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Pyriform sinus

The pyriform sinus (also spelled piriform sinus, and known as the pyriform recess, pyriform fossa, or smuggler's fossa) is a pear-shaped subsite of the hypopharynx, forming paired recesses on either side of the laryngeal inlet.^[1]^[2] Anatomically, each pyriform sinus is a mucosal-lined depression posterolateral to the laryngeal opening, extending from the pharyngoepiglottic fold superiorly to the upper border of the cricoid cartilage inferiorly.^[1] Its medial boundary is the aryepiglottic fold, the lateral boundary is the inner surface of the thyroid cartilage, and the posterior boundary is the low posterior pharyngeal wall.^[3]^[2] The anterior wall of the pyriform sinus overlies the internal branch of the superior laryngeal nerve, which provides sensory innervation to the hypopharynx and larynx.^[1] Functionally, the pyriform sinuses contribute to the swallowing mechanism as part of the "swallowing crescent," directing food and liquids laterally around the larynx into the esophagus while protecting the airway.^[3] They remain open during quiet respiration but can constrict during phonation or high-pitched vocalization, influencing voice production.^[3] Clinically, the pyriform sinus is significant as the most common site of hypopharyngeal malignancy, where squamous cell carcinoma accounts for approximately 95% of cases, often presenting with advanced disease due to its submucosal location and lymphatic drainage.^[2] It is also prone to congenital fistulas, foreign body impaction, and iatrogenic injury during intubation or endoscopy.^[2]

Terminology

Etymology

The term "pyriform sinus" derives from the Latin "pirum," meaning "pear," and "forma," denoting shape, thus referring to its pear-shaped configuration, while "sinus" indicates a recess or cavity in anatomical contexts.^[1] An alternative spelling, "piriform," reflects the same etymological root from "pirum," with both variants used interchangeably in medical literature to describe this hypopharyngeal structure.^[4] The nomenclature evolved from earlier Latin designations such as "sinus piriformis" or "fossa piriformis," used in anatomical literature to denote the pear-shaped recess lateral to the laryngeal inlet.^[3] Detailed anatomical descriptions of the pyriform sinus emerged in 19th-century literature.

Synonyms

The pyriform sinus is commonly referred to by several alternative names in medical literature, including the piriform sinus (an alternative spelling derived from the Latin pirum for pear), pyriform recess, pyriform fossa, and smuggler's fossa. The term "smuggler's fossa" originates from historical accounts of smugglers hiding small valuables, such as diamonds encased in lead balls, by swallowing them to lodge in the recess.^[1]^[5]^[6]^[7] Regional and historical variations include the piriform recess and the Latin nomenclature fossa piriformis or recessus piriformis, used in older medical works to denote the pear-shaped depression.^[4]^[8]^[6] In different fields such as otolaryngology and radiology, these synonyms are employed interchangeably for the hypopharyngeal structure, but care is taken to distinguish it from unrelated terms like "pyriform aperture," which specifically describes the pear-shaped nasal opening in craniofacial anatomy.^[1]^[9]^[10]

Anatomy

Structure and boundaries

The pyriform sinus is a bilateral, pear-shaped recess within the hypopharynx, forming a depression posterolateral to the laryngeal inlet on each side of the airway. It serves as a subsite of the hypopharynx and is also referred to as the piriform fossa or pyriform recess, derived from its characteristic shape resembling a pear. In adults, it measures approximately 2-3 cm in superior-inferior length, with variations in width (around 1.4 cm) and depth (around 1.3 cm), and slight asymmetry between the left and right sides may occur due to individual anatomical differences.^[11] The pyriform sinus extends superiorly from the pharyngoepiglottic fold (connecting the lateral pharyngeal wall to the epiglottis) to the level of the cricopharyngeus muscle inferiorly, where its apex approaches the upper esophageal sphincter. Its mucosal lining consists primarily of stratified squamous epithelium, which provides protection against mechanical stress during swallowing, though transitions to pseudostratified ciliated columnar epithelium may occur in adjacent respiratory regions. Beneath the anterior mucosal wall runs the internal branch of the superior laryngeal nerve.^[2]^[1]^[12] The structure is defined by distinct boundaries that enclose its recess-like form. Medially, it is bordered by the aryepiglottic fold superiorly and the arytenoid and cricoid cartilages inferiorly, with the lateral glossoepiglottic fold contributing to the upper medial limit. Laterally, the inner surface of the thyroid cartilage and the thyrohyoid membrane form the boundary, separating it from the paraglottic space. Anteriorly, the cricoid cartilage delineates the forward extent, particularly at the apex. Posteriorly, it opens to the postcricoid region, blending with the posterior pharyngeal wall and postcricoid cushion.^[1]^[12]^[3]

Relations

The pyriform sinus maintains distinct positional relationships with adjacent structures in the neck, which are crucial for surgical navigation and understanding potential spread of pathology. Superiorly, it is bordered by the epiglottis and arytenoid cartilages, connected via the aryepiglottic fold that forms its medial superior limit.^[1] This fold extends from the lateral edge of the epiglottis to the apex of the arytenoid cartilage, creating a continuous boundary that separates the sinus from the supraglottic larynx.^[13] Inferiorly, the pyriform sinus transitions directly into the esophagus at the pharyngoesophageal junction, where the cricopharyngeus muscle functions as the primary component of the upper esophageal sphincter.^[14] This junction marks the point where the hypopharynx narrows to meet the cervical esophagus, with the sinus apex often aligning at the level of the cricoid cartilage.^[2] Laterally, the pyriform sinus is bounded by the inner surface of the thyroid cartilage and thyrohyoid membrane, with the thyroid lobe situated external to the cartilage. In close proximity lies the recurrent laryngeal nerve, embedded within the paratracheal fascia in the tracheoesophageal groove, positioning it vulnerable to invasion by lesions in this region. Medially, the pyriform sinus directly faces the laryngeal inlet, bounded by the aryepiglottic fold and the lateral aspects of the arytenoid and cricoid cartilages.^[1] This adjacency places the sinus in immediate proximity to the vocal folds, increasing procedural risks such as inadvertent injury during transoral or endoscopic interventions.^[15] Posteriorly, the pyriform sinus relates to the posterior pharyngeal wall, while its anterior-lateral extent is defined by the oblique line of the thyroid cartilage, which separates the sinus lumen from the course of the internal branch of the superior laryngeal nerve.^[16] This nerve branch runs submucosally along the anterior wall of the sinus after piercing the thyrohyoid membrane superiorly, providing sensory innervation to the mucosa.^[1]

Blood supply and innervation

The arterial supply to the pyriform sinus primarily arises from branches of the superior thyroid artery, with additional contributions from the inferior thyroid artery and the ascending pharyngeal artery.^[2]^[17] The superior thyroid artery, originating from the external carotid artery, provides the main vascular input via its superior laryngeal branch, while the inferior thyroid artery (from the thyrocervical trunk) anastomoses with it to ensure robust perfusion.^[2] The ascending pharyngeal artery, a branch of the external carotid, supplies the posterior and lateral aspects through smaller pharyngeal branches.^[17] Venous drainage occurs via the superior and inferior thyroid veins, which converge into a pharyngeal venous plexus and ultimately empty into the internal jugular vein.^[13] This drainage pattern parallels the arterial supply, facilitating efficient return of deoxygenated blood from the hypopharyngeal region.^[13] Lymphatic drainage from the pyriform sinus follows a medial-to-lateral pathway, primarily to the deep cervical lymph nodes, with key involvement of levels III and IV along the jugular chain.^[2] This regional drainage is clinically relevant for patterns of metastasis in hypopharyngeal pathologies, as the pyriform sinus's lymphatics connect directly to these nodes without prominent superficial involvement.^[2] Sensory innervation of the pyriform sinus mucosa is provided by the internal branch of the superior laryngeal nerve, a division of the vagus nerve (cranial nerve X), which supplies the area superior to the vocal cords.^[17]^[13] Inferior portions may receive contributions from the glossopharyngeal nerve (cranial nerve IX) via the pharyngeal plexus.^[17] Motor innervation is indirect, mediated through the pharyngeal plexus—primarily from the vagus nerve—which innervates the pharyngeal constrictor muscles influencing sinus dynamics during swallowing.^[2]^[13]

Embryology

Development

The pyriform sinus develops from endodermal outpocketings known as the third and fourth pharyngeal pouches, which arise during weeks 4 to 7 of embryonic gestation as part of the pharyngeal apparatus.^[18] These pouches form between the pharyngeal arches along the lateral walls of the primitive pharynx, contributing to the caudal extension of the laryngopharynx, where the pyriform sinus emerges as a pear-shaped recess.^[19] The third pharyngeal pouch specifically gives rise to elements of the pyriform fossa, while the fourth pouch influences adjacent structures in the laryngopharyngeal region.^[18] Pouch formation begins prominently by week 5, with the structures separating from the foregut endoderm by approximately week 8 as the larynx begins to descend and differentiate.^[19] The development of the pyriform sinus is closely tied to derivatives of the branchial arches, particularly the fourth arch, which contributes mesenchymal elements that form surrounding laryngeal cartilages such as the thyroid and cricoid.^[20] Neural crest cells migrating into these arches provide the connective tissue framework, while endodermal components from the pouches line the sinus interior. This coordinated arch-pouch interaction during weeks 4-7 delineates the sinus boundaries, reflecting the embryonic divisions that persist into adulthood.^[21]

Congenital anomalies

The pyriform sinus fistula (PSF), also known as congenital pyriform sinus fistula (CPSF), is a rare developmental abnormality arising from incomplete obliteration of the third or fourth pharyngeal pouch during embryogenesis.^[22] This persistent tract typically originates at the apex of the pyriform sinus and follows a characteristic course, penetrating the cricothyroid membrane and extending inferiorly toward the thyroid gland, often looping around its lateral aspect before reaching the root of the neck.^[22] The anomaly is predominantly left-sided, with studies reporting left involvement in 91-97% of cases, attributed to asymmetric regression of the branchial pouches during development.^[22]^[23] PSF accounts for 2-10% of all branchial cleft anomalies, which themselves represent a small fraction of congenital neck masses, rendering it an exceedingly uncommon condition.^[23] Other congenital anomalies associated with the pyriform sinus region include branchial cleft cysts or sinuses embedded in the lateral pharyngeal wall, derived from similar embryonic remnants of the second, third, or fourth pouches.^[24] Additionally, variants of thyroglossal duct cysts may impinge on adjacent thyroid structures, occasionally mimicking or complicating pyriform sinus malformations due to their proximity in the anterior neck.^[25]^[26] These anomalies are frequently asymptomatic at birth and remain undetected until early childhood, when bacterial colonization leads to recurrent suppurative thyroiditis, neck abscesses, or cystic masses in the anterior cervical region.^[27] Diagnosis typically involves imaging modalities such as barium swallow esophagography to visualize the fistulous tract or computed tomography (CT) fistulography to delineate its extent and thyroid involvement.^[28]^[23]

Function

Role in swallowing

During the pharyngeal phase of swallowing, the pyriform sinus functions as a key conduit for the passage of the food bolus around the larynx, directing it toward the esophagus while minimizing the risk of aspiration into the airway.^[29] As the bolus enters the hypopharynx, the tilted epiglottis deflects it laterally into the pyriform recesses, bypassing the laryngeal inlet. This lateral diversion is facilitated by the sinus's pear-shaped structure, bounded medially by the aryepiglottic fold and laterally by the thyroid cartilage and pharyngeal wall, which channels the bolus efficiently past the protected larynx.^[2] The propulsion of the bolus through the pyriform sinus is driven by the sequential contraction of the pharyngeal constrictor muscles, which squeeze the contents inferiorly toward the cricopharyngeus.^[29] These muscles, including the superior, middle, and inferior constrictors, generate peristaltic waves that clear the sinus and ensure smooth transit.^[2] Concurrently, the pyriform sinus coordinates with the relaxation of the upper esophageal sphincter (UES) at its inferior extent, where the cricopharyngeus muscle relaxes under neural control from the glossopharyngeal and vagus nerves, allowing the bolus to enter the esophagus without obstruction.^[29] In normal deglutition, the pyriform sinus also provides temporary volume accommodation for small amounts of residue, typically a thin mucosal coating, which supports the overall safe progression of the bolus and prevents immediate overload of the esophageal inlet.^[29] This reservoir-like capacity, though minimal in healthy individuals, aids in maintaining pharyngeal clearance during the rapid pharyngeal phase, which lasts approximately 1 second.

Protective mechanisms

The pyriform sinus plays a critical role in airway protection through sensory mechanisms mediated by the internal branch of the superior laryngeal nerve (ISLN), which provides sensory innervation to its mucosa.^[13] This nerve detects the presence of a bolus or potential irritants in the hypopharynx, enabling rapid sensory feedback during swallowing to prevent laryngeal penetration.^[30] If bolus material or foreign particles threaten to enter the airway, the ISLN triggers the cough reflex, facilitating expulsion and safeguarding the lower respiratory tract.^[31] As a structural reservoir, the pyriform sinus functions as a "moat" adjacent to the laryngeal inlet, trapping small foreign particles, residual food, or liquid that might otherwise spill over during swallowing, thereby preventing their entry into the larynx.^[32] This holding capacity is particularly effective in the upright position, where laryngeal elevation creates a barrier, allowing trapped residues to be cleared via secondary peristaltic waves or saliva flow rather than direct aspiration.^[33] Due to its anatomical proximity to the aryepiglottic fold, which forms its medial boundary, the pyriform sinus contributes to glottic closure during the pharyngeal phase of swallowing.^[1] Contact of fluid or material with the pyriform sinus mucosa stimulates sensory afferents that promote transient vocal cord adduction, enhancing laryngeal inlet sealing and airway protection.^[34] The ISLN also conveys sensations of temperature from the pyriform sinus, allowing modulation of swallow initiation based on bolus characteristics to optimize protective responses.^[31] Extreme temperature stimuli can elicit heightened laryngeal reflexes, ensuring timely adjustments in swallowing coordination to minimize aspiration risk.^[30]

Clinical significance

Infections and inflammation

The pyriform sinus is susceptible to infectious and inflammatory processes due to its anatomical location in the hypopharynx, adjacent to the larynx and esophagus. Acute suppurative thyroiditis (AST) secondary to a pyriform sinus fistula represents a primary infectious complication, particularly in pediatric patients, where the fistula serves as a conduit for bacterial entry into the thyroid gland. This congenital tract, often originating from the third or fourth branchial pouch, allows pathogens from the pharynx to ascend, leading to recurrent left-sided thyroid abscesses. Common causative bacteria include Streptococcus species, such as Streptococcus viridans, with presentations typically involving neck swelling, fever, odynophagia, and torticollis. These infections are often recurrent without fistula excision, and imaging such as contrast-enhanced CT or barium swallow is essential for diagnosis.^[35] Infections can also extend from adjacent pharyngeal conditions, such as viral or bacterial pharyngitis, potentially involving the pyriform sinus due to its proximity to the peritonsillar space. Peritonsillar abscesses, commonly caused by group A Streptococcus, may spread inferiorly toward the hypopharynx, resulting in localized edema or secondary infection in the pyriform recess, exacerbating symptoms like severe sore throat and dysphagia. This extension is facilitated by the shared lymphatic drainage and mucosal continuity in the oropharynx and hypopharynx, though direct pyriform involvement remains uncommon and typically manifests as part of broader deep neck infections.^[36]^[37] Chronic inflammation of the pyriform sinus often arises from laryngopharyngeal reflux (LPR), a manifestation of gastroesophageal reflux disease where gastric contents irritate the hypopharyngeal mucosa. This leads to mucosal edema, erythema, and hyperplasia in the pyriform sinus, observable on laryngoscopy, contributing to symptoms such as globus sensation, chronic cough, and voice changes. LPR-induced inflammation is pepsin-mediated and persists due to repeated exposure, distinguishing it from acute bacterial processes. Management focuses on acid suppression therapy to reduce mucosal damage.^[38]^[39]

Neoplasms

The most common neoplasm of the pyriform sinus is squamous cell carcinoma, which accounts for approximately 95% of hypopharyngeal cancers, with the pyriform sinus being the most frequently affected subsite.^[40] Risk factors for this malignancy mirror those of other head and neck squamous cell carcinomas, primarily tobacco use and alcohol consumption, which synergistically increase susceptibility through chronic mucosal irritation and carcinogenic exposure.^[12] The T-stage classification under the American Joint Committee on Cancer (AJCC) system for hypopharyngeal tumors, including those in the pyriform sinus, is based on tumor size and local extension; for instance, T1 lesions are limited to one subsite and measure ≤2 cm, while T2 involves extension to adjacent structures such as the aryepiglottic fold or measures >2 cm but ≤4 cm without hemilaryngeal fixation, and higher stages reflect deeper invasion toward the apex or beyond.^[41] The pyriform sinus is classified as a subsite within the hypopharynx under the AJCC TNM staging system (8th edition), where overall stage grouping integrates T, N, and M categories to guide prognosis and treatment; advanced stages (III-IV) predominate at diagnosis due to the often silent progression of these tumors.^[42] Five-year survival rates for advanced-stage hypopharyngeal cancers range from approximately 30% to 50%, influenced by factors such as nodal involvement and therapeutic modality, though outcomes remain poorer compared to other head and neck sites.^[40] Other neoplasms in the pyriform sinus are rare, including adenocarcinoma arising from glandular elements and lymphoma originating from lymphoid tissue, which together comprise less than 5% of cases.^[40] Early detection of these tumors is challenging with conventional endoscopy owing to the deep recess anatomy of the pyriform sinus, often resulting in presentation at advanced stages.^[43] Lymphatic spread typically occurs to the jugular chain lymph nodes (levels II-IV), with a notable risk of bilateral involvement due to the pyriform sinus's proximity to midline structures facilitating crossover drainage.^[44]^[45]

Other conditions

Foreign body impaction in the pyriform sinus typically involves food particles or sharp objects, such as chicken bones or toothpicks, becoming lodged in the recess due to its anatomical location adjacent to the airway. This condition can lead to symptoms including dysphagia, sore throat, voice changes, and nonproductive cough, with potential complications like local edema or perforation if untreated.^[46]^[47] Diagnosis often relies on imaging, such as lateral neck X-rays or computed tomography (CT) scans, which reveal the foreign body in the lateral wall or fossa of the pyriform sinus.^[46]^[47] Removal is generally accomplished via endoscopic procedures, including direct laryngoscopy and esophagoscopy under general anesthesia, allowing for safe extraction and resolution of symptoms without further intervention in most cases.^[47] Iatrogenic injury to the internal branch of the superior laryngeal nerve, which provides sensory innervation to the pyriform sinus mucosa, can occur during procedures such as endotracheal intubation or hypopharyngeal biopsy. This damage disrupts sensation in the supraglottic region, potentially leading to hoarseness, vocal fatigue, and altered pitch control due to impaired feedback during phonation.^[48] Intubation-related trauma, particularly in difficult airways, may stretch or compress the nerve as it courses near the pyriform apex, while biopsy risks arise from direct instrumentation in the sensitive mucosal area.^[50]^[51] Such injuries are often transient but can contribute to prolonged dysphonia if fibrosis develops, emphasizing the need for careful procedural technique to minimize nerve vulnerability.^[48] Diverticula of the pyriform sinus are rare outpouchings, resembling Zenker's diverticulum in their posterior hypopharyngeal location but occurring at the inferior apex of the sinus, potentially arising from acquired herniation of the pharyngeal wall. These pouches can fill with retained food or secretions, leading to progressive dysphagia to solids and liquids over years, as well as regurgitation and halitosis.^[52] The risk of aspiration is heightened due to residue pooling in the dilated sinus, which may mimic a true diverticulum on imaging like videofluoroscopic swallow studies, predisposing patients to pneumonia or respiratory failure from inhaled material.^[53] Diagnosis involves contrast esophagram or CT to distinguish dilatation from congenital anomalies, with management focusing on symptomatic relief through dietary modifications or endoscopic intervention in severe cases.^[52] Radiation effects in the pyriform sinus commonly manifest as post-treatment fibrosis in patients receiving therapy for hypopharyngeal or laryngeal cancers, where cumulative doses exceeding 60-70 Gy to the pharyngeal constrictors induce progressive collagen deposition and tissue stiffening. This fibrosis reduces the compliance and contractility of the sinus walls and surrounding muscles, impairing bolus clearance during swallowing and leading to residue accumulation that heightens aspiration risk.^[54] Late-onset changes, appearing months to years after treatment, stem from chronic inflammation and vascular damage, altering the hypopharynx's biomechanical function and contributing to persistent dysphagia.^[55]^[54] Management involves multidisciplinary approaches, including swallowing therapy, to mitigate functional decline, though severe cases may require hyperbaric oxygen or pentoxifylline-based protocols to counteract fibrotic progression.^[55]

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Bronchoscopy was performed with aspiration of about 5 mL of contrast material. The patient was later successfully extubated without complication, however a ...
[55]
Pathophysiology of Radiation-Induced Dysphagia in Head and Neck ...
Apr 20, 2016 · The goal of this review is to discuss the pathophysiology of radiation-induced injury and elucidate areas that need further exploration.
[56]
Radiation-Induced Fibrosis in Patients with Head and Neck Cancer
Jan 30, 2022 · Radiotherapy-related fibrosis remains one of the most challenging treatment related side effects encountered by patients with head and neck cancer.Missing: pyriform sinus