antibiotics, and nothing by mouth. Repeat imaging was performed 10 days after initial CT which revealed interval resolution of pneumomediastinum. Patient was started on clear liquids and diet was advanced thereafter. Case 2: 20-year-old male presented to emergency department (ED) with intractable nausea and vomiting after cocaine inhalation. Patient subsequently developed substernal chest pain with shortness of breath. Physical examination was notable for subcutaneous emphysema in the neck, shoulders, and back. Emergent CT revealed extensive pneumomediastinum with extension of air into the chest, back, and neck (Figure B). Gastrograffin esophagram revealed extravasation of contrast at GE junction. The patient underwent primary closure of esophageal perforation. The patient was monitored closely on the inpatient service until his symptoms improved and he was discharged on hospital day 14. Discussion: The optimal management of esophageal perforation remains debatable, particularly for small well-contained perforations. With advances in minimally invasive techniques, the need for surgical exploration appears to be diminishing. Neither patient in this case series suffered from underlying esophageal disease. Both patients had an injury to the distal esophagus that was addressed within 24 hours of presentation; however, one patient was managed conservatively whereas the other patient was managed surgically. While the outcome for both cases was favorable, the morbidity involved with surgical intervention was higher. Perhaps, a minimally invasive approach should be considered in all non-emergent cases prior to surgical intervention in an effort to further decrease morbidity.[2287] Figure 1. A. CT thorax revealing free air around distal esophagus (see yellow arrow) B. CT thorax demonstrating extensive air throughout the mediastinum, extending into the pericardial sac and soft tissues of chest.

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