Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary?

OBJECTIVE: The purpose of our study was to determine the necessity of fluoroscopic esophagography in patients with pneumomediastinum on CT but without CT findings of esophageal perforation.

MATERIALS AND METHODS: From January 1, 2006, through December 31, 2010, there were 4305 fluoroscopic esophagography examinations including 533 with CT identified from a search of our PACS. Patients with pneumomediastinum on CT who were subsequently referred for emergent fluoroscopic esophagography to exclude esophageal perforation were enrolled. Fluoroscopic esophagography examinations performed within 3 days of CT were included. Patients with a history of esophageal disease were excluded. As a result, 103 patients were enrolled in the study; patients were divided into groups on the basis of whether there was additional clinical history of esophageal damage (trauma group) or not (nontrauma group). Images were reviewed by two board-certified radiologists blinded to the clinical data and radiologic reports for the presence or absence of esophageal perforation. A positive result on CT was defined as esophageal injury or periesophageal infiltration that coexisted with periesophageal air. A positive fluoroscopic esophagography result was defined as oral contrast medium leakage from the esophagus.

RESULTS: Esophageal perforation was diagnosed in 15 of the 103 patients. The CT findings were significantly correlated with esophageal perforation (p < 0.001 in the trauma group, and p = 0.001 in the nontrauma group). The respective sensitivity and negative predictive value (NPV) of CT versus fluoroscopic esophagography in the trauma group were 100% versus 66.7% and 100% versus 87.9%; in the nontrauma group, the sensitivity and NPV were 100% for CT and fluoroscopic esophagography. Thus, the sensitivity and NPV of CT were either superior or equal to those of fluoroscopic esophagography.

CONCLUSION: The results of our study suggest that performing fluoroscopic esophagography in patients with pneumomediastinum is unnecessary when CT is negative for esophageal perforation.