Introduction
Penetrating trauma to the hypopharynx and cervical esophagus is a potentially life-threatening injury, which may be the result of iatrogenic injury, accidental impalement, or assault. Multiple routine procedures and surgeries (intubation, nasogastric tube placement, rigid and flexible esophagoscopy with or without dilation/biopsy/foreign body removal, Zenker’s diverticulectomy, cervical spine surgery, and transesophageal echocardiography) carry a risk of visceral perforation, which if not recognized can quickly lead to patient compromise. Patients involved in major motor vehicle accidents, especially when ejected from the car, are at high risk for impalement injuries. Finally, the victims of violent crimes (stabbings and gunshot wounds) also may suffer aerodigestive tract injuries. Typically, the patients with potential noniatrogenic penetrating traumas have multiple confounding injuries (spinal instability, fractures, cranial injuries, vascular injuries), which may delay recognition of the visceral injury.
As perforations can quickly lead to life-threatening danger space infections, including mediastinitis, a high index of suspicion is necessary. The most critical factor affecting patient outcome is the time between the injury and the initiation of treatment. Rapid diagnosis and treatment are paramount to patient survival, as a delay in treatment of more than 24 hours significantly increases morbidity and mortality.
Many iatrogenic perforations and penetrating gun shot wound (GSW) or stab wounds can be managed conservatively with broad-spectrum antibiotics against upper aerodigestive tract flora (e.g., ampicillin-sulbactam, clindamycin), nasogastric tube placement, and nothing by mouth status for 3 to 5 days.
Adequate nutrition is necessary for healing, and in cases where nasogastric tube placement is not feasible, laparoscopic gastrostomy tube placement can be performed.
Key Operative Learning Points
- 1.
High index of suspicion is necessary to identify patients with penetrating trauma to the hypopharynx and cervical esophagus, as the early symptoms may be subtle, and delayed recognition may be life-threatening.
- 2.
The most common cause of penetrating trauma is iatrogenic, accidental visceral injury during a procedure.
- 3.
The signs and symptoms of a perforation include neck pain, dysphagia, odynophagia, new onset fever, tachycardia, chest pain, subcutaneous emphysema, or pneumomediastinum and should raise suspicion for pharyngeal perforation.
Preoperative Period
History
- 1.
History of present illness
- a.
Potential mechanisms of injury should be investigation
- 1)
Iatrogenic:
- a)
Intraluminal instrumentation of the aerodigestive tract: Intubation, nasogastric tube placement, rigid and flexible esophagoscopy with or without dilation/biopsy/foreign body removal, Zenker’s diverticulectomy, and transesophageal echocardiography
- b)
External trauma—Cervical spine surgery, open Zenker’s
- a)
- 2)
Traumatic; motor vehicle collision (MVC) ejection, gunshot, or stab wound
- 1)
- b.
The stability of a patient should be assessed.
The ABCs of trauma (airway, breathing, circulation) should be assessed and addressed prior to further evaluation of a suspected perforation. In the cases of gunshot wounds and stabbings, the patient may also have life-threatening laryngeal and tracheal injuries, which may necessitate an immediate surgical airway.
- c.
The patient’s symptoms should be assessed.
Neck pain, dysphagia, odynophagia, vocal pain, voice changes, and chest pain are all potential symptoms of a perforation, particularly after an at-risk procedure in the vicinity of the hypopharynx or esophagus.
- d.
Nil per os (NPO) status
Has the patient been eating? Is there pain with eating?
- a.
- 2.
Past medical history
- a.
Prior treatment
- b.
Medical illness: ingestion of a foreign body
- c.
Surgery: recent surgical procedure involving the neck, spine, or aerodigestive tract Zenker’s diverticulectomy
- d.
Family history
- e.
Medications
- a.
Physical Examination
- 1.
Vital signs
As perforations can quickly lead to patient compromise, an assessment of vital signs and airway is critical. Fever, tachycardia, hypotension, tachypnea, and hypoxia can occur with perforation injuries. Airway symptoms, including dysphonia, hoarseness, and stridor, should alert the team to consider a surgical airway, such as a cricothyroidotomy or awake tracheostomy, depending upon the patient’s stability.
- 2.
Neck
Examination of the neck may reveal fluctuance, bruising, evidence of recent surgical incision, or subcutaneous emphysema. Penetrating external trauma may also result in injury to the great vessels and airway.
- 3.
Flexible fiberoptic laryngoscopy
Confirms a safe and patent airway and may reveal mucosal abnormalities and bleeding if the trauma is high in the hypopharynx. Vocal fold mobility can be evaluated, as well as whether the patient is a candidate for intubation or requires an awake tracheostomy.
Imaging
- 1.
Chest radiograph
- a.
Chest radiograph is an expedient method to assess for subcutaneous emphysema, pneumomediastinum, pneumothorax, or tracheal shift.
- a.
- 2.
Esophagogram
- a.
Esophagogram is the most sensitive test for detecting perforation, ranging from 75% to 100%. Water-soluble contrast, such as meglumine diatrizoate (Gastrograffin), is the preferred method for detecting perforations, as the extravasated contrast is quickly absorbed and cleared by the tissues, unlike barium. However, Gastrograffin is extremely damaging to pulmonary tissues and may lead to life-threatening pneumonitis and pulmonary edema due to powerful osmotic shifts. Therefore it should be avoided in patients at risk for aspiration or complex laryngotracheal injury. A negative esophagogram does not definitively rule out a perforation, and thus when the index of suspicion is high, patients should still be managed accordingly to clinical findings.
- a.
- 3.
Computed tomography (CT) spine/neck/chest
- a.
When concomitant spine, vascular, or laryngotracheal injury is suspected in the stable patient, a CT is useful for evaluating soft tissue damage. In the case of suspected perforation, especially with a negative swallow study, a CT scan of the neck will often demonstrate free air in the soft tissues, as well as the extent of fluid collection/infection in the danger space and mediastinum, leading to prompt exploration and drainage. Pneumomediastinum, pneumothorax, and pleural infections can also be more clearly seen and prompt earlier intervention by a Thoracic Surgery ( Fig. 47.1 ).
Fig. 47.1
Axial computed tomography scan demonstrating free air in the deep planes of the neck, suggestive of an injury to the aerodigestive tract.
- a.
- 4.
Angiography
- a.
If zone 3 vascular injury is also suspected in the stable patient, angiography is useful for triaging management of the patient’s problems.
- a.
Indications
- 1.
Evidence of large perforation on esophagogram
A large pharyngeal defect is unlikely to heal spontaneously and will require direct repair or soft tissue flap coverage.
- 2.
Chest radiograph demonstrating significant (or increasing) subcutaneous emphysema, pneumothorax, or tracheal shift
In the case of expanding free air with airway shifting or pneumothorax, neck exploration with drain placement and likely chest tube insertion is necessary to prevent pulmonary compromise.
- 3.
Progressive decline in patient stability despite conservative management
Patients with progressive fevers and cardiopulmonary instability require surgical intervention, as they are likely developing mediastinal fluid collections and mediastinitis requiring drainage.
Contraindications
- 1.
Patients who respond to conservative management
- 2.
Major airway, vascular, and spine injuries require stabilization prior to investigation for visceral injury to the pharynx.
The patient should be stabilized first from an ABC standpoint and be covered with broad-spectrum antibiotics if perforation is suspected, prior to diagnostic tests (esophagogram) being performed.
Preoperative Preparation
- 1.
Confirm cervical c-spine clearance.
- 2.
Confirm plan for airway management—intubation versus tracheostomy.
- 3.
Discontinue antiplatelet drugs if possible.
- 4.
Monitor Hb/Hct and transfuse if necessary.
Operative Period
Anesthesia
General: Surgery will require instrumentation of the pharynx and/or exploration with in the neck. To perform this safely, the airway must be secured and patient movement controlled.
Positioning
Supine: The patient is positioned the same as any neck exploration or endoscopy with the head of the bed turned toward the surgeon.
Perioperative Antibiotic Prophylaxis
Ampicillin-sulbactam (3 grams IV)
Piperacillin/tazobactam (3.375 grams IV)
Clindamycin with ciprofloxacin if allergic to penicillin
Monitoring
Recurrent laryngeal nerve (RLN)—In cases of patients with a intact and functioning larynx, for whom intubation is feasible, real-time recurrent laryngeal nerve monitor (while not shown in the literature) may be used to aid in laryngeal nerve identification and preservation during exploration of a contaminated neck wound.
Instruments and Equipment to Have Available
- 1.
Basic rigid panendoscopy set
- 2.
Basic neck dissection set: scalpel, scissors, retractors (Army/Navy, Deaver, Richardson), fine dissecting forceps (McCabe, Jake’s), needle drivers, and suture
- 3.
Nasogastric tube
- 4.
Drains: Penrose drain, Jackson-Pratt drain
- 5.
Methylene blue
Key Anatomic Landmarks
- 1.
Laryngeal framework: The thyroid ala is a thin wedge-shaped cartilage, which houses the arytenoids and false and true vocal folds, and is positioned on top of the cricoid. The cricoid cartilage is the only complete cartilaginous ring of the airway. Anteriorly the cricothyroid membrane bridges the two structures and is the site for placement of an emergent airway (cricothyroidotomy).
- 2.
Inferior pharyngeal constrictors: This muscle originates from the thyroid ala and cricoid cartilage in two separate bellies. Zenker’s diverticulum develops between the two bellies of this muscle (thyropharyngeal and cricopharyngeal) in a small gap, known as Killian’s triangle.
- 3.
Recurrent laryngeal nerve: The recurrent laryngeal nerve courses from the thoracic inlet superiorly along the tracheoesophageal groove and enters the larynx at the posterior edge larynx between the thyroid ala and cricoid at the cricoarytenoid joint. The right recurrent laryngeal nerve has a more oblique course and in rare cases (retroesophageal subclavian artery) may be nonrecurrent.
- 4.
Thyroid gland: A highly vascular horseshoe-shaped endocrine gland that bridges over the cricoid or upper trachea, overlies the esophagus, and occupies the bilateral central compartment (see Chapter 78 ).
- 5.
Parathyroid glands: Small (3 to 5 mm) amber-colored endocrine glands deep to the thyroid lobe that control calcium absorption (see Chapter 84 ).
Prerequisite Skills
- 1.
Upper aerodigestive tract endoscopy (see Chapter 18 , Chapter 45 )
- 2.
Neck dissection and exploration (see Chapter 64 , Chapter 75 )
Operative Risks
- 1.
Intraoperative injury to the recurrent laryngeal nerve
If initial attention is paid to nerve identification using the laryngeal landmarks listed previously prior to management of the visceral injury, the risk is significantly reduced. In some settings, nerve monitoring may be beneficial. In cases of bilateral injury, tracheostomy may be necessary.
- 2.
Parathyroid injury
Leads to hypoparathyroidism and hypocalcemia. Preventable by performing meticulous dissection deep to the thyroid and identifying the glands, prior to addressing the perforation. In cases of recognized parathyroid injury, the glands may be minced and reimplanted into neck musculature. Intraoperative parathyroid hormone testing can be used to predict parathyroid function postoperatively, when injury is suspected.
- 3.
Bleeding
The common carotid artery, subclavian artery, thyrocervical trunk, jugular vein and superior thyroid vessels, and anterior jugular veins all course through this region and, depending on the location and trajectory of injury, may be involved. Meticulous dissection and high index of suspicion for preoperative trauma prevent injury to the major vessels.
- 4.
Substernal extension
In cases where the injury or neck infection extends substernally a Thoracic surgeon should be consulted for intraoperative management.
Surgical Technique: Direct Repair—Small and Early-Recognized Defects
Endoscopy: (see Chapter 18 , Chapter 45 )
Prior to neck exploration, endoscopy/esophagoscopy may be helpful for assessment of the perforation and guided placement of a nasogastric tube. Care should be taken to avoid further expansion of the perforation. Insufflation flexible esophagoscopy is not recommended, as this will increase subcutaneous free air.
A horizontal neck crease at the level of the laryngeal framework is marked and injected with local anesthesia between the anterior sternocleidomastoid muscle edges ( Fig. 47.2 ).
