Ann Otol Rhinol LaryngollOl:1992

CONSERVATIVE MEDICAL MANAGEMENT OF TRAUMATIC

PHARYNGOESOPHAGEAL PERFORATIONS

SANFORD R. DOLGIN, MD THOMAS W. WYKOFF, MD

NARENDRA R. KUMAR, MD ANTHONY J. MANIGLIA, MD
CLEVELAND, Omo

Traditionally, surgical treatment has been the acceptable management for perforation of the pharyngoesophageal tract secondary
to blunt and penetrating trauma. From July 1983 to June 1990, we managed 10 patients with this type of lesion by a conservative medical
management approach. Mirror or fiberoptic flexible laryngoscopy was performed in the majority of cases to ascertain the nature of the
injury. An esophagogram is very helpful to locate and evaluate the extent of the injury. All patients were treated with broad-spectrum
intravenous antibiotic therapy and no oral feeding. There were no complications or need for surgical treatment in any of the cases. The
head and neck surgeon, in selected cases, should consider the possibility of using conservative management of pharyngoesophageal
perforations. This approach has proven in our hands to be relatively safe and cost-effective, resulting in no disability or prolonged
hospitalization of our patients. This study involves two institutions (two affiliated hospitals of Case Western Reserve University School
of Medicine) with different surgeons selecting appropriate antibiotic therapy. It is a retrospective review. No controls were made by
random selection of cases treated surgically. These cases, if not properly managed, may lead to fatal outcomes.
KEY WORDS - antibiotic therapy, conservative management, pharyngoesophageal perforation.

INTRODUCTION Signs and symptoms that are indicative of pharyngo-

The choice of management of pharyngoesopha-
geal perforations has been controversial. Tradition-
ally, surgical closure has been the preferred approach
since the late 1940s.l- 5 However, in the past 30 years,
there have been numerous series advocating conser-
vative medical management. 1-12 This approach relies
heavily on early diagnosis and a high index of suspi-
cion, institution of broad-spectrum intravenous anti-
biotic therapy, and no oral feedings. The most com-
mon cause of these injuries is iatrogenic, ie, instru-
mentation.vb!' Esophagoscopy for diagnostic and
therapeutic management has an incidence of perfora-
tion of 0.1 % to 1% with rigid instrumentation and
0.01 % with a flexible esophagoscope.! Bleeding and
technical difficulty associated with the procedure
should alert the operator to an increased possibility of
injury.l-l? The most common site for these perfora-
tions is the cricopharyngeal region. I 1,13 Trauma sec-
ondary to endotracheal intubation is not a common
occurrence and is usually due to a very difficult
intubation or to the inexperience of the individual
placing the tube, an emergent setting, or the use of a
stylet with the procedure. 5, ll ,13,14 There are also re-
ports of injury to neonates in intensive care units
attributed to the use of rigid suction catheters, nasogas-
tric and endotracheal tube placement, and digital trau-
ma by the physician during resuscitative efforts. 15-17
Spontaneous rupture, foreign bodies, and blunt trau-
ma are other noted causes.4,5,l1
From the Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Presented at the meeting of the American Broncho-Esophagological Association, Waikoloa, Hawaii, May 5-6,1991.
REPRINTS - Anthony J. Maniglia, MD, Dept of Otolaryngology-Head and Neck Surgery, 2074 Abington Rd, Cleveland, OH 44106.
esophageal injury are subcutaneous emphysema, pain,
dysphagia, and sepsis. 1,12 In higherinjuries, dysphagia,
cervical pain, and subcutaneous emphysema occur
commonly. With lower esophageal injuries, retroster-
nal and midthoracic pain, abdominal rigidity, and
splinting of respiration can occur. 10,12 Radiographic
(x-ray) studies usually confirm the above findings
and additionally reveal the presence of pneumomedi-
astinum and pneumothorax, and an esophagogram
reveals the location of the injury by leakage of the
contrast medium in the majority of cases. I ,5,8
The patient should be followed up closely in a
monitored setting once treatment is initiated. If the
status of the patient deteriorates secondary to cervical
or mediastinal abscess, then surgical drainage should
be performed without delay.i-'?
MATERIALS AND METHODS
A retrospective review from July 1983 to June
1990 at three institutions revealed a total of 10 pa-
tients sustaining traumatic pharyngoesophageal per-
foration that was managed conservatively (see Table).
Conservative management of these patients included
nothing by mouth, intravenous fluids and antibiotics,
and nasogastric decompression with subsequent feed-
ing if a nasogastric tube could be safely passed. There
were no mortalities among this group and no failures
of conservative management requiring surgical inter-
vention.

209

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210 Dolgin et al, Pharyngoesophageal Perforations

PHARYNGOESOPHAGEAL PERFORATIONS
Time to Time
Treatment Until
From Intravenous Oral
Case Age Sex Cause Location Injury Antibiotics Used Feeding
26y M Assault Oropharynx and <12 h Ampicillin, clindamycin, lOd
hypopharynx gentamicin
2 21 Y F Iatrogenic Not found 12-24 h Trimethoprim- 3d
sulfamethoxazole,
metronidazole
3 79 Y M Iatrogenic Not found <12h Cefazolin lOd
4 45 Y M Iatrogenic Hypopharynx <12h Netilmicin, clindamycin 5d
5 57 Y M Trauma Oropharynx and 12-24 h Cefazolin, metronidazole IOd
hypopharynx
6 39 Y M Trauma Hypopharynx 12-24 h Cefazolin, metronidazole 8d
7 45 Y M Iatrogenic Hypopharynx <12 h Cefazolin 5d
8 92y M Iatrogenic Esophagus <12 h Cefazolin, metronidazole, Received
gentamicin gastros-
tomy
9 73 Y F Iatrogenic Hypopharynx <12h Cephalothin, pencillin G 1d
10 18 d F Assault Oropharynx and >24h Penicillin, gentamicin 8d
hypopharynx

The ages at the time of diagnosis ranged from 18
days to 92 years, with a mean age of 48 years. There
were seven males and three females; six were white
and four black.
The time period from injury to diagnosis ranged
from immediate to several days, with the majority of
diagnoses within several hours. There were seven
patients with diagnoses within 12 hours, two patients
between 12 and 24 hours, and one, a neonate, several
days after the trauma had occurred at home secondary
to child abuse.
The cause of the injuries was believed to be related
to assault or trauma in four patients and iatrogenic in
six patients. The injury was located in the oropharynx
or hypopharynx in seven patients, and in the lower
esophagus in one patient. There were two patients in
whom the site ofinjury could not be precisely located
on physical or radiographic examination.
The most common presenting symptom at diagno-
sis was subcutaneous emphysema, which was present
in all of the patients. Radiographic studies revealed
pneumomediastinum in four of nine patients (44%)
and pneumothorax in one of nine (11%). Gastrografin
or barium swallow studies demonstrated a leak in
three of four (75%) patients.
was subcutaneous emphysema of the neck without
hoarseness or airway distress. Indirect laryngoscopy
showed edema and a laceration of the right lateral
oropharynx. There was no evidence of laryngeal
trauma. Plain x-ray films showed subcutaneous em-
physema in the neck and a pneumomediastinum. A
Gastrografin esophagogram and a computed tomog-
raphy scan demonstrated cervical subcutaneous em-
physema and a leak at the level of the left pyriform
sinus. The patient was treated with intravenous ampi-
cillin' gentamicin, and clindamycin for 7 days. Naso-
gastric feeding was discontinued and he was begun
on oral feedings on the 10th day. His overall recovery
was uneventful.
Case 2. A 21-year-old woman underwent an un-
eventful tonsillectomy under general anesthesia. The
endotracheal intubation was reportedly atraumatic.
On the first postoperative morning, she was found to
have minimal subcutaneous emphysema of the neck
at the region of the right angle of the mandible.
Indirectlaryngoscopy revealed normal findings. Plain
x-ray films confirmed the presence of subcutaneous
air. The patient was given nothing by mouth and
received intravenous trimethoprim-sulfamethoxazole
and metronidazole. She was discharged on the third
postoperative day with a prescription for oral Bactrim.

CASE REPORTS Case 3. A 79-year-old man underwent surgery for

The following cases illustrate the methods of con-
servative management used.
Case 1. A 26-year-old man was admitted to the
hospital after an alleged assault in which he was
punched in the face and neck. On examination there
an abdominal aortic aneurysm. On the second postop-
erative day, he was resuscitated following a cardiopul-
monary arrest with difficult orotracheal intubation.
He developed severe subcutaneous emphysema of
the neck and a right-sided pneumothorax requiring a
chest tube. He was extubated after 10 days ofintrave-

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 Dolgin et al, Pharyngoesophageal Perforations
nous cefazolin therapy. The subcutaneous emphyse-
ma resolved and he was allowed clear liquids follow-
ing extubation. He was discharged in stable condi-
tion.
Case 4. A 45-year-old man was admitted to the
hospital with a 3-day history of emesis. He was a
known diabetic and had alcoholic liver disease. He
denied any complaints of fever, neck pain, hoarse-
ness, dysphagia, or odynophagia at the time of admis-
sion. Following a difficult nasogastric tube place-
ment, he was found to have subcutaneous emphyse-
ma of the neck. Indirect laryngoscopy showed edema
and blood in the left pyriform sinus. Plain x-ray films
confirmed the presence of subcutaneous emphysema
of the neck with minimal pneumomediastinum. A
Gastrografin study showed no evidence of a leak. The
patient was given nothing by mouth and was treated
with intravenous netilmicin and clindamycin. On the
fifth day, his medication was changed to oral penicil-
lin and he was given a clear liquid diet. He recovered
without complications.
Case 5. A 57-year-old man was admitted to the
hospital following a motor vehicle accident. He was
unresponsive when first examined in the emergency
room and was intubated with difficulty. His neuro-
logic status subsequently improved and he was ex-
tubated after a few hours. On the following day, he
was noticed to have subcutaneous emphysema of the
left side of the neck and upper chest that was con-
firmed by plain x-ray films. Indirect laryngoscopy
showed trauma to the posterior pharyngeal wall. He
was given nothing by mouth for 2 days and received
intravenous cefazolin and metronidazole. Clear liq-
uids were started on the third day and antibiotics were
discontinued after 1 week. He was discharged on the
10th day in good condition.
Case 6. A 39-year-old man was admitted to the
hospital after sustaining fractures to the hip and ankle
in a motor vehicle accident. Consultation was re-
quested on the following day to evaluate the patient
because of subcutaneous emphysema in his neck.
The patient complained of neck and throat pain. He
denied any hoarseness or respiratory difficulty. On
examination, he had extensive subcutaneous emphy-
sema of the neck, mainly on the left side, with
extension down to the inguinal region. Indirect laryn-
goscopy revealed an injury to the posterior hypo-
pharyngeal wall adjacent to the left pyriform sinus.
Chest x-ray films did not show evidence of pneumo-
thorax or pneumomediastinum, but did reveal exten-
sive subcutaneous emphysema in the chest wall.
Lateral neck x-ray films demonstrated air in the
prevertebral column. The patient was treated with
intravenous cefazolin and metronidazole for 1 week.
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211
A clear liquid diet was begun on the eighth hospital
day. His subcutaneous emphysema slowly resolved
and the hypopharyngeal injury healed without com-
plications.
Case 7. A 45-year-old man underwent a difficult
intubation for a planned direct micro laryngoscopy
and excision of a vocal cord nodule. Postoperatively,
the patient developed neck pain. Physical examina-
tion and neck x-ray films revealed subcutaneous
emphysema. A Gastrografin swallow study revealed
a right pyriform fossa leak. The patient was treated
with intravenous cephalothin for 5 days with nothing
by mouth, and his recovery was uneventful.
Case 8. A 92-year-old man with a 5-year history of
episodes of esophageal spasm was admitted with a 5-
day history of dysphagia, odynophagia, and inability
to tolerate oral intake. He underwent flexible esoph-
agoscopy by the gastrointestinal service that revealed
a food bolus impaction in the lower esophagus. The
service tried to remove it, but was unsuccessful.
Rigid esophagoscopy to remove the foreign body and
biopsy to evaluate for peptic stricture, tumor, or
achalasia was performed by the otolaryngology ser-
vice on the following morning and the bolus was
encountered at 31 to 34 em in the esophagus. The
esophagoscope could not be passed beyond this point
and biopsy specimens were taken at 31 and 33 em.
There were no discrete lesions appreciated. The pa-
tient tolerated the procedure well, but became febrile
(39.0°C) and tachycardic 4 hours later. He com-
plained of middle back pain and was tachypneic.
Auscultation revealed left-sided rhonchi and rales. A
chest x-ray film revealed subcutaneous emphysema
and a pneumomediastinum. He had been receiving
nothing by mouth postoperatively. He was given
intravenous cefazolin, metronidazole, and gentamicin
and was transferred to the intensive care unit for
monitoring. A nasogastric tube was not placed and
intravenous hyperalimentation was begun.
A barium swallow study immediately following a
negative Gastrografin swallow study was performed
on the third postoperative day and showed a moder-
ate-size leak (Fig 1). Because of the patient's age and
medical history, it was decided not to surgically
repair the perforation. He recovered over a 3-week
period and was discharged in stable condition with a
gastrostomy for esophageal stricture. A follow-up
esophagogram confirmed healing of the perforation
prior to discharge.
Case 9. A 73-year-old woman underwent 7 to 10
unsuccessful attempts at endotracheal intubation for
a planned lumbar laminectomy. The patient devel-
oped immediate subcutaneous emphysema in the
212 Dolgin et al, Pharyngoesophageal Perforations

Fig 1. (Case 8) A) Chest x-ray (anteroposterior view; portable technique) showing pneumomediastinum (arrows). B) Barium
swallow study revealing extravasation of contrast medium (arrows) from moderate-size, lower esophageal perforation.

neck that was greatest on the left side. Tooth 7 was
fractured. The operation was canceled and the patient
was observed postoperatively. She was placed on a
regimen of intravenous cephalothin and penicillin G
and remained afebrile. Fiberoptic laryngoscopy re-
vealed left lateral and posterior pharyngeal wall
ecchymoses. The larynx was normal. The patient
tolerated a clear liquid diet begun on the following
morning. Her subcutaneous emphysema was resolv-
ing. She was discharged in stable condition on the
second hospital day on a l O-day course of Augmentin.
Case 10. An 18-day-old girl was admitted to the
hospital for dark hematemesis that had begun that
morning. Her medical history included normal gesta-
tional age with a breech delivery requiring a cesarean
section. The patient was afebrile with clear, bubbling
saliva in her mouth. Findings on oral, neck, and lung
examinations were unremarkable; however, a chest
x-ray film revealed pneumomediastinum and a lat-
eral neck film showed free air in the lateral neck and
pharyngeal soft tissues (Fig 2). A complete blood
count exhibited only a moderate neutrophilia. Otolar-
yngology consultation was requested to evaluate the
patient for a congenital branchial malformation, tra-
cheoesophageal fistula, or injury secondary to child
abuse.
The patient underwent rigid laryngoscopy and
esophagoscopy. Superficial ulceration with eschar of
the hard and soft palate and left tonsillar area was
seen and appeared to indicate an injury several days
old. It was not consistent with an injury that might
have occurred at resuscitation at the time of delivery

Fig 2. (Case 10) A) Soft tissue neck x-ray (lateral projection) showing free air in pharyngeal soft tissues (arrow). B) Chest x-ray
(anteroposterior view; portable technique) revealing pneumomediastinum (arrow).

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 Dolgin et al, Pharyngoesophageal Perforations 213

18 days earlier. A 1.5-cm laceration of the posterior perforations occurred in the lower esophagus and 6
pharyngeal wall extended down to the prevertebral patients had an associated malignancy within the site,
fascia. Esophagoscopy showed slight edema and a I- of which 5 healed with conservative management.
to 2-mm area of ulceration of the right posterolateral Lyons et a16 reported 9 cases of lower esophageal
esophagus just above the gastroesophageal junction. perforation treated successfully in a conservative
fashion, of which 4 patients presented late to the
The patient was given intravenous penicillin and
hospital in a toxic state with mediastinitis and were
gentamicin and a nasogastric tube was placed. A
"too sick" to withstand surgery. Wesdorp et a1 4 re-
follow-up chest x-ray film showed no increase in air
viewed 54 cases of instrumental esophageal perfora-
on the following day. A clear liquid diet was begun on
tion treated conservatively, and their findings and
day 8. The antibiotics were converted to oral Augmen-
recommendations were similar. They recorded a mor-
tin on day 10. She was discharged home in stable
tality rate of 0% (0 of 19 patients) in perforations
condition on day 11 with visitation by the protective
without associated malignancy and 8.6% (3 of 35
service after initial investigations for child abuse
patients) in those with malignancy.
were negative. However, a bone scan performed on
an outpatient basis 3 days after discharge was posi- Blunt trauma can result from acceleration-decel-
tive for healing rib fractures that were subtle and eration injuries from motor vehicle accidents, blows
initially missed on chest x-ray films, confirming the to the neck, and strangulation injuries. A perforation
suspicion of child abuse. This patient has had no of the pharyngoesophagus can result from blunt trauma
hearing loss or other complication secondary to treat- to the neck when the laryngeal cartilages are com-
ment. press~d against the vertebral bodies. Hypertrophic,
antenor osteophytes of the cervical vertebrae have
No ?atients developed abscess formation or high
bee~ reported to cause perforation, as has hyperex-
elevation of temperature, other than the patient in
tension of the cervical spine with rupture of the
case 8, probably because of early diagnosis and
pharyngoesophagus.lv-!
adequate treatment.
Subcutaneous emphysema, pneumomediastinum,
DISCUSSION and pneumothorax are common manifestations of
blunt and penetrating injuries to the neck and chest. 2,S
Injury to the upper aerodigestive tract can occur
If crepitus is present following trauma, one must
~r?m pene!ratin~ or blunt trauma.4-6,S,1O Iatrogenic
assume there is a tear in the aerodigestive tract. Chest
~nJury to t~IS region is not uncommon after endoscop-
and soft tissue x-ray films of the neck should be
IC evaluation and following difficult endotracheal
obtained to detect subcutaneous and intrathoracic air.
and nasogastric intubation.U'P Most reported series
Cervical and mediastinal emphysema can be seen
of pharyngoesophageal perforations involve evalua-
radiographically in 95% of patients with cervical
tion of the injuries at different levels and are second-
esophageal injuries.'? Pneumomediastinum can be
~ to variou~ mecbanisms.j-" An injury secondary to
missed in about half of cases if only anteroposterior
instrumentation has a more favorable prognosis, be-
chest films are obtained. With the addition of a lateral
cause of the likelihood of earlier diagnosis and a
view, nearly 100% accuracy is achieved. Pneumo-
higher locat~on. A spontaneous perforation is usually
thorax occurs in about 50% of patients with pneumo-
larger and diagnosed much later, commonly involves
mediastinum.P The reliability of the Gastrografin
the intrathoracic esophagus, and deeply soils the
swallow study ranges from 75% to 1oo%.s This
mediastinum with bacteria and gastric juices because
contrast agent is water soluble and produces less
of its explosive nature. 2,4,5,9,10 Mengoli and Klassen 1
reaction than barium if extravasated into the medias-
in 1965 were among the first to advocate conserva-
tim~m.5,12,21 If a repeat esophagogram is indicated,
tive management. They gave nonsurgical treatment
?arlUm can be used for its higher resolution capabil-
to 18 of21 cases ofesophageal perforation secondary
ity. A computed tomographic scan with contrast is
t~ esophagoscopy. They noted that the key to early
recommended as an adjunctive study to determine
diagnosis and prompt institution ofcare with intrave-
the site and extent of the injury. This can direct the
?OuS antibiotic therapy and alimentation was a high
surgeon preoperatively if an abscess is present in the
index of suspicion for injury. Undue bleeding and
neck or in the mediastinum requiring surgical drain-
technical difficulties during instrumentation and post-
age. It is especially useful in a patient who is critically
operative pain, fever, and subcutaneous emphysema
ill, since minimal positioning of the patient is re-
led them to an early diagnosis. Chest radiography and
quired to perform the study.22
an esophagogram further confirmed and located the
injury. Their reported mortality was 6% with this Surgical treatment consists ofeither primary repair
approach. Of further interest is that 14 of these of the perforation or drainage alone. According to

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214 Dolgin et al, Pharyngoesophageal Perforations
Hagan, IS extensive subcutaneous or prevertebral em-
physema should mandate surgical drainage. Most
authorities feel that primary closure of the injury
should be performed; however, this may be difficult
after 24 hours because of patient deterioration and
friability of the infected tissues. Tucker and Padula23
noted that if the perforation is inaccessible and exten-
sive dissection is necessary to ensure proper expo-
sure, primary closure is not mandatory and simple
drainage is all that is needed. There is no general
agreement as to the duration of drainage. In Hagan's
series, IS drains were removed as early as the second
and third postoperative days. Hagan also proposed
that surgical treatment be reserved for very small
(less than 1 em) perforations with minimal subcuta-
neous emphysema. Complications related to upper
aerodigestive tract injuries carry a 10% to 15% mor-
tality rate. Injuries to the middle and lower portions
of the esophagus appear to be more serious, with as
great as a 50% morbidity and mortality rate. 10, 11 The
length ofhospitalization and the mortality rate double
in patients who receive diagnoses 24 hours after the
start of symptoms. S- IO,12 Although various authors
recommend direct rigid endoscopy whenever pos-
sible to evaluate the extent of the injury, we and other
authors have found this not to be essential. 24,25
Our approach differs from the protocol suggested
by others. We have conservatively treated patients
with extensive subcutaneous and retropharyngeal
emphysema with success. The majority of our pa-
tients received diagnoses within hours. Our patient in
case 8 exemplifies the success of early institution of
conservative management in an elderly patient with
a lower esophageal perforation who, because of age
and medical history, was not an ideal surgical candi-
date. We believe that patients treated with a conser-
vative protocol should be monitored closely for the
development ofcervical abscess or mediastinitis and,
if necessary, be explored and drained surgically with-
out delay. In the series of Shockley et al, 25 two
patients treated conservatively required surgical ex-
ploration at 48 and 72 hours after initiation of antibi-
otic therapy. According to Loop and Groves.l" 25%
of patients treated conservatively will develop cervi-
cal abscess.
In our series, there was no uniformity as to the
choice or duration of antibiotics prescribed or the use
of nasogastric decompression and feeding. Proximal
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 Dolgin et al, Pharyngoesophageal Perforations 215

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THE UCSF OTOLARYNGOLOGY UPDATE: 1992

The UCSF Otolaryngology Update: 1992, will be held November 5-7, 1992, at the Ritz-Carlton Hotel in San Francisco, California.
For more information, please contact the University of California, Extended Programs in Medical Education, Room LS-105, San
Francisco, CA 94143-0742; telephone: (415) 476-4251.

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