Pharyngeal perforation is a rare and serious injury. Infection
of the surrounding anatomical structures may occur due to contamination
of the oral cavity. Therefore, immediate diagnosis and subsequent treatment
appear to be essential.
We present the case of a patient who sustained an odontoid fracture
that was associated with a pharyngeal perforation. The pharyngeal
injury was not noted initially, although the clinical findings, preoperative
radiographs, and computed tomography scans suggested a pharyngeal
tear. To our knowledge, such an injury has not been reported previously.
Nevertheless, in a patient with a fracture of the cervical spine
and bleeding from the mouth, pharyngeal perforation should be considered.
Pharyngoesophageal injuries in patients with cervical spine trauma
are rare. Such injuries have been reported after blunt trauma and
after penetrating injuries caused by knives, gunshots, and missiles3. Injuries of the pharynx may be complicated
by cervical abscess, spondylodiscitis, mediastinitis, cervical fistula,
esophageal stricture, or formation of diverticula. To our knowledge,
an odontoid fracture associated with a pharyngeal tear has not been
reported previously. In the case of our patient, the exact mechanism
of the injury was not determined retrospectively. Nevertheless,
severe instability of the upper cervical spine should be considered
when perforation of the pharyngeal wall and odontoid fracture have
occurred. The open injury of the pharynx was not noted during the
initial clinical evaluation of our patient, and therefore the odontoid
fracture was treated operatively through an anterior retropharyngeal
approach. Even during the intubation and the initial operation,
the injury was not detected. An early diagnosis in this case would
not have been difficult had we been aware of the injury. If the
pharyngeal perforation had been diagnosed preoperatively, we might
have postponed the fracture fixation until the tear had healed.
Alternatively, we might have treated the injury with a dorsal atlantoaxial
arthrodesis or with nonoperative measures such as the application
of a halo device. Pharyngoesophageal injuries in patients with cervical
spine trauma have been treated with extraoral feeding, exploration
of the neck, or operative repair of the esophagus3.
Anterior cervical discectomy and arthrodesis with metal implants
in patients with pharyngoesophageal injuries frequently have been
associated with cervical osteomyelitis3.
Therefore, alternative methods of stabilization of cervical spine
fractures have been suggested3.
Although the pharyngeal perforation in our patient was not noted
initially, osseous healing occurred, without infection, after early
anterior stabilization.
Bleeding from the mouth and nose following head trauma, as was
reported by our patient, should have led to an immediate and careful
examination of the ear, nose, and throat region. Retropharyngeal
air was present and could have been detected on lateral radiographs
or computed tomography scans. Nevertheless, the abnormal presence
of air was not noted because of concentration on the fracture site
rather than on soft-tissue changes.
A cervical spine fracture that is associated with bleeding from
the mouth and nose should alert the physician to the possibility
of a pharyngeal injury. Careful examination of radiographs and computed tomography
scans and immediate inspection of the oral cavity will help to establish
the correct diagnosis early enough to provide appropriate treatment.