Issue: 2018 > August > photo quiz

Answer to Photo Quiz: Sudden subcutaneous emphysema and dysphagia in a 46-year-old woman

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Endoscopy showed a 9 cm rupture of the proximal esophagus (figure 2), macroscopically not suspect for underlying malignant or ulcerative disease. Broad spectrum antibiotics were started, and the patient was transferred to a tertiary academic center, where a 12 cm partially covered esophageal stent was placed. Despite antibiotic treatment, mediastinal and pleural drainage, her condition worsened and she developed mediastinitis. CT-thorax showed progressive infiltration, increase in pleural effusion and a persisting mediastinal pocket. Ultimately a video assisted thoracoscopy (VATS) was performed and two additional drains were placed. After two weeks the stent was removed because of a persistent defect not covered by the stent. This persistent defect spontaneously closed within the subsequent seven days.
Subsequently, she gradually recovered. A video fluoroscopic swallowing exam did not show any leakage. Oral feeding was being built up slowly, and one month after hospital admission she was discharged in good condition.
Esophageal perforation is a rare but potentially life-threatening condition, with overall mortality of 18%.1 Spontaneous perforation known as Boerhaave’s syndrome accounts for approximately 15% of perforations.2 Inconsistently with the classic distal perforation of this syndrome, our patient presented with a spontaneous proximal rupture, most likely due to the muesli or a sharp foreign body in the muesli, although we never retrieved one.


All authors declare no conflict of interest. No funding or financial support was received.


  1. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77:1475-83.
  2. Sepesi B, Raymond DP, Peters JH. Esophageal perforation: surgical, endoscopic and medical management strategies. Curr Opin Gastroenterol. 2010;26:379-83.