From the Departments of Surgery (Dr Bass) and Pediatrics (Dr Muirhead), Children's Hospital of Eastern Ontario, Ottawa.
A PREVIOUSLY healthy 15½-year-old boy with a 7-day history of intermittent fever with temperatures up to 38.5°C, anorexia, nausea, irritability, persistent migraine headaches, and a 9.5-kg weight loss was seen in the emergency department complaining of left lateral neck pain. No discrete masses were palpable, and the thyroid and overlying skin felt normal. On day 9 symptoms persisted, and the left thyroid lobe was enlarged (4-cm long) and firm. A clinical diagnosis of subacute thyroiditis was made, and nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed pending results of thyroid function tests. Two days later he returned with a further 2.7-kg weight loss, dysphagia, positional dyspnea, and marked fatigue. The left thyroid lobe was hard, tender, and 6.5-cm long. The isthmus and the right lobe felt normal, and there was no cervical lymphadenopathy. Tracheal compression was present on chest radiograph, and ultrasonography was performed (Figure 1). An inadequate sample was obtained for fine-needle aspiration; no purulent material was aspirated. Serum thyroxine levels from day 7 were markedly elevated at 97.9 pmol/L (reference range, 10-25 pmol/L), and TSH was incompletely suppressed at 0.03 mIU/L. Antimicrosomal antibodies were present at a titer of 1:1600 and thyroglobulin antibodies at 155.6 pmol/L (reference range, 0-32 pmol/L). Failure of response to NSAIDs led to the administration of a tapering course of prednisone. A barium esophagram was performed and demonstrated the cause of the problem (Figure 2).
Antibiotics were administered with normalization of thyroid function test findings and clinical status during 4 weeks; however, a unilateral goiter persisted. An ultrasonogram of the thyroid showed a 2.9 × 5.5 × 2.9-cm homogenous mass within the left thyroid lobe. No cystic components were present, and some hyperemia and bilateral cervical chain lymphadenopathy were noted. After administrating antibiotics, the patient underwent direct laryngoscopy. An opening of a fistula from the left pyriform sinus was identified, and a left hemithyroidectomy was performed. During the dissection of the upper pole, laryngoscopy was repeated, and light was applied directly to the pyriform sinus with its transillumination identified in the operative field. The sinus tract was identified and transected, and a probe was introduced through the sinus and visualized with the laryngoscope (Figure 3). The fistulous tract was completely resected. On histopathologic examination there was fibrosis within the left lobe of the thyroid and the fistulous tract was lined with squamous epithelium.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Pediatrics editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 6
Customize your page view by dragging & repositioning the boxes below.
Users' Guides to the Medical Literature
Users' Guides to the Medical Literature
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.