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of a 65−year−old patient caused by the perforation of the proximal esophagus by an accidentally swallowed toothpick. The patient presented at our emergency unit with increased dysphagia and retro− sternal pain for the past 6 days. The con− sumption of solid food had not been possible for the past 3 days. Swallowing liquids induced retrosternal pain. Choking on a solid piece of food or accidentally swallowing a foreign body was denied. The symptoms had started shortly after his last solid meal 6 days previously. The laboratory results showed elevated C−re− active protein levels (11.6 mg/dl) and an elevated lactate dehydrogenase of 348 U/ l. The patient reported no medical history and no current medication. A computed tomography scan showed multiple en− larged lymph nodes near the maxilla and a solid tissue formation in the posterior mediastinum. Below this tumor, a local thickness of the esophagus was noticed accompanied by pathologic contrast medium−enhancement of the wall. More− over, multiple enlarged lymph nodes peri− tracheal were detected (l" Fig. 1). The pa− tient was suspected of having of an esoph− ageal tumor and was referred to our unit for upper gastrointestinal endoscopy. The endoscopy showed, at 20 cm below the alignment, the orifice of a fistula sur− rounded by fibrin−covered tissue and in− flammation up to 17 cm (l" Fig. 2 a). No signs of a tracheo−esophageal fistula were seen. For further histological examination, a biopsy from the region of the fistula ori− fice was taken, during which a toothpick was discovered and endoscopically removed (l" Fig. 2 b). Under parenteral nutrition and antibiotic therapy for several days the patient im− proved rapidly, and a control computed tomography scan and upper gastrointes− tinal endoscopy showed only small areas of residual inflammation. There are several case reports in the lit− erature reporting ingestion of a toothpick as the cause for perforation of the stom− ach, duodenum or even the colon [1± 3], but so far no reports describing an esoph− ageal perforation have been published.

Unusual cause for dysphagia: perforation of the proximal esophagus by a toothpick