History (including chief complaint, history of present illness and relevant past and family medical history)
16 year old male presented to the emergency department with difficulty breathing, midline chest pain and blood tinged emesis. He also reported a cough associated with a feeling of something stuck in his throat. He was at a restaurant eating chicken wings a few hours prior to presentation when he suddenly started to choke on a chicken bone he swallowed. Past medical history significant for Asthma and Gastroesophageal reflux disease. No significant family history.
Physical examination findings (including vital signs)
Temp: 99.5 °F Heart Rate: 77 Respiratory Rate:16 BP:131/58
General: Sleepy but arousable, no acute distress
HEENT: Atraumatic, moist mucous membranes, no lymphadenopathy noted
Lungs: No increase in work of breathing, diminished breath sounds at the bases Left > Right, no palpable subcutaneous crepitus
Heart: Regular rate and rhythm, no murmurs/gallops/rubs
Abdomen: Soft, non-tender, non-distended, Bowel sounds diminished
Neuro: Cognitively intact
Extremities: Bilaterally equal pulses, no edema or cyanosis
Skin: No abnormal skin findings
Laboratory or Diagnostic imaging or Procedures:
CBC, CMP on admission were within normal limits
Initial Chest Xray showed pneumomediastinum. In addition to pneumomediastinum, Chest CT findings suggested at least a mucosal injury allowing gas to dissect into the wall of the esophagus. However no contrast extravasation was identified in the study for the source of the air leak.
First Esophagram demonstrated extravasation along the right side of the esophagus at the T4 level. EGD and stent placement were performed on day 2 after admission. His EGD showed mucosal changes including ringed esophagus, mucosal friability and stenosis indicative of underlying eosinophilic esophagitis which further increase risk for perforation. There was a linear tear at the mid-esophagus.
Second Esophagram performed 4 days later demonstrated no esophageal leak, presence of esophageal stent and 3 clips which were scheduled to be removed in 2-3 weeks.
Final Diagnosis & Management/Discussion:
Esophageal perforation following ingestion of a sharp foreign body is a rare cause of pneumomediastinum in the late adolescent age group. The factors affecting mortality following esophageal perforation is the time interval between injury and treatment as well as the treatment choice. Stent placement is an unusual non-surgical management option in the pediatric population. Even though historically operative repair has been the standard of care, stents demonstrate rapid leak occlusion, provide the opportunity for early oral nutrition, significantly reduce hospital length of stay, are removable, and avoid the potential morbidity of operative repair.
