[Perforation of the hypopharynx after esophagogastroduodenoscopy].

HISTORY AND CLINICAL FINDINGS: A 57-year-old immunocompromised man (OKT3 therapy following rejection reaction after renal transplantation) was presented to the ENT clinic because of progredient dysphagia and pain in the neck region. Twelve hours before, a esophagogastroduodenoscopy had been performed in an external clinic.

INVESTIGATIONS: There was palpable crepitation over the area of the larynx. Laboratory tests showed an increase of CRP and leucocytosis. Computed tomography with contrast agent showed a pronounced emphysema of the neck and extravasation on the level of the larynx. An x-ray with esophagramm showed a leakage of contrast agent at the hypopharynx.

TREATMENT AND COURSE: The patient received 1 × 2 g Ceftriaxon and 3 × 400 mg Metronidazol intravenously. Endoscopy with rigid instruments showed a 0.5 cm slit-like lesion of the left sinus piriformis with putrid secretion. Via a trans-cervical approach a parapharngeal abszess of 2 cm was explored and treated with drainage and lavage. The upper esophageal sphincter was slitted and the pharynx perforation multilayered closed from outside. A CT scan after 24 hours showed decreasing emphysema with signs of an absczess. The further clinical course was uneventful. After 3 months a bland cervical scar and normal ENT status could be observed at a patient free of symptoms.

CONCLUSION

Perforation of the upper aerodigestive tract is a rare complication of a flexible esophagogastroduodenoscopy. Early diagnosis and treatment is needed to prevent the development of sepsis, an abscess or a mediastinitis as potential life threatening effects with a poor prognosis. Depending on the defect size and the overall situation a conservative or surgical management should be followed. Special attention should be paid to immunocompromised patients after a esophagogastroduodenoscopy as clinical signs of a perforated aerodigestive tract may be reduced or missing.