Penetrating Trauma to the Hypopharynx and Cervical Esophagus

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
  - 2)
    Traumatic; motor vehicle collision (MVC) ejection, gunshot, or stab wound
- 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?
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

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.
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.
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 ).
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.

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

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