Hypopharyngeal perforation caused by intraoperative transesophageal echocardiography

Abstract

Intraoperative transesophageal echocardiography (TEE) is an invaluable tool for cardiac surgical decision-making. TEE is considered reasonably noninvasive and safe, but insertion and manipulation of the TEE probe can lead to complications. Here, we report a patient with aortic stenosis who experienced TEE-associated hypopharyngeal perforation at the pyriform sinus complicated by esophageal trauma, pneumomediastinum and pneumoretroperitoneum. Based on this case, we suggest that rare complications be kept in mind when using TEE intraoperatively.

Esophageal perforation after transesophageal echocardiography: A case report

“…In his review of 35 cases of EP, Sainathan reported that 75% occurred when TEE was performed in the operating room during cardiac surgery. Other case reports of TEE induced EP also occurred in an intraoperative setting [[7], [8], [9], [10], [11]]. The reason for this higher risk during intraoperative TEE may be explained by the prolonged, continuous pressure of the TEE probe to the esophageal mucosa, added to the possible low blood circulation in the esophagus during a cardiac surgery.…”

Oesophageal perforation following transoesophageal echocardiography: A case report on successful conservative management

“…These include Mallory-Weiss tear, oesophageal stenosis, Barrett’s oesophagus, Zenker’s diverticulum, tumour or strictures. Medications which may affect the integrity of oesophageal mucosae such as corticosteroids and bisphosphonates also increases the risk of oesophageal injury [2,7,8]. It is essential to note, however, that most cases of oesophageal perforation occur in patients with perceived low risk and hence, screening for predisposing risk factors may not eliminate the risk of perforation [9].…”

Visually guided TEE probe insertion, making a case based on anatomic variation: A cadaveric study

“…The prevalence of major complications owing to esophageal perforation in transesophageal echocardiography (TEE) is generally low, with a complication rate of <3% and often <1% . Perforation occurs most often in the right piriform sinus, but the reasons behind perforations in TEE are not well understood . Though few in number, almost all of the complications in TEE are related to trauma from blind esophageal intubation.…”

“…While the resistance at other levels can be understood and solved in real time by direct visualization or palpation with the finger of the endoscopist, owing to the proximal location of these levels, the resistance felt at the UES level can neither be visualized nor felt by the “blind” endoscopist. It is at this level where most perforations occur at the piriform sinus . Although rare, esophageal perforation leads to mediastinitis, which carries a reported mortality rate of as high as 60% …”

“…It is at this level where most perforations occur at the piriform sinus. 2 Although rare, esophageal perforation leads to mediastinitis, which carries a reported mortality rate of as high as 60%. 3 The potential variations in UES anatomical relationship with surrounding structures, such as the piriform sinus or larynx, have not been adequately described in the literature.…”