Eur Spine J (2007) 16:501505

DOI 10.1007/s00586-006-0202-0

O R I G I N A L A RT I C L E

Infrahyoid muscle flap for pharyngeal fistulae after cervical spine

surgery: a novel approachReport of six cases
Rainer O. Seidl Andreas Niedeggen
Ingo Todt Martin Westhofen Arne Ernst

Received: 8 May 2006 / Revised: 19 July 2006 / Accepted: 29 July 2006 / Published online: 22 August 2006

Springer-Verlag 2006

Abstract A report of our experiences involving the

treatment six male patients with a new method of
closing perforations in the pharynx and upper
esophagus, following surgery of the cervical spine
region. Perforation of the pharynx and upper esophagus are rare complications following cervical spine
surgery. The grave consequences of these complications necessitate in most cases immediate surgical
therapy. In most cases, the first step involves the removal of the cervical plate and screws. The defect was
then closed using a vascular pedicled musculofascia
flap derived from the infrahyoid musculature. In all
cases, the flap healed into place without complications. The patients began taking oral nutrients after
an average of seven postoperative (512) days. In
none of the cases did functional disorders or complications arise during the follow-up period (15 years).
The infrahyoid muscle flap is well suited for reconstruction of the posterior pharyngeal wall and the
upper esophagus.

R. O. Seidl (&) I. Todt A. Ernst

Department of Otolaryngology, Head and Neck Surgery
at UKB, Free University of Berlin,
Warener Strasse 7, 12683 Berlin, Germany
e-mail: [email protected]
A. Niedeggen
Spinal Cord Injury Center at UKB,
Free University of Berlin, Warener Strasse 7,
12683 Berlin, Germany
M. Westhofen
Department of Otolaryngology, Head and Neck Surgery
at RWTH Aachen, University of Aachen,
Pauwelsstrasse 30, 52074 Aachen, Germany

Keywords Pharynx Esophagus Perforation

Infrahyoid muscle flap Ventral spondylodesis
Complication
Introduction
Pharyngeal and esophageal perforations are burdened
with a high morbidity and mortality rate. An early
diagnosis determines and influences the patients further condition. Complications can be reduced by an
appropriate and rapid therapeutic intervention [3].
While small-circumscribed perforations can be treated conservatively, larger and direct perforations require rapid surgical intervention. There is a variety of
surgical procedures for treating such injuries. As well as
direct suturing, mucosal flaps, autotransplants and jejunocolonic interposition grafts are utilised. In 1981
Rubin described the use of a sternocleidomastoid
muscle (SCM) flap as another surgical alternative [5, 8].
This article will report on a vascular pedicled flap for
surgical fistulae intervention in the area of the pharynx
following anterior cervical spine surgery.
Materials and methods
A retrospective study from 1999 to 2004 treating six
patients at a Trauma Center for pharyngeal fistulae
following anterior cervical spine surgery.
Case report
A 67-year-old male patient presented with recurrent
pharyngocutaneous fistula in the right cervical region
over the preceding 3 years.

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In November 1998, following an accident resulting

in a complete functional quadriplegia at the level of
C5C6, the patient underwent a ventral stabilization as
the primary therapy. A revision operation involving
ventral osteosynthesis replacement was carried out a
few days later as a result of postoperative instability.
Recurrent infections and abscesses in the right cervical
area complicated the postoperative course. Multiple
operative and conservative therapies were attempted,
however, without succeeding in closing the fistula or
improving the clinical condition.
Following transfer to our clinic, radiological examination showed protrusion of the screws into the
esophagus (Figs. 1, 2 ). A revision operation was carried out via the existing scars in the right cervical region. Releasing the scarred SCM from the larynx and
thyroid, a perforation in the posterior part of the
pharynx at the level of C5C6 over the cervical plate
and screws was observed. After removing the cervical
plate and screws, and hence enabling complete visualization of the defect (3 cm7 cm), a right-sided infrahyoid muscle flap was prepared. The superior
branch of the ansa cervicalis laterocranial to the hyoid
bone was localized. Preservation of the arteriae thyreoidea superior and venae thyreoideae superiores was
necessary to supply the musculofascia graft. The infrahyoid musculature was subsequently released at the

Fig. 1 Preoperative video fluoroscopy. The arrow shows the

pharyngeal perforation

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Eur Spine J (2007) 16:501505

Fig. 2 Preoperative CT scan. The arrow indicates the cervical

plate and screws

hyoid bone. The muscles were elevated after separation in the middle line medial-to-lateral from the larynx and thyroid. The length of the flap will be defined
through variations of the clavicular discontinuation
level. Further preparation was carried out in the caudocranial direction along the carotid artery and the jugular vein including the ansa cervicalis (Figs. 3, 4 ).
The pedicled flap was rotated into the defect region
at the pharynx posterior side. The defect edges on the
pharynx were excised and the graft was sutured in two
layers. Subsequently, the wound was closed and a
drainage inserted. The patient was fed via a nasogastric

Fig. 3 The infrahyoid musculature has a pedicle including the

superior thyroid artery and vein (4) and the superior branch of
the ansa cervicalis [7]

Eur Spine J (2007) 16:501505

503

Fig. 4 Separation of the musculofascia flap and preparation of

the vasculature (4) and the ansa cervicalis nervi hypoglossi (5) [7]

tube for the following 7 days. Healing of the wound

was of primary importance. X-ray examinations 7 days
postoperative showed a proper esophageal passage
(Figs. 5, 6 ).

Results
During the period 1999 to 2003, six male patients were
treated for a pharyngeal fistula, using an infrahyoid flap
as described, following cervical spine surgery. The

Fig. 6 Postoperative CT scan: the cervical plate and screws have

been removed; the pharynx has been reconstructed using an
infrahyoid flap (1); the arrow indicates the missing sternohyoid
muscle (2), used for pharyngeal reconstruction

mean age of the patients was 64.2 (2476) years. The

fistulae existed on an average for 131.8 (15420) days.
A mean of 2.5 (05) operations had been carried out in
order to treat the fistulae. In all cases prior to reoperation a pharyngeal fistula was visible at the level of C4
through C6 by radiological examination. In each case
the cervical plate and screws were removed intraoperatively. The fistula was closed as described. Postoperatively, patients were fed for 7.5 (512) days via a
nasogastric tube. In all of the cases no complications
occurred and the flap healed into place without any
problems. Oral nutrition was started 7.5 (512) days
postoperatively following radiological ruling out of a
fistula. Regular endoscopic examinations showed epithelization of the infrahyoid flap after 46 weeks.
During the follow-up period (15 years), no further
fistulae appeared in these patients (see Table 1).

Discussion

Fig. 5 Postoperative video fluoroscopy (7 days). The pharynx

and esophagus are visualised with no indications of a fistula or
stenosis

Esophageal injuries after osteosynthesis of the cervical

spine are rare or infrequent complications. The frequency of implant penetration into the esophagus is
given as 1 in 500 (0.2%) by Tew and Mayfield [9] and 0
in 100 (0%) by Aebi et al. [1]. The frequency of abscess
formation following an operative revision of a cervical
spine injury was given as 4 in 400 (1%) by Kelly et al.
[4]. Causes for the injuries cited included incorrect
screw length, injuries to the mucosa as a result of

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Table 1 Patient information

Eur Spine J (2007) 16:501505

Name

Age
(years)

Spinal
level

Fistula
duration (days)

Number of
operations

Removal of
nasogastric
tube (days)

Complications

O.L. $
S.I. $
B.F. $
R.J. $
D.M. $
K.R. $

49
57
51
24
67
29

C5C7
C5C6
C5C6
C4C6
C5C6
C5C6

210
15
54
61
420
31

4
0
2
2
5
2

9
6
12
4
7
7

incorrect preparation or implant plates, or postoperative instability [6].

As well as iatrogenic esophageal lesions caused by
sharp surgical instruments during cervical spine surgery, other such injuries may also be caused by mediastinoscopy or endoscopy. On the whole, the
proximal esophagus is particularly vulnerable to injury
as a result of its topographical location near the cervical spine. Traumatic lesions of the cervical esophagus
were described in 2040% of all esophageal injuries.
The cricopharyngeal region (C5C6) is at particularly
high risk because of the attachment of the esophageal
mucosa to the fascia [6].
To reduce mortality, the diagnosis should be confirmed by imaging CT and video fluoroscopy as soon as
possible. Timing and treatment of the perforation depends on how early it is diagnosed. In general, early,
aggressive intervention reduced morbidity and mortality [3]. If the perforation is found immediately, at the
time of initial surgery or procedures, a simple suture
should suffice. If the perforation is detected during the
first hours or days after operation, surgical closure,
careful drainage and thorough irrigation of the area
operated upon should be performed in order to reduce
the risk of a wound infection.
If there is a delay in detecting a perforation, there
will usually be a neck fistula with or without an abscess.
Treatment of abscesses should include the removal and
closure of the fistulous tract, reinforcement using
muscle flaps and placement of drains in the inflamed
area. If the abscess is not accompanied by a fistula,
incision and drainage with continuous suctioning of
saliva from the esophagus is to be performed [6].
Application of an SCM flap is a further surgical
alternative for closing an esophageal fistula [5, 8]. In our
view, the lack of a clearly defined arterial blood supply,
the late oral intake (59.2 days [5]), the limitations of
modelling and consequent risk of stenosis limit the
applicability of this regional flap. Other reconstructive
techniques, e.g., jejunal grafts or esophageal resection
are technically more demanding, requiring a greater
surgical effort and having a higher morbidity [3].

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In 1977 Clairemont was first to describe the preparation of an infrahyoid muscle flap [2]. In 1978
Weerda described a procedure for tracheal reconstruction [11]. Wang et al. (1986) [10] and Remmert
et al. (1994) [7] expanded this procedure to reconstructive procedures for tongue defects. Innervation
of the flap using the ansa cervicalis as described for
reconstructive surgery of the tongue is of less
importance for treatment of pharyngeal defects but
can, however, have a positive effect on the swallowing
ability.
The flap in comparison with other procedures, in
particular the muscle graft from the m. sternocleidomastoideus, offers clearer advantages. The flap, possessing a definite arterial and venous supply, is simple
to prepare via the necessary operative approach to the
defect or the wound, and is of a suitable thickness for
reconstructive defects on posterior esophagus. It is
possible to treat defects with a diameter of up to
4 cm 7 cm. The flap is also suitable for reconstructive
defects following tumor operations.

Conclusion
Injury to the pharynx and upper esophagus requires
rapid operative revision. Various operative procedures
are available for treatment. The infrahyoid muscle flap
presented here is recommended because of its ease of
preparation, its assured arterial and venous supply, and
its good modeling for the treatment of larger defects
(4 cm 7 cm).

References
1. Aebi M, Mohler J, Zach GA, Morscher E (1986) Indication,
surgical technique, and results of 100 surgically-treated
fractures and fracture-dislocations of the cervical spine. Clin
Orthop Relat Res 203:244257
2. Clairmont AA, Conley JJ (1977) Surgical techniquethe
strap muscle flap. J Otolaryngol 6:200202
3. Jones WG 2nd, Ginsberg RJ (1992) Esophageal perforation:
a continuing challenge. Ann Thorac Surg 53:534543

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4. Kelly MF, Spiegel J, Rizzo KA, Zwillenberg D (1991) Delayed pharyngoesophageal perforation: a complication of
anterior spine surgery. Ann Otol Rhinol Laryngol 100:201
205
5. Navarro R, Javahery R, Eismont F, Arnold DJ, Bhatia NN,
Vanni S, Levi AD (2005) The role of the sternocleidomastoid muscle flap form esophageal fistula repair in anterior
cervical spine surgery. Spine 30:E617E622
6. Orlando ER, Caroli E, Ferrante L (2003) Management of
the cervical esophagus and hypopharynx perforations complicating anterior cervical spine surgery. Spine 28:E290E295
7. Remmert S, Majocco A, Sommer K, Ahrens KD, Weerda H
(1994) A new method of tongue reconstruction with neurovascular infrahyoid musclefascia flaps. Laryngorhinootologie 73:198201

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8. Rubin JS (1986) Sternocleidomastoid myoplasty for the repair of chronic cervical esophageal fistulae. Laryngoscope
96:834836
9. Tew JM, Mayfield FH (1976) Complications of surgery of the
anterior cervical spine. Clin Neurosurg 23:424434
10. Wang HS, Shen JW, Ma DB, Wang JD, Tian AL (1986) The
infrahyoid myocutaneous flap for reconstruction after
resection of head and neck cancer. Cancer 57:663668
11. Weerda H (1978) One stage reconstruction of the trachea
with an island flap. Arch Otorhinolaryngol 221:211214

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