Introduction:
Hypopharyngeal perforations can be an acutely life-threatening condition. Common aetiologies include penetrating iatrogenic injuries. Hypopharyngeal perforations secondary to blunt trauma is rare, with less than 30 cases reported in the literature. To our understanding, this unique case is the first reported of its mechanism.
Case:
A 50-year-old male with no medical history presented to the emergency department after being injured by a buffalo. The patient was directly hit by the buffalo and pinned to a fence. He reported left-sided chest pain, abdominal pain, and left leg pain. He was clinically stable and examined to have open fracture of the fibula which was confirmed on X-Ray. Computed Tomography (CT) trauma identified retropharyngeal gas extending to the right carotid sheath. An otolaryngologist reviewed the patient and found mild tenderness along the right sternocleidomastoid muscle. The patient had no hoarseness, dysphagia, subcutaneous emphysema and flexible naso-endoscopy was normal. Gastroscopy identified a small tear in the posterior aspect of the hypopharynx, 15cm from the incisors at the cricopharyngeal sphincter. Gastrograffin swallow showed no contrast leakage and a normal swallow mechanism. The patient was managed non-operatively and monitored in hospital while awaiting definitive orthopaedic management of the fibula fracture. The patient was commenced on intravenous dexamethasone to reduce neck and airway swelling and intravenous ceftriaxone/metronidazole for antibiotic prophylaxis for 72 hours. The patient was cleared for discharge home four days after his initial injury to complete a five-day course of amoxicillin and clavulanic acid.
Discussion and key learning points:
Less than two percent of all hypopharyngeal perforations are caused by blunt neck trauma. Hypopharyngeal perforation in blunt trauma occur with compression of the laryngeal cartilage against the posterior vertebra leading to an increased pharyngeal pressure and perforation. Perforations generally occur on the posterior pharyngeal wall at the level of the Kilian’s Dehiscence due to anatomical weakness. They may be asymptomatic or present with neck, thoracic or chest pain, odynophagia, dysphagia, hoariness of voice, stridor, haemoptysis and subcutaneous emphysema. Gold standard investigation for diagnosis is a Gastrograffin swallow-enhanced CT scan. Bedside flexible naso-endoscopy has a limited diagnostic accuracy but may be useful to ascertain whether endotracheal intubation is necessary. Operative management is recommended in patients with haemodynamic instability, sepsis, involvement of the oesophagus, or when the perforation is greater than 2cm in diameter. Non-operative management is reserved for stable patients with small tears. Complications include long-term speech and swallowing difficulties, deep neck infections, pharyngeal fistula, stricture formation, acute mediastinitis, sepsis, and death. Therefore, close surveillance and follow-up, including repeat imaging, is recommended upon discharge from the hospital.