International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 1 , Pages 9-11, March 2006

Cervical esophageal rupture after blunt neck trauma: Surgical primary repair and long-term follow-up

Department of Pediatric Surgery, Children's Hospital, “Teresa Herrera”, Complexo Hospitalario Universitario, “Juan Canalejo”, A Coruña, Spain

Received 3 August 2005; received in revised form 21 October 2005; accepted 27 October 2005.

Article Outline

Summary 

Cervical esophageal rupture secondary to non-penetrating injury is exceedingly rare in pediatric patients. Less than 10 cases have been reported in the world literature. We report a case of a 9-year-old boy that suffered an esophageal perforation following cervical blunt trauma. The diagnosis was delayed 48h but surgical primary repair was effective and recovery was uneventful. Early diagnosis and operative management options are discussed.

Keywords: Esophageal perforation, Blunt neck trauma

 

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1. Introduction 

Cervical esophageal rupture secondary to blunt neck trauma in childhood is an extremely rare entity associated with a high degree of morbidity and mortality. Early identification of these injuries is critical because life-threatening sepsis may develop if delay in diagnosis. Reports cite a 92% mortality if the injury was untreated more than 48h [1]. There is considerable controversy surrounding the assessment and elective management of children with non-penetrating cervical trauma and esophageal rupture. In patients who have delayed diagnosis, surgical primary repair is usually not feasible. We report a case of a 9-year-old boy that suffered an esophageal perforation following blunt cervical trauma. The diagnosis was delayed 48h but surgical primary repair was effective and recovery was uneventful. Early diagnosis and operative management options are discussed.

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2. Case report 

A 9-year-old boy was referred to our Hospital from other Medical Centre with the diagnosis of blunt neck trauma two days before. The injury was caused by incidental struck in the neck after fall onto edge of a kitchen table. Child abuse was excluded by Mental Health Services. Social Team made an exhaustive evaluation of the family situation based on a protocol developed in our Hospital for detect child abuse. On physical examination there was auditory stridor, anterior cervical crepitous and right neck haematoma and edema. Plain neck X-ray was remarkable for subcutaneous and retropharyngeal emphysema. CT scan of the head and neck revealed subcutaneous emphysema and suspected esophageal rupture. Direct laryngoscopy and esophagoscopy showed a cervical esophageal laceration. Cervical surgical exploration was performed and revealed a 2cm esophageal perforation cover by fibrin tissue (Fig. 1). Surgical primary repair followed by two non-aspirative drainages was decided intraoperatively (Fig. 2). The patient was managed in Pediatric Intensive Care Unit with broad-spectrum antibiotics during 2 weeks and mechanical ventilation for 24h. Postoperative course was uneventful and started on oral intake 10 days after surgical repair. Barium swallow esophagogram at day 7 postoperatively was normal. The patient was discharged well on day 16 after surgery and had no problems during the long-term follow-up period of six years.

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3. Discussion 

Esophageal perforation in paediatric patients is an extremely rare injury. Less than 10 cases of blunt cervical esophageal perforations were reported in childhood [2], [3], [4], [5], [6], [7]. Most reports of esophageal rupture mainly concern adult series [8]. These reports cited an incidence of 0.001% of esophageal perforation following blunt trauma. External blunt trauma accounts for less than 10% of all esophageal perforations, most of them resulting from penetrating or iatrogenic injuries [2], [9], [10], [11], [12], [13], [14], [15], [16]. In these cases of cervical blunt neck trauma in children is indispensable to rule out the possible existence of underlying child abuse [1], [4].

Since esophageal rupture from blunt neck trauma is so exceedingly rare, this injury is not often suspected and a delay in diagnosis of more than 24h occurs in near 50% of cervicothoracic esophageal lacerations [2].

Barotrauma resulting from a compressive neck injury is the most credible hypothesis for the infant's esophageal perforation. A rapid and “suddenly” rise in esophageal pressure can exceed the tensile strength of the esophagus leading to laceration [4]. These esophageal cervical injuries are difficult to diagnose. One must have a high index of suspicion when the blunt trauma involves neck or thorax and the patient presents typical signs and symptoms like stridor or subcutaneous emphysema. It is necessary to perform an aggressive and complete evaluation of the infant including CT examination of the neck, chest X-ray, esophagoscopy and esophagogram with water-soluble contrast material because delay or misdiagnosis increases morbidity [4], [5], [9].

Treatment of cervical esophageal perforations must be prompt, hopefully within 16–24h of incoming injury [5]. An aggressive but individualized approach is warranted in most cases. Surgical repair and drainage should be standard treatment for large perforations involving the esophagus in which spontaneous healing cannot be expected [3], [17]. Some authors suggest that conservative medical management with antibiotics and nasogastric tube could be useful in tears less than 2cms [3]. Other therapeutic options in the management of these disruptions also include temporary esophagostomy with secondary closure or esophagectomy with the option of delayed reconstruction [18], [19], [20]. Surgical primary closure with drainage is probably the more risk option in patients with a delay in the diagnosis and the development of an abscess is of greater concern [4]. The length and the site of the lesion suggested us to perform a surgical exploration although the delayed diagnosis. The lesion was approximately 1.5cm in length, with clean borders and was located lateral in esophagus, facilitating an easier surgical cervical access. The characteristics of the tear allowed us to realize a primary closure and fortunately there were no secondary complications in the long-term follow-up.

Pediatric esophageal perforation from external blunt trauma is exceedingly rare. Evaluation requires X-ray, CT scan, endoscopy and esophagogram after clinical suspect. Therapy must be guided by clinical symptoms but standard management includes surgical exploration. We think according with others, that surgical primary repair with drainage must be first attempted in all cases with early diagnosis (first 24h).

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References 

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PII: S1871-4048(05)00004-3

doi:10.1016/j.pedex.2005.10.002

International Journal of Pediatric Otorhinolaryngology Extra
Volume 1, Issue 1 , Pages 9-11, March 2006

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