Case Presentation: This is a case of a 68-year-old female with a history of a recent cryptogenic stroke and atrial fibrillation who presented for an elective TEE for patent foramen ovale (PFO) evaluation and possible closure. TEE revealed a PFO with evidence of a right-to-left shunt. After completion, the patient reported exquisite neck tenderness, severe dysphagia and difficulty breathing. Physical examination revealed neck and chest tenderness with crepitus. Immediate chest x-ray and CT scan of the soft tissue revealed pneumomediastinum with subcutaneous emphysema at the level of the neck highly suspicious of esophageal perforation without an exact location. The patient became progressively septic and hemodynamically unstable requiring intubation, sedation, broad spectrum antibiotics, and vasopressor support. Urgent diagnostic esophagoduodenoscopy (EGD) revealed complete perforation of the esophagus at the level of the hypo-pharynx down to mid-esophagus. Cardiothoracic surgery and otorhinolaryngology were consulted and the patient underwent same day surgical debridement of the neck with neck tube drainage without immediate esophageal repair.

Discussion: Esophageal perforations due to TEE is an exceedingly rare complication. Certain esophageal pathologies such as esophageal web, stricture, or esophagitis may carry a higher risk of perforation. Our patient had partial and full thickness rupture of the esophagus leading to septic shock. Given the extent of injury, endoscopic intervention was not feasible. Similar cases have been described leading to multi-organ failure and death from complications [2]. Our patient likely had an esophageal stricture leading to mucosal injury due to the TEE, yet survived with conservative surgical management. Therefore, early recognition and intervention can decrease morbidity and mortality. TEE-induced perforations are perceptively caused by elevated mucosal pressure caused by the probe, and/or from pre-existing esophageal abnormalities [2]. Contraindications to TEE include substantial dysphagia, severe instability of cervical vertebrae and esophageal disorders such as diverticulum, fistula, laceration, severe inflammation, stricture, tumor and varices [2-3]. Classic esophageal perforation symptoms consist of chest pain, dyspnea, emesis, and fever. Diagnosis can be achieved by an upright chest X-ray followed by Gastrografin esophagram [2-3]. An esophagram was not pursued in our patient as she was hemodynamically unstable requiring mechanical ventilation. CT of the soft tissue may assist in identifying underlying gas but direct visualization with laryngoscopy or EGD is necessary to determine the extent of the injury. Surgical closure and debridement of the perforation is the standard of care along with hemodynamic support, antibiotics, airway protection, and orogastric suction with decompression.

Conclusions: TEEs are considered a safe procedure and are frequently performed. Our case describes a rare but life-threatening complication of an elective TEE leading to septic shock and multi-organ dysfunction. Operators must be aware of this complication in order to expedite and escalate the necessary care.

IMAGE 1: CT of the head and neck revealing subcutaneous emphysema (arrow) due to esophageal perforation

IMAGE 2: Diagnostic EGD revealing perforated esophagus