Spontaneous pharyngoesophageal perforations

Abstract

We report a case of spontaneous multiple perforations of pharyngoesophagus presenting with odynophagia and chest pain. Computed tomography identified a deep neck infection with necrotizing mediastinitis, and esophagography showed leakage of contrast from the pharyngeal wall, pyriform sinus, and thoracic esophagus. Empiric antibiotics, adequate debridement, and resection of the ruptured esophagus with reconstruction were required for complete resolution of the patient's symptoms. Although the simultaneous multiple perforations involving pharyngoesophagus are rare, clinicians should not neglect its possible occurrence.

Factors affecting perforation of the esophagus in patients with deep neck infection

“…The presence of mediastinitis was a significant risk factor in both univariate and multivariate analyses for esophageal perforation (Table 2). Previous reports also showed that esophageal perforation and mediastinitis usually occurred together [27,28]. When the mediastinum is severely infected with micro-abscesses and gas formation (Fig.…”

Airway management in a patient with a deep neck abscess and tortuous brachiocephalic artery: Case report and review of the literature

“…Because hemorrhage was not noted when the larynx was expanded, the pharyngeal mucosa could have been injured by the tube. Another possibility is that the mucosa tore spontaneously during the pharyngeal reflex, since spontaneous pharyngeal and esophageal perforation has been reported in patients with a deep neck abscess and descending necrotic mediastinitis [22]. In our patient, the pharyngeal mucosa was probably fragile because the abscess had been present for a relatively long period since an abscess of the left parapharyngeal space was already diagnosed at the previous hospital.…”

Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold

“…Esophageal perforation secondary to vomiting, also known as Boerhaave's, is much more common than pharyngeal perforation and typically occurs in the lower third of the esophagus at an area of natural narrowing [12]. e aryepiglottic fold, which forms the medial border of the pyriform sinus, may have an increased risk of perforation as compared to surrounding oropharyngeal tissue as the pyriform sinus lacks a longitudinal muscular layer, which reinforce the mucosal layers when faced with increased pressures such as with vomiting [12,13]. Oral contrast extravasation should be visible on CT imaging as in this case, and in cases of suspected pharyngeal perforation, CT of the neck and thorax with water soluble contrast is the diagnostic modality of choice [14].…”

“…If esophageal perforation is suspected, a contrast esophagram remains the gold standard study, as it is the most reliable in demonstrating the presence and location of an esophageal perforation [7]. ere are only a handful of other case reports of spontaneous pharyngeal perforation: one in association with necrotizing mediastinitis, odontogenic infection, and others related to forceful vomiting in the context of a "common cold," vaginal delivery, or even sneezing against closed mouth and nostrils [12][13][14][15]. e first of these cases involved a middle-aged male with a history of both alcohol abuse and uncontrolled diabetes mellitus whose symptoms began with forceful vomiting without signs of infection, and only 1 week later developed signs of a deep space neck infection [13].…”

“…ere are only a handful of other case reports of spontaneous pharyngeal perforation: one in association with necrotizing mediastinitis, odontogenic infection, and others related to forceful vomiting in the context of a "common cold," vaginal delivery, or even sneezing against closed mouth and nostrils [12][13][14][15]. e first of these cases involved a middle-aged male with a history of both alcohol abuse and uncontrolled diabetes mellitus whose symptoms began with forceful vomiting without signs of infection, and only 1 week later developed signs of a deep space neck infection [13]. To our knowledge, the case presented here is the second case in the published literature of pharyngitis leading to spontaneous perforation and descending necrotizing mediastinitis.…”