Perforation of the esophagus most commonly occurs after instrumentation and usually involves the thoracic esophagus (90%). Spontaneous esophageal perforation is much less common (11–15%). Etiology involves an increase in intraluminal pressure against a closed glottis occurring with retching or vomiting.
A 57 year-old non-smoker African-American female presented with a chief complaint of sore throat and a neck mass for one week prior to admission. She did not have any recent esophageal instrumentation and denied recent vomiting or retching episodes. Past medical history included only hypertension. The pain was right-sided, sharp, constant and worsened with cough. The patient had received and completed a course of antibiotics (second-generation cephalosporin) without relief. On admission, she was hypoxic with oxygen saturation of 87% on ambient air. Pertinent exam findings include good dentition, a firm, tender, nonerythematous submandibular mass and decreased breath sounds over the right chest with dullness to percussion. Leukocyte count was 7.6 with 69% bandemia. Chest X-ray showed hydropneumothorax encompassing the right hemithorax. Thoracentesis was performed which revealed turbid, purulent fluid. The cell count was 138,000 with 96% neutrophils. The pH was 7.9, LDH was 5764 U/L, triglycerides 50 mg/dL, protein 1.1 g/dL and the amylase was 52 U/L. Computed tomography scan of the neck and chest revealed air in the pharynx as well as the mediastinum. Gastrograffin study confirmed cervical esophageal perforation. The patient was emergently taken to the operating room. Right neck exploration, drainage of abscess, right thoracotomy and decortication were performed. Gastrostomy tube was placed without repair of esophageal tear. The patient made a slow recovery and repeat gastrograffin study three weeks after admission showed resolution of the perforation. The final culture from the pleural fluid grew Klebsiella pneumoniae.
Thoracic esophageal perforation is much more common than cervical esophageal perforation. The site of perforation usually occurs at an area of natural narrowing such as at the level of the aorta or the gastroesophageal junction. The piriform fossa is also vulnerable as there is no reinforcing longitudinal muscle layer. The classic triad of symptoms associated with spontaneous esophageal perforation includes vomiting, chest pain and subcutaneous or mediastinal air, but is present in only 50% of cases. Chest pain is the most common symptom and is usually localized to the site of perforation. There is an increase in morbidity and mortality as time to diagnosis increases, especially 24 hours after inciting event. Imaging can be useful in diagnosis but may not be definitive. Mediastinal emphysema is very suggestive of the diagnosis, but is seen in only 40% of patients. Rupture of the mediastinal pleura causes a pneumothorax in up to 77% of patients. In two-thirds of patients, the perforation is on the left side, in one-fifth on the right side and in one-tenth it is bilateral. Contrast esophagram, preferably with a water-soluble medium such as gastrograffin, carries approximately a 90% sensitivity rate in detecting extravasation. The diagnosis of esophageal perforation should always be considered with an exudative pleural effusion. Pleural effusion is relatively uncommon in cervical esophageal perforation, occurring in 10% of patients, while it can occur in up to 50% of patients with thoracic esophageal peforation. Typically, the pH is very low while the amylase is elevated.
We present a case of cervical esophageal perforation without a clear inciting event. The patient presented with a neck mass, but was also hypoxic. Pleural fluid analysis and imaging were keys to making the diagnosis in this case.
Sumita Sinha, No Financial Disclosure Information; No Product/Research Disclosure Information