PMC7139174_01
(a) Fibroscopic examination before the first surgery, showing swelling of the
epiglottis and arytenoid region on both sides and pooling of saliva from the
posterior part of the tongue to both sides of the piriform sinus. (b)-(d)
Contrast-enhanced computed tomography (CT) before the first surgery, showing
a low-density area (LDA) that was thought as abscess formation in the caudal
region of the right tonsil, right false vocal cord, epiglottis, and right
arytenoid region ((b) white arrow: LDA in the caudal region of right tonsil,
(c) black arrow: LDA from epiglottis to right arytenoid region, and (d)
white arrowhead: LDA in right false vocal cord). (e) and (f) Direct
laryngoscopy during the first surgery, showing an abscessed epiglottis,
especially in the right side ((e) black arrowhead), and a necrotic region in
the right false vocal cord ((f) asterisk) at the first surgery.
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A flexible direct laryngoscopic examination showed swelling of the epiglottis and arytenoid region on both sides and pooling of saliva from the posterior part of the tongue to both sides of the piriform sinus (Figure 1(a)). Contrast-enhanced computed tomography (CT) revealed a low-density area (LDA) that was thought as abscess formation in the caudal region of the right tonsil, right false vocal cord, epiglottis, and right arytenoid region (Figure 1(b)-(d)). An inferior tracheotomy was performed on the patient, who then underwent an abscess tonsillectomy and drainage of the abscess in the epiglottis and right arytenoid region under direct laryngoscopy (Figure 1(e)). Necrosis of the right false vocal cord was identified during direct laryngoscopy (Figure 1(f)).
(a)-(d) Contrast-enhanced computed tomography (CT) before the second surgery,
showing a low-density area (LDA) that was thought as abscess formation in
the right anterior neck region (white arrow, black arrow, black asterisk,
and white asterisk). (e) Right neck after the second surgery on the fourth
day after admission (white arrowhead: tubes for saline irrigation; black
arrowhead: silicon vacuum drain).
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In CT images, there was an LDA that was thought as abscess formation under the right anterior neck region (Figure 2(a)-(d)). After the second surgery, saline irrigation in the wound was started (Figure 2(e)), and the CRP concentration continued to decrease gradually.
(a)-(c) Contrast-enhanced computed tomography (CT) before the third surgery,
showing a low-density area (LDA) that was thought as abscess formation in
the right anterior neck region ((a) white arrow) and as a necrotic region in
the right false vocal cord ((b) and (c) black arrow). (d) and (e) Direct
laryngoscopy during the third surgery, showing a necrotic region in the
right false vocal cord ((d) white arrowhead), and the perforation was
confirmed by flushing colored water from the neck wound to the right false
vocal cord ((b) black arrowhead). (f) Right neck with the V.A.C. dressing
(white arrow) after the third surgery. (g)-(i) Laryngoscopy gradually
showing the granulated false vocal cord wound (pictures taken on specific
days after admission: (g) 10th day, (h) 30th day, and (i) 210th day).
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On the ninth day after admission, the patient underwent follow-up contrast-enhanced CT again, and the LDA that was in the necrotic region of the right false vocal cord remained in the CT images (Figure 3(a)-(c)). The perforation was confirmed under direct laryngoscopy by flushing colored water from the neck wound to the right false vocal cord (Figure 3(d) and (e)). The V.A.C. dressing was joined to a vacuum pump (Figure 3(f)) to obtain a negative pressure of around 50 mmHg. The dressing was changed every 36-48 h. The wound on the right false vocal cord gradually healed (Figure 3(h)) but had not yet completely epithelized by the end of 1 year after the discharge (Figure 3(i)), which is why outpatient follow-ups were still continuing.