Hypopharyngeal rupture associated with Hangman's fracture after blunt trauma

Joshua Wolf, BS

Medical Student IV

George Miller, MD

Chief Surgical Resident

Raymond Sultan, MD

General Surgery Resident

Maurizio Miglietta, DO

Assistant Professor of

Surgery

Spiros Frangos, MD, MPH

Assistant Professor of

Surgery

Department of Surgery

Bellevue Hospital Center

New York University

School of Medicine

New York, NY

Introduction: Hangman's fractures, also referred to in the literature as traumatic spondylolisthesis, are bilateral fractures of the pedicle or pars involving the C2 vertebral body. Hypopharyngeal perforations are rare and typically observed in patients involved in motor vehicle collisions. Both injuries are life-threatening and must be recognized early to prevent complications.

Results and discussion: The authors report the case of a hemodynamically stable patient who presented to the hospital after a motor vehicle collision. Radiology studies revealed a Hangman's fracture and hypopharyngeal perforation. The patient was successfully treated nonoperatively. The authors' literature review indicates that this may be the first report of a hypopharyngeal rupture associated with a Hangman's fracture.

Conclusion: Hangman's fractures and hypopharyngeal ruptures usually can be managed nonoperatively. Surgical intervention for Hangman's fractures should be limited to patients with failed alignment of the cervical spine. In cases of hypopharyngeal perforation, operative repair should be undertaken when the perforation is extensive or medical management fails.

Hypopharyngeal perforations and Hangman's fractures are rare and potentially life-threatening complications of blunt trauma. We report the case of a patient who sustained both of these injuries during a motor vehicle collision. The patient was treated successfully without surgery.

Case report

A 34-year-old woman was an unrestrained backseat passenger involved in a high-speed motor vehicle collision. On arrival to the hospital, she was hemodynamically stable and reported cervical spine pain. The physical examination demonstrated no neurological deficit, but significant tenderness of the cervical spine was elicited on palpation. Computed tomography (CT) scans revealed bilateral pars interarticularis fractures in C2 with spondylolisthesis, as well as vertebral body fractures in C3-6 (Figure 1). Retropharyngeal and paratracheal air were noted at C2. A pharyngoesophagram showed contrast extravasation at the level of the left piriform sinus (Figure 2).

The patient was closely monitored, and her hypopharyngeal perforation was managed with diet restriction and antibiotics. The cervical spine fractures were treated using a hard collar. The patient did not develop a localized abscess or sepsis nor did she demonstrate any neurological compromise. Four days after the injury, the pharyngoesophagram was repeated and showed resolution of the hypopharyngeal leak. The patient was started on clear liquids and quickly advanced to eating solid food. She was discharged from the hospital 6 days after admission wearing a hard collar for her spinal injuries.

Figure 1—CT scan of the cervical spine showing bilateral pars interarticularis fractures of C2 (Hangman's fracture), as well as retropharyngeal and paratracheal air.

Figure 2—Pharyngoesophagram showing contrast extravasation at the level of the left piriform sinus near the Hangman's fracture (arrow).

Discussion

This case appears to be the first report of hypopharyngeal perforation associated with a traumatic Hangman's fracture. This is often referred to as traumatic C2 spondylolisthesis. The literature suggests that 50% to 85% of modern-day Hangman's fractures result from motor vehicle collisions.¹ During impact, extreme hyperextension of the cervical spinal column causes fractures in both C2 pedicles and dislocation of the C2-3 intervertebral disc, damaging supporting ligaments and causing a potentially life-threatening transection of the spinal cord.²

The largest single-institution study of Hangman's fractures included 74 patients, 90% of whom were treated successfully with nonoperative management (2 patients died prior to receiving any treatment).³ Injuries were stabilized for 10 to 16 weeks using halo braces (n = 56), sterno-occipital mandibular immobilization devices (n = 6), or Philadelphia collars (n = 3). Surgical fusion was performed on 7 patients (10%) whose hard collars failed to properly support and align their cervical spines. The authors concluded that Hangman's fractures in patients who have no associated neurological deficits should be managed initially with external immobilization.

In cases involving neurological compromise, it may be necessary to use cardiopulmonary support, corticosteroids, or surgical fusion to avoid fatal neurological injuries.² A major complication of nonoperative management in patients with simple Hangman's fractures is incomplete consolidation of the bone fragments. In such cases, surgical intervention using metal implants, bone grafts, or threaded screws may be considered from an occipito-cervical posterior or transoral anterior approach.¹

Hyperextension of the cervical spine caused our patient's Hangman's fracture, but the exact nature of her hypopharyngeal rupture is less clear. Blunt trauma can lead to hypopharyngeal perforation through several mechanisms. First, it is possible for bony or cartilaginous fragments to shear or directly penetrate the hypopharynx or cervical esophagus.⁴ It is also possible for the posterior hypopharynx or cervical esophagus to perforate if it becomes trapped between vertebral bodies as the hyperextended spinal column normalizes.⁵ Barotrauma can cause a perforation if the airway is compressed bya direct nonpenetrating blow from an object, such as a steering wheel or seatbelt. As air is forcibly expelled against this resistance, it can tear through Killian's dehiscence, a weakness in the posterior hypopharynx that contains only mucosa and serosa. There was no direct impact to the patient's neck in this case; thus barotrauma is not a likely mechanism. It is possible that the patient's posterior hypopharynx may have been damaged by shearing forces from the cervical spine during hyperextension. The concurrent C2 fractures and spondylolisthesis may have exerted additional forward pressure on the hypopharyngeal wall, contributing to the injury. Regardless of the mechanism of injury, management of hypopharyngeal rupture secondary to blunt trauma is unclear because of the paucity of reported cases. The general choice of treatment is immediate operative drainage or medical therapy. Clinicians must maintain a high index of suspicion for such injuries, and rapid diagnosis is critical to prevent fatal complications.⁶

Retrospective reviews and case reports over the past several decades have recommended medical management for most hypopharyngeal or cervical esophageal ruptures secondary to blunt trauma.⁷ Dolgin and colleagues report 10 cases of traumatic cervical esophageal perforations that were managed medically without complications or fatalities.⁸ Flexible laryngoscopy and contrast-enhanced esophagrams were used for early diagnosis and follow-up surveillance. Oral feedings were restricted, and broad-spectrum antibiotic therapy was initiated as soon as lesions were detected. Niezgoda and colleagues evaluated 10 patients who had traumatic pharyngoesophageal perforations and determined that successful medical management correlates with smaller lesions (<2 cm) and surgery is best reserved for larger pharyngeal ruptures or those that involve the esophagus.⁹ The coexistence of a stable Hangman's fracture with a small hypopharyngeal rupture should not alter management of either injury.

Conclusion

Our case appears to be the first published report of a patient whose Hangman's fracture may have contributed to a hypopharyngeal perforation following blunt trauma during a motor vehicle collision. Our patient's injuries were successfully managed nonoperatively. In general, surgical intervention for Hangman's fractures should be reserved for patients with failed alignment of the cervical spine, while operative repair of hypopharyngeal perforations should be reserved for cases involving extensive rupture or when medical management has failed.

References

1. Boullosa JL, Colli BO, Carlotti CG Jr, et al. Surgical management of axis' traumatic spondylolisthesis (Hangman's fracture). Arq Neuropsiquiatr. 2004;62(3B):821-826.
2. Calatayud Maldonado V, Maiman DJ. Management of Hangman's fracture. Surg Neurol. 1997;47(4):326-327.
3. Greene KA, Dickman CA, Marciano FF, et al. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine. 1997;22(16):1843-1852.
4. Cross KJ, Koomalsingh KJ, Fahey TJ 3rd, et al. Hypopharyngeal rupture secondary to blunt trauma: presentation, evaluation, and management. J Trauma. 2007;62(1):243-246.
5. Nerot C, Jeanneret B, Lardenois T, et al. Esophageal perforation after fracture of the cervical spine: case report and review of the literature. J Spinal Disord Tech. 2002;15(6):513-518.
6. Ho KF, Soo G, Abdullah VJ, et al. Hypopharyngeal perforation after blunt neck trauma. J Otolaryngol. 2004;33(3):200-202.
7. Smith D, Woolley S. Hypopharyngeal perforation following minor trauma: a case report and literature review. Emerg Med J. 2006;23(1):e7.
8. Dolgin SR, Wykoff TW, Kumar NR, et al. Conservative medical management of traumatic pharyngoesophageal perforations. Ann Otol Rhinol Laryngol. 1992;101(3):209-215.
9. Niezgoda JA, McMenamin P, Graeber GM. Pharyngoesophageal perforation after blunt neck trauma. Ann Thorac Surg. 1990;50(4):615-617.

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