Editorial Branchial fistula arising from pyriform sinus: positive esophagogram despite active infection Clinical Imaging 37 (2013) 615–616 We read with interest the article Branchial fistula arising from pyriform sinus: CT diagnosis of a case and discussion of radiological features by Chauhan et al. [1]. The authors have reviewed the literature well and presented the classic computed tomography findings of a rarely encountered condition. In their patient, the barium swallow study did not visualize the fistulous tract. We would like to share a similar case and highlight the barium study findings. A 21-year-old male presented with history of repeated neck infections since the age of 3 years. He had been treated multiple times with antibiotics and repeated incisions and drainage. On examination, he had extensive scar tissue in the left anterior neck; along with multiple cutaneous openings (Fig. 1). There was a soft fluctuant swelling at the local site. The patient underwent needle aspiration, which drained approximately 20 ml of pus. Subsequently, on the same day, a barium study was performed. The barium examination revealed a blind-ending tract extending from the tip of left pyriform sinus coursing anteroinferiorly, with increased pre- tracheal soft tissue (Figs. 2, 3). The contrast enhanced MRI performed 3 days later revealed a rim enhancing air-filled cavity in the soft tissue in the anterior neck (Fig. 4), which might have formed following the aspiration of pus. There was no intrathoracic extension; however, we need to be wary of it because of multiple pathways of spread of infections between cervical and thoracic regions [2]. We concluded the diagnosis of pyriform sinus fistula because of the clinical features and the characteristic radiological findings. It has been suggested that barium studies should be performed after clearing the acute infection to decrease the rate of false–negative results [3,4]. In an article published by J Bar Ziv et al. [3], they reported two patients with negative initial esophagograms during the acute phase. Subsequent esophagogram following treatment was successful in filling up the tract in both the patients. Gan et al. [5] also reported a case in which the barium examination was negative despite it being performed 2 weeks following the initial episode when the swelling had subsided. It appears that the nonvisualization may be partly related to degree of inflammation. However, the non-opacification of the tract may also be related to the properties of the fistula-like caliber of the opening. In the case reported by Chauhan et al. [1], the barium study was negative. We, however, were able to get the diagnosis on barium study despite the active purulent disease just before the barium examination. It is possible that the tract opening was large enough to allow the barium to track through despite the infection and inflammation. Sandeep Sharma Nauroze A. Faizi Gopesh Gupta Dinesh Sharma Health Square H1-A Hauz Khas, New Delhi Delhi 110020 E-mail address: sandyshrma@gmail.com References [1] Chauhan NS, Sharma YP, Bhagra T, Sud B. Branchial fistula arising from pyriform fossa: CT diagnosis of a case and discussion of radiological features. Clin Imaging 2012;36(5):591–4. [2] Oliphant M, Wiot JF, Whalen JP. The cervicothoracic continuum. Radiology 1976;120(2):257–62. [3] Bar-Ziv J, Slasky BS, Sichel JY, Lieberman A, Katz R. Branchial pouch sinus tract from the piriform fossa causing acute suppurative thyroiditis, neck abscess, or both: CT appearance and the use of air as a contrast agent. Am J Roentgenol 1996;167(6): 1569–72. [4] Miller D, Hill JL, Sun CC, et al. The diagnosis and management of pyriform sinus fistula in infants and young children. J Pediatr Surg 1983;18:377–81. [5] Gan YU, Lam SL. Imaging findings in acute neck infection due to pyriform sinus fistula. Ann Acad Med Singapore 2004;33:636–40. 0899-7071/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clinimag.2012.12.008 Contents lists available at SciVerse ScienceDirect Clinical Imaging journal homepage: http://www.clinicalimaging.org