Iatrogenic Pharyngoesophageal Perforation in Premature Infants

Abstract

An iatrogenic perforation is often difficult to diagnose and can easily be confused with esophageal atresia. Clinical findings, a plain chest x-ray, an esophagography and endoscopy are helpful. Surgery can be avoided in most instances. The outcome is not always favorable especially as premature neonates are at risk of severe concomitant pathology.

Iatrogenic Esophageal Perforation: An Occurrence from Feeding Tube Placement in a Premature Infant with a Pneumothorax

“…First, trauma during placement of a feeding or endotracheal tube or suctioning of the upper airway can cause EP. The second cause is related to pressure necrosis caused by chest drain placement 5,1315) . The pre disposing factors are prematurity and the presence of congenital structural abnormalities in the esophagus.…”

Iatrogenic perinatal pharyngoesophageal injury: A disease of prematurity

“…Regarding the latter, a history of polyhydramnios or difficulty passing a feeding tube supports a diagnosis of esophageal atresia, whereas a difficult intubation or extensive upper airway instrumentation, bloody secretions, respiratory distress, pneumothorax or pneumomediastinum, and malpositioned feeding tube are thought to favor a diagnosis of pharyngoesophageal perforation [3]. Additional imaging with computed tomography or oral contrast may be of use.…”

“…Subsequently, numerous case series have documented additional patients with upper aerodigestive injury following perinatal airway instrumentation; although reported in both term and preterm infants, an overall predilection for premature neonates is evident in the literature [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. Reflexive cricopharyngeal muscular constriction and esophageal narrowing and compression against cervical vertebrae with extension of the infant head have been hypothesized to make the posterior hypopharynx and esophageal introitus the site of the vast majority of these injuries [2,3]. Signs of injury may be nonspecific and possibly delayed, with common findings including subcutaneous or mediastinal emphysema, drooling, dyspnea, fever, difficulty passing a feeding tube, and general clinical deterioration [3,23].…”

“…This clinical presentation strongly overlaps with that of esophageal atresia; further differential diagnosis includes pseudodiverticulum and esophageal duplication. Further complicating matters, the superior mediastinal radiolucency typically seen on chest X-ray in patients with pharyngoesophageal perforation is also characteristic of esophageal atresia, leading to misdiagnosis and potentially unnecessary thoracotomy [3,9,[20][21][22]24]. Authors have suggested strategies for differentiating pharyngoesophageal Objective: Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage.…”

“…Reflexive cricopharyngeal muscular constriction and esophageal narrowing and compression against cervical vertebrae with extension of the infant head have been hypothesized to make the posterior hypopharynx and esophageal introitus the site of the vast majority of these injuries [2,3]. Signs of injury may be nonspecific and possibly delayed, with common findings including subcutaneous or mediastinal emphysema, drooling, dyspnea, fever, difficulty passing a feeding tube, and general clinical deterioration [3,23]. This clinical presentation strongly overlaps with that of esophageal atresia; further differential diagnosis includes pseudodiverticulum and esophageal duplication.…”