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

Surgical management of non-traumatic hypopharyngeal perforation with descending mediastinitis

Perforation of the hypopharynx is an extremely rare condition of various etiologies. In even rarer cases, it can lead to mediastinitis, a serious complication with a high mortality rate of up to 35%. We present a case of a 52-year-old male patient with a purulent descending mediastinitis caused by a rare condition of rupture of the hypopharynx after the ingestion of solid food. Mediastinal gas and fluid as well as pleural empyema were observed on CT scan. The case is unique because of the cervical surgical approach used to treat it, as well as a number of techniques that appear to control the infection and treat the source of mediastinitis. The patient recovered completely 20 days postoperatively and was followed up clinically and by computed tomography without persistent symptoms or late complications.

Perforating pharyngeal injury caused by minor blunt trauma to the neck: A case report

Background

Pharyngeal perforation has been documented as a consequence of substantial external force applied to the neck. Such trauma is frequently accompanied by additional organ injury and cervical fracture. In this report, we present an exceptionally rare instance in which minor blunt trauma to the neck resulted in pharyngeal injury without concomitant damage to other organs.

Case presentation

An 18-year-old woman sustained a contusion of the neck due to blunt trauma to the left submandibular region from her bicycle handlebar grip following a collision with a motor vehicle. The patient exhibited a minor contusion of the neck, devoid of active bleeding or hematoma. Furthermore, she did not express any concerns regarding the condition of her neck or throat. A medical examination revealed the absence of abnormal breath sounds in the neck and the absence of any deformity or deviation of the airway. Despite the absence of a foreign body, computed tomography demonstrated the presence of free air extending through the interstitial space between the sternocleidomastoid muscle and larynx, reaching the posterior pharyngeal wall. While the wound was being cleansed with saline solution, the patient reported a sensation of water entering the mouth, which led to the confirmation of a perforation injury to the pharynx. No evidence of leakage was observed during the drinking tests, and the fistula was determined to be unidirectional. The patient was admitted to the hospital for follow-up and discharged on the third day without any additional complications. The outpatient examination conducted on the sixth day following the injury revealed no abnormalities in the physical findings.

Conclusion

Perforating pharyngeal injuries resulting from minor blunt trauma are exceedingly uncommon. In the present case, the water injection test and drinking test were instrumental in both confirming the diagnosis and determining the appropriate treatment plan.

What Is New with Cervical Perforations? A Clinical Review Article

Approximately 15% of all esophageal perforations occur within the cervical esophagus. Advances in medical care and surgical technique overtime have led to decreased mortality associated with esophageal perforations. While early recognition, accurate characterization, and adequate drainage, or repair when appropriate, remain the mainstays in the management of cervical perforations, endoscopic innovation has provided a minimally invasive option in the management of this disease and expanded the armamentarium of options available to providers.

Extended Prophylactic Antibiotics in Penetrating Neck Aerodigestive Injuries Are Not Associated with Improved Outcomes

Background: Literature currently supports the limited use of prophylactic antibiotics within the trauma population. However, data supporting limited (≤24 h) or extended (>24 h) use in penetrating aerodigestive neck injuries is lacking. We sought to describe the role of prophylactic antibiotics in this population and hypothesized there was no reduction in complications for patients on extended prophylactic antibiotics. Methods: Using a single-center trauma registry, patients with penetrating aerodigestive neck injuries were identified over a 5-year period. Demographics, injuries, management, and prophylactic antibiotic utilization were collected. Patients were stratified by the utilization of extended prophylactic antibiotics. Outcomes included infection, leak, reinterventions, and mortality. Results: Of 436 patients with penetrating neck injuries, 72 (17%) patients were identified with aerodigestive injuries. Forty-one (57%) patients received extended (>24 h) prophylactic antibiotics, whereas 31 (43%) received limited (≤24 h) prophylactic antibiotics. There was no difference in the patient demographics or injury severity score between the two groups. Extended prophylactic antibiotic use was associated with higher rates of infection (22% vs. 3%, p = 0.036) and leak (15% vs. 0%, p = 0.034) and no difference in reintervention (20% vs. 3%, p = 0.068) or mortality (10% vs. 13%, p = 0.719) compared with limited prophylactic antibiotics. Median duration of extended antibiotic use was 7 days. Operative intervention was equivalent across extended prophylactic antibiotics and limited antibiotics groups (59% vs. 58%, p = 0.968). Conclusions: There is insufficient evidence to support the extended (>24 h) use of prophylactic antibiotics in patients with penetrating neck aerodigestive injuries.

Survey of pharyngeal foreign bodies in Japan: An ecological study using the nationwide claims data

OBJECTIVE

Pharyngeal foreign bodies (PFBs) are a prevalent disease affected by food culture and dietary habits, with fish bones as the leading cause. Most studies were limited to specific regions, and a nationwide survey was not conducted in Japan. In this ecological study, we aimed to conduct a nationwide analysis of outpatient PFB cases in Japan over three years, focusing on seasonal trends, sex- and age-stratified cases, and regional differences.

METHODS

We used the National Database of Health Insurance Claims and Specific Health Checkups of Japan open data from April 2019 to March 2022. The case data were analyzed by month, age, sex, and prefecture. Additionally, we calculated the standardized claim ratios (SCRs) for each prefecture and investigated the association between dietary habits, food culture, and SCR of PFBs using a two-level linear regression model.

RESULTS

We analyzed a total of 164,337 outpatient PFB cases in Japan, revealing an average incidence rate of 45.6 per 100,000 persons. The seasonal trend revealed a peak in July each year from 2019 to 2021, confirming seasonality in PFB incidents. Children reported a higher incidence rate. Living west of Japan and expenditure on fish and shellfish had a strongly positive association with the SCR of PFBs.

CONCLUSION

Our nationwide survey reveals that, even within Japan, there were regional variations influenced by food culture and dietary habits. The data showed that PFB incidence was higher among children, highlighting the need for preventive education.

LEVEL OF EVIDENCE

Level 3.

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.

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.

[Update on neck trauma]

BACKGROUND

Important organs and structures are located in the cervical region. In case of blunt and penetrating trauma, emergency situations may arise.

OBJECTIVE

Emergency management as well as diagnostic and therapeutic steps pertaining to neck injuries are presented.

CONCLUSION

Shock therapy and airway management are essential, fast management of neck injuries highly relevant.