Transection of the base of the tongue caused by penetrating injury

Traumatic transection of the base of the tongue can be a life-threatening injury because of blood loss and airway obstruction. Airway control, hemostasis, and meticulous anatomic repair are necessary to prevent speech and airway dysfunction. Laryngeal injuries, when present, require these same principles.

Neonatal pharyngeal pseudodiverticulum mimicking esophageal atresia

Pseudodiverticulum of the hypopharynx is an infrequent but potentially serious complication of orogastric or nasogastric tube insertion and endotracheal intubation. We report two cases of injury to the hypopharynx resulting in a pseudodiverticulum of the hypopharynx that was initially diagnosed as esophageal atresia. Both cases were managed successfully by conservative therapy. We also review the literature regarding neonatal pharyngeal pseudodiverticulum.

Larynx and hypopharynx

Cross-sectional imaging with CT and MR imaging plays an indispensable complementary role to endoscopy in the pretherapeutic work-up of laryngeal and hypopharyngeal cancer and is very valuable for the detection of tumor recurrence after surgery or radiation treatment as well. Close interdisciplinary co-operation and the radiologist's familiarity with therapeutic options and challenges are required in order to use these powerful diagnostic tools in an optimal fashion. Other indications for cross-sectional imaging of the larynx and hypopharynx include uncommon neoplasms, benign masses, inflammatory disorders, and trauma.

Traumatic injuries of the alimentary tract in children

Traumatic alimentary tract (AT) perforations in children secondary to instrumentation, though rare, can occur at any age, especially in neonates and young infants. Awareness of such a possibility is essential for prompt management to be initiated. Over a 10-year period (1986-1995), eight pediatric patients with AT perforations secondary to instrumentation were managed at the American University of Beirut Medical Center. Five had upper AT injuries that included three hypopharyngeal, one esophageal, and one gastric lesion. The remaining three patients had lower AT injuries involving the transverse colon in one and the rectum in two. All the patients but two (one with a hypopharyngeal and one with an esophageal injury) were managed surgically and all survived. These rare injuries are discussed in addition to the preventive measures to be taken.

Piriform sinus perforation during Esophageal-Tracheal Combitube placement

The Esophageal-Tracheal Combitube is a new alternative airway device. Few complications of its use have been reported. This article reports a case of a 71-year-old female with angioedema of the tongue and airway obstruction who suffered piriform sinus rupture during Combitube placement by prehospital personnel, resulting in massive subcutaneous emphysema. Caution is required when using this device in all but the most controlled situations.

Pneumomediastinum following penetrating oral trauma

Pneumomediastinum can result from a puncture wound or laceration to the hypopharynx. This is a case report of an 18-month-old child who fell with a pen in his mouth. Initial physical examination was unremarkable, but the child developed neck swelling, fever, and irritability over the next 12 hours. Repeat examination revealed marked pneumomediastinum and subcutaneous emphysema. The pathophysiology and treatment of pneumomediastinum are reviewed.

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE

To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries.

METHODS

The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed.

RESULTS

No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula.

CONCLUSIONS

Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.

Conservative management of penetrating hypopharyngeal wounds

OBJECTIVE

To demonstrate the applicability of nonoperative treatment to penetrating hypopharyngeal wounds.

DESIGN

A prospective study.

MATERIALS AND METHODS

An analysis of patients with penetrating hypopharyngeal wounds who were treated nonoperatively at the Hospital Universitario del Valle (Cali, Colombia) during 4 years (beginning January 1990) was performed. Patients older than 13 years with proven lesions produced by penetrating trauma were included. Patients with foreign-body-induced or iatrogenic lesions (orotracheal intubation, endoscopy) or immediate need for surgery (for associated lesions) were excluded. Nonoperative management consisted of nasogastric tube for feeding, suspension of oral intake, and parenteral antibiotics for 7 days.

MEASUREMENTS AND MAIN RESULTS

Fourteen patients met the above criteria. Gunshot wounds (n = 11) were the most common trauma. An esophagogram/endoscopy demonstrated the lesions. The only complication in the group consisted of a cervical abscess, which presented in a patient during the first week of treatment. There were no complications such as fistula, leakage, and Horner's syndrome.

CONCLUSIONS

Conservative management is a good and safe alternative when indicated in penetrating hypopharyngeal wounds.

Thermal injury to the upper aerodigestive tract after microwave heating of food

Microwave-heated food may cause serious injury if it is not allowed to cool before consumption. We describe a case in which a hypopharyngeal burn occurred following consumption of a microwave-heated potato immediately after cooking.

Perforation in hypopharynx and deep cervical emphysema caused by blunt external trauma

We present a case in which a blunt external trauma caused a perforating wound in the hypopharynx without any superficial damage on the skin of the neck. Deep cervical emphysema and general signs of systemic infection followed. The wound was sutured through an endoscope and the patient recovered uneventfully. The importance of the early diagnosis is emphasized.

Management of traumatic hypopharyngeal injuries

Violation of the hypopharynx by external penetrating trauma is an uncommon occurrence that may lead to life-threatening infectious complications if not recognized promptly and treated appropriately. A retrospective review of 48 such injuries seen during a 10-year period showed that flexible fiberoptic endoscopic examination is the best screening tool for recognition of a possible hypopharyngeal mucosal violation. Direct laryngopharyngoscopy is the best method of definitively diagnosing the injury. Size of the visualized mucosal violation alone is not sufficient information on which to base the decision for medical management versus surgical intervention (i.e., immediate exploration and drainage). Rather, the size, exact site of injury, and mechanism of the injury must be considered to have equal importance. Associated vertebral body fractures may negatively influence acute outcome if diagnosis and treatment of the hypopharyngeal injury are delayed by the cervical spine injury.

Composite reconstruction of the esophagus and hypopharynx after severe caustic injury

The ingestion of caustic materials may cause burns and subsequent strictures of the esophagus. Depending on the extent of the injury, the stricture may require dilation, excision, or bypass with an esophageal replacement. There is also a risk of esophageal dysfunction, perforation, and malignancy. Here is presented a case of a burn so severe that the hypopharynx was deformed and the esophagus destroyed. Composite techniques restored complete gastrointestinal continuity while maintaining excellent swallowing function.

Cases of death caused by gas or warning firearms

Five cases of lethal injuries caused by gas or warning firearms are discussed. In one suicide case a modified weapon (elongated barrel) and steel bullets were used to fire a shot into the head, the bullets lodged in the skull and lethal bleeding resulted. In the other cases conventional gas weapons without evidence of alteration were used for contact shots; injuries were caused by the effect of propelling powder gases. Two of these cases were suicides (temporal contact shot and back of the neck contact shot), one was an accident (inguinal contact shot with lethal bleeding), and one was an attack by another person with a contact shot against the neck with bilateral tears of the hypopharynx. After successful surgery, a delayed death occurred 12 days later caused by bleeding into the airways from the ruptured external carotid artery.

Upper airway obstruction--an unusual complication following a minor scalding injury

A 14-month-old girl suffered a 10 per cent scalding injury from hot water of the type sometimes recognized as 'the teapot syndrome'. The hot water also reached the hypopharynx where it caused marked swelling of the mucosa and hence obstruction of the airway. Increasing respiratory distress made endotracheal intubation necessary 4.5 h after the accident. The girl was extubated 26 h later, and breathing was normal. The external burns were initially treated with baths and dressing changes. They healed mostly spontaneously, but four areas had to be grafted. This case report shows that thermal burns of the mouth and pharynx, followed by oedema and upper airway obstruction, can occur also in a minor scalding injury involving the face. Respiratory distress makes intubation necessary.

Free flap reconstruction of recalcitrant hypopharyngeal stricture

A case report is presented of the use of a jejunal microvascular free flap for the reconstruction of a hypopharyngeal stricture caused by caustic ingestion. Although the airway was reestablished, there was aspiration and diplophonia. This case is discussed as an example of an effective treatment of a difficult problem, but one posing secondary problems arising from the use of jejunum.

Platysma myocutaneous flap for repair of hypopharyngeal strictures

Hypopharyngeal strictures, either isolated or in conjunction with laryngeal and esophageal strictures, can occur following lye ingestion. Extensive stricture formation requires reconstruction to create a functional funnel system that empties below the cricoid. Esophageal replacement is not a substitute for adequate hypopharyngeal reconstruction. The pectoralis major muscle is often inadequate, because it yields too much bulk and often leads to continued aspiration. The platysma myocutaneous flap for hypopharyngeal reconstruction has not been previously reported. The inferiorly based platysma myocutaneous flap was used in two of our patients with lye burns, and bilateral superiorly based flaps were used in one. All are able to eat normally and have no significant stenosis. The platysma myocutaneous flap is a relatively simple and reliable alternative that is within the capability of every head and neck surgeon.