Cocaine Induced Pharyngeal Perforation-an Unusual Case Presentation of Facial and Cervical Emphysema with Pneumomediastinum

Objectives: Causes of cervical and facial surgical emphysema with pneumomediastinum are uncommon but can be life threatening and need urgent management in a high dependency setting. We present a case secondary to cocaine induced hypopharyngeal perforation which was not easy to diagnose as the patient was not forthcoming with his history of cocaine use. Clinicians should maintain a high index of suspicion when patients present with spreading cervical emphysema and also suggest an algorithm for management of non-iatrogenic subcutaneous emphysema and odynophagia. Case summary: We presented a case report of a 39 year old man presented with three days history of sudden severe odynophagia and coughing frothy blood stained sputum. Initial chest and neck soft tissue radiograph revealed cervical surgical emphysema. After further questioning, he admitted to recent regular cocaine nasal inhalation. Subsequent CT neck and thorax showed extensive subcutaneous emphysema likely due to an esophageal perforation. This was confirmed by gastrografin swallow test, which demonstrated a posterior hypopharyngeal perforation. The patient was managed conservatively in a HDU by keeping him nil by mouth and treatment with IV Piperacillin/Tazobactam and Clindamycin. He initially received total parenteral nutrition but subsequently refused further intravenous nutrition. He was discharged with nasogastric feeding in the community. Follow-up swallow test two weeks following discharge showed resolution of the perforation. Subsequent to this, we developed an algorithm with an emphasis on early stabilisation and thorough assessment prior to definitive investigation to improve management. Conclusion: Cocaine induced pharyngeal perforation is a rare but potentially life-threatening condition if left undiagnosed and without prompt and aggressive conservative treatment. Thorough history taking is vital with maintenance of high level of suspicion as the likely pathologies can be life threatening. Early involvement of multidisciplinary team advice is also critical.