Perforation of right piriform sinus
2 week history of necrotic wound over right side of neck on background of recent surgery and radiotherapy for piriform sinus SCC
Neck and chest
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CT neck and chest shows extensive subcutaneous emphysema tracking down neck predominantly on the right side.
Gas is seen tracking through right carotid space, right parapharyngeal space and right masticator space. The gas ascends along the carotid space through jugular foramen to enter the right jugular bulb, marking its superior extent.The gas descends along the visceral space to the supraclavicular region and jugular notch inferiorly. No extension in retrophrayngeal, epidural or mediastinal spaces.
The collection on the right side of the neck tracks from superficial cervical fascia through to deep cervical fascia into the visceral space. The collection is causing some mass effect and compression of hypophraynx. The thickening and submucosal edema in the region of right piriform sinus with small collection adjacent to apex raises the possibility of local perforation.
The right internal jugular vein is obliterated by gas.
Wound swabs grew Klebsiella pneumoniae and mixed alpha hemolytic streptococci. The patient's cervical abscess was managed by intravenous antibiotics, surgical debridement and a pectoralis major flap.