acute distress. In addition, her heart rate is 91 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 119/69 mm Hg. She has a warm, very tender, firm, anterior, left-sided 1.5-cm mass at the level of the thyroid gland. The mass moves when she swallows. Findings on the rest of her physical examination are normal. Laboratory investigation reveals a white blood cell count of 17.2×103/μL (17.2×109/L) with 74% neutrophils and 14% lymphocytes, hemoglobin of 13 g/dL (130 g/L), and platelet count of 423×103/μL (423×109/L). C-reactive protein (CRP) measurement is elevated at 1.6 mg/dL (normal, 0.3 to 1.0 mg/dL). Computed tomography (CT) scan of her neck with intravenous contrast enhancement suggests the diagnosis (Fig. 1). Figure 1. Axial computed tomography scan of the neck with intravenous contrast enhancement. The patient's physical and laboratory findings and CT scan of the neck are consistent with acute suppurative thyroiditis. The CT scan reveals a multilocular inflammatory phlegmon/abscess-in-evolution involving the superior pole of the …

Acute suppurative thyroiditis (AST) resulting from a bacterial infection is an infrequent but potentially life-threatening endocrine emergency. Traditional management of this disease has been surgery in conjunction with targeted antibiotic therapy. Recent nonrandomized reports of small series have demonstrated good outcomes using less invasive approaches. No randomized clinical trials have been performed. Here, we provide a review of the literature and an approach to this problem based on expert opinion.The literature was reviewed utilizing PubMed, and a representative case of AST was presented to a panel of experts. Endocrinology, surgery, and infectious disease experts responded to a series of questions regarding diagnosis, management, prognosis, and harm.Combining a broad spectrum of clinical expertise and the published literature, the authors suggest a clinical algorithm as a guide to management, addressing both diagnosis and acute and long-term management.Published studies indicate a trend toward less invasive management during active inflammation and infection and regarding definite therapy. Remaining questions are presented to foster an evidence-based approach to this disease. Ideally, future randomized, controlled trials will provide data to improve the therapy and outcome of AST.

Objective:We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy.Method:A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented.Results:A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence.Conclusion:To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

The prevalence of infection with methicillin-resistant Staphylococcus aureus is increasing. Methicillin-resistant Staphylococcus aureus is also being recognised as an important pathogen in head and neck infections. This review summarises studies published over the past two decades which illustrate the growing prevalence of methicillin-resistant Staphylococcus aureus, and the current therapeutic approaches to head and neck infections caused by this bacterium. These infections include sinusitis, otitis, periorbital cellulitis, cervical lymphadenitis, tonsillitis, thyroiditis, retropharyngeal abscess, and abscesses and wounds of the neck. Treatment of head and neck infections associated with methicillin-resistant Staphylococcus aureus includes drainage and debridement, as well as administration of local and systemic antimicrobials that provide coverage against these organisms and against potential aerobic and anaerobic pathogens that may be present if the infection is polymicrobial.

To elucidate the etiology of suppurative thyroiditis in children and recommend a management algorithm.Case series of 5 pediatric patients with a diagnosis of suppurative thyroiditis seen between January 1999 and April 2007.All 5 patients primarily presented with left-sided intrathyroidal abscesses. The number of infections from first presentation to the time of definitive diagnosis ranged from 1 to 5. Three patients underwent incision and drainage of the abscess once, and 2 had the procedure performed 3 times. Barium swallows identified a piriform sinus tract on the left side in 2 of the 5 patients. Telescopic hypopharyngoscopy identified the internal opening in all 5. Three were managed with complete excision of their tracts and 2 with cauterization of the internal opening with silver nitrate. All 5 are currently asymptomatic.Suppurative thyroiditis is a very rare infection in children. A left-sided intrathyroidal abscess should immediately arouse suspicion of a piriform sinus tract. Barium swallows may identify the etiology in some cases. Definitive diagnosis requires a hypopharyngoscopy, with detailed telescopic examination of the left piriform fossa apex. Endoscopic chemical cautery of the internal opening is a safe and effective technique, with very low morbidity, and has the potential for cure.

Objective This study aims to assess the efficacy of a novel endoscopic management for congenital pyriform sinus fistula (CPSF) using potassium titanyl phosphate (KTP) laser assisted endoscopic tissue fibrin glue biocauterization in children. Method From 2010 to 2014, a total of 5 children with recurrent or acute suppurative thyroiditis or neck abscess secondary to CPSF were enrolled retrospectively in this study. Results Mean age at the first time of endoscopic biocauterization was 6.2 ± 0.7 (5–7) years. The barium swallow study detected a fistula in four cases. Endoscopy identified an internal opening at the pyriform sinus in all cases with four on the left side and one on the right side. All patients underwent KTP laser assisted endoscopic tissue fibrin glue biocauterization as treatment for CPSF. Only one case required the second endoscopic procedure due to fluctuation of symptoms. Post-endoscopic follow-up duration of these patients was 24.6 ± 11.6 (7–36) months. Neither complications nor recurrences were noted during follow-up in all patients. Conclusions For children presenting with repeated acute suppurative thyroiditis or neck infections, clinicians should highly suspect the possibility of CPSF. Endoscopy should be performed not only to confirm the diagnosis but also could be served as an initial treatment modality of biocauterization by KTP laser and tissue fibrin glue, which was demonstrated as a less invasive, safe, and effective method in children.

A 60-year-old woman with diabetes and symptomatic urinary tract infection presented to us with a painful neck swelling for 2 weeks. We discuss diagnostic and management issues in acute suppurative thyroiditis caused by Escherichia coli.

Objective To report a case of recurrent acute suppurative thyroiditis (AST) caused by a piriform sinus fistula (PSF). Methods We review the related literature and describe the clinical presentation, diagnostic evaluation, and management of a patient with recurrent AST due to PSF. Results A 50-year-old woman presented with recurrent episodes of pain and swelling in the left anterior neck area and odynophagia. The initial episode, 1 year previously, lasted for 1 month, and her condition improved with a short course of prednisone. Subsequently, the neck pain recurred and extended upward to both sides of the neck. She was suspected of having thyroiditis and was treated with prednisone for 6 weeks, but the symptoms persisted. Physical examination showed tenderness and induration of the skin over the left lobe of the thyroid. Ultrasonography disclosed an ill-defined solid-cystic area in the left thyroid lobe. Fine-needle aspiration cytology revealed acute inflammation, consistent with an infected cyst. A computed tomographic scan of the neck showed obscuration of the fat planes involving the left strap musculature and evidence suggestive of microabscesses. Prolonged intravenous antibiotic treatment ultimately alleviated the symptoms. Direct laryngoscopy revealed a fistula extending anteriorly from the apex of the piriform sinus. The patient underwent complete fistulectomy and left thyroid lobectomy and was asymptomatic on followup. Conclusion PSF should be suspected as a cause of recurrent AST. Absence of fever, toxemia, and local erythema does not rule out the condition. Unresponsiveness to corticosteroid therapy in thyroiditis should suggest the diagnosis. Complete fistulectomy and resection of the involved thyroid lobe result in permanent cure. (Endocr Pract. 2007;13:662-666)