Title : Severe pharyngo-cervical infection and persistent oropharyngeal–cervical fistula following needle aspiration in a previously irradiated clival chordoma: A case report
Abstract:
Objectives: Deep neck infections in previously irradiated tissues are rare but potentially devastating complications. Impaired vascularity, radiation-induced necrosis, and mucosal fragility predispose these patients to severe infections even after minor mucosal interventions. We present a case of a pharyngo-cervical infection with formation of a persistent oropharyngeal–cervical fistula following needle aspiration in a patient with a history of high-dose local radiotherapy for clival chordoma.
Methods: A 40-year-old woman, previously treated for clival chordoma with subtotal resection and proton beam radiotherapy (2008), and for C1–C2 recurrence with CyberKnife radiotherapy (2015), underwent needle aspiration of the upper oropharyngeal mucosa in December 2021. Soon after, she developed severe cervical infection involving the oropharynx, parapharyngeal, and upper cervical spaces. Imaging revealed a pathological fracture of the anterior arch of C1 and the formation of a fistulous tract between the oropharyngeal cavity and the C1–C2 vertebral region, consistent with osteoradionecrosis complicated by deep infection. In April 2022, an occipitocervical fusion was performed to stabilize the pathological fracture. Intraoperative cultures yielded Serratia odorifera and Klebsiella pneumoniae as the causative pathogens. The patient was treated successfully with targeted intravenous antibiotics — Meropenem (Meronem) and Daptomycin (Cubicin) — achieving control of systemic infection and normalization of inflammatory markers. Despite infection control, the oropharyngeal–cervical fistula persisted.
Results: At the latest follow-up in October 2025, the patient remained neurologically intact and functionally independent. A CT scan demonstrated a large communication between the oropharyngeal cavity and the pre- and paraspinal spaces on the left, extending beyond the midline at the C2 level, with an enlarged communication channel compared to imaging two years earlier. A multidisciplinary team (Infectious Diseases, Plastic Surgery, and Neurosurgery) proposed surgical closure of the defect using a vascularized free flap. However, the patient declined due to concerns about surgical morbidity. She continues under close clinical and laboratory surveillance with intermittent antibiotic therapy. PET-CT showed no evidence of tumor recurrence.
Conclusion: This case highlights the profound vulnerability of irradiated cervical tissues to infection after minor iatrogenic injury. The combination of mucosal breach, osteoradionecrosis, and deep contamination can lead to persistent fistula formation between the oropharynx and the cervical spine. Management is complicated by poor tissue vascularity and proximity to critical neurovascular structures. Targeted antimicrobial therapy and multidisciplinary coordination are essential to achieve infection control and prevent catastrophic sequelae.
