Cervical Osteomyelitis After Pharyngeal Surgical Manipulation

Abstract

To the Editor We congratulate D'Souza and colleagues on their article, "Cervical Spine Spondylodiscitis After Esophageal Dilation in Patients With a History of Laryngectomy or Pharyngectomy and Pharyngeal Irradiation," 1 for bringing attention to a rare but potentially devastating complication of esophageal dilation in patients with postradiation head and neck cancer. We have observed similar events in our patients at the University of Pittsburgh.We can recall 3 cases of patients aged 52 to 74 years who developed cervical osteomyelitis after pharyngeal surgical manipulation. All patients had undergone radiation treatment for hypopharyngeal or laryngeal cancer. One patient underwent multiple direct laryngoscopic procedures and a biopsy procedure of an ulcerative pharyngeal wall lesion, and 2 patients had esophageal dilations for treatment of dysphagia. They presented 4 weeks to 24 weeks after the procedures with complaints of neck pain and were treated with a combination of surgical debridement and intravenous antibiotics. Unfortunately, all patients had diet limitations after treatment, with 2 patients remaining dependent on percutaneous endoscopic gastrostomy (PEG) tubes for nutrition.Similar to Dr D'Souza and colleagues, 1 we emphasize that no mucosal injuries or perforations were noted during the surgic al interventions. Esophageal dilation is a well-tolerated procedure, 2 but studies 3,4 show that it induces a transient bacteremia. Patients with postradiation head and neck cancer may develop occult mucosal injuries during dilations, which are prone to wound healing complications and infection. At our institution, we are considering starting prophylactic antibiotics prior to pharyngeal intervention in this patient population.Additionally, as in case number 4 in Dr D'Souza's article, 1 2 of our patients were "incidentally" diagnosed with cervical osteomyelitis on surveillance imaging. This implies that the diagnosis of osteomyelitis may often be missed. Literature review revealed 1 case presented by Ekbom et al 2 of a 56-year-old woman with a history of laryngeal cancer postradiation, esophageal dilation, and neck pain, who had negative findings on computed tomography examination, and was later diagnosed with osteomyelitis on magnetic resonance imaging. Magnetic resonance imaging has the highest specificity in diagnosing cervical osteomyelitis 5 ; however, the indications and timing of imaging for this patient population are not clear.We concur with D'Souza et al 1 that head and neck surgeons must maintain a high clinical suspicion for cervical osteomyelitis in any patient with postradiation cancer who has a history of recent pharyngeal surgery and presents with neck pain. Further research is necessary to elucidate the role of prophylactic antibiotics and imaging in preventing and diagnosing this rare complication.

Cervical Osteomyelitis After Pharyngeal Surgical Manipulation—Reply

“…In Reply We would like to thank Dr Govil et al for their insight into this potentially devastating diagnosis in patients with irradiated head and neck cancer, and for adding further patient data to be considered. Indeed, cervical spine spondylodiscitis can be a challenging diagnosis, especially when detected only on surveillance imaging in an otherwise asymptomatic patient .…”