Cervical Thymic Cyst as a Cause of Acute Suppurative Thyroiditis Osamu OZA~, Takashi SUGIMOTO,Akira Svzt:v~, Tohru YASHIRO,Kunihiko ITo and Yasuhiro HOSODA* ABSTRACT: A case of acute suppurative thyroiditis following a perithyroidal abscess, which was thought to have resulted from infection of a cervical thymic cyst, is reported herein. The patient was an 8 year old asthmatic Japanese boy who originally presented with tender swelling o f the left anterior neck in July, 1986. Although pharyngography could not clearly demonstrate the pyriform sinus fistula, a hypoechoic area around the left lobe of the thyroid gland was noted on ultrasonography. Incisional drainage revealed Streptococcus miUeri. A diagnosis of acute suppurative thyroiditis was established, and a cystic tubular mass was surgically resected from the left perithyroidal space some time later. Histopathological examination of the specimen revealed partly cystic thymic tissue along with parathyroid tissue. These observations suggested that acute suppurative thyroiditis in this case was caused by a perithyroidal abscess and that a perithyroidal abscess may also result from infection of a cervical thymic cyst. KEY WORDS: acute suppurative thyroidltis, cervical thymic cyst, perithyroidal abscess of a cervical thymic cyst. INTRODUCTION CASE REPORT
Acute suppurative
thyroiditis (AST), also known as thyroid gangrene or thyroidal abscess, 1 is thought to originate from another septic focus within the b o d y Y In 1979, Takai et al.4 demonstrated the pyriform sinus fistula as the main route of infection for AST, since when surgical resection of the fistula has begun to achieve good results. During the five year period from 1983 through 1987, eight patients with AST underwent surgery at Ito Hospital. The case we present herein was considered to have originated from infection
The Surgical Branch, Ito Hospital, Tokyo,Japan *The Department of Pathology, Keio University School of Medicine, Tokyo,Japan Reprint requeststo: Osamu Ozaki, MD, The Surgical Branch, Ito Hospital, 4-3-6 Jingatmae, Shibuya-ku, Tokyo 150,Japan
An 8 year old Japanese boy originally presented to our clinic in the middle of July, 1986, with swelling of the left anterior neck, slight fever and a sore throat. These symptoms were accompanied by an asthmatic attack. On August 10, his temperature rose to 39~ and abscess formation was present in the anterior neck. He received incisional drainage of the abscess at another hospital and his symptoms subsided. Four months later, he presented again with fever and a sore throat with anorexia, and was admitted to Ito Hospital on December 6. The patient, 131 cm in height and 28.2 kg in weight, looked pale and his skin was dry. His temperature was 38.0~ and pulse rate 124/sec. The skin over the swelling in the
JAPANESEJOURNALOFSURGERY,VOL.20, No. 5 pp. 593-596, 1990
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Ozaki et al.
Jpn. J. Surg. September 1990
Fig. 3. Surgical specimen.
Fig, 1. Pharyngograph. A pyriform sinus fistula is not clearly demonstrated.
Fig. 2. Ultrasonograph. A hypoechoic area is noted around the left thyroid lobe. left anterior neck was reddish in color, warm and painful. Tenderness without fluctuation was noted and his tonsils were hyperemic and swollen. Laboratory data on admission showed findings of acute inflammation, with a WBC o f 14,300 and a CRP o f over 6(+). Thyroid function was normal except for a slight increase in TSH (6.2 #U/ml). A pyriform sinus fistula was not clearly demonstrated by pharyngography (Fig. 1), however, an ultrasonography revealed an ill-defined hypoechoic space from the anterior to the lateral aspects o f the left thyroid lobe; a finding that strongly suggested AST (Fig. 2).
Because three days of intravenous antibiotics did not improve his condition at all, incisional drainage was carried out on December 9, Streptococcus milleri was disclosed in the grayish-yellow purulent exudate. Several days after the drainage, his temperature and CRP returned to normal, and he was discharged on December 26, with an appointment for fistulectomy several months later. H e was followed up by his family doctor until July 4, 1987, when he presented again with fever and swelling of the anterior neck, and was referred to Ito Hospital. Incisional drainage revealed yellow-green malodorous pus which demonstrated Streptococcus sp. and Eikennela corrodens and he underwent surgery on July 29, 1987.
Surgical findings A collar incision was made into the left anterior neck at the level of the cricoid cartilage and the left perithyroidal space o p e n e d . T h e left t h y r o i d l o b e showed marked adhesion to the surrounding tissue, forming an inflammatory scar. Preparation was carried out from the upper pole of the left thyroid lobe to the inferior constrictor muscle of the pharynx, but no fistula structure was found. Preparation was then continued to the left thyroid lobe along the carotid artery, where a cystic, funicular structure, 3 cm long and 5 mm thick, was found running from the lateral wall of the lower pharynx u n d e r n e a t h the superior thyroid artery to the inflammatory scar on the left thyroid lobe (Fig. 3).
Histological findings
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Acute suppurative thyroiditis
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Fig. 4. Histological findings of the specimen. Inflammatory granulation of the cyst wall (left; HE X40) and thymus tissue with parathyroid tissue (right; HE )
Acute suppurative
thyroiditis (AST), also known as thyroid gangrene or thyroidal abscess, 1 is thought to originate from another septic focus within the b o d y Y In 1979, Takai et al.4 demonstrated the pyriform sinus fistula as the main route of infection for AST, since when surgical resection of the fistula has begun to achieve good results. During the five year period from 1983 through 1987, eight patients with AST underwent surgery at Ito Hospital. The case we present herein was considered to have originated from infection
The Surgical Branch, Ito Hospital, Tokyo,Japan *The Department of Pathology, Keio University School of Medicine, Tokyo,Japan Reprint requeststo: Osamu Ozaki, MD, The Surgical Branch, Ito Hospital, 4-3-6 Jingatmae, Shibuya-ku, Tokyo 150,Japan
An 8 year old Japanese boy originally presented to our clinic in the middle of July, 1986, with swelling of the left anterior neck, slight fever and a sore throat. These symptoms were accompanied by an asthmatic attack. On August 10, his temperature rose to 39~ and abscess formation was present in the anterior neck. He received incisional drainage of the abscess at another hospital and his symptoms subsided. Four months later, he presented again with fever and a sore throat with anorexia, and was admitted to Ito Hospital on December 6. The patient, 131 cm in height and 28.2 kg in weight, looked pale and his skin was dry. His temperature was 38.0~ and pulse rate 124/sec. The skin over the swelling in the
JAPANESEJOURNALOFSURGERY,VOL.20, No. 5 pp. 593-596, 1990
594
Ozaki et al.
Jpn. J. Surg. September 1990
Fig. 3. Surgical specimen.
Fig, 1. Pharyngograph. A pyriform sinus fistula is not clearly demonstrated.
Fig. 2. Ultrasonograph. A hypoechoic area is noted around the left thyroid lobe. left anterior neck was reddish in color, warm and painful. Tenderness without fluctuation was noted and his tonsils were hyperemic and swollen. Laboratory data on admission showed findings of acute inflammation, with a WBC o f 14,300 and a CRP o f over 6(+). Thyroid function was normal except for a slight increase in TSH (6.2 #U/ml). A pyriform sinus fistula was not clearly demonstrated by pharyngography (Fig. 1), however, an ultrasonography revealed an ill-defined hypoechoic space from the anterior to the lateral aspects o f the left thyroid lobe; a finding that strongly suggested AST (Fig. 2).
Because three days of intravenous antibiotics did not improve his condition at all, incisional drainage was carried out on December 9, Streptococcus milleri was disclosed in the grayish-yellow purulent exudate. Several days after the drainage, his temperature and CRP returned to normal, and he was discharged on December 26, with an appointment for fistulectomy several months later. H e was followed up by his family doctor until July 4, 1987, when he presented again with fever and swelling of the anterior neck, and was referred to Ito Hospital. Incisional drainage revealed yellow-green malodorous pus which demonstrated Streptococcus sp. and Eikennela corrodens and he underwent surgery on July 29, 1987.
Surgical findings A collar incision was made into the left anterior neck at the level of the cricoid cartilage and the left perithyroidal space o p e n e d . T h e left t h y r o i d l o b e showed marked adhesion to the surrounding tissue, forming an inflammatory scar. Preparation was carried out from the upper pole of the left thyroid lobe to the inferior constrictor muscle of the pharynx, but no fistula structure was found. Preparation was then continued to the left thyroid lobe along the carotid artery, where a cystic, funicular structure, 3 cm long and 5 mm thick, was found running from the lateral wall of the lower pharynx u n d e r n e a t h the superior thyroid artery to the inflammatory scar on the left thyroid lobe (Fig. 3).
Histological findings
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Fig. 4. Histological findings of the specimen. Inflammatory granulation of the cyst wall (left; HE X40) and thymus tissue with parathyroid tissue (right; HE )
