Volume 5 | December 2018
Image | Esophagus

Dysphagia Caused by Cervical Plate Erosion through the Hypopharynx

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Shana Kothari, MD1, and Tarek Almouradi, MD2

1Department of Internal Medicine, University of Illinois at Chicago, Advocate Christ Medical Center, Oak Lawn, IL
2Department of Gastroenterology, Advocate Christ Medical Center, Oak Lawn, IL

ACG Case Rep J 2018;5:e104. http://dx.doi.org/10.14309/crj.2018.104. Published online: December 19, 2018.

Case Report

A 53-year-old woman with a history of neurofibromatosis, Hodgkin’s lymphoma, and C3–T2 fusion 4 years prior for swan-neck cervical deformity was admitted for evaluation of left frontal skull mass and progressively worsening dysphagia of solid foods and thick liquids over 6 weeks. Computed tomography (CT) of the abdomen, pelvis, and lumbothoracic spine showed multiple hypodense liver lesions and diffuse sclerotic bone lesions within the thoracic and lumbar spine, ribs, sacrum, and ischium suspicious for metastatic malignancy. Fine-needle aspiration of the liver lesions yielded immunochemistry positive for focal CA 19-9 staining suggestive of adenocarcinoma of upper gastrointestinal (GI) origin. Serum CEA and CA 19-9 were within normal limits.

Figure 1. Esophagogastroduodenoscopy showing a foreign metal object in the hypopharynx above the upper esophageal sphincter.

Esophagogastroduodenoscopy did not reveal an upper GI tumor; however, a metal object was seen in the hypopharynx just above the upper esophageal sphincter (Figure 1). It appeared to be fixed and could not be moved with grasping forceps. The adult gastroscope could not be advanced beyond the object; however, the ultraslim could. A sagittal CT view of the neck with contrast showed the offset of the anterior cervical internal fusion plate with direct communication to the hypopharyngeal airway and suggesting erosion through the posterior hypopharyngeal soft tissue (Figure 2). Given the patient’s multiple comorbidities and presumably metastatic cholangiocarcinoma, neurosurgery service recommended medical management rather than surgical management. A 6-week course of intravenous ertapenem was initiated due to the high risk of abscess formation. The patient underwent gastric tube placement for feeding and was eventually discharged under hospice care.

Figure 2. Sagittal view of the neck with contrast-enhanced computed tomography showing direct communication between the anterior cervical internal fusion plate and the hypopharyngeal airway.

Dysphagia is an underrecognized but significant complication of cervical fusion surgeries.1 The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02% and 1.49% with a mortality rate of 6%.2 Most esophageal erosions occur in the intraoperative or immediate postoperative setting, although there has been an increase in cases with delayed presentation, which often lead to dramatic clinical deterioration with a higher mortality risk of 20–50%.3 Most esophageal injuries are due to iatrogenic injury intraoperatively from inappropriate placement or dislodgement of retractors or hardware migration. Delayed injuries are typically due to chronic compression, abscess formation, repetitive friction of the plating system, or hardware dislodgement and chronic migration.4 Diagnosis can be made with cervical radiographs; however negative imaging does not rule out esophageal injury. Operative intervention is recommended, but conservative medical treatment is appropriate depending on the patient and the clinical circumstances.5

Although cervical endplate erosion of the esophagus has been well documented in the literature, hypopharyngeal erosion has only been reported once previously.6 It is imperative that health care providers are vigilant and complete a thorough workup in patients with persistent or worsening dysphagia who have undergone a previous anterior cervical surgery.


Disclosures

Author contributions: S. Kothari and T. Almouradi wrote the manuscript. T. Almouradi is the article guarantor.

Financial Disclosure: None to report.

Informed consent was obtained for this case report.

Correspondence: Shana Kothari, Department of Internal Medicine, University of Illinois at Chicago, Advocate Christ Medical Center, 4440 95th St, Oak Lawn, IL 60453 (shana.kothari@advocateheatlh.com).

Received April 2, 2018; Accepted November 12, 2018


References

  1. Carucci LR, Turner MA, Yeatman CF. Dysphagia secondary to anterior cervical fusion: Radiologic evaluation and findings in 74 patients. AJR Am J Roentgenol. 2015;204:768–75.Article | PubMed
  2. Amhaz HH, Kuo R, Vaidya R, Orlewicz MS. Esophageal perforation following cervical spine surgery: A review with considerations in airway management. Int J Crit Illn Inj Sci. 2013;3(4):276–8.PubMed
  3. Nathani A, Weber AE, Wahlquist TC, Graziano GP, Park P, Patel RD. Delayed presentation of pharyngeal erosion after anterior cervical discectomy and fusion. Case Rep Orthop. 2015;2015:173687.Article | PubMed
  4. Yang S, Lee SB, Cho KS. Delayed esophagus perforation after anterior cervical spine surgery. Korean J Neurotrauma. 2015;11:191–4.Article | PubMed
  5. Mehta N, Jiv Singh Nagpal S, Confer B, Vargo J, Bhatt A. Migration and erosion of cervical spine hardware into the esophageal lumen causing odynophagia and dysphagia. ACG Case Rep J. 2016;3(4):e164.Article | PubMed
  6. Pichler W, Maier A, Rappl T, Clement HG, Grechenig W. Delayed hypopharyngeal and esophageal perforation after anterior spinal fusion: Primary repair reinforced by pedicled pectoralis major flap. Spine. 2006; 31:E268–70.Article | PubMed

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Copyright: © 2018 Kothari et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.