{"id":"770b4791-a313-4c6d-9b64-70ad0481abf5","slug":"pharyngeal-perforation-a-rare-complication-of-occipitocervical-injury","title":"Pharyngeal perforation: A rare complication of occipitocervical injury","authors":["Alberto Vandenbulcke","Giulia Cossu","Juan Barges Coll"],"abstract":"Background: Atlantoaxial dislocation is a rare injury following high-energy trauma. We report an undescribed complication of atlantoaxial dislocation. Case Description: A 75-year-old man presented with atlantoaxial dislocation and Jefferson C1 fracture after a high-energy trauma. Occipitoaxial stabilizations were performed the day after. A nasopharyngeal fistula was identified at day 5 causing a persistent epistaxis. Conclusion: Nasopharyngeal fistulization of C1 bony fragment is a rare complication of complex occipitocervical injury. Combined treatment with ENT surgeon should be considered. 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. (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. 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 ]. Sagittal bone CT sequence showing postoperative craniocervical junction. 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. 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. 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. Patient’s consent not required as patients identity is not disclosed or compromised. There are no conflicts of interest.","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/articles/770b4791-a313-4c6d-9b64-70ad0481abf5/featured/hero-1781562288669.png","publishDate":"2021-06-28T00:00:00.000Z","doi":"10.25259/SNI_22_2021","categories":["Trauma","Image Report"],"fullTextUrl":"https://surgicalneurologyint.com/wp-content/uploads/2021/06/10928/SNI-12-308.pdf"}