Ann Thorac Surg 2009;87:1620. doi:10.1016/j.athoracsur.2008.08.063
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Perforated Esophagus or Large Diverticulum?
Wai-ka Hung, FRCS*
Department of Surgery, Kwong Wah Hospital, Hong Kong, China
* Address correspondence to Dr Hung, Kwong Wah Hospital, Department of Surgery, 25 Waterloo Rd, Kowloon, Hong Kong, China (Email: hwkhwk{at}netvigator.com).
A 50-year-old man presented to the physician for investigation of dyspnea. A chest roentgenogram showed bilateral lower lobe infiltrate (Fig 1,
black arrows), and the result of a sputum culture was negative. Interstitial pneumonitis was diagnosed, and steroid therapy was commenced. He also had hoarseness and choking, and therefore a video fluoroscopic swallow study was performed that showed contrast leakage from the esophagus into mediastinum (Fig 1, white arrows). Computer tomography showed an air–fluid collection beside the trachea (Fig 2,
white arrow shows the collection and black arrow shows a nasogastric tube in the esophagus).
A surgeon was consulted, but no clinical evidence of esophageal perforation and sepsis was found. An endoscopy was performed to clarify the diagnosis and it showed a normal esophagus without perforation. On fluoroscopic examination, the extravasated contrast (Fig 3,
white arrows) was alongside the esophagus (Fig 3, black arrows) and was actually present within a 10-cm-long diverticulum starting at the hypopharynx extending down the mediastinum.
Aspiration from the diverticulum resulted in pneumonia, which was misdiagnosed as interstitial pneumonia. He was kept nil by mouth with nasogastric tube feeding. With the resolution of pneumonia, the patient was advised to undergo diverticulectomy and cricopharyngeal myotomy; however, he refused the procedure and defaulted follow-up.
