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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 199-201

Sternocleidomastoid flap for repair of pharyngocutaneous fistula following anterior cervical spine surgery


Department of Surgery, College of Medicine and Medical Sciences, Taif University, P.O. Box: 888; Department of Surgery, King Abdul-Aziz Specialist Hospital, P.O. Box: 10127, Taif, Kingdom of, Saudi Arabia

Date of Web Publication9-Dec-2015

Correspondence Address:
Majed Al-Mourgi
Department of Surgery, College of Medicine, Taif University, P.O. Box: 888, Taif 21947
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0521.171428

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  Abstract 

Pharyngocutaneous fistula is a rare complication of anterior cervical approach for spinal surgery. In this report, I will present the case of a 25-year-old Indian male who developed pharyngocutaneous fistula after fixation of cervical vertebral fracture using the anterior approach. The condition was diagnosed first as wound infection, and the pharyngeal injury was confirmed by computed tomography scan with contrast. The repair was done using sternocleidomastoid muscle flap. Being familiar with pharyngocutaneous fistula as a complication of anterior cervical approach for spinal surgery is essential for early diagnosis and repair of the fistula. Reinforcement by sternocleidomastoid muscle flap is proved to be effective to prevent recurrence.

Keywords: Anterior cervical approach, pharyngocutaneous fistula, sternocleidomastoid


How to cite this article:
Al-Mourgi M. Sternocleidomastoid flap for repair of pharyngocutaneous fistula following anterior cervical spine surgery. Saudi J Health Sci 2015;4:199-201

How to cite this URL:
Al-Mourgi M. Sternocleidomastoid flap for repair of pharyngocutaneous fistula following anterior cervical spine surgery. Saudi J Health Sci [serial online] 2015 [cited 2019 May 20];4:199-201. Available from: http://www.saudijhealthsci.org/text.asp?2015/4/3/199/171428


  Introduction Top


Pharyngo or esophagocutaneous fistulas are rare complications of anterior cervical approach, which is a safe procedure for cervical spine surgery.[1],[2],[3] This approach is more commonly complicated by hematoma formation, dysphonia, and dysphagia.[4] The incidence of these fistulas ranges from 0.1% to 1%.[5] Conservative treatment for small fistulas is the usual treatment of choice and when discovered early postoperatively; however, the failure of conservative treatment or larger fistulas require surgical repair with muscle flap.[6],[7],[8],[9] In this report, I present a pharyngocutaneous fistula after anterior cervical spinal surgery in a 25-year-old male.


  Case Report Top


A 25-year-old Indian male was admitted to our hospital on June 2014, after road traffic accident with the fracture of C5 and quadriplegia. After resuscitating the patient, he was admitted to the Surgical Intensive Care Unit, and the supervising neurosurgery team planned a cervical spine fixation. The fixation was done after 4 weeks through anterior cervical approach. On the 6th postoperative day, the patient developed right-sided neck swelling with signs of inflammation. The general surgery department was consulted where they diagnosed the condition as wound infection with abscess formation. In the operating room, the exploration was done through 8 cm incision over the anterior border of sternomastoid where pus and food materials came from the wound, and after irrigation of the site, the cavity was explored but no pharyngeal or esophageal injuries could be detected, so the wound was closed after inserting two drains. Computed tomography (CT) with contrast study [Figure 1] was performed, and right posterior pharyngeal tear was revealed. Supervising team consulted our departments (thoracic surgery) as experts in pharyngo-esophageal surgery, and a planned exploration was decided after control of infection. The patient was fed through nasogastric (NG) tube, received intravenous antibiotics, and the drains were not removed until inflammatory signs subsided. Exploration was performed through the previous incision over the anterior border of the right sternomastoid muscle and extended few centimeters superiorly. Debridement of the cavity was done, and the pharynx and the upper esophagus were mobilized, where 10 mm right posterior pharyngeal tear was detected [Figure 2]. After irrigation with saline, the edges of the tear were refreshed and repaired primarily in 2 layers. The right sternocleidomastoid muscle was divided at its sternoclavicular heads and mobilized to its middle part on its superior pedicle, and its neurovascular supply was preserved. The muscle flap was inserted between the repaired pharyngeal perforation and exposed part of plate and screws, and sutured to the prevertebral fascia. The drain was applied. The NG tube was removed after 1 week, and gastrografin study was performed where it revealed no leak. The drain was removed on the 9th postoperative day [Figure 3], and the sutures were removed on the next day with good wound healing. Follow-up of the patient for 6 months revealed no recurrence of the fistula.
Figure 1: Computed tomography with contrast showing right posterior pharyngeal tear (yellow arrow)

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Figure 2: The fistula is exposed during operation (gray arrow), and the plates and screws can be seen (yellow arrow)

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Figure 3: The patient 10 days after operation, just before removal of the sutures

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  Discussion Top


Pharyngocutaneous fistula after anterior spinal surgery is a rare complication; Fountas et al.[5] recorded in their reviews an incidence ranging between 0.1% and 1%. Newhouse et al.[6] found that the most common site of perforation occurs at the level of C5–C6 due to proximity to the pharynx and upper esophagus, in addition to the thin wall of the viscous. In this case, the injury occurred after fixation of C5.

Gaudinez et al.[8] and Morrison [9] suggested in their studies that the effects of trauma as hyperextension or fracture are the main causes of pharyngeal injury. It is clear that these factors are not related to our case as the cervical fixation was done 4 weeks after trauma and during that period, no manifestations were recorded.

Graham [7] found that most of perforations occur during surgery secondary to retraction and sharp instrumentation with very few cases occurring as late complications (presenting after 3 days). Other causes of injury include alteration of the anatomical plain, use of grafts, and multiple level anterior plating.[5],[6],[7],[8],[9]

In the present case, the patient was normal in the first 5 days and manifested on the 6th postoperative day after application of anterior plate.

Diagnosis of pharyngocutaneous fistula is based essentially on clinical symptoms as the development of early postoperative wound infection, throat or neck pain, subcutaneous air in the neck, odynophagia, cellulitis, mediastinitis, or/and evidence of systemic sepsis.[1],[2],[3],[10] In this patient, the case was diagnosed first as wound infection with abscess formation, and the general surgeon failed to find the site of leak.

Han et al.[10] verified in their study that plain X-ray lateral view may show air in the soft tissues or widened retropharyngeal space, and contrast study helps in identifying the location and the extent of perforation. However, he concluded that a negative radiographic examination does not rule out pharyngeal injury, and most diagnoses are based on clinical symptoms. In the present case, CT with contrast study accurately diagnosed the presence of right posterior pharyngeal injury when primary exploration failed to discover it.

Detection of the fistula during the original operation indicates immediate repair; however, if it is small and diagnosed within 24–48 h, it can be treated conservatively with parenteral antibiotics and NG tube placement.[7] If the fistula is large or diagnosed after 48 h, most of the investigators prefer to control infection first, to be followed by closure, muscle flap support, and wound drainage.[11],[12],[13],[14],[15],[16] Benazzo et al.[15] and Ahn et al.[16] verified in their studies that sternocleidomastoid flap was superior to omental free flap due to its proximity to the pharynx, easy mobilization, suitable size and decreased chance of microvascular thrombosis. In the present case, the diagnosis was established on the 6th postoperative day and after initial exploration and control of local infection, the repair was done using a sternocleidomastoid flap with complete healing. Follow-up of the patient for 6 months revealed no recurrence of the fistula.

Removal of fixation plates, considering it as foreign bodies that may interfere with healing is controversial, and it may be advised by some surgeons; however, in the present case and other similar studies, healing was established without the removal of the plates.[4],[15],[16],[17]


  Conclusion Top


Being familiar with pharyngocutaneous fistula as a complication of anterior cervical approach for spinal surgery is essential for early diagnosis and repair of the fistula. Reinforcement by sternocleidomastoid muscle flap is proved to be effective to prevent recurrence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Solerio D, Ruffini E, Gargiulo G. Successful surgical management of a delayed pharyngo-esophageal perforation after anterior cervical spine plating. Eur Spine J 2008;17:280-4.  Back to cited text no. 2
    
3.
Paradells VR, Pérez JB, Vicente FJ, Florez LB, de la Viuda MC, Villagrasa FJ. Esophageal, pharyngeal and hemorrhagic complications occurring in anterior cervical surgery: Three illustrative cases. SurgNeurol Int 2014;5:126-30.  Back to cited text no. 3
    
4.
Patel NP, Wolcott WP, Johnson JP, Cambron H, Lewin M, McBride D, et al. Esophageal injury associated with anterior cervical spine surgery. Surg Neurol 2008;69:20-4.  Back to cited text no. 4
    
5.
Fountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976) 2007;32:2310-7.  Back to cited text no. 5
    
6.
Newhouse KE, Lindsey RW, Clark CR, Lieponis J, Murphy MJ. Esophageal perforation following anterior cervical spine surgery. Spine (Phila Pa 1976) 1989;14:1051-3.  Back to cited text no. 6
    
7.
Graham JJ. Complications of cervical spine surgery. A five-year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine (Phila Pa 1976) 1989;14:1046-50.  Back to cited text no. 7
    
8.
Gaudinez RF, English GM, Gebhard JS, Brugman JL, Donaldson DH, Brown CW. Esophageal perforations after anterior cervical surgery. J Spinal Disord 2000;13:77-84.  Back to cited text no. 8
    
9.
Morrison A. Hyperextension injury of the cervical spine with rupture of the oesophagus. J Bone Joint Surg Br 1960;42-B: 356-7.  Back to cited text no. 9
[PUBMED]    
10.
Han SY, McElvein RB, Aldrete JS, Tishler JM. Perforation of the esophagus: Correlation of site and cause with plain film findings. AJR Am J Roentgenol 1985;145:537-40.  Back to cited text no. 10
    
11.
Iyoob VA. Postoperative pharyngocutaneous fistula: Treated by sternocleidomastoid flap repair and cricopharyngeus myotomy. Eur Spine J 2013;22:107-12.  Back to cited text no. 11
    
12.
Seidl RO, Niedeggen A, Todt I, Westhofen M, Ernst A. Infrahyoid muscle flap for pharyngeal fistulae after cervical spine surgery: A novel approach – Report of six cases. Eur Spine J 2007;16:501-5.  Back to cited text no. 12
    
13.
Vrouenraets BC, Been HD, Brouwer-Mladin R, Bruno M, van Lanschot JJ. Esophageal perforation associated with cervical spine surgery: Report of two cases and review of the literature. Dig Surg 2004;21:246-9.  Back to cited text no. 13
    
14.
Navarro R, Javahery R, Eismont F, Arnold DJ, Bhatia NN, Vanni S, et al. The role of the sternocleidomastoid muscle flap for esophageal fistula repair in anterior cervical spine surgery. Spine (Phila Pa 1976) 2005;30:E617-22.  Back to cited text no. 14
    
15.
Benazzo M, Spasiano R, Bertino G, Occhini A, Gatti P. Sternocleidomastoid muscle flap in esophageal perforation repair after cervical spine surgery concepts, techniques, and personal experience. J Spinal Disord Tech 2008;21:597-605.  Back to cited text no. 15
    
16.
Ahn SH, Lee SH, Kim ES, Eoh W. Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture. J Clin Neurosci 2011;18:1374-80.  Back to cited text no. 16
    
17.
Orlando ER, Caroli E, Ferrante L. Management of the cervical esophagus and hypofarinx perforations complicating anterior cervical spine surgery. Spine (Phila Pa 1976) 2003;28:E290-5.  Back to cited text no. 17
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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