Abstract Background Piriform sinus tract (PST) is a rare congenital condition. A delay in diagnosis is common leading to recurrent inflammation. Method A retrospective review was performed on all cases of PST treated at a tertiary referral centre between May 1997 and May 2012. Results Eighteen patients were reviewed with a mean age of 5.4years at presentation (ranged from 0day to 14years). Most patients presented as acute inflammation (88.9%) and 16 had a left sided lesion. 72.2% of the PST are identified by contrast swallow study. The diagnostic yield was significantly higher if the study was done after the initial acute inflammation settled. Ultrasonography and computer tomography are less sensitive. The median duration from presentation to diagnosis was 17.6months (ranged 0–120months). Ten patients (55.6%) experienced recurrent inflammation before confirming the diagnosis. Fistulectomy alone was performed in 15 patients while an additional en-bloc hemithyroidectomy was done in 2 patients. Conclusion PST should be suspected in children presenting with a left deep neck abscess. Contrast swallow study is very effective in making diagnosis but has to be postponed after the acute inflammation settles. The condition can be effectively treated by fistulectomy without hemithyroidectomy in majority of our cases.