This composite of three intraoperative clinical photographs illustrates the surgical management of a pyriform sinus fistula (PSF) in the cervical region. Panel A demonstrates the identification of the fistula tract, which is visually enhanced using methylene blue dye. The tract appears as a distinct blue-stained tubular structure located medial to the inferior angle of the thyroid cartilage within the surgical field. Panels B and C show the progressive surgical steps of ligation and excision. In Panel B, surgical instruments (forceps and clamps) are used to isolate and stabilize the blue-stained fistula for suture ligation. Panel C depicts the final stages where the fistula is excised from the surrounding soft tissues, with surgical retractors providing exposure of the hypopharyngeal surgical site. The series highlights the importance of dye injection for intraoperative visualization of the fistula's anatomical course to ensure complete resection and reduce the risk of recurrence, which is the gold standard treatment for congenital branchial pouch anomalies.

This clinical photograph provides an intraoperative view of the surgical excision of a branchial fistula tract in the right neck. The operative field is exposed through a surgical incision, with drapes and retractors maintaining visibility. A gloved finger and surgical forceps are seen manipulating the tissues. Two key structures are labeled: 'TG' (Thyroid Gland) and 'PS' (Pyriform Sinus). A distinct, elongated, fibrous fistula tract is clearly visible, extending from the superior pole of the right thyroid gland toward the right pyriform sinus. The thyroid tissue appears hemorrhagic and partially dissected, reflecting the surgical manipulation required to isolate the tract. The image illustrates the complex anatomical relationship between the branchial fistula and adjacent endocrine and pharyngeal structures, specifically highlighting the pathway where a fourth branchial pouch sinus typically traverses. This material is educationally relevant for otorhinolaryngology and endocrine surgery trainees to understand the surgical anatomy of congenital neck fistulas.

A multi-panel figure illustrating two types of T-tube sinus tract duodenal fistulas. Panels A and C are anatomical diagrams showing the relationship between intrahepatic stones, the common bile duct, the T-tube sinus tract, and the duodenum. Panels B and D are fluoroscopic images (T-tube cholangiography) demonstrating these complications. In Type I (A and B), the diagram shows the T-tube unintentionally inserted directly into the duodenum through a fistula; the corresponding cholangiogram in Panel B shows contrast material filling the duodenum with an absence of opacification in the biliary tree, indicating complete diversion or distal blockage of the sinus tract. In Type II (C and D), the diagram depicts a fistula allowing communication between the T-tube sinus, duodenum, and common bile duct; the cholangiogram in Panel D shows initial contrast filling of the duodenal loop followed by retrograde opacification of the common bile duct and intrahepatic ducts. The image serves as an educational reference for hepatobiliary complications following procedures for intrahepatic stone extraction, specifically the diagnostic presentation of iatrogenic fistulous tracts on imaging.

This clinical photograph captures an intraoperative view of a surgical neck dissection for the management of a recurrent pyriform sinus fistula (PSF). The surgical field shows exposed deep cervical fascia and soft tissues. A white arrow points to the remaining fistula tract, which appears as a small, cylindrical, pale-colored tubular structure a few millimeters in diameter. Key surgical instruments in the field include a Senn retractor being used on the right to provide lateral traction for better visualization of the deeper structures, and hemostatic forceps or a clamp on the left manipulating adjacent tissue. Black silk sutures are visible at the superior margin of the incision. The image illustrates the complex anatomy and the surgical challenge of identifying and excising the complete tract in recurrent cases to prevent future infection or abscess formation.