Staff Physiatrist Emory University Atlanta, Georgia, United States
Case Diagnosis: Esophageal fistula, discitis, and osteomyelitis.
Case Description: 41-year-old male status-post motor vehicle accident. Initial evaluation revealed C5-C7 burst fractures resulting in complete C4 tetraplegia. Following posterior spinal fusion from C2-T2, the patient presented for inpatient rehabilitation three months post-injury. Upon arrival, he complained of feeling a lump in his throat (globus pharyngeus), but outside hospital modified barium swallow study (MBSS) and esophagogastroduodenoscopy (EGD) revealed no evident dysphagia. Repeat EGD revealed no abnormalities. Despite these negative findings, patient's globus pharyngeus persisted over the next few weeks. Repeat MBSS identified possible esophageal fistula, confirmed on esophagram with tracts leading into the C6-C7 pre-vertebral space. CT imaging revealed extraluminal gas and remodeling of the C6-C7 vertebral bodies. MRI also confirmed discitis and osteomyelitis at this level. Patient then underwent successful surgical management with anterior cervical discectomy and fusion, C6-C7 corpectomy, and repair of the esophageal fistula.
Discussions: Although the etiology of globus pharyngeus remains unclear, it is thought to be a diagnosis of exclusion following a negative work-up for dysphagia. Conservative management is recommended, with speech and cognitive therapy playing key roles. However, the patient’s lack of improvement despite these interventions prompted a re-evaluation with MBSS uncovering an occult esophageal fistula. While esophageal fistulas are a rare but well-documented complication of anterior spinal surgery, they are seldom described in literature following posterior spinal surgery (as in this case). Given this minimal incidence of fistula formation and the likely chronicity of both fistula and infection, it was difficult to ascertain whether the fistula led to infection or vice versa. The situation was further complicated in the setting of complete tetraplegia, which can obscure pain and autonomic regulation that would otherwise point to infection.
Conclusions: This case highlights a rare presentation where globus pharyngeus was the only tangible symptom for potentially life-threatening onset of esophageal fistula, discitis, and osteomyelitis.
