Submucosal Perforation of the Esophagus in the Neonate

Abstract

Excessive salivation, with choking, coughing and cyanosis on attempts at feeding in a newborn infant reasonably suggest esophageal atresia. Yet, other less common lesions may present the same signs. Of these, the simple esophagotracheal fistula, without atresia, is well known, while instances of congenital pharyngo-esophageal and true esophageal diverticula, with or without coexisting esophagotracheal fistulae, have only occasionally been reported (BRINTNALL & KRIDELBAUGH 1950, KNOX 1951, ROBB 1952 and GRANT & ARNElL 1959).An apparently even more rare disorder in the neonate with the same symptomatology is submucosal perforation of the esophagus. The clinical features and the radiologic appearances of this lesion on the basis of experience gained from two cases recently studied will be described in this communication. During its preparation, however, the records of a third case treated in another hospital became available and were included in the study. The radiologic features and the findings at operation of this third case well support the etiologic hypothesis for the disorder.

Esophageal perforation in the newborn

“…Spontaneous perforations affect the distal portion of the esophagus and are considered to be a n a t o m i c a l defects, or they are due to intrinsic dysfunction o f the esophagus which are often initiated by esophagitis [5]. Catheters used for removing secretions or for naso-gastric feeding have been the cause of almost all the traumatic perforations of the esophagus [2,3,5,7]. Extremely rare cases have been r e p o r t e d where perforation has been caused during laryngoscopy [9] or after introduction of a finger into the m o n t h to perform fetal extraction during breech delivery [4].…”

“…Such perforations usually occur at the p h a r y n g o -e s o p h a g e a l junction where the cricopharingeal muscle narrows the lumen to a greater degree than elsewhere along the esophagus. A factor favoring perforation is compression of the esophagus against a cervical vertebra [3,6]. This can occur during forced extension of the infant's neck.…”

“…S y m p t o m s a c c o m a n y i n g esophageal perforation are s o m e w h a t non-specific: i.e., respiratory distress, cyanosis, increased salivation and increased oral mucous secretions, difficulty in feeding with choking or cyanotic episodes, and vomiting or cough [3,5]. However, the most c o m m o n sign is difficulty in passage of a naso-gastric tube [1, 3,5].…”

“…The use of a boron swallow can give excellent results in illustrating the signs: paraesophageal leakage of the contrast medium can be observed or one may see a diffuse opaque cloudiness. Also the outline of a pseudo-cavity with distinct margins may be observed [1, 3,5]. In almost all the reported cases the esophageal lumen has been patent as far as the stomach.…”

“…Depending on the type and seriousness of the condition as demonstrated radiographically and clinically, further treatment may have to include feeding though a gastrotomy or total parenteral nutrition. Only rarely is it necessary to perform thoracotomy for surgically repair the esophageal lesion [1,3].…”