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- rare but life threatening
- high morbidity and mortality
- most common causes: post op complications, esophageal perforation (Boerhaave syndrome)
- Esophageal perforation usually occurs just above gastro esophageal junction
- leakage from esophagus due to a necrotic neoplasm
- extension of infection from neck, retroperitoneum or intrathoracic structures
- ill, high fever, tachycardia, chest pain
imaging
Chest Xray
- widening, ill-defined mediastinal outline
- streaks or collections of air within mediastinum
- mediastinal air-fluid levels
- air in soft tissues of neck
- pleural effusions frequent and on the left
- often lower lobe pneumonia or atelectasis
- esophagogram with water soluble contrast identifies site of leak
CT
- optimal technique
- increased attenuation of mediastinal fat
- free gas bubbles in mediastinum
- localized fluid collections
- enlarged lymph nodes
- pleural effusions
- empyema
- subphrenic or pericardial collection may or may not be present
- In post op cases – distinguishing retrosternal hematoma from reactive granulation tissue or cellulitis difficult
- substernal fluid collections, pockets of air normal in first 20 days post sternotomy