A noncontrast CT scan of the head offers a number of advantages, including evaluation of pleura, mediastinum, and aorta. It is often very difficult to see the exact perforation site on a CT scan of the head. The patient may be in severe pain, and analgesia may be required. Establish an IV, provide oxygen, and place the patient on a monitor. Because airway compromise may be present, full resuscitative facilities should be readily available at bedside.
Diagnosis can be difficult but is important to rapid definitive therapy.
As soon as diagnosis is considered, initiate investigation to ascertain site and extent of rupture. Early diagnosis is important for optimum management. The most favorable outcome is obtained by following primary closure within 24 hours. For patients presenting with mild symptoms or minimal evidence of sepsis, a barium enema may show perforation contained within mediastinum and draining back into the esophagus. Rarely, tube thoracostomy may be urgently used to decompress the chest.