Conservative Medical Management of Traumatic Pharyngoesophageal Perforations

Abstract

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.

Management of cervical esophageal and hypopharyngeal perforations

“…Early reports focused on immediate and definitive surgical management of cervical esophageal or hypopharyngeal perforations by transcervical exposure, primary closure of the defect, and the placement of transcutaneous drains [1]. Subsequent [2][3][4][5][6]. By using broad-spectrum prophylactic antibiotics and withholding oral feeding, a conservative strategy may avoid the morbidity associated with surgery.…”

Paediatric hypopharyngeal perforation: Child abuse until proved otherwise?

“…Some authorities suggest exploration of the neck with drainage in all cases [27]. We would support the more conservative approach advocated by other authors [28,29]. A significant abscess collection will require external drainage although smaller collections have been known to resolve with antibiotic therapy alone [21].…”

Pharyngeal Perforation and Pseudodiverticulum Formation After Anterior Cervical Spine Plating

“…A series of 10 patients were successfully treated with this regimen and recovered without complications or need for surgery. 8 However, all perforations in this series of patients resulted from trauma or iatrogenic injury, and all but 1 were discovered and treated within 24 hours of injury.…”

“…Conservative medical management has proved successful for select patients with small perforations in the acute setting. 4,8 Typically, such patients suffer trauma to the hypopharynx or iatrogenic injury during surgery in which the perforation is immediately apparent. Appropriate medical management includes giving nothing by mouth, intravenous administration of antibiotics and fluids, and nasogastric decompression (assuming a nasogastric tube can be passed safely).…”