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Few people survive blunt trauma in which the trachea and oesophagus are transected.
A 10-year-old girl sustained a severe neck injury following blunt trauma to the neck in a high-speed jet-skiing accident in Egypt, in which she hit a line outstretched between two boats. After rescue from the sea she was unconscious with an obstructed airway. An emergency cricothyroidotomy was performed by a passing anaesthetist, followed by immediate intubation via the cricothyroidotomy site to relieve the airway obstruction. She was then transferred to a local hospital.
Her injuries included a fracture/dislocation of the second on third cervical vertebrae (C2-C3) without evidence of spinal cord or spinal nerve root injury. Exploration of the neck revealed a transected trachea and oesophagus. She was electively paralysed and mechanically ventilated via a formal tracheostomy and her cervical spine was stabilized by halotraction. A feeding gastrostomy was inserted.
Three weeks following the injury she was transferred, paralysed and mechanically ventilated, to Great Ormond Street Hospital, London. The neck wound now was grossly infected and she was extremely malnourished: free gastro-oesophageal reflux had caused difficulties in establishing gastrostomy feeds. The proximal oesophagus had closed off, requiring her to spit out her saliva. The distal oesophagus remained open as a fistula in the neck wound. Plain X-ray (Figure 1), computerized tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine showed a well opposed but clear subluxation of C2 on C3. Four days after admission she underwent an occiput to C4 posterior spinal fusion with split calvarial bone, and a feeding jejunostomy was inserted to provide full enteral nutrition. Immobilization of the neck was maintained for three months after this operation, with a halo-jacket, until CT scanning suggested the fusion was complete. She was mobilizing with assistance within one month.
Reconstruction of her oesophagus was undertaken four months after admission. Flexible bronchoscopy and oesophagoscopy showed paralysed and abducted vocal cords, indicating bilateral recurrent laryngeal nerve injury. The fistulous opening in the neck communicated with the lower oesophagus. The distal part of the cervical oesophagus was mobilized into the superior mediastinum and anastomosed end-to-end with the proximally transected oesophagus. The trachea was reconstructed three weeks later. Laryngeal release and mobilization of the thoracic trachea was necessary to allow closure without tension. A new tracheostomy was constructed distal to the repair, during which a laryngocutaneous fistula and an anterior oesophageal fistula were identified and closed. The oesophageal reconstruction healed with a minor stricture which responded to bouginage. Continuing problems with aspiration and recurrent respiratory infections developed because of laryngeal incompetence and necessitated an epiglottopexy to protect the airway. As a result she was aphonic but could communicate with an electrolarynx.
At one-year follow-up, swallowing was unimpeded with no evidence of aspiration and weight gain was satisfactory. She was coping well with her permanent tracheostomy and was again enjoying jet-skiing.
Few cases of combined oesophageal and tracheal transection in association with a cervical spine injury have been reported previously in blunt neck trauma. Hermon et al.1, Ayabe et al.2, and Aseoka et al.3 reported combined tracheal and oesophageal rupture, but in these cases transection was not complete. Chen et al.4 reported complete cricotracheal separation in association with cervical spine injury, but their patient did not sustain an oesophageal injury.
Complete disruption of the trachea is usually fatal. Severe neck trauma is often associated with cervical spine injury, recurrent laryngeal nerve damage and damage to other vital structures. Pneumomediastinum and pneumothorax requires emergency tube thoracostomy and tracheostomy5. Rupprecht et al.6 reported acute haemorrhage from rupture of the thyroid gland following blunt neck trauma. Other complications include acquired tracheo-oesophageal fistula7,3 and retropharyngeal abscesses8.
A specialist multidisciplinary approach to management of these rare cases is important and is best achieved in a tertiary referral centre. The extent of the injury must be delineated accurately by CT, MRI and contrast studies. The timing of the various stages of the operative reconstruction requires careful planning.