819 - Complications of Laryngeal Cancer Treatment: How Esophageal Stricture led to Cervical Fusion

Esophageal Fistula and Vertebral Osteomyelitis Presenting as Neck Pain

Case Description:



A 69-year-old male presented with chronic worsening neck pain. His medical history included recurrent squamous carcinoma of the right true vocal cord, status post chemoradiation and laryngectomy. As a late effect, he developed esophageal stricture, requiring repeat dilations. Neck pain began shortly after one such esophageal dilation, with an MRI showing isolated retropharyngeal fluid collection. He completed a course of antibiotics, and while his neck pain improved initially, it progressively worsened after finishing the treatment. A follow-up MRI revealed progression to C4-6 discitis/osteomyelitis with a fistula to the nasopharynx. He was treated with vancomycin, ertapenem, and fluconazole. ENT performed fistula repair and esophageal reconstruction, debriding a large area of necrosis found intraoperatively. His symptoms improved post-surgery, but he was later admitted emergently when cervical X-rays revealed new kyphosis, raising concerns about cervical instability from chronic osteomyelitis. He underwent C2-T2 posterior fusion and has since recovered well, continuing long-term antibiotics.








 

Discussions:

Patients with head and neck cancer often require multimodal treatment, which is associated with a high rate of neuro-musculoskeletal complications. These may include chronic neck pain, cervical dystonia, chronic shoulder pain, dropped head syndrome, trismus, dysphagia, and esophageal strictures. Esophageal strictures typically occur more than 30 days after radiation and often require repeated dilation to maintain patency. Up to one-third of strictures recur after initial dilation. While claims data show that the overall complication rate of esophageal dilation is low (0.215%), both complications (10.6%) and esophageal rupture (5.4%) are significantly more common in head and neck cancer survivors.

Conclusions:

Head and neck cancer survivors are at higher risk of esophageal complications and neck pain. Although rare clinicians remain vigilant for less typical presentations of neck pain and potential for esophageal complications including fistulas which is this case lead to osteomyelitis.