Diseases Of The Nose Throat And Ear

214 THE LARYNX, BRONCHI AND OESOPHAGUS

exist, namely, perforation by foreign body, excessive vomiting, surgical
trauma, and erosion by caustics or drugs, but the commonest cause is
oesophagoscopy.

The perforation may be in the cervical oesophagus or the thoracic oeso-
phagus and it is important to distinguish these in the management of the
condition. Perforation of the cervical oesophagus may be caused by trying to
force a way through cricopharyngeus thus creating a false passage posteriorly
(through the weak area), or by entering a pharyngeal pouch instead of the
oesophagus and attempting to force a way through it. In the thoracic
oesophagus perforations are most likely to occur by attempting to dilate a
benign or malignant stricture, or by taking too deep a biopsy of a carcinoma
or an oesophagitis. Rough attempts at removal of sharp foreign bodies can
also perforate the oesophagus.

DIAGNOSIS. The symptoms manifest themselves within a few hours of the
procedure. There is pain in the back between the shoulder blades and also
painful dysphagia. After a short time the temperature rises rapidly to around
39 °C and surgical emphysema is palpable. Radiography shows a broadened
mediastinum and if Dionosil is swallowed, the site of the perforation may be
seen.

TREATMENT. At whatever stage the diagnosis is made a nasogastric tube
should be passed, all oral feeding stopped, broad-spectrum antibiotics
started and half-hourly vital sign charts commenced. If the diagnosis is made
in the first 24 hours the neck or the chest should be opened, the perforation
closed surgically and the wound drained. If the diagnosis is delayed, the
edges of the perforation become necrotic, surgical closure is less certain and a
conservative line of treatment is more likely to be successful. It is in this group
that the mortality is high.