Pharyngeal perforation: A rare complication of occipitocervical injury

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A 75-year-old man was the victim of a high-energy road accident. When emergency medical services arrived, he was in cardiac arrest (CA) and presented bilateral nonreactive mydriatic pupils. A rigid cervical collar was applied, and cardiopulmonary resuscitation (CPR) was initiated. CPR was discontinued after 12 min when spontaneous circulation returned. A Glasgow Coma Scale of 3 was described. The patient was intubated, fully sedated on site and airlifted to our emergency room.

When we performed the neurological evaluation, he presented with symmetric miotic nonreactive pupils and a preserved oculocardiac reflex and a polytrauma CT scan showed a Jefferson fracture of C1 with anterior atlantoaxial dislocation [Figure 1a and b]. Cerebrocervical magnetic resonance imaging (MRI) confirmed the atlantoaxial dislocation with a complete bilateral lesion of the alar ligaments and articular capsule. Avulsion of the left periosteal insertion of the transverse ligament (Dickman’s et al., Type Ib injury)[1] was reported.

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Figure 1:: (a) Sagittal bone CT sequence showing anterior dislocation of C2, with a basion density interval of 16 mm and multifragmented fracture of the anterior C1 arc. (b) Axial bone CT sequence showing a Jefferson fracture of C1: bilateral fracture of the anterior and posterior arcs pointed by the blue arrows. (c) Sagittal T2-weighted MRI sequence showing the anterior dislocation of C2 associated with prevertebral hematoma and suspicion of pharyngeal perforation from the anterior arc fragments.

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A prevertebral hematoma from C2 to C5 was also present, with a suspicion of pharyngeal perforation from the anteriorly displaced C1 fragment [Figure 1c]. Otorhinolaryngologist (ENT) endoscopic evaluation showed a mucosal bulging over the bony fragment without any visible perforation.

Considering the fracture’s high instability, the absence of major cerebral lesions at cerebral MRI performed 4 h after the trauma and the presence of brainstem reflexes, occipitoaxial stabilization with an occipital plate, and C2 pars screws was performed the day after the trauma. A postoperative CT scan confirmed a correct placement of the pars screws with no major displacement of the C1 bony fragment [Figure 2].

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Figure 2:: Sagittal bone CT sequence showing postoperative craniocervical junction.

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On postoperative day 5, a second ENT evaluation was performed following an episode of massive epistaxis. A nasopharyngeal fistula of the thin mucosal layer identified preoperatively, with exposure of a bony fragment of C1 [Figure 3]. A therapeutic abstention was decided because of his unfavorable neurological evolution.

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Figure 3:: Pharyngeal inspection with a curved laryngoscope showing a perforation in the posterior wall of the pharynx caused by the anteriorly displaced fragment of the C1 fracture.

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Occipitocervical bony and ligamentous lesions are rare fatal injuries following high-energy trauma.[2,4] They are frequently associated with severe neurological impairment and CA. Rhinopharyngeal fistulization of the anterior osteosynthesis material/odontoid screws after surgery is described in the literature,[3,5] while fistulization secondary to displaced bony fragments has not been previously described. Treatment should include fixation of the occipitocervical instability and surgical repair of the pharyngeal defect using a transoral approach, prophylactic antibiotics, and nasogastric tube feeding.