[Perforation of the hypopharynx after esophagogastroduodenoscopy]

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.

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.

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.

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.