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J R Soc Med. 2001 August; 94(8): 402–403.
PMCID: PMC1281635

Jet-ski injury: severe blunt neck trauma with survival

G Davies, BSc MRCS, S Leighton, MB FRCS(Orl),1 R Hayward, FRCS,2 and L Spitz, PhD FRCS

Few people survive blunt trauma in which the trachea and oesophagus are transected.

CASE HISTORY

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.

Figure 1
X-ray of cervical spine showing subluxation of C2 on C3

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.

COMMENT

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.

References

1. Hermon A, Segal K, Har-El G, et al. Complete cricotracheal separation following blunt trauma to the neck. J Trauma 1987;27: 1365-7 [PubMed]
2. Ayabe H, Tsuji H, Akamine S, et al. Combined transection of the trachea and oesophagus following cervical blunt trauma. Thorac Cardiovasc Surgeon 1993;41: 193-5 [PubMed]
3. Aseoka M, Usami N, Sasaki M, et al. Combined rupture of trachea and esophagus following blunt trauma—a case report. J Jap Assoc Thorac Surg 1998;46: 215-19 [PubMed]
4. Chen FH, Fetzer JD. Complete cricotracheal separation and third cervical spinal cord transection following blunt neck trauma: a case report of one survivor. J Trauma 1993;35: 140-2 [PubMed]
5. Schoem SR, Choi SS, Zalzal GH. Pneumomediastinum and pneumothorax from blunt cervical trauma in children. Laryngoscope 1997;107: 351-6 [PubMed]
6. Rupprecht H, Rumenapf G, Braig H, et al. Acute bleeding caused by rupture of the thyroid gland following blunt neck trauma. J Trauma 1994;36: 408-9 [PubMed]
7. Dev A, Ghosh P, Deaka RC. Acquired tracheo-oesophageal fistula. J Laryngol Otol 1998;102: 378-9 [PubMed]
8. Pickles JM. Retropharyngeal abscess complicating a neck wound. J Laryngol Otol 1988;102: 552-3 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press