Clinical records Spontaneous rupture of the pharynx By I. D.

FRASER

and G. T.

WILLIAMS

(Edinburgh)

Introduction

rupture of the pharynx must be exceedingly rare. We are aware of only one such reported case (Davidson, 1964). Spontaneous rupture of the oesophagus is well known and spontaneous rupture of the stomach has been reported (Cronin, 1959). This case report concerns a patient in whom the history, clinical and operative findings are consistent with a spontaneous rupture of the pharynx. SPONTANEOUS

Case report

The patient was a healthy woman aged 70 years. On Christmas day she had travelled by bus to her daughter's home for lunch. On arrival she had felt unwell and had decided to have only some vegetable soup and pudding. Immediately following this she vomited a number of times. During a particularly severe bout she experienced the sudden onset of severe pain in the neck and her anxious relations noticed, with some alarm, that the right side of her neck seemed to swell visibly. The swelling further increased in size gradually over the next few hours and was accompanied by the onset of inspiratory and expiratory stridor which remained constant overnight. The following morning she presented at the Accident and Emergency Department. She was found to be drowsy with noisy respirations. Her pulse was 88 per minute and her blood pressure was 160/100 mm Hg. Her respirations were 28 per minute. On examination she had a swollen neck which was most marked below the right mandible. She was very tender in this area and surgical emphysema could be palpated from her right mandible to the right clavicle. A history of dysphagia for 20 years was obtained. She found difficulty in swallowing pills and had to chew her food carefully; there had been no weight loss. No investigation of dysphagia had been undertaken. Plain radiographs of her neck and chest were taken. The neck films confirmed the extensive presence of air in the soft tissues and showed displacement of the trachea to the left (Figs. 1 and 2). She was transferred to the E.N.T. Department of the Edinburgh City Hospital. The previous findings were confirmed and indirect laryngoscopy was carried out. This was difficult on account of the presence of tenacious mucus in the pharynx, but a right parapharyngeal swelling was noted posterior and lateral to the tonsil which was pushed forwards and medially. The swelling stretched from just behind the upper pole of the right tonsil to the apex of the right pyriform fossa. 317

I. D. Fraser and G. T. Williams In view of the stridor, the parapharyngeal swelling, the displacement of the trachea from the midline and the presence of extensive subcutaneous emphysema it was decided to explore the neck and create a tracheostomy. This was carried out about 24 hours after the original sudden onset of the pain and swelling.

FIG. 1. Antero-posterior X-ray of neck showing the extensive surgical emphysema in the soft tissues and displacement of the trachea.

Operation An endotracheal tube was passed without difficulty after aspiration of tenacious mucus. A 10 cm. horizontal incision was made in a skin crease in the right side of the neck at the level of the cricoid. The tissues of the neck were immediately noted to be oedematous and air could be seen lying in the fascial planes. The right pyriform fossa region was approached by retracting the sternomastoid muscle with the great vessels laterally, the larynx with the thyroid gland medially, after ligation and division of the middle thyroid vein. Oedema of all tissues and the greatest amounts of air were encountered above the pyriform sinus and posterior to the pharynx. There was no suggestion of leakage of air through the apex of the right pleura or from the larynx and trachea. No foreign body was seen or palpated and at this stage there was no detectable breach in the pharyngeal wall. Pharyngoscopy, however, revealed an infected tear in

Clinical records

FIG. 2. Lateral X-ray of neck showing the extensive surgical emphysema.

the pharyngeal mucosa in the postero-lateral wall of the pyriform sinus and a i cm. breach in the inferior constrictor deep to it. The tear was extended by another I cm. to drain about 2 cc. of pus from within the pharyngeal wall. No attempt was made to suture this in view of the poor condition of the tissues. A large haemovac drain was introduced, deep to the site, through the neck wound and a tracheostomy fashioned through a separate horizontal incision. An attempt was made to pass a nasogastric tube but the oesophageal opening could not be identified as multiple oedematous folds were encountered. Subsequent culture of the pus showed a moderate growth of antibiotic sensitive Staph. aureus; no gas producing organisms were found. The patient was given intravenous fluids for the next 48 hours. She was given a 10-day course of Ampicillin. On the third day a nasogastric tube was passed without difficulty and tube feeding was commenced. She made a satisfactory recovery following this and oral feeding was commenced on the seventh post-operative day. The tracheostomy was allowed to close spontaneously three days after operation. A cine barium swallow was performed as an out-patient in the fourth week and this showed a smooth well-defined localized stricture at the level of che crico-pharyngeus (Figs. 3 and 4). Subsequent oesophagoscopy confirmed the benign nature of this stricture which was easily dilated. There was complete healing of the pharynx. Her dysphagia has since improved. 319

I. D. Fraser and G. T. Williams

FIG. 3. Still from cin6 barium swallow showing the benign stricture.

FIG. 4. Still from cin6 barium swallow showing the benign stricture. 320

Clinical records Discussion In establishing the diagnosis of spontaneous rupture of the pharynx it is necessary to consider the possibility of perforation due to disease or foreign body. No history suggestive of a foreign body was obtained nor was one found. A benign stricture at the level of the crico-pharyngeus was found but the tear did not directly involve it. Our case compares closely with the previously recorded patient with spontaneous rupture of the pharynx. Both cases had long-standing histories of dysphagia. In both cases the onset of pain and swelling of the neck were synchronous with surgical emphysema throughout the soft tissue of the neck; the air was not apparently confined by the fascial planes. The previous case ruptured whilst swallowing as opposed to vomiting in our patient. Our patient had stridor with displacement of the trachea necessitating tracheostomy which was not reported in the previous case. A probable explanation for this is the length of time that elapsed before operation in our patient. Oedema had developed in the air-containing soft tissues and displaced the trachea. The stridor appears to have been due to tenacious mucus in the laryngopharynx which pain prevented her from swallowing. The aetiology is not known but the findings in both cases suggest a bursting pressure within the pharynx. The presence of a stricture below the pharynx may have caused some weakening of the constrictor muscle but, apart from the tear, the muscle appeared neither thinned nor hypertrophied at operation. There were some redundant mucosal folds noted in the pharynx at subsequent endoscopy and the cine baiium swallow gave an impression of a slightly dilated pharynx but no pharyngeal pouch was demonstrated. We are unable to explain how the tear occurred above the stricture when we would have expected the greatest pressure to be below the stricture during the act of vomiting, unless the pharynx 'burst' initially on swallowing and vomiting then produced a rapid leak of air. Davidson (1964) suggests a possible predilection for rupture to occur on the left side in the postero-lateral area and quotes three cases where rupture occurred at this side following accidental raising of the pharyngeal pressure by compressed gases. In our patient the lesion was on the right side but also in the postero-lateral position.

Summary A case of spontaneous rupture of the pharynx is described occurring during the act of vomiting. Comparisons are made with the only known previously recorded case of spontaneous pharyngeal rupture.

Acknowledgement We are indebted to Dr. G. D. McDowall for permission to publish this case report and to the Radiology Department, Royal Infirmary, Edinburgh. 321

I. D. Fraser and G. T. Williams REFERENCES 47, 43.

CRONIN, K. (1959) British Journal of Surgery, DAVIDSON, J. S. (1964) Thorax, 19, 332.

Ear, Nose and Throat Department, Ward 3, City Hospital, Greenbank Drive, Edinburgh EHio 5SB.

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Spontaneous rupture of the pharynx.

A case of spontaneous rupture of the pharynx is described occurring during the act of vomiting. Comparisons are made with the only known previously re...
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