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Nehme-Paz, Nieves Rodríguez-Acevedo, Ismael Arán-González" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Tamara" "apellidos" => "González-Paz" "email" => array:2 [ 0 => "tamaragp1986@hotmail.es" 1 => "tamara.gonzalez.paz@sergas.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Abdul R." "apellidos" => "Nehme-Paz" ] 2 => array:2 [ "nombre" => "Nieves" "apellidos" => "Rodríguez-Acevedo" ] 3 => array:2 [ "nombre" => "Ismael" "apellidos" => "Arán-González" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Otorrinolaringología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Espondilodiscitis cervical secundaria a inserción de prótesis fonatoria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2230 "Ancho" => 1583 "Tamanyo" => 240980 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Pre-treatment CT scan showing increased prevertebral soft tissues anterior to C5–C7 with collections of fluid at this level (white arrow). (B) Diagnostic NMR showing both vertebral oedema and destruction, such as compressive myelopathy at level C6–C7.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical Case</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 46-year-old male patient with a history of total laryngectomy for glottic cancer underwent placement of a Provox<span class="elsevierStyleSup">®</span> Vega™ Voice Prosthesis 22.5 FR, 8<span class="elsevierStyleHsp" style=""></span>mm, using the secondary tracheoesophageal puncture technique. One week later he attended the emergency department with a fever of 39.7<span class="elsevierStyleHsp" style=""></span>°C despite antibiotic treatment with amoxycillin/clavulanic acid 875<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h and clindamycin 300<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h, associated with neck pain and dysphagia. Examination revealed the intramural prosthesis surrounded by small granuloma on its left side, with no signs of infection; it was changed and sent for microbiological study. Blood cultures were also taken.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After 10 further days with the same antibiotic treatment associated with antipyretics, we assessed the regimen again at the clinic one month after surgery. At that time the patient had no fever, but his dysphagia with solid foods continued, associated with bilateral cervicobrachialgia. Examination showed selective pain on palpation of both trapezius muscles and on lateral movement of the trunk, radiating to the upper limbs, strength, and sensitivity were preserved.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A cervical radiograph was taken showing mass effect between C4 and C7, it was not possible to define an inflammatory process or tumour recurrence.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given these results, it was decided to admit the patient and perform a CT scan which showed spondylodiscitis C6–C7, with partial destruction of the anterior aspect of both vertebral bodies and tissue imprint with soft tissue density inside the spinal canal, and an increase in soft tissues in the prevertebral space and hypopharynx, suggestive of inflammation/infection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The results from the microbiology department showed a positive blood culture, and that the prosthesis was colonised by <span class="elsevierStyleItalic">methicillin resistant staphylococcus aureus</span> (MRSA). Therefore treatment was started with vancomycin 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h associated with meropenem 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h, in line with the antibiogram.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cervical NMR imaging confirmed the spondylodiscitis shown on the CT scan, the posterior wall of C6 was slightly displaced towards the canal with stenosis/compression of the canal, and there was altered signal in the spinal cord. There appeared to be compressive myelopathy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, an assessment was requested by the neurosurgery department and the department of internal medicine which indicated treatment with ceftazidime 2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h and linezolid 600<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h intravenously for 11 days, and a Philadelphia type rigid collar. The departments requested analysis which showed normal levels of leukocytes, indeterminate CRP (0.93<span class="elsevierStyleHsp" style=""></span>mg/dl) and elevated ESR (45<span class="elsevierStyleHsp" style=""></span>mm/h); with normal EMG. The patient was discharged with linezolid 600<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and rifampin 600<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h, to be taken orally for a month and a half.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The follow-up CT scan, performed one month after treatment, showed significant improvement and the lesion almost resolved (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). By contrast, the NMR continued to show the intervertebral image, but with less enhancement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Analyses showed normal CRP (0.1<span class="elsevierStyleHsp" style=""></span>mg/dl) and ESR (7<span class="elsevierStyleHsp" style=""></span>mm/h) levels.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient is currently asymptomatic; X-rays show an almost complete cure of his spondylodiscitis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Complications after placement of a phonatory prosthesis are common, and include leakage or fungal colonisation. Other more serious complications include paraoesophageal abscesses, cellulitis, bronchial aspiration of the prosthesis, cervical osteomyelitis and spondylodiscitis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Spondylodiscitis is an inflammatory process which initially affects the intervertebral disc and then extends to the vertebral bodies, occasionally affecting the surrounding soft tissues, due to haematogenous spread. In recent years, the incidence of discitis has increased due to the greater number of immunosuppressed, elderly, and iatrogenic patients, and anaesthetic or surgical practices on the spinal column in particular.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In a study performed by Hopkinson et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> it was demonstrated that the principal clinical symptoms were vertebral pain in 91% of patients and fever in 68%. In 58% of cases a diagnosis is reached between 2 weeks and 6 months from the onset of symptoms. The onset is occasionally insidious.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The most common location is lumbar (60%), followed by dorsal (26%–34%), a cervical location is rare (10%–13%).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> This location should be suspected if there is cervical pain with inflammatory characteristics and test results that are suggestive of infection.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Ninety-five percent of spondylodiscitis are monomicrobial. Gram-positive predominate (69.3%), followed by Gram-negative (21.5%) and fungal, especially in immunosuppressed patients (9.2%). The causative germ in 43.1% of cases is <span class="elsevierStyleItalic">Staphylococus aureus</span>, MRSA<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> in 12.3%.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Early diagnosis is based on thorough anamnesis, appropriate clinical examination, and imaging tests. NMR is the radiological method of choice for diagnosing this condition because it is highly sensitive.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Treatment is generally conservative using a rigid collar and associating prolonged broad spectrum antibiotherapy, generally cloxacillin associated with a third-generation cephalosporin. Specific antibiotherapy is started when the causative agent is isolated. It is appropriate to use high intravenous doses in the first 2 weeks, then orally until 3 months’ treatment has been completed.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">There are only 2 similar cases documented in the references.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,10</span></a> In both cases, the theories postulated were dehiscence of the posterior pharyngeal wall after placement of a rigid oesophagoscope, accidental puncture of the posterior oesophageal wall and chronic decubitus of a prosthesis of a larger length than necessary. In our case it was probably due to accidental puncture of the posterior oesophageal wall at the time of the puncture.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion, persistent neck pain after the insertion of a phonatory prosthesis by puncture should alert us to spondylodiscitis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of Interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-02" "fechaAceptado" => "2015-07-21" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Paz T, Nehme-Paz AR, Rodríguez-Acevedo N, Arán-González I. Espondilodiscitis cervical secundaria a inserción de prótesis fonatoria. Acta Otorrinolaringol Esp. 2016;67:239–241.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2230 "Ancho" => 1583 "Tamanyo" => 240980 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Pre-treatment CT scan showing increased prevertebral soft tissues anterior to C5–C7 with collections of fluid at this level (white arrow). (B) Diagnostic NMR showing both vertebral oedema and destruction, such as compressive myelopathy at level C6–C7.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2382 "Ancho" => 1583 "Tamanyo" => 221268 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Post-treatment CT showing a significant decrease of the soft tissue lesion and the disappearance of the fluid levels. (B) Post-treatment NMR where the C6–C7 vertebral destruction is unaltered, but showing compressive myelopathy and ependymal ectasia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cervical spondylodiscitis: a rare complication after phonatory prosthesis insertion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Bolzoni" 1 => "G. Peretti" 2 => "C. Piazza" 3 => "D. Farina" 4 => "P. 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Journal Information
Vol. 67. Issue 4.
Pages 239-241 (July - August 2016)
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Vol. 67. Issue 4.
Pages 239-241 (July - August 2016)
Case study
Cervical Spondylodiscitis Secondary to Insertion of Voice Prosthesis
Espondilodiscitis cervical secundaria a inserción de prótesis fonatoria
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Tamara González-Paz
, Abdul R. Nehme-Paz, Nieves Rodríguez-Acevedo, Ismael Arán-González
Corresponding author
Servicio de Otorrinolaringología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
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