Page 103 - Portuguese Journal - SPORL - Vol 61. Nº2

the same, the pharynx is a less common site of direct access to the posterior wall of the
6
perforation because of the differences between
the anatomical features of the pharynx and
esophagus, the greater resistance of the
pharyngeal tissues , and, most importantly,
3
the level of the spine at which the surgery is
performed. Spinal surgery is most frequently
performed at the C4-C7 level, which explains
1,6
the lower incidence of perforation of the
pharynx. The pharynx is affected when the
surgery is performed at the C2-C3 level, 2,6,7 as
in the case described herein.
Pharyngeal perforation has diverse clinical
presentations. Perforation should be
suspected when there is a previous history
of anterior spine surgery and symptoms
such as odynophagia, dysphagia, foreign
body sensation, de novo tumefaction of the
neck, fever, dyspnea, and cough, and the
1,2
extruding material is sometimes visible in the
pharyngoesophageal region. Among these
symptoms, dysphagia is the most frequently
reported in the literature. 6,10 Complications
such as the formation of a pharyngoesophageal
fistula and cervical abscess may also occur ab
initio, with impairment of the airway and
1,10
9
aspiration pneumonia, potentially leading to
1
sepsis and even death. The mortality rate is
8
approximately 20% in the first 24 hours and
increases to 50% afterward.
1
In addition to pharyngeal and esophageal
perforation, other complications may result
from anterior spine surgery with migration of
osteosynthesis material, including recurring
lesions of the laryngeal nerve with paralysis of
the larynx, lesion of the trachea, lesion of the
large vessels, compression of nerve structures,
cerebrospinal fluid fistula, and meningitis. 2
The diagnostic and therapeutic approaches
to pharyngeal perforations should be
individualized by considering the severity
and clinical course of the perforation, basal
status of the patient, comorbidities, results of
imaging exams, and complications. 5
Regarding the diagnostic approach, some
authors recommend that transoral endoscopy
be initially performed. This technique is
3,11
associated with low morbidity and allows
pharynx, as was performed in the present
case, for the initial diagnosis and treatment
and has good results.
Moreover, imaging exams are an essential
part of the approach to perforation. X-ray
of the cervical spine reveals the presence
of emphysema, pneumomediastinum, and
the presence of air in the retropharynx and
paravertebral spaces. Cervical CT displays the
1
location of the material and its relationship
with the anatomical structures, involvement
of the adjacent soft tissues and blood vessels,
and complications such as hematoma,
laryngeal lesion, abscess, and presence
of extra-esophageal air. The esophageal
1,11
transit contrast exam also plays an important
role in the evaluation of perforations and
can detect the presence and extension of a
pharyngoesophageal fistula. 11
When these diagnostic exams are insufficient
to diagnose the patient’s condition or when
there is a high probability of complications
(such as infection), it may be necessary to
perform surgical exploration 1,6,10 through
emergency tracheotomy. 9,10
Some authors recommend that in the case of a
perforation without associated complications,
especially small perforations (smaller than 1
or 2 cm), 11,12 conservative treatment should be
preferred, including fluid therapy, intravenous
antibiotics, and nasogastric tube feeding,
with subsequent introduction of an oral liquid
diet. 2,6,11 The literature shows that the timing
is variable and that the spontaneous closure
of the perforation and complications must
be considered. Surgical closure is required
in the case of perforations that do not close
spontaneously. When primary closure fails, or
2
the defect is extensive, reconstruction should
be performed in a one-stage operation using
a muscle, microvascular, or other flap. 1
Owing to the rarity of this clinical condition,
there is no consensus regarding the diagnostic
and therapeutic approaches; therefore, cases
should be evaluated individually. It is important
to have a high index of suspicion to ensure
an early diagnosis and timely treatment and
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