An 18-year-old male presented to a local emergency department following a high school football game. He complained of hoarseness and difficult, painful swallowing. During the game, he was running with the ball when he was hit in the facemask of his helmet twice during the same play. After the first hit, the chinstrap of his helmet became dislodged posteriorly and rotated under his chin. With the second hit to his facemask, he felt the chinstrap tighten, forcing him to swallow. He continued to play a majority of the game but began to notice anterior neck pain, shortness of breath, odynophagia, sore throat, and hoarseness.
On initial examination, the patient's voice was raspy and he complained of anterior neck pain with odynophagia. The decision was made to transfer the patient to the nearest Level I trauma center for further evaluation of suspected blunt neck trauma.
Upon arriving at the trauma center approximately one hour later, the physical exam revealed a small (1 cm) midline mandibular laceration, stable vital signs, and clear breath sounds bilaterally. Mild soft tissue swelling of the neck suggesting possible subcutaneous emphysema was found, however, no crepitus was noted. A chest radiograph was within normal limits. The patient's cervical spine was non-tender to palpation along the spinous processes with full range of motion.
Cervical radiographs revealed air in the prevertebral soft tissues, posterior to the hypopharynx (Figure 1). A computed tomography (CT) scan of the neck was performed, revealing an irregularity of the posterior hypopharyngeal wall and extensive air in the soft tissues of the neck extending from the nasopharynx to the mediastinum (Figures 2 and 3). An esophagram confirmed the diagnosis of a small posterior hypopharyngeal perforation (Figure 4).
The patient initially was admitted to the Intensive Care Unit for close observation. He was kept nil per os (NPO) and treated conservatively with cefotetan 1 gram every 12 hours and metronidazole 500 milligrams every 12 hours intravenously. Esophagrams were repeated every two days and showed gradual improvement with no extravasation noted by the sixth day of hospitalization. At that time, the patient was afebrile with a normal white blood cell count and differential. His initial symptoms of anterior neck pain, shortness of breath, and odynophagia were resolved. The patient was dismissed on a clear liquid diet with close outpatient follow-up. An esophagram three weeks after the initial injury confirmed a healed lesion.