An 11-year-old girl presented with hoarseness as the first symptom of pyriform sinus fistulas (PSFs), a rare congenital anomaly of the third or fourth brachial pouch. On admission, she had fever, hoarseness, and an elastic soft mass on her left anterior neck. Contrast-enhanced computed tomography showed an abscess infiltrating the thyroid gland and an air pocket near the pyriform sinus. Treatment with cefotaxime and dexamethasone resolved the hoarseness, leading to PSF diagnosis.