A 78-year-old man presented with a major complaint of back pain. A contrast-enhanced
computed tomography (CT) scan showed a 2-cm hypovascular, irregular, tumorous lesion
in the body of the pancreas that was invading the celiac, splenic, and common hepatic
arteries. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was planned.
First, an upper gastrointestinal endoscopy was performed, during which the endoscope
(GIF-H290Z; Olympus Medical Systems, Tokyo, Japan) passed easily through the left
hypopharynx. The endoscope for the EUS-FNA (GF-UCT260; Olympus Medical Systems, Tokyo,
Japan) was then carefully inserted, but it was difficult to pass the scope into the
esophagus. After two or three attempts, a sense of breaking through the mucosa was
felt via the scope, so upper gastrointestinal endoscopy was carried out again. It
was discovered that a perforation had occurred on the inside of the left hypopharyngeal
entrance ([Fig. 1]). The scope was withdrawn, and a further CT scan showed a pneumomediastinum and
intraperitoneal free air ([Fig. 2 a]).
Fig. 1 Upper gastrointestinal endoscopy showing a perforation that had occurred on the inside
of the left hypopharyngeal entrance.
Fig. 2 Computed tomography (CT) scans done: a after the hypopharyngeal perforation was noted on endoscopy, showing a pneumomediastinum
(arrow) and intraperitoneal free air (arrow head); b 7 days later, showing significant improvement with the pneumomediastinum and intraperitoneal
free air having almost disappeared.
Although emergency surgery was considered, the patient’s general condition was stable,
and conservative therapy was therefore chosen. The patient was started on meropenem
and was forbidden to take food and drink for 7 days, after which a CT scan was performed
again, which this time indicated significant improvement ([Fig. 2 b]). The patient was allowed to start eating again and no relapse occurred.
EUS has been used for many years in both diagnosis and treatment. A few cases of hypopharyngeal
perforation during EUS have been reported [1]. The rate of cervical esophageal perforation is reported to be 0 % – 0.03 % [2]
[3]. Perforation of the esophagus is associated with a mortality rate of 2 % – 36 %,
with early identification and management having been shown to decrease the associated
morbidity and mortality [4].
This is a first report to show that pneumomediastinum caused by hypopharyngeal perforation
during EUS-FNA can be treated conservatively. If the patient’s condition is stable,
we would choose conservative treatment for hypopharyngeal perforation; however, the
option of surgical treatment should the patient’s condition worsen must not be lost.
Endoscopy_UCTN_Code_CPL_1AL_2AB
