Management of cervical esophageal and hypopharyngeal perforations

Penetrating hypopharyngeal foreign body impalement of the thyroid gland: A case report of rare complication of ingested fish bone

INTRODUCTION AND IMPORTANCE

Foreign body ingestion complicated by hypopharyngeal perforation is an uncommon but potentially life-threatening condition. Early recognition and appropriate management are crucial to prevent serious complications. We present an extremely rare case highlighting the importance of this clinical entity.

CASE PRESENTATION

A 60-year-old female presented with odynophagia 10 days after ingesting fish and chicken. Imaging revealed a linear foreign body penetrating through the left lateral hypopharyngeal wall into the left thyroid lobe, with surrounding inflammatory changes. The patient underwent neck exploration, which identified a sharp fishbone lodged in the postero-medial aspect of the left thyroid lobe, necessitating a left hemithyroidectomy for removal.

CLINICAL DISCUSSION

To our knowledge, this is the first reported case of hypopharyngeal perforation by an ingested foreign body penetrating the thyroid gland itself. Despite its rarity, early recognition is crucial to prevent complications like abscess, mediastinitis, and mortality. A high index of suspicion is needed in patients with odynophagia or neck pain after ingesting fish. Advanced imaging and surgical intervention may be required for the management of larger perforations or those involving surrounding structures.

CONCLUSION

This unique case highlights an extremely rare presentation of hypopharyngeal perforation with extension into the thyroid gland caused by an ingested fish bone. Prompt diagnosis through appropriate imaging and treatment with surgical exploration and foreign body removal was key to ensuring a positive outcome. Increased awareness of this potential complication is essential among clinicians.

Vomiting-induced pharyngeal perforation during bowel preparation for colonoscopy: A case report

BACKGROUND

Effective bowel cleansing is essential for a successful colonoscopy. Laxatives, such as polyethylene glycol, are commonly used for bowel preparation. Vomiting is a frequent complication during bowel preparation, and forceful vomiting can potentially lead to esophageal perforation, as reported in several previous cases. However, pharyngeal perforation during bowel preparation has not been previously documented. Here, we present a case of pharyngeal perforation induced by forceful vomiting during bowel preparation.

CASE SUMMARY

A 38-year-old man with a history of hypertension, dyslipidemia, diabetes mellitus, and end-stage renal disease on hemodialysis was admitted for evaluation of recurrent abdominal pain. The patient complained of sudden pain in the neck, throat, and anterior chest following forceful vomiting during bowel preparation. Physical examination revealed crepitus under the skin of the neck and anterior chest on palpation, and upper gastrointestinal endoscopy revealed pharyngeal perforation. The perforation site was located above the upper esophageal sphincter, which distinguished it from Boerhaave's syndrome. Conservative medical management was chosen after consultation with a thoracic surgeon and an otolaryngologist, considering the patient's mild symptoms, stable vital signs, and the small size of the lesion; the perforation resolved without endoscopic or surgical intervention. The patient was discharged from hospital two weeks after the perforation.

CONCLUSION

Despite its rarity, pharyngeal perforation should be considered a potential complication of bowel preparation for colonoscopy.

Transoral traumatic perforation of the pyriform sinus by a marker pen: report of an infant case

BACKGROUND

Perforation of the pyriform sinus, included in hypopharyngeal injury, is a rare condition typically caused by iatrogenic factors. We present a case of an infant who developed deep cervical and mediastinal abscesses due to a traumatic pyriform sinus perforation caused by accidentally falling with a marker pen in the mouth.

CASE PRESENTATION

An 11-month-old healthy male infant fell on a trampoline with a marker pen in his mouth. The patient developed swelling in the neck 3 h after the incident and was taken to a regional general hospital. Although a laryngoscopy showed no perforation in the oral cavity or posterior pharynx, a computed tomography (CT) scan revealed significant emphysema extending from the cervix to the mediastinum. The patient was transferred to our tertiary hospital and admitted to the intensive care unit, where he was mechanically ventilated, and antibiotic therapy was initiated. On day 3 of admission, a CT scan revealed deep abscesses in the cervical and upper posterior mediastinum with pneumomediastinum. Although his respiratory status stabilized and he was temporarily weaned, the fever recurred. Pharyngoesopagography revealed significant leakage of contrast from the left pyriform sinus to the mediastinum. Consequently, surgical drainage of the abscess was performed on day 10. Two low-pressure continuous suction drains were placed, one in the posterior mediastinum and the other close to the pyriform sinus. Pharyngoesophagography on postoperative day (POD) 7 demonstrated decreased contrast leakage into the posterior mediastinum. The patient was initiated on enteral nutrition through a nasogastric tube. The patient was discharged on POD 31 after the suction drains were replaced with open Penrose drains, and enteral nutrition via nasogastric tube was continued at home. The Penrose drains were removed on POD 54, and salivary leakage ceased on POD 111.

CONCLUSIONS

Although injuries to the oral cavity and posterior pharynx are more easily recognized, the existence of injury in the pyriform sinus can be challenging to evaluate. However, prompt and appropriate management, including intubation, antibiotic therapy, surgical drainage, and nutritional support, is critical in preventing life-threatening complications.

Hypopharyngeal perforation caused by blunt trauma in buffalo attack

A male in his 50s arrived by ambulance at a regional Australian hospital after being pinned by a buffalo against a fence by the chest and abdomen. Primary and secondary surveys identified an open fibula fracture and superficial abrasions. CT trauma series identified retropharyngeal free gas extending to the right carotid sheath. Flexible nasoendoscopy revealed a normal upper airway and no site of perforation. Oesophagoscopy and gastroscopy were completed to evaluate for a site of free gas leakage. A hypopharyngeal tear was identified 15 cm from the incisors at the cricopharyngeal sphincter. A gastrograffin swallow was completed which showed no leak. The decision was made to manage the patient conservatively with intravenous dexamethasone and intravenous ceftriaxone/metronidazole for antibiotic prophylaxis. The patient had his diet gradually upgraded and was discharged home 4 days later with oral amoxicillin and clavulanic acid.

Hypopharyngeal Perforation Following Foreign Body Ingestion: A Case Report

Foreign body ingestion is a common complaint frequently seen in otolaryngology. Some sharp foreign bodies may get impacted in the aerodigestive tract causing a perforation. However, hypopharyngeal perforation is a rare injury that needs early recognition due to its significant morbidity. In this case report, we report a case of hypopharyngeal perforation caused by foreign body ingestion in an adult patient. A 60-year-old female presented with a foreign body sensation in the throat, dysphagia, and odynophagia. A neck CT scan showed a foreign body in the hypopharynx with a collection of free air along the posterior pharyngeal wall. She underwent laryngoscopy and esophagoscopy for examination and foreign body removal. Following the procedure, the patient was treated conservatively for a week and then discharged home in a stable condition. Hypopharyngeal perforation following foreign body ingestion is uncommon. A high index of suspicion is required to reach an early diagnosis and treatment.

A new "Ice Globe" method for dilating leaking cervical esophageal strictures

An esophageal stricture may develop during healing of a large esophageal perforation. When such a stricture occurs, mechanical dilatation is the treatment of choice. As in our case, if a cervical esophageal stricture and leakage are present together, the treatment becomes even more challenging. As a new treatment method, we made spherical ice globes of various sizes using molds created with a 3D printer to treat the esophageal stricture and prevent its progression. This method can be used to safely treat leaking cervical esophageal strictures. A step-by-step of how to do it has been described.

Thoracic esophageal injury due to a neck stab wound: a case report

BACKGROUND

Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade.

CASE PRESENTATION

A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries.

CONCLUSIONS

The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Pyriform sinus rupture caused by blunt trauma

Hypopharyngeal perforation (HP) is a potentially life-threatening condition most associated with iatrogenic injury and foreign body impaction. Additionally, a number of cases of posterior HP have been reported following blunt cervical trauma. We present a case of a construction accident causing lateral hypopharyngeal rupture. Visceral perforation was initially diagnosed on computed tomography (CT) imaging and managed conservatively. We speculate this region may be particularly vulnerable to injury due to an anatomic transition in adjacent fascial support. A review of 29 prior cases suggests that this may be the first reported case of blunt trauma causing rupture of the pyriform sinus. However, significant heterogeneity exists in diagnostic approach. Radiography and CT are rapid, sensitive modalities for suggesting pharyngeal perforation, while fluoroscopy and endoscopy can better assess injury size and location and monitor resolution. Early radiologic recognition of hypopharyngeal injury is essential to initiate appropriate treatment. In certain cases, including our own, both the presence and specific location of perforation may be identified on initial CT images.

Transoral Endoscopic Approach to Repair Early Pharyngeal Perforations After Anterior Cervical Spine Surgery without Failure of Instrumentation: Our Experience and Review of Literature

BACKGROUND

Pharyngoesophageal injury during anterior cervical spine surgery is a rare and potentially life-threatening complication; generally it is the result of intraoperative manipulation or hardware erosion and sometimes may be due to weakness of the pharyngoesophageal wall from pre-existing pathologic conditions, such as diabetes, gastritis, or obesity.

CASE DESCRIPTION

We describe the management strategies in patients with an early postoperative hypopharyngeal perforation that occurred after anterior cervical spine surgery without failure of instrumentation, and we present a case treated endoscopically at our institution.

CONCLUSIONS

Appropriate treatment for pharyngoesophageal perforations is controversial and not investigated in detail. There is a lack of prospective studies comparing initial conservative versus surgical approaches to treatment. In addition, endoscopic management is growing as a therapeutic option, but no consensus concerning the indications for an endoscopic approach in the treatment of pharyngoesophageal injury in anterior cervical spine surgery is currently reached. A common theme proposed in the literature is that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. A customized interdisciplinary surgical approach is essential for successful treatment. Use of the transoral endoscopic approach is a useful noninvasive method to treat this rare but potentially devastating complication.

Intra-abdominal nasogastric tube placement following inadvertent nasopharyngeal perforation

We report the case of a patient who had a nasogastric tube inserted following cardiac surgery that was determined to be appropriately sited on chest X-ray. Following initiation of nasogastric feeding, however, the patient became acutely unwell. Subsequent computed tomography imaging demonstrated that the nasogastric tube had perforated through the posterior nasopharynx and passed through the mediastinum into the abdominal cavity. A laparotomy and washout was required, and following a prolonged intensive care stay with multiple further interventions, the patient ultimately survived to discharge. Pharyngeal wall perforation is a rare but serious complication of attempted nasogastric tube insertion. Risk factors include the need for repeated attempts and patients with an altered mental state. The appropriate steps in confirming the position of nasogastric tubes both clinically and radiologically are reviewed in the context of this rare and serious complication.

Assessment and treatment of hypopharyngeal and cervical esophagus injury: Literature review

Wounds and perforations of the upper gastrointestinal tract are serious and life-threatening. The hypopharynx and cervical esophagus, by their respective anatomical positions, are exposed to traumatic wounds, most often during diagnostic tests, but management such wounds remains a subject of discussion. The present article analyzes the current state of knowledge on epidemiology, etiologies, risk factors, diagnostic management, prognostic factors and available treatments.

Circumferential Pharyngoesophageal Reconstruction and Total Larynx Preservation with Extra-anatomical Free Flaps

Supplemental Digital Content is available in the text.

Reconstruction of total circumferential pharyngeal defects following caustic or stenosant lesions of the pharynx present major challenges with respect to minimizing surgical morbidity and restoring functional deficits. With recent advances in microvascular free tissue transfer, the options for pharyngeal reconstruction have multiplied in order to maximize swallowing and voice. There is long experience in the reconstruction of the pharynx and the cervical esophagus in oncological patients after total pharyngolaryngectomy, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 new techniques for total circumferential pharyngeal reconstruction respecting swallowing and voice by means of extra-anatomical bypasses (visceral or fasciocutaneous), upholding the larynx in its original placement.

Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated

BACKGROUND

Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries.

METHODS

Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners.

RESULTS

127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury.

CONCLUSION

Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

Case report of a conservative management of cervical esophageal perforation with acrylic glue injection

BACKGROUND

perforation of the upper aerodigestive tract is a potentially life-threatening condition. The appropriate treatment of cervical esophageal perforation is still controversial.

CASE PRESENTATION

we report a case of cervical esophageal perforation that was effectively treated by a conservative management with acrylic glue injection.

DISCUSSION

the management of cervical esophageal perforations has been controversial and little studied. Various treatment options, including surgical and nonsurgical management have been advocated, and no gold standard surgical treatment has yet been established. Some authors have recommended immediate surgical intervention, especially in penetrating trauma, conversely, several studies support conservative management.

CONCLUSIONS

we consider that the application of acrylic glue can be considered a promising, minimally invasive therapeutic option in the management of cervical esophageal perforation. However, the sufficient accumulation of similarly treated cases is necessary in order to confirm the efficacy and safety of this treatment modality.

The importance of early recognition in management of ERCP-related perforations

BACKGROUND

Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition.

METHODS

The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes.

RESULTS

14,045 ERCP's were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately.

CONCLUSIONS

Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.

Blunt Pharyngoesophageal Injuries: Current Management Strategies

BACKGROUND:

Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration.

METHODS:

The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay.

RESULTS:

A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03).

CONCLUSION:

Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature

STUDY DESIGN

Multicenter retrospective case series and review of the literature.

OBJECTIVE

To determine the rate of esophageal perforations following anterior cervical spine surgery.

METHODS

As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis.

RESULTS

The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired.

CONCLUSIONS

Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.