Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

An esophageal perforation is an uncommonly encountered life-threatening emergency that can lead to leakage of gastric contents into surrounding esophageal tissue. It is most commonly due to iatrogenic injury, typically involving endoscopy, intubation, or esophageal surgery. We describe an unusual case of esophageal perforation secondary to the removal of infected cervical spine hardware. A 73-year-old male with cervical spine central stenosis with history of an anterior cervical spinal fusion of C5-C7 over 40 years ago presented to the emergency department at the request of his pulmonologist. A CT scan of the neck was obtained in the outpatient setting, as the patient had admitted to an enlarging neck mass over the last month. Initial findings were concerning for a new supraclavicular lymph node. After independent review by his pulmonologist, there were concerns for a paraspinal necrotizing infection, for which he was advised to present to the emergency department. On arrival, blood pressure was 148/69, heart rate 78, respiratory rate of 17, and pulse oximetry of 98% breathing ambient air. Labs were remarkable for a white blood cell count of 11.3 bil/L and a C reactive protein of 38.6 mg/L. A repeat CT neck revealed a possible abscess and multiple foci of gas tracking along the C3-C6 left paraspinal tissues. An image guided aspiration was performed, and fluid cultures were negative. He was discharged home on oral antibiotics but returned one week later with worsening lethargy and neck pain. Vitals remained stable on re-admission. Labs were significant for a while blood cell count of 11.8 bil/L. A CT neck showed an increase in the left sided fluid collection, extending into the lateral soft tissues of the neck. The patient was then taken to the operating room with neurosurgery for definitive management of cervical spine hardware removal and evacuation of the deep neck abscess. Surgical cultures grew candida glabrata and candida albicans. Post-operatively, the patient had new onset dysphagia, and additional imaging revealed extensive soft tissue gas tracking throughout the superficial and deep spaces of the neck, concerning for airway injury. He was later intubated for airway protection. A direct laryngoscopy and neck washout revealed significant purulence and a 4 cm posterior esophageal wall defect. This was repaired with a myofascial pedicled sternocleidomastoid flap. He was discharged in stable condition with intravenous micafungin for 30 days. Esophageal perforations are most commonly iatrogenic and rarely reported as a result of cervical spine hardware. Additionally, fungal infections caused by infected hardware are infrequent. Upon further review, the patient had a history of fungal esophagitis one year prior. Imaging during admission demonstrated significant anterior displacement of the cervical hardware, which had eroded the esophagus. Its removal likely uncovered this defect and contributed to the etiology of the perforation. This case underscores the importance of independent review of imaging, as well as highlights this rare etiology of esophageal perforation secondary to infected cervical spine hardware.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

Download

Share

COinS