- Email: [email protected]
Blunt handlebar injury causing pharyngeal perforation
Injury Extra (2005) 36, 373—375
www.elsevier.com/locate/inext
CASE REPORT
Blunt handlebar injury causing pharyngeal perforation G.R. Christey * Trauma Services, Auckland City Hospital, P.O. Box 92-024, Grafton Road, Auckland, New Zealand Accepted 23 November 2004
Introduction Blunt pharyngeal perforation is a rare injury that may be difficult to diagnose but can lead to potentially disastrous consequences if overlooked. Handlebar impact is a rare mechanism of injury more commonly associated with abdominal injuries in children following falls from bicycles. This paper reports a young male who suffered blunt pharyngeal perforation from a low-speed motorcycle handlebar impact to the neck and had successful non-operative management of a 5 cm posterior pharyngeal laceration.
Case report A previously fit and well 16-year-old male was admitted after falling from his motorcycle at low speed while riding through an apple orchard, impacting the left side of neck on the end of his handlebar. At the scene he had minor haemoptysis, a contusion to the left side of his neck (Fig. 1), and a hoarse voice but no dyspnoea or stridor. He was alert and oriented with a pulse rate of 80 min, respiratory rate 24 min and systolic blood pressure 120 mmHg. On arrival at the Emergency Department his observations had remained stable though he had devel* Tel.: +61 9 379 7440x6322; fax: +61 9 307 8931. E-mail address: [email protected].
oped minor subcutaneous emphysema on the left side of the neck. Trauma radiology revealed pneumomediastinum on lateral cervical (Fig. 2) and chest films. Duplex ultrasound of the neck revealed no vascular deficits but emphysema precluded adequate visualisation of the extent of haematoma in the neck. Flexible laryngoscopy revealed only blood at the laryngeal inlet and salivary pooling. The cords were intact and there was no significant laryngeal oedema or obvious laceration. Within 1 h of this procedure the patient vomited, coughed, and developed severe surgical emphysema, with a ‘‘bullfrog’’ neck. He underwent immediate awake intubation and emergency direct laryngoscopy and oesophagoscopy which revealed a 5-cm laceration of the posterior pharyngeal wall down to cricopharyngeus with dissection to the prevertebral fascia. Tracheostomy and nasogastric tubes were placed. A post-op chest X-ray revealed a right pneumothorax which was treated with an intercostal drain. The patient was managed non-operatively with nasogastric feeding and broad-spectrum intravenous antibiotics. A gastrograffin swallow at ten days post-injury (Fig. 3) showed no significant residual cavity and solid oral intake was reinstituted. He made an uneventful recovery and was discharged 12 days post-injury with no residual deficits.
1572-3461/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.11.024
374
G.R. Christey
Figure 1
Left side of neck at admission showing impression from handlebar.
Discussion Less than 2% of pharyngeal perforations are due to blunt trauma,1 and only 12 previous cases have been reported in the literature.3 Management guidelines proposed by Niezgoda et al.4 are based on the
Figure 2
analysis of 11 cases with lacerations less than 4 cm. The recommendation of these authors was that lacerations over 2 cm long should be repaired surgically. Dolgin et al.2 managed 10 cases of pharyngoesophageal perforation non-operatively and recommended this approach as first line treatment.
Lateral neck X-ray at admission showing prevertebral air.
Blunt handlebar injury
Figure 3
375
Gastrograffin study at Day 10 showing minimal extraluminal leakage.
Evidence of sepsis should prompt immediate investigation and drainage of collections by external or transoral approaches on the basis of the anatomic location.5 This case illustrates that non-operative management of blunt pharyngeal perforation with laceration greater than 4 cm may be successful, however more work is required to determine which patients and injuries may be appropriate for this approach. Effective treatment relies on early diagnosis of this injury, which should be suspected in any patient with neck pain, hoarseness, dyspnoea, stridor or subcutaneous emphysema following blunt trauma to the neck.
References 1. Berry BE, Oschner JL. Perforation of the oesophagus: a 30-year review. J Thorac Cardiovasc Surg 1973;65:1—7. 2. Dolgin SR, Kumar NR, Wykoff TW, Managlia AJ. Conservative medical management of traumatic pharyngeal perforation. Ann Otol Rhinol Laryngol 1992;101:209—15. 3. Hagr A, Kamal D, Tabah R. Pharyngeal perforation caused by blunt trauma to the neck. Can J Surg 2003;46(1):57—8. 4. Niezgoda JA, McMenamin P, Graeber GM. Pharyngoesophageal perforation after blunt neck trauma. Ann Thorac Surg 1990;50:615—7. 5. Ursic CM, Shah SV, Kaviani A. Neck abscesses after blunt cervical trauma. J Trauma 2001;51:146—8.
www.elsevier.com/locate/inext
CASE REPORT
Blunt handlebar injury causing pharyngeal perforation G.R. Christey * Trauma Services, Auckland City Hospital, P.O. Box 92-024, Grafton Road, Auckland, New Zealand Accepted 23 November 2004
Introduction Blunt pharyngeal perforation is a rare injury that may be difficult to diagnose but can lead to potentially disastrous consequences if overlooked. Handlebar impact is a rare mechanism of injury more commonly associated with abdominal injuries in children following falls from bicycles. This paper reports a young male who suffered blunt pharyngeal perforation from a low-speed motorcycle handlebar impact to the neck and had successful non-operative management of a 5 cm posterior pharyngeal laceration.
Case report A previously fit and well 16-year-old male was admitted after falling from his motorcycle at low speed while riding through an apple orchard, impacting the left side of neck on the end of his handlebar. At the scene he had minor haemoptysis, a contusion to the left side of his neck (Fig. 1), and a hoarse voice but no dyspnoea or stridor. He was alert and oriented with a pulse rate of 80 min, respiratory rate 24 min and systolic blood pressure 120 mmHg. On arrival at the Emergency Department his observations had remained stable though he had devel* Tel.: +61 9 379 7440x6322; fax: +61 9 307 8931. E-mail address: [email protected].
oped minor subcutaneous emphysema on the left side of the neck. Trauma radiology revealed pneumomediastinum on lateral cervical (Fig. 2) and chest films. Duplex ultrasound of the neck revealed no vascular deficits but emphysema precluded adequate visualisation of the extent of haematoma in the neck. Flexible laryngoscopy revealed only blood at the laryngeal inlet and salivary pooling. The cords were intact and there was no significant laryngeal oedema or obvious laceration. Within 1 h of this procedure the patient vomited, coughed, and developed severe surgical emphysema, with a ‘‘bullfrog’’ neck. He underwent immediate awake intubation and emergency direct laryngoscopy and oesophagoscopy which revealed a 5-cm laceration of the posterior pharyngeal wall down to cricopharyngeus with dissection to the prevertebral fascia. Tracheostomy and nasogastric tubes were placed. A post-op chest X-ray revealed a right pneumothorax which was treated with an intercostal drain. The patient was managed non-operatively with nasogastric feeding and broad-spectrum intravenous antibiotics. A gastrograffin swallow at ten days post-injury (Fig. 3) showed no significant residual cavity and solid oral intake was reinstituted. He made an uneventful recovery and was discharged 12 days post-injury with no residual deficits.
1572-3461/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.11.024
374
G.R. Christey
Figure 1
Left side of neck at admission showing impression from handlebar.
Discussion Less than 2% of pharyngeal perforations are due to blunt trauma,1 and only 12 previous cases have been reported in the literature.3 Management guidelines proposed by Niezgoda et al.4 are based on the
Figure 2
analysis of 11 cases with lacerations less than 4 cm. The recommendation of these authors was that lacerations over 2 cm long should be repaired surgically. Dolgin et al.2 managed 10 cases of pharyngoesophageal perforation non-operatively and recommended this approach as first line treatment.
Lateral neck X-ray at admission showing prevertebral air.
Blunt handlebar injury
Figure 3
375
Gastrograffin study at Day 10 showing minimal extraluminal leakage.
Evidence of sepsis should prompt immediate investigation and drainage of collections by external or transoral approaches on the basis of the anatomic location.5 This case illustrates that non-operative management of blunt pharyngeal perforation with laceration greater than 4 cm may be successful, however more work is required to determine which patients and injuries may be appropriate for this approach. Effective treatment relies on early diagnosis of this injury, which should be suspected in any patient with neck pain, hoarseness, dyspnoea, stridor or subcutaneous emphysema following blunt trauma to the neck.
References 1. Berry BE, Oschner JL. Perforation of the oesophagus: a 30-year review. J Thorac Cardiovasc Surg 1973;65:1—7. 2. Dolgin SR, Kumar NR, Wykoff TW, Managlia AJ. Conservative medical management of traumatic pharyngeal perforation. Ann Otol Rhinol Laryngol 1992;101:209—15. 3. Hagr A, Kamal D, Tabah R. Pharyngeal perforation caused by blunt trauma to the neck. Can J Surg 2003;46(1):57—8. 4. Niezgoda JA, McMenamin P, Graeber GM. Pharyngoesophageal perforation after blunt neck trauma. Ann Thorac Surg 1990;50:615—7. 5. Ursic CM, Shah SV, Kaviani A. Neck abscesses after blunt cervical trauma. J Trauma 2001;51:146—8.