Case Presentation: A 26-year-old male presented with a 6-hour history of anterior neck pain and swelling. Symptoms started few minutes after he had dinner (tuna and a carbonated beverage). Otherwise, he denied any recent illness, trauma or intake of unusual substances and had no other past medical history. On exam, he was afebrile and hemodynamically stable. There was anterior neck tenderness on palpation along with crepitus. X-ray of neck confirmed subcutaneous emphysema correlating with the crepitus. After several attempts of failed confrontation, patient confessed to have vomited few times prior to dinner in order to get rid of ecstasy out of his system, so that it would not show up on Urine toxicology test on the next day at work. Pain started few hours after his dinner. CT scan showed extensive gas dissecting within the planes of the inferior neck bilaterally and extending into the mediastinum (pneumomediastinum). Gastrograffin swallow study did not show any leaks. However, due to high suspicion, barium swallow was done, which showed a leak likely from a pharyngeal rupture. ENT was consulted and decision was made to manage patient conservatively. Intravenous antibiotics were started, patient was made NPO and nasogastric tube was inserted with caution. Eventually, patient was started on tube feeding and observed for a week. Repeat CT scan and barium study showed resolution of the subcutaneous air and the perforation.

Discussion: Pharyngeal and cervical esophageal perforation are rare entities, mostly associated with trauma from instrumental manipulation; however spontaneous rupture is uncommon.  These are differentiated from Boerhaave syndrome (which is a transmural perforation of esophagus), by its location above upper esophageal sphincter and also the mechanics of perforation. They share similar symptoms which include a history of vomiting with chest pain, neck pain and subcutaneous emphysema. Although, complications including mediastinitis, expansion of pneumomediastinum are less common with pharyngeal perforation, early recognition and management is important to prevent massive subcutaneous emphysema, respiratory compromise and other fatal consequences. High index of suspicion is required as patients can present with vague symptoms. X-ray or CT scan usually demonstrates subcutaneous emphysema, as in our case. To localize perforation, swallow study with contrast, preferably water soluble contrast like gastrograffin is useful. In our patient, gastrograffin failed to show any perforation and hence barium study was done. Smaller pharyngeal tears can be managed conservatively with antibiotics and nasogastric tube, while larger tears are managed surgically. Restricting oral intake for a few days is important to avoid expansion of subcutaneous emphysema or infection. Patients who have eaten between the onset of perforation and diagnosis were reported to be at higher risk of failure of conservative management.  In our patient, food and soda intake prior to presentation probably precipitated the symptoms, however fortunately he improved with conservative management alone. Follow-up imaging in about week after discharge is advised to confirm improvement.

Conclusions: Pharyngeal and cervical esophageal perforation are rare entities and differ from Boerhhave’s syndrome with different mechanism, natural course, complications and management.