- Department of Surgery, Cheng Ching General Hospital, Taichung, Taiwan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
DOI:10.4103/2152-7806.69383© 2010 Lau WH This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Lau W, Chang W, Tsuei Y, Cheng W, Chao S, Shen C. Nasopharyngeal gangrenous abscess with skull base extension caused by Escherichia coli after esophageal dilatation for esophageal reconstruction. Surg Neurol Int 16-Sep-2010;1:56
How to cite this URL: Lau W, Chang W, Tsuei Y, Cheng W, Chao S, Shen C. Nasopharyngeal gangrenous abscess with skull base extension caused by Escherichia coli after esophageal dilatation for esophageal reconstruction. Surg Neurol Int 16-Sep-2010;1:56. Available from: http://sni.wpengine.com/surgicalint_articles/nasopharyngeal-gangrenous-abscess-with-skull-base-extension-caused-by-escherichia-coli-after-esophageal-dilatation-for-esophageal-reconstruction/
Background:Esophageal dilatation is the most widely used treatment option for the management of esophageal strictures. Complications include bleeding, brain abscess, esophageal perforation and bacteremia. Nasopharyngeal gangrenous abscess after the esophageal dilatation is very rare. Endonasal endoscopic surgery was performed to treat the lesion and a successful result was obtained.
Case Description:A 59-year-old woman with a previous history of dilatation for esophageal stricture was admitted with a low-grade fever, headache, neck pain and cranial nerve abnormalities including sixth nerve palsy. Imaging studies aroused suspicion of necrotic retropharyngeal tumor with clivus, condylar process and cavernous sinus invasion. Biopsy with a pharyngosope was performed by an ENT doctor. The pathology showed acute necrotic inflammation, tissue granulation and bacteria colonies. Navigation with endonasal endoscopic surgery was chosen to treat the skull base and nasopharyngeal abscess. Bacterial culture showed Escherichia coli. Symptoms improved after the operation and treatment with antibiotics.
Conclusion:A nasopharyngeal gangrenous abscess with extension to the skull base in the case of esophageal reconstruction after esophageal dilatation is extremely rare. Physicians dealing with esophageal stricture should keep in mind that a nasopharyngeal abscess is a potential complication of esophageal dilatation.
Keywords: Endonasal endoscopic, esophageal dilatation, esophageal stricture, esophageal reconstruction, nasopharyngeal abscess, Escherichia coli
The most common procedure used for the esophageal stricture is esophageal dilatation which has dose associated risks. Esophageal perforation is the worst complication. The perforation rate is reported to range between 0.1 and 0.4%.[
A 59-year-old woman had a history of esophageal benign tumor after esophagectomy and reconstruction with gastric tube, 4 years ago. She had past history of neck pain radiating to the left shoulder and occipital region. Severe neck pain limited her range of motion. She had been admitted to a hospital with the suspicion of cervical disk herniation with cervical radiculopathy.
Two months before admission, she complained of dysphagia, and esophageal dilatation was performed due to the stricture. One month later, she developed diplopia, slurred speech and dysphasia. Low-grade fever and whitish rhinorrhea were also noticed. On neurological examination, the patient was alert and oriented. She had severe neck pain, left sixth nerve palsy, mildly slurred speech and dysphagia. Other cranial nerves, including III, IV, V, had no defect. Muscle strength was normal in upper extremities. The deep-tendon reflexes were normal bilaterally. Sensory examination showed nothing unusual. Laboratory studies were within the normal range. A plain chest film showed a supradiaphragmatic gastric bulb. C-reactive protein levels were elevated to 3.6mg/dL (normal range 0.0-0.8 mg/dL). Magnetic resonance imaging (MRI) of sellar region disclosed a thickening of the nasopharyngeal wall with irregular contrast enhancement. Ill-defined enhancement was seen over the skull base including the left cavernous sinus, left parasellar region, clivus, bilateral petrosal apex, condylar process of the occipital bone and C1 vertebra [
(a) MRI scan of sella. Preoperative axial, coronal and sagittal images after intravenous administration of gadolinium diethylenetriamine penta-acetic acid are shown. Thickening of the nasopharyngeal wall with irregular contrast enhancement is seen. Ill-defined enhancement over the skull base including the clivus, bilateral petrosal apex and condylar process of the occipital bone is also seen. Prominent enhancement over the left cavernous sinus and left parasellar region can also been seen. (b) Two months postoperative axial, coronal, and sagittal postgadolinium images show improvement. Residual left sixth nerve palsy was presented after the surgery, while other cranial neurolopathies improved. There were some residual abscesses in the left cavernous sinus and parasellar region (arrow)
We took an endonasal endoscopic approach to treat the suprasellar and nasopharyngeal lesion. Gray brownish necrotic tissue of soft to firm nature was removed [
Esophageal dilatation is the most widely used option for the treatment of esophageal strictures. It is associated with bacteremia in 22 -72% of the procedures[
Retropharyngeal abscesses are uncommon but are potentially lethal. Abscesses in adults are usually secondary to the trauma of upper aerodigestive tract caused by foreign bodies or iatrogenic instrumentation such as dental procedures, feeding tube insertion, oral tracheal intubation, esophagoscopy, etc. The most commonly isolated pathogen is Streptococcus pyogenes followed by Staphylococcus aureus.[
A minimally invasive endonasal endoscopic surgery was commonly used for approached the abscesses over the clivus, sellar, parasellar region and cavernous sinus. The major advantage of this operation is that it provides the most direct anatomical route to the lesion without transversing the major neurovascular structures.[
A nasopharyngeal gangrenous abscess in the case of esophageal reconstruction with extension to the skull base following esophageal dilatation is extremely rare. Tissue sampling is important to differentiate an infectious disease from malignancy. In endonasal endoscopic surgery, the endoscope allows us an extended view over the skull base around the sellar region and onto the surrounding structures.[
1. Appignani A, Trizzino V. A case of brain abscess as complication of esophageal dilation for caustic stenosis. Eur J Pediatr Surg. 1997. 7: 42-3
2. Bautista-Casasnovas A, Varela-Cives R, Estevez Martinez E, Jardon Bahia JA, Barca PR, Dargallo Carbonell T. What is the infection risk of oesophageal dilatations?. Eur J Pediatr. 1998. 157: 901-3
3. Botoman VA, Surawicz CM. Bacteremia with gastrointestinal endoscopic procedures. Gastrointest Endosc. 1986. 32: 342-6
4. Cavallo LM, Cappabianca P, Galzio R, Iaconetta G, de Divitiis E, Tschabitscher M. Endoscopic transnasal approach to the cavernous sinus versus transcranial route: Anatomic study. Neurosurgery. 2005. 56: 379-89
5. Chen HC, Tzaan WC, Chen TY, Tu PH. Esophageal perforation complicating with spinal epidural abscess, iatrogenic or secondary to first thoracic spine fracture?. Acta Neurochir. 2005. 147: 431-4
6. Esposito F, Becker DP, Villablanca JP, Kelly DF. Endonasal transsphenoidal transclival removal of prepontine epidermoid tumors: Technical note. Neurosurgery. 2005. 56: 443-
7. Everett ED, Hirschmann JV. Transient bacteremia and endocarditis prophylaxis: A review. Medicine. 1977. 56: 61-77
8. Fanous MM, Margo CE, Hamed LM. Chronic idiopathic inflammation of the retropharyngeal space presenting with sequential abducens palsies. J Clin Neuroophthalmol. 1992. 12: 154-7
9. Hernandez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc. 2000. 51: 460-2
10. Pontell J, Har-El G, Lucente FE. Retropharyngeal abscess: Clinical review. Ear Nose Throat J. 1995. 74: 701-4
11. Rontal E, Meyerhoff W, Duvall AJ. Metastatic abscess as a complication of retrograde esophageal dilatation. Ann Otol Rhinol Laryngol. 1973. 82: 643-8
12. Schlitt M, Mitchem L, Zorn G, Dismukes W, Morawetz RB. Brain abscess after esophageal dilation for caustic stricture: Report of three cases. Neurosurgery. 1985. 17: 947-51