Hypopharyngeal perforation caused by blunt trauma during consensual fellatio: an expectant management approach

Perforation of the pharynx is a rare occurrence but has the potential to cause mediastinitis and has an attendant mortality risk. Though numerous mechanisms have been described, we report a unique case of a young woman who presented with a sore throat, odynophagia and subcutaneous emphysema, a short time after performing fellatio. A contrast swallow confirmed hypopharyngeal perforation. She was managed expectantly with nasogastric feeding and empirical antibiotics. The perforation took 4 weeks to heal, but there were no residual swallowing problems at 3-month follow-up. We will explore the incidence and causes of pharyngeal perforation and discuss the options for and risks of surgical repair. This case highlights that non-surgical management of such injuries can be both safe and feasible, and reinforces the importance of ensuring confidentiality and the need for vigilance regarding potential non-consensual injury.

Delayed fatal upper-airway obstruction due to laryngopharyngeal burns and thermal epiglottis

A 48-year-old man complained of throat swelling and difficulty swallowing after eating hot food. Several hours later, he collapsed and was observed to be gasping for breath. Bystander and ambulance-initiated cardiopulmonary resuscitation was unsuccessful, and he was pronounced deceased at the scene. At autopsy, the aryepiglottic folds were markedly oedematous, with adjacent areas of mucosal inflammation and necrosis from a recent burn. Death was attributed to upper-airway obstruction due to glottic inlet oedema associated with epiglottic and laryngopharyngeal thermal injury. Although thermal epiglottitis not involving fire is an unusual injury and is rarely fatal, the reported case demonstrates a lethal episode arising from the ingestion of excessively hot food. Thermal epiglottitis therefore represents an uncommon cause of delayed upper-airway obstruction in adults that should be considered in individuals presenting with a sore throat and shortness of breath, particularly if there is a history of hot-food ingestion.

Uncommon foreign body in the hypopharynx: A case report

RATIONALE

Pharyngeal foreign bodies are a common complaint in emergent cases, and sometimes can be lethal. A large variety of foreign bodies may lodge in the pharynx. We present a case of uncommon foreign body in the hypopharynx.

PATIENT CONCERNS

A 9-month-old boy presented for an hour of crying associated with having congee. No abnormality was revealed in physical examination or cervicothoracic computed tomography (CT) scan. Flexible laryngoscopy showed a size tag on the posterior hypopharyngeal wall.

DIAGNOSES

Foreign body in the hypopharynx.

INTERVENTIONS

The foreign body was removed from the hypopharynx.

OUTCOMES

The patient was discharged after the removal of the foreign body.

LESSONS

Infants with foreign bodies in the hypopharynx may presented with no obvious clinical manifestation. Pharyngeal foreign bodies may be the potential for disastrous consequences. Otolaryngologists should pay attention to these foreign bodies.

Iatrogenic perforation of hypopharynx as a cause of severe descending necrotizing mediastinitis: A case report

The authors present a case report of severe descending necrotizing mediastinitis (DNM) etiologically of unrecognized traumatic endotracheal intubation with hypopharynx-esophageal junction perforation. Patient was treated inadequately for seven days in local hospital what was the cause of sepsis progression into the septic shock with multiorgan dysfunction syndrome. Patient was transferred to specialized hospital and was immediately operated in general anaesthesia - combined transcervical approach and lateral thoracotomy was used for mediastinal drainage and debridement. Combination of appropriate conventional and surgical therapy led to reversing of the unfavorable situation.

Difficult intubation resulting in surgical repair of esophageal and hypopharyngeal perforation

Although rare, perilous injury of the aerodigestive tract due to traumatic endotracheal intubation can have devastating consequences for patient and provider. Resulting serious complications of injury may involve esophageal perforation, pneumomediastinum, mediastinitis, retropharyngeal abscess, vocal cord paralysis, arytenoids dislocation, and hypopharyngeal pseudodiverticulum. Morbidity, mortality, and legal and financial consequences can be enormous. Early identification and treatment of suspected injury will promote patient recovery and thwart life-threatening progression of injury. This case report presents a 70-year-old woman scheduled for an elective hip arthroplasty. Intraoperatively she was unable to be intubated, and her operation was canceled. In the post-anesthesia care unit, the patient underwent an otolaryngology consultation and was admitted for observation of reactive airway edema. Pharyngoesophageal perforation was diagnosed several days later and required surgical repair.

Accidental cell phone ingestion with pharyngeal impaction

BACKGROUND

35 year old intoxicated male ingested an unusual, large foreign object (cell phone).

OBJECTIVE

To report the ingestion of an unusual large foreign object with hypopharyngeal impaction, complications, and treatment.

DISCUSSION

Foreign body ingestion in the adult population is more prevalent in those who engage in drug or alcohol abuse. Impaction and perforation of the upper aerodigestive tract can lead to significant and potentially fatal complications including parapharyngeal/retropharyngeal abscess, mediastinitis, and aortoesophageal fistula. The treatment of foreign object ingestion is dependent on the type of foreign object ingested, its location, and potential for perforation. Endoscopic removal under general anesthesia is the treatment method recommended for foreign bodies impacted at the cricopharyngeus or esophagus.

CONCLUSIONS

We report the only case of the accidental ingestion of an entire cell phone with casing. A plain film x-ray of the neck can be used in the assessment of the location of radiopaque foreign objects and in diagnosing potential complication.

Vocal cord paralysis caused by stingray

Foreign bodies in the oral cavity and pharynx are commonly encountered in the emergency room and outpatient departments, and the most frequently observed of these foreign bodies are fish bones. Among the possible complications resulting from a pharyngeal foreign body, vocal cord fixation is extremely rare, with only three cases previously reported in the English literature. The mechanisms of vocal cord fixation can be classified into mechanical articular fixation, direct injury of the recurrent laryngeal nerve, or recurrent laryngeal nerve paralysis secondary to inflammation. The case discussed here is different from previous cases. We report a rare case of vocal cord paralysis caused by the venom of a stingray tail in the hypopharynx.

Total laparoscopic esophageal bypass using a colonic conduit for corrosive-induced esophageal stricture

BACKGROUND

The colon and the stomach are the most commonly used conduits for esophageal replacement in patients with esophageal strictures resulting from corrosive ingestion. The replacement surgeries have traditionally been performed by an open approach. While laparoscopic replacement surgery using a stomach conduit has been previously reported, a total laparoscopic bypass using a colonic conduit has not been previously described. We herein describe the surgical technique and results of laparoscopic esophageal bypass using a colonic conduit.

METHODS

Patients with corrosive stricture involving the esophagus with the proximal level at the hypopharynx, or those with concomitant gastric scarring, were selected. The surgery was performed with the patient in a supine position using five abdominal ports and a hockey stick/transverse skin crease neck incision. The main steps include colonic mobilization and assessment of the adequacy of the marginal vascular arcade, creation of a retrosternal tunnel, preparation of the colonic conduit, neck dissection, delivery of the colonic conduit into the neck and cervical pharyngo/esophagocolic anastomosis, and intra-abdominal cologastric and ileocolic anastomosis.

RESULTS

During the study period, 39 patients with corrosive stricture of the esophagus were managed surgically at our center with either gastric or colonic bypass. Of these, 22 patients underwent an open procedure (12 retrosternal colonic bypasses and 10 retrosternal gastric bypasses) and 17 patients underwent a laparoscopic procedure (13 retrosternal gastric bypasses and 4 retrosternal colonic bypasses). Patients with stricture at the hypopharynx (n = 2) or those in whom the stomach was contracted (n = 2) were considered for a laparoscopic esophagocoloplasty. The average duration of surgery of these latter four patients was 370 (380, 320, 360, and 420) min and the mean estimated blood loss was 100 mL. All patients could be ambulated on the first postoperative day and were allowed oral liquids by the 7th postoperative day. Compared with patients who underwent an open colonic bypass, there was significantly less need for analgesics. At a median follow-up of 5 (range 3-6) months, all patients are euphagic to solid diet and have excellent cosmetic results.

CONCLUSION

Laparoscopic colonic bypass is an achievable, safe, and effective procedure for the management of corrosive strictures of the esophagus.

[Esophagoplasty in combined scarry lesions of the esophagus, laryngopharynx and the trachea in children]

The experience of plasty of the pharynx and esophagus with graft of the free small intestine segment was presented in 12 children after burn stricture by the potassium permanganate. The technical aspects of operation using methods of the reconstructive vascular surgery were described. Good short-term result was obtained in all the patients. The long-term results were investigated during 15 years. It was observed, that the graft diverticulum developed by 4-7 years in 3 patients, whom repeated operation should be performed. According to the authors, the regional plasty of the esophagus by free revasculizated small intestine graft was really effective surgical supply and could be considered as the method of choice in limited scarry lesions of the pharynx and cervical esophagus, but the method should be improved.

A bone to pick? Fish bones of the upper aerodigestive tract: review of the literature

BACKGROUND

Fish bones are of particular interest to the otolaryngologist as accidental ingestion is one of the most common reasons for otolaryngology-related emergency department referrals. Furthermore, removal of fish bones deeply lodged in the oropharynx or hypopharynx can be both hazardous and technically difficult, and failure to accomplish safe removal could result in considerable morbidity and various critical complications.

OBJECTIVE

We present here a literature review on the topic of fish bones in otolaryngology with a focus on selection of patients for intervention and on removal techniques. We emphasize that retained fish bones should be approached with caution as their course can at times be unpredictable, as we describe here.

Hypopharyngeal perforation: an unusual complication of transesophageal echocardiography

Physicians frequently use transesophageal echocardiography (TEE) for clinical cardiology and during surgery. It is considered a safe procedure, and only a few cases of complications have been reported in the literature. We present the case of a 78-year-old man who experienced a perforation of the hypopharynx following TEE. The perforation went unrecognized for 10 days. Computed tomography identified a cervical abscess, which was drained. The patient recovered and was doing well at the 1-year follow-up. Hypopharyngeal perforation is a rare but potentially life-threatening complication. Surgeons should know and recognize its clinical signs to prevent its occurrence.

[Mediastinal abscess caused by self-mutilation of the hypopharynx]

A 44-year-old male with a non-specific psychological disturbance was diagnosed with septicemia. The patient had unsuccessfully tried to remove what he believed to be a fish bone from his throat. Computed tomography revealed a descending abscess in the mediastinum along with perforations in the pharynx and oesophagus to the mediastinum. He was treated with antibiotics and drainage of the abscess and discharged after six weeks without sequelae. Sharp foreign bodies in the pharynx should be removed professionally to avoid perforation and thus mediastinitis.

[Complications of elective esophago-gastro-duodenoscopy (EGDS). Personal experience and literature review]

INTRODUCTION

Although upper gastrointestinal (GI) endoscopy is reasonably safe, it is not perfectly so. The complication rate is about 0.1% for EGDS. Aim of this study is to schedule and evaluate all possible complications, starting from personal experience in Operative Unit of Surgical Endoscopy.

PATIENTS AND METHODS

We evaluated all EGDS performed at the Operative Unit of Surgical Endoscopy of Policlinico in Palermo between January 2000 and January 2008. A single staff of endoscopists performed diagnostic and therapeutic exam. All complications were tabulated and scheduled to identify possible risk factors or indicators procedure- or patient-related.

RESULTS

5.258 patients (43.6 %) experienced temporary and self-limiting hypoxia (SaO2 < 85%); we report totally 18 complications (0.15%), according to literature data: 2 hypopharinx perforations (0.016%), 2 middle esophagus perforation (either with death of patients = 0.016%), 3 post-biopsy hematomas of the gastric wall (0.02%) and 2 duodenal wall (0.016%) 6 (0.04%) post-polypectomy bleeding, 1 abscess post-percutaneous endoscopic gastrostomy (PEG) (0.008%) and 1 accidentally PEG remove (0.008%).

DISCUSSION

EGDS-related complications may occur and cannot be prevented completely even in expert hands however, early recognition and proper management will lead to better outcome. Because of the complexity of endoscopic procedures has increased, endoscopists need to be aware of all possible procedure-related complications and should use strategies to minimize it.

CONCLUSIONS

Endoscopic complications will inevitably occur if an endoscopist does many procedures. The knowledge of potential complications and their expected frequency can lead to improved risk-benefit analysis by physicians and patients as well as true informed consent by patients. Early recognition of complications and prompt intervention may minimize patient morbidity.

Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study

BACKGROUND

Examination of the laryngopharyngeal area is not always performed during routine upper gastrointestinal (UGI) endoscopy although initial studies reported pathological findings in 0.9-3.5% of cases. The aim of this study was to prospectively evaluate the accuracy of screening the laryngopharyngeal area during routine UGI endoscopy, before insertion of endoscope into the oesophagus, to avoid a misinterpretation of trauma-related hyperaemia or erythema as signs of laryngitis.

METHODS

The study included 1297 patients undergoing elective UGI endoscopy, asymptomatic in the laryngopharyngeal area, who underwent a carefully structured examination of the laryngopharyngeal area, videotaped for later blinded review. If pathological findings were suspected, patients were referred to otorhinolaryngologists for additional evaluation. In all cases the DVDs were reviewed by two ear, nose, and throat (ENT) specialists blinded to the endoscopic findings.

RESULTS

In 1130 (87.12%) patients the examination was performed successfully before insertion of the endoscope into the oesophagus. Gastro-oesophageal reflux disease (GORD) symptoms were present in 254 (22.5%) patients, and erosive oesophagitis was documented in 89 (7.9%) patients. In 44 (3.89%) patients the pathology was suspected by the endoscopist and confirmed by the otorhinolaryngologists. Moreover, 8 (0.71%) patients were found to have laryngeal pathology in the DVDs reviewed by the ENT specialists, further confirmed by laryngoscopy. Sensitivity, specificity, positive, and negative predictive values were 84.61%, 100%, 100%, and 99.26%, respectively, for detecting laryngeal abnormalities by the endoscopist. The most important findings were leukoplakia (n=4), posterior laryngitis (n=16), Reinke's oedema (n=2), and hyperkeratosis of arytenoid folds (n=2). A strict correlation emerged between GORD and posterior laryngitis (75%) and between GORD and Reinke's oedema (100%), documented by pHmetry. A significant association was also observed between heavy smoking and leukoplakia (75%), and hypertrophy of pharyngeal tonsils (100%), respectively. All other findings were lesions without clinical significance.

CONCLUSIONS

Screening examination of the laryngopharyngeal area should be part of each UGI endoscopy revealing important laryngeal pathology.

Management of hypopharyngeal and esophageal perforations in children: three case reports and a review of the literature

We report 2 cases of pediatric hypopharyngeal perforation that occurred during endoscopy and 1 case of esophageal perforation that developed during nasogastric tube insertion at a tertiary care academic medical center. These cases were identified during a retrospective chart review. All 3 patients were treated with intravenous antibiotics and nasogastric tube feedings, and none experienced further sequelae. Perforations of the hypopharynx and esophagus in children during endoscopy or insertion of endotracheal and nasogastric tubes are not uncommon. Many affected children can be managed conservatively without surgical drainage, depending on the cause and specific location of the perforation and the timing of the diagnosis. We discuss the clinical criteria for various management options, and we offer an algorithm that outlines important clinical considerations in the decision-making process. Our aim in presenting these cases is to increase awa reness of the management options for children with hypopharyngeal and esophageal perforations and to demonstrate the effectiveness of nonsurgical management in selected cases.

The safety zone of percutaneous cervical approach: a dynamic computed tomographic study

STUDY DESIGN

A prospective study using computed tomography (CT) scans.

OBJECTIVE

To identify the structures at risk and the safety zone of a percutaneous cervical approach.

SUMMARY OF BACKGROUND DATA

A percutaneous cervical approach may injure the important structures of the anterior neck. However, the dynamic locations of vital structures and the structures at risk by routine trajectory have not been analyzed.

METHODS

Thirty patients were enrolled for this study. We obtained the CT scans of the cervical spine at each level of the intervertebral disc from C3-C4 to C6-C7, after manually pushing the airway in the same position and manner of discography. The patients ingested contrast materials for imaging of their digestive tracts and were injected intravenous contrast materials for imaging of vascular structures, just before obtaining images. We estimated the distances from the operator's fingertip to the digestive tract on the left side and to the carotid artery on the right side, at each level. The safety zone was determined by the sum of 2 distance calculations. We identified the anatomic structure at risk by simulated needle insertion toward the center of the disc through the safety zone.

RESULTS

At C3-C4, the safety zone was measured 18.9 +/- 6.6 mm. The superior thyroidal artery (STA) was located in the safety zone of C3-C4 in 86.7%. At C4-C5, the safety zone was measured 23.5 +/- 6.5 mm. The STA and the right lobe of the thyroid gland (TG) were located in the safety zone in 26.7% and 30%, respectively. At C5-C6, the safety zone was measured 33.7 +/- 6 mm. The TG was located in the safety zone of C5-C6 in 76.7%. At C6-C7, the safety zone was 29.2 +/- 4.5 mm. The TG was located on the approach plane in 90%.

CONCLUSION

The safety zone was wider at the distal level (C5-C6, C6-C7) than at the proximal level (C3-C4, C4-C5). The safest needle entry point should be between the pushing point of the airway and the pulsating point of the carotid artery. In addition, the needle should be approached toward the center of the disc. A percutaneous cervical approach allows a low risk of pharyngoesophageal structure injury and is considered a safe diagnostic technique in dynamic imaging studies.

Vocal cord fixation caused by an impacted fish bone in hypopharynx: report of a rare case

We report a rare case of vocal cord fixation caused by a fish bone in the hypopharynx. The patient was a 72-year-old woman. She presented with hoarseness that had appeared suddenly while eating baked fish. The diagnosis was suggested by a clinical history and confirmed by a computed tomography scan. The fish bone was removed via microlaryngoscopic operation under general anesthesia. The restoration of her vocal cord mobility required a few months. Vocal cord fixation is an extremely rare complication of a pharyngeal foreign body. In all of the few cases reported previously, the fixation was caused by mechanical obstruction of vocal cord movement or by recurrent nerve palsy secondary to inflammation. Our case is not typical of mechanical or inflammatory fixation. It is possible that the recurrent nerve was damaged directly by the fish bone.

Lodged oesophageal button battery masquerading as a coin: an unusual cause of bilateral vocal cord paralysis

An 11-month-old girl with an oesophageal foreign body was presented: from the radiographic appearance it was presumed to be a coin. Microlaryngoscopy 5 h after ingestion revealed a button battery impacted in the hypopharynx with severe damage to the oesophageal mucosa. The patient was intubated for 6 days in the intensive care unit because of stridor and respiratory distress. Repeat microlaryngoscopy demonstrated bilateral vocal cord palsy, which was presumed to be secondary to the involvement of the recurrent laryngeal nerves in the injury. We recommend that in the absence of a history of observed ingestion, it should be assumed that coin-like foreign bodies are button batteries until proven otherwise.

Paediatric hypopharyngeal perforation: child abuse until proved otherwise?

A case of paediatric hypopharyngeal perforation in a 7-month-old infant is reported. The diagnosis was delayed because it was not considered. It later transpired that the injury had been inflicted by one of the child's parents. Criminal proceedings were successfully brought against both parents and the child and his siblings were taken into foster care. A review of the available literature on paediatric hypopharyngeal perforation, excluding iatrogenic and external trauma mechanisms of injury suggests that non-accidental injury is by far the most common aetiology. Suspected child abuse remains one of the most sensitive and challenging areas in medicine. Awareness that non-iatrogenic paediatric hypopharyngeal perforation in the absence of external trauma is highly suggestive of a non-accidental injury is critical, and may save a child from subsequent abuse.

Delayed hypopharyngeal and esophageal perforation after anterior spinal fusion: primary repair reinforced by pedicled pectoralis major flap

STUDY DESIGN

This report documents a case of delayed hypopharyngeal and esophageal perforation after anterior spinal fusion and reviews relevant literature.

OBJECTIVES

Presentation of an alternative solution of primary repair and reinforcement of a delayed esophageal and hypopharyngeal perforation after anterior spinal fusion.

SUMMARY OF BACKGROUND DATA

Anterior plating is generally used for stabilization after cervical spine trauma. Esophageal and hypopharyngeal perforation is a rare but potentially life-threatening complication due to mediastinitis with consecutive septic shock and multiorgan failure.

METHODS

Our patient was operated on after cervical trauma caused by car accident. The neurologic condition did not improve in the postoperative period. About 4 months later, the patient had increasing dysphagia as well as episodes of odynophagia. Flexible esophagoscopy showed a perforation of a part of the plate from the hypopharynx down to the proximal esophagus. Primary repair reinforced by a pedicled pectoralis major flap was done without complications.

RESULTS

Postoperative fluoroscopy as well as endoscopy showed no signs of perforation. Swallowing was possible without any further episodes of dysphagia or odynophagia. Neck movement was unconfined.

CONCLUSIONS

Primary repair reinforced by pedicled pectoralis major flap has been shown to be an alternative in case of combined hypopharyngeal and esophageal perforation due to orthopedic spine stabilization. Advantage of the pectoralis major muscle flap is no functional loss of neck movement.

Hypopharyngeal perforation following minor trauma: a case report and literature review

Hypopharyngeal perforation is mainly reported in association with high velocity road traffic accidents, or with low velocity direct blows to the neck. We report a case of hypopharyngeal perforation following a low velocity motorcycle accident where neither of these mechanisms of injury was apparent. A 52 year old man was referred from the emergency department (ED) with a sore throat and dysphagia, following a low speed side impact accident. A gastrograffin swallow demonstrated a posterior pharyngeal wall tear. After 11 days of conservative hospital treatment, he recovered and was discharged. The presumed mechanism of injury in this case was cervical spine hyperextension without cervical compression.

Die Perforation des Hypopharynx als seltene, lebensbedrohliche Komplikation der endotrachealen Intubation

BACKGROUND

Endotracheal intubation is regarded as the gold standard technique to secure the airway with a low complication rate, however, perforating tracheal or esophageal injuries are rare but severe complications.

MATERIALS AND METHODS

Two cases of hypopharyngeal perforation after intubation are presented and discussed.

RESULTS

While intubation of the first patient was anticipated to be difficult, the second patient did not present any risk factors. One patient developed a typical clinical pattern of difficult swallowing, soft tissue emphysema of the neck, pyrexia, and leukocytosis. The other initially showed minor symptoms but increasing difficulties in swallowing led to the diagnosis of a retropharyngeal abscess. A subsequent acute airway obstruction required emergency invasive airway access. In both cases surgical intervention in combination with antibiotic therapy resulted in complete healing.

CONCLUSIONS

Physicians performing endotracheal intubation or dealing with patients after intubation, should be aware of the clinical symptoms because only early diagnosis and therapy can prevent development of mediastinitis. In "cannot intubate-cannot ventilate" situations, wide bore transtracheal airway access under local anaesthesia and spontaneous breathing should have priority and temporary tracheotomy should also be considered. To prevent hypopharyngeal injury a thorough evaluation of the "difficult airway" and the atraumatic performance of direct laryngoscopy and endotracheal intubation are mandatory.

Late hypopharyngo-esophageal perforation after cervical spine surgery: proposal of a therapeutic strategy

BACKGROUND

Hypopharynx and esophagus are occasionally at risk of perforation after cervical spine surgery. Although relatively rare--compared to the frequency of anterior instrumentation--hypopharyngo-esophageal perforation has to be considered as a late complication. An interdisciplinary surgical strategy is required for treatment.

MATERIALS AND METHODS

We herein propose a flow sheet for an interdisciplinary treatment strategy. The concept is based on the authors' personal experiences with this rare complication in a high-volume center for esophageal surgery.

RESULTS

Our interdisciplinary surgical strategy is based on three central parameters that determine the course of treatment: (1) The patient's general condition and signs of systemic infection determine the requirement for critical care management. (2) The stability of the spine (to be addressed by the orthopedic surgeon) determines the requirement for dorsal stabilization, prior to the mandatory removal of the anterior osteosynthesis material that is damaging the hypopharyngo-esophageal structures. (3) The surgical strategy for treatment of the gastrointestinal perforation--the decision to undertake either primary repair or resection--is based on its morphological characteristics; whether it is covered or free, whether it is associated with severe local infection or not, whether the defect is small or large.

CONCLUSIONS

Hypopharyngo-esophageal perforations after spine surgery are an interdisciplinary challenge, best treated by a concert of specialists (ICU, orthopedic surgeon, and gastrointestinal surgeon).

Management of cervical aerodigestive injuries

The management of patients with cervical injuries is highly controversial. Some authorities advocate mandatory exploration for all such injuries, while others advocate selective exploration. This paper will objectively review the evidence supporting each approach. The non-operative approach may be pursued through a variety of diagnostic modalities and this paper will also review the evidence supporting their use in cervical trauma. A clear understanding of these modalities and their relative merits is mandated by the potential severity of cervical injuries and their need for rapid intervention.

Perforation of the piriform recessus by a swallowed glass splinter presenting as pneumomediastinum in a child

The swallowing of sharp glass splinters is rare due to the difficulty of swallowing such objects, and perforation of the piriform recessus and mediastinitis are unusual complications. Perforation of the piriform recessus due to a swallowed sharp glass splinter requires prompt treatment. This report describes a child who was operated on immediately after the diagnosis of perforation of the piriform recessus and was managed successfully. Light-guided pharyngoscopy was very useful for detecting the region of perforation. The literature on such injuries is reviewed here, and the problems associated with treating children with perforation of the piriform recessus and mediastinitis caused by swallowed glass splinters are discussed.

Esophageal and pharyngeal injuries associated with the use of the esophageal-tracheal Combitube

The Combitube is a ventilatory device consisting of a twin lumen tube with proximal and distal inflatable cuffs. The major benefit of the Combitube is that its design and function allow for ventilation through non-laryngoscope-assisted insertion into either the trachea, or esophagus. As with any invasive procedure, intubation using the Combitube carries certain risks and potential complications. The majority of complications are relatively minor; however, a rare and serious complication reported primarily in the anesthesiology literature is laceration of the esophagus. This reportedly rare injury is increasingly seen by medical examiners/coroners in the forensic setting. This paper presents a series of three cases of esophageal laceration and a single case of perforation of the hypopharynx associated with the use of the Combitube, while also exploring potential mechanisms of injury. In addition, this work demonstrates the vital role the medical examiner/coroner plays in identifying existing or potential problems with current or emerging medical devices.

Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography

OBJECTIVES/HYPOTHESIS

The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization.

STUDY DESIGN

Randomized, prospective clinical study.

METHODS

In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts.

RESULTS

No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]).

CONCLUSION

Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery]

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

Management of the cervical esophagus and hypofarinx perforations complicating anterior cervical spine surgery

STUDY DESIGN

Five cases of esophageal or pharyngeal perforation diagnosed during or after anterior cervical spine surgery are presented.

OBJECTIVE

To outline a protocol for the early diagnosis and treatment of iatrogenic pharyngoesophageal perforations.

SUMMARY OF BACKGROUND DATA

Pharyngoesophageal perforations after anterior cervical spine surgery are uncommon or rarely reported complications. They may have serious functional consequences, including death, if they are not diagnosed promptly and treated effectively. These potentially fatal conditions require a surgical and medical therapy.

METHODS

Clinical course, diagnostic tools and guidelines for the management of five patients presenting esophagopharingeal perforations are illustrated.

RESULTS

These five cases resulted in definitive healing of the laceration without functional consequences.

CONCLUSION

We believe that awareness of these complications and their causes, prompt recognition of the symptoms and immediate and multimodality therapies are essential tools to achieve successful results.

Management of hypopharyngeal and cervical oesophageal perforations

BACKGROUND

Perforations of the hypopharynx and the cervical oesophagus are infrequent severe situations, which may even be life-threatening for patients.

METHODS

We review seven cases of intraluminal perforations of the hypopharynx or cervical oesophagus treated at our department between 1999 and 2001.

RESULTS

In this series of patients, foreign bodies were the main cause of perforation. In four cases, the treatment was surgical by means of a cervicotomy and/or thoracotomy and drainage; in the other three cases, conservative treatment was applied. In some cases, the morbidity was considerable but there were no mortalities.

CONCLUSIONS

The treatment of perforations of the hypopharynx and the cervical oesophagus must be individualized and multidisciplinary. The early diagnosis of these perforations is an important factor for prognosis.

[Undetected hypopharyngeal perforation with deep neck abscess and mediastinitis due to transesophageal echocardiography]

Hypopharyngeal perforation is a rare but dangerous complication caused by diagnostic procedures. If there is any suspicion of perforation of the upper airways and/or upper digestive tract, immediate diagnostic and therapeutic procedures are indicated. Possible complications of a hypopharyngeal perforation are deep neck infection with subsequent mediastinitis and haemorrhage from major cervical vessels, both of which have high mortality rates. We present the case of a 65 year old male patient with perforation of the hypopharynx after transesophageal echocardiography which was unrecognized for more than 1 week. Clinical symptoms of hypopharyngeal perforation may initially be unspecific. Esophagography (Gastrografin administration) and computed tomography as well as esophagoscopy are needed to certify the diagnosis and to evaluate the extent of the lesion. Pathological findings as well as diagnostic and therapeutic needs are demonstrated and discussed.

[Penetrating injuries of the neck: review of 16 operated cases]

BACKGROUND

Cervical lesions from penetrating trauma in the neck are increasing together with other types of trauma especially in big towns. Nevertheless in Italy a Register of Trauma is still lacking and no guidelines are available. Conservative management is also advocated and is still under discussion. Comparison of diagnostic tools and evaluation of different treatments in case of vascular damage is also expected.

PATIENTS AND METHODS

A series of 16 penetrating lesions of the neck including various degrees of severity were treated over a span of 5 year. The penetrating trauma was due to stab wound or similar causes in 11 cases; to gunshot wound in 3 and to traffic accidents in 2 cases. All of them received surgical treatment. In 56% of cases (9/16) of cases vascular structures were involved, in 4 cases the aerodigestive tract was involved (25%), and in 1 the spinal cord was injured (6%) resulting in a Brown-Sequard syndrome. Other patients presented with superficial lesions, and reconstruction of muscles by simple suture or ligature of veins could obtain complete healing.

RESULTS

The penetrating trauma brought about death in 2 cases (1 stab wound, 1 gunshot wound), while 1 lesion of carotid artery and 4 lesions of jugular vein were successfully repaired. In 1 case of lesion in zone 3 a serious bleeding from damage to lingual artery was cured in spite of the minimal width of the external injury. Hypopharyngeal lesions could be treated in 2 cases. One was associated with lethal vascular damage. In 1 case of tracheal lesion with cervical hematoma and dyspnea, patency of the airways became the main concern and and a cannula was placed in the trachea. The Brown-Séquard syndrome could improve with rehabilitation therapy in 3 years. All of the minimal cervical lesions healed with uneventful course.

CONCLUSIONS

The penetrating trauma in the neck may show various degrees of severity: nevertheless, no cervical penetrating trauma should be underestimated in spite of the minimal width of the lesion. Surgical exploration was invariably the preferred treatment in our experience.

[Perforation of hypopharynx -- a uncommon complication of transesophageal endosonography]

BACKGROUND

Today the endoscopical sonography of the oesophagus and heart is a useful diagnostic procedure. Perforations of the oesophagus or hypopharynx after this procedure are grave and life-threatening complications of this invasive diagnostic procedure.

MATERIAL AND METHODS

In the past 8 years we observed 3 cases of hypopharyngeal perforation as complication of endosonographic procedure. These cases were evaluated retrospectively.

RESULTS

In all 3 cases an increased resistance against insertion of the probe had been observed. In two cases the perforation was found in the right sinus piriformis. The third patient had a perforation of the posterior hypopharyngeal wall adjacent to the upper oesophageal sphincter. The former patients underwent an open transcervical revision, in the latter patient the perforation was clipped endoluminally to his impaired general condition.

CONCLUSIONS

Perforations of the hypopharynx represent a rare but potentially life threatening complication of transoesophageal sonography. The endoscopically working physician should know and recognize the clinical signs for surgical treatment before further complications (e. g. mediastinitis) may occur.

Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury

OBJECTIVE

To determine safe criteria for the management of patients with crepitance of the neck.

HYPOTHESIS

Upper aerodigestive tract injury may lead to significant morbidity and mortality. Historically, this kind of injury has been managed by immediate surgical exploration, repair, and drainage. More recently, a nonoperative approach has been advocated.

STUDY DESIGN

Retrospective chart review of patients admitted to the University of Louisville Trauma Center with suspected upper aerodigestive tract injury.

METHODS

We reviewed the charts of 236 patients admitted to the trauma service from 1995 to 1999 with the diagnosis of aerodigestive tract injury or subcutaneous emphysema.

RESULTS

Nineteen patients were identified with cervical emphysema or cervical crepitance, or both, thought to be caused by an upper aerodigestive tract injury. The average patient age was 38.5 years; 68% of patients were men. The mechanisms of injury were motor vehicle accident (43%), gunshot wound (37%), assault (10%), blunt neck trauma (5%), and stabbing (5%). Each patient presented with cervical emphysema shown by radiograph or crepitance, or both; 21% had dysphagia and 63% were hoarse or had stridor. Location of the injury was tracheal or laryngeal in 37%, hypopharyngeal in 27%, oral pharynx in 16%, esophageal in 5%, and unidentified in 15% of patients. Because of suspected aerodigestive tract injury, 79% of patients were taken to the operating room for direct laryngoscopy and esophagoscopy, and abnormalities were found in 80%. The diameter of the average laceration of the upper aerodigestive tract was 1.6 cm. Associated injuries included mandible fractures in 37% of patients. Broad-spectrum antibiotics were given to 95% of the patients. The initial management involved immediate surgical exploration in 55% of the total number of patients, with 83% of the surgically explored patients undergoing tracheotomy. The remaining 45% of patients were managed without surgery. Complications occurred only in operative patients, with aspiration occurring in 10%, bilateral hypoglossal nerve paralysis in 5%, and vocal cord paralysis in 5%. None of the patients developed postinjury or operative abscess.

CONCLUSION

The findings show that suspected upper aerodigestive tract injury can be managed without surgery but that a high index of suspicion for airway compromise and associated facial injuries must be considered.

Cololaryngostomy procedure in caustic esophageal burns

The study presented herein was undertaken to report an original case of cololaryngostomy operation in caustic esophageal burns. Cololaryngostomy application to a chronic caustic esophageal burn case is reported with a detailed literature review of the topic. For the first time in the world, the larynx was used for the integrity of the gastrointestinal system by applying a cololaryngostomy procedure as it was found to be the only intact and reliable tissue in the operation. The patient started to gain weight in a 3-month period. Oral nutrition and speech were also achieved. Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx and esophagus is an important reconstructive problem. In reconstruction, the aim should be the supplementation of both oral nutrition and speech.

Hypopharyngeal perforation: an uncommon cause of pneumoperitoneum

Endotracheal intubation is common practice being performed both electively and as an emergency. Complications of this procedure are uncommon. A case is described of hypopharyngeal rupture after emergency intubation that presented with a pneumoperitoneum. The clinical signs, relevant investigations and management options are discussed for this injury and the need is emphasised for a high index of suspicion in order to make an early diagnosis.

Hypopharyngeal perforation during laparoscopic Roux-en-Y gastric bypass

Laparoscopic Roux-en-Y gastric bypass was recently introduced as an alternative surgical treatment for morbid obesity. The technique involves placement of a 21-mm anvil transorally down to the gastric pouch for creation of the gastroenterostomy anastomosis using an EEA stapler placed transabdominally. Esophageal injury is a theoretical concern with transoral manipulation of the anvil. The authors present a case of hypopharyngeal perforation after an attempted transoral insertion of an EEA anvil. The perforation was treated with neck exploration and drainage. We discuss the mechanism of injury and alternative method for placement of the gastric anvil.

Hypopharyngeal perforation from a swallowed fork: a brief report and comment

Hypopharyngeal perforations are usually seen as a complication of endotracheal intubation by less experienced physicians in emergency situations. The site most commonly perforated is the pharynx, posterior to the cricopharyngeal muscle; the second most common site is the pyriform sinus. We report here an unusual cause of hypopharyngeal perforation from a swallowed plastic fork in a psychiatric patient.