title: Management of cervical esophageal and hypopharyngeal perforations.
abstract: OBJECTIVE
  Evidence is limited for outcomes of surgical versus conservative management for patients with cervical esophageal or hypopharyngeal perforations.
  
  
  METHODS
  Patients with cervical esophageal or hypopharyngeal perforations treated between 1994 and 2014 were identified using an institutional database. Outcomes were compared between patients who underwent operative drainage and those who had conservative management with broad-spectrum antibiotics and withholding oral intake.
  
  
  RESULTS
  Twenty-eight patients were identified with hypopharyngeal or cervical esophageal perforations, mostly due to iatrogenic (nasogastric tube placement, endoscopy, endotracheal intubation) injuries (68%). Fourteen were treated initially with conservative management and 14 with initial surgery. Six patients failed conservative treatment and two patients failed surgical treatment. Patients managed conservatively who had eaten between injury and diagnosis (p=0.003), those who had 24 hours or more between the time of injury and diagnosis (p=0.026), and those who showed signs of systemic toxicity (p=0.001) were significantly more likely to fail conservative treatment and require surgery. No variables were significant for treatment failure in the surgical group. Of the 20 patients who ultimately underwent a surgical procedure, two required a second procedure.
  
  
  CONCLUSIONS
  Patients who have eaten between the time of perforation and diagnosis, have 24 hours or more between injury and diagnosis, and those that show signs of systemic toxicity are at higher risk of failing conservative management and surgical drainage should be considered. For patients without these risk factors, a trial of conservative management can be attempted.
authors.affiliation: Department of Otolaryngology Head and Neck Surgery, Washington University in St. Louis, Saint Louis, MO, USA. Electronic address: zengaj@ent.wustl.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Zenga
authors.affiliation: Division of Cardiothoracic Surgery, Washington University in St. Louis, Saint Louis, MO, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kreisel
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA.
authors.forename: Vladimir M
authors.initials: VM
authors.lastname: Kushnir
authors.affiliation: Department of Otolaryngology Head and Neck Surgery, Washington University in St. Louis, Saint Louis, MO, USA.
authors.forename: Jason T
authors.initials: JT
authors.lastname: Rich
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D019468:Disease Management; D004322:Drainage / Q000379:methods*; D004939:Esophageal Perforation / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007013:Hypopharynx / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D009333:Neck; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012421:Rupture / Q000628:therapy; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents