Iatrogenic perforation of the hypopharynx or cervical oesophagus is a well-recognised life-threatening complication.

Previous studies have demonstrated that conservative management with broad-spectrum antibiotics and withholding oral feeding may avoid morbidity associated with surgical repair.

This study addresses when conservative management should be employed and when this strategy may delay definitive management making the situation more complex. Twenty-eight adult patients with iatrogenic hypopharyngeal or cervical oesophagus perforation confirmed by imaging or endoscopic visualisation from a single centre were analysed, spanning 1994-2014. Fourteen patients were managed conservatively, whilst 14 were initially managed surgically with procedures ranging from neck drainage, chest drainage, mucosal closure, muscle flaps or combinations of these procedures. Six patients failed conservative management but were successfully treated after surgical salvage intervention. Univariate analysis identified that patients who failed conservative therapy were more likely to be demonstrating systemic toxicity, had eaten between injury or for whom >24 had passed between injury and identification of the injury. This has lead to the authors producing a simple algorithm stressing the importance of early intervention and identification of systemic toxicity as key features to guide management. Patients who have eaten following injury are recommended for immediate surgical intervention to prevent delay in management. 

Management of cervical esophageal and hypopharyngeal perforations.
Zenga J, Kreisel D, Kushnir VM, Rich JT.
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Rohit Verma

North West Deanery, UK.

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