What is the medical management of an upper esophageal sphincter injury?

Medical Management of Upper Esophageal Sphincter Injury

The medical management of upper esophageal sphincter (UES) injury should follow a non-operative approach in stable patients with early presentation, contained injury, and minimal contamination, including nil per os, broad-spectrum antibiotics, proton pump inhibitor therapy, and early nutritional support. 1

Initial Assessment and Diagnosis

• Diagnostic workup:

  • Contrast-enhanced CT and CT esophagography (95% sensitivity, 91% specificity) 2
  • Flexible endoscopy for direct visualization of injury site 2
  • Assessment for pneumomediastinum, pleural effusions, paraesophageal collections, and free air

• Criteria for non-operative management:

  • Early presentation (less than 24 hours)
  • Absence of symptoms and signs of sepsis
  • Contained perforation by surrounding tissues
  • Minimal peri-esophageal extravasation
  • Absence of massive pleural contamination 1

Non-Operative Management Protocol

1. Immediate measures:

   • Nil per os (NPO) status
   • Broad-spectrum antibiotics covering aerobic and anaerobic bacteria
   • Proton pump inhibitor therapy 1
   • Endoscopic placement of nasogastric tube 1

2. Nutritional support:

   • Early introduction of nutritional support via enteral feeding or total parenteral nutrition 1
   • Essential for esophageal healing and recovery

3. Additional interventions:

   • Drainage of pleural collections and peri-esophageal abscesses using percutaneous radiology techniques 1
   • Pleural decortication by video-thoracoscopy if needed
   • Endoscopic techniques (clips, stents, internal vacuum drainage) 1

Endoscopic Management Options

• Endoscopic stenting:

  • Minimal 2-4 week duration of stent placement to allow sealing of perforation 1
  • Particularly useful as adjunct treatment in patients with persistent leakage following surgical treatment 1

• Specialized techniques:

  • Endoluminal vacuum therapy for closure of esophageal defects 1
  • Upper esophageal sphincter dilatation may be considered in cases of dysphagia with disordered UES opening 1

Swallowing Rehabilitation

• Dietary modifications:

  • Thickened liquids reduce aspiration risk compared to thin liquids 1
  • Spoon delivery is safer than cup drinking 1
  • Dietary recommendations should be prescribed and refined by testing with foods and liquids simulating normal diet 1

• Swallowing exercises:

  • Shaker exercise: sustained and repetitive head lifts three times daily while in supine position to strengthen cervical musculature 1
  • Masako technique: tongue hold between teeth or lips paired with dry swallow 1
  • Muscle training augmented with electromyographic biofeedback 1

Monitoring and Follow-up

• Post-procedure monitoring:

  • Monitor patients for at least 2 hours in recovery room 1
  • Provide clear written instructions on fluids, diet, and medications 1
  • Ensure patients are tolerating water before discharge 1

• Signs of complications:

  • Suspect perforation when patients develop persistent pain, breathlessness, fever, or tachycardia 1
  • Perform CT scan with oral contrast if perforation is suspected 1

Indications for Surgical Intervention

• Surgery should be undertaken in all patients who do not meet non-operative management criteria 1
• Patients should be taken to the operating room as soon as possible if surgery is indicated 1
• Mortality increases significantly when surgical treatment is delayed beyond 24 hours (from <10% to >30%) 1, 2
• Specific indications include:
  • Irretrievable foreign body
  • Perforation with extensive contamination
  • Foreign body close to vital structures
  • Signs of systemic toxicity 1

Surgical Approaches

• Cervical perforation: Direct repair through left neck incision with circumferential esophageal mobilization 2
• Thoracic perforation: Primary repair with tension-free closure and debridement to healthy tissue 2
• Minimally invasive techniques: Should be considered first-line treatment in referral centers 1

By following this comprehensive approach to managing upper esophageal sphincter injuries, clinicians can optimize patient outcomes while minimizing complications and mortality.