although , esophageal injuries are uncommon , patients with esophageal perforation may have significant complications with worse outcome . therefore , high index of suspicion is needed for early diagnosis and timely management of such injuries . this hollow viscus structure is susceptible to damage by external blast wave compression and the risk of perforation is greater at points where tissue density changes . however , the incidence of external air compression of the anterior chest wall causing esophageal perforation is an uncommon event that can be missed initially . herein , we report a rare case of esophageal perforation following an external air - compression injury along with the relevant review of literatures . a 38-year - old male worker who mistakenly tried to dismantle a cylinder which was a full of nitrogen gas , suddenly a high pressure gas released and hit his chest at a distance of 30  cm . the patient was transferred immediately to the trauma unit with a complaint of chest pain and shortness of breath . on the initial examination , he was found to have normal vital signs and his chest x - ray revealed large left sided pneumothorax ( fig . 1 , upper panel ) that was managed by chest tube insertion . on the third post - injury day , the chest tube drained 1500  ml of foul smelling cloudy fluid . cultures were obtained and patient was started empirical intravenous antibiotics . however , due to continued drainage , anaerobic growth with methicillin - resistant staphylococcus aureus ( mrsa ) on culture of pleural effusion , and increased white blood cells , a left anterior  lateral thoracotomy with decortication was performed on the 7th day ( for removal of empyemic membrane ) and 2 chest tubes were inserted ( fig . the blue color of the dye was observed inside the chest tube within 15  min ( fig . 2 ) suggesting the presence of esophageal leak into the pleural cavity and hence , chylothorax was excluded . injury in the lower third of the esophagus was subsequently confirmed on chest ct scan with oral contrast and gastrografin study ( figs . 3 and 4 ) . patient was kept on parental nutrition and within 2 weeks , repeated endoscopic and gastrografin study revealed healing of the esophageal injury . blunt esophageal injuries are uncommon particularly , post - external air - blast trauma which has been reported in < 0.01% of the esophageal perforation cases . in such trauma cases , the external pressurized air forms a shock wave which usually directed to the hollow viscus including esophagus through the mouth . injuries to the lower , middle and upper esophagus were reported in 12 , 4 and 4 cases , respectively . previously , we have reported a case of blunt trauma due to fall of heavy object that resulted in injury to the middle esophagus requiring surgical repair through the right thoracotomy . the low incidence of esophageal injuries is attributed to its protection by hard shell of chest wall , flexibility and deep seated location in the posterior mediastinum . experimental studies have investigated the pressure needed to cause esophageal rupture and showed that rupture of the esophagus may occur with an average pressure of 5  psi . anatomically , the lower end of the esophagus is the weakest portion , so the majority of spontaneous ruptures occur in the distal third . the diagnosis of esophageal perforation is relatively difficult when the perforation site is located in the lower thoracic region . in the present case , the diagnosis of perforation in the lower third esophagus was not expected and was missed initially even after thoracotomy , mainly due to extreme inflammatory process and empyema . in retrospect , given the foul smelling odor during thoracotomy should have raised the suspicion , however , there was significant difficulty performing decortication to release the trapped lung . usually , patients suffering from lower esophageal perforation presented with pneumomediastinum and pneumothorax and this could be attributed to the same mechanism of injury , as rapid compression / decompression of internal organs . though , chest pain and dyspnea are frequently observed in patients with esophageal perforation , these signs are not specific indicators of esophageal rupture . chest pain is considered as the primary symptom of esophageal perforation and is persistently observed in the majority ( > 70% ) of cases with full thickness perforation . early diagnosis of esophageal rupture is of vital importance , and once the diagnosis is confirmed , esophageal perforation should be management on urgent basis by a team of experts . the role of oral methylene blue in the differential diagnosis of esophageal injury was appreciated in our case . early diagnosis of esophageal perforation ( < 12  h ) requires direct surgical repair , although the data on use of stent in traumatic injuries are lacking . however , iatrogenic injuries to the esophagus are often managed by temporary stenting . in case of delayed diagnosis ; conservative management is preferable as surgical closure might be contraindicated in some patients . in contrast , port et al . reported successful repair of delayed esophageal rupture that was diagnosed > 72  h post - injury . current literatures have demonstrated an increasing utility of temporary endoscopic esophageal stents for closure of esophageal leakage and to recover gastrointestinal continuity . our case was managed successfully by an endoscopic stenting and the patient was kept on parental nutrition , although enteral nutrition is advisable . the mortality rate of esophageal perforation has been reported as up to 20% , however , this figure may reach the double with treatment beyond the first 24  h post - injury . in general , the outcome of esophageal perforation is influenced with many factors including the cause , location of injury , coexistent esophageal disease , and the time elapsed between perforation and initiation of therapy . patients with external air - compression injury presented with chest pain and pneumothorax should be suspected for esophageal perforation . for early diagnosis of such rare injuries , high index of suspicion and thorough radiological evaluation appropriate drainage , antibiotic and temporary endoscopic esophageal stenting seem to be the promising treatment approach in selected patients . this case report has been approved by the medical research center ( irb # 14012/14 ) , hamad medical corporation , doha , qatar . mm : data collection , drafting and approval of manuscript.ha : data collection , drafting and approval.ae : data analyses , drafting and approval.ia : data interpreting , drafting and approval.ah : manuscript drafting and approval.aa : data collection , drafting and approval.rl : data collection , drafting and approval.hal : data interpreting , drafting and approval.key learning pointsblunt esophageal injuries are uncommon particularly , after external air - blast trauma.high index of suspicion for early diagnosis of this injury is needed.appropriate drainage , antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients . blunt esophageal injuries are uncommon particularly , after external air - blast trauma.high index of suspicion for early diagnosis of this injury is needed.appropriate drainage , antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients . appropriate drainage , antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients .
introductionblunt esophageal injuries secondary to external air compression of anterior chest and abdomen complicated with esophageal perforation are uncommon events associated with worse outcomes.presentation of casewe reported a rare case of esophageal perforation following an external air - compression injury along with the relevant review of literatures . the patient presented with chest pain and shortness of breath and 
 was managed with tube thoracostomy , followed by thoracotomy and eventually with temporary endoscopic stenting.discussionin such trauma case , the external pressurized air forms a shock wave which usually directed to the hollow viscus . 
 patients with external air - compression injury presented with chest pain and pneumothorax should be suspected for esophageal perforation.conclusionhigh index of suspicion is needed for early diagnosis of esophageal perforation after blunt trauma . 
 appropriate drainage , antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients , especially with delayed diagnosis .