PP is a challenging clinical entity that requires careful consideration regarding diagnosis and treatment. The rarity of PP and the diversity of its causative factors underscore the need for dedicated research and differentiated approaches to improve patient outcomes [1, 2].

Our study, focused on iatrogenic and traumatic PP, delves into the complexities surrounding diagnostic and treatment interventions. The comprehensive review of medical records from 36 patients treated at the Quaternary Medical Center of Otorhinolaryngology between 2010 and 2020 forms the basis of our insights.

Our findings suggest an association between the location of pharyngeal perforation and the risk of mortality during hospitalization. Specifically, patients with hypopharyngeal perforations have an almost 42-fold higher risk of mortality compared to those with epipharyngeal or oropharyngeal perforations. This emphasizes the need for tailored interventions, vigilant monitoring, and potentially different treatment modalities based on the perforation site. However, these results should be interpreted with caution due to the limited patient sample.

PP may be suspected from the history and findings on physical examination, but the diagnosis depends on imaging and endoscopic examination [4, 7]. If a perforation is identified endoscopically, it may also be closed simultaneously with an endoscopic closure technique, depending on certain criteria such as the location, size and margins of the defect. Endoscopic closure techniques include Through-the-Scope-Clips, Over-the-Scope-Clips, esophageal stents and endoscopic suturing techniques [20].

The gold standard for the diagnosis of PP is imaging by contrast esophagography with a water-soluble contrast agent. Barium provides better contrast images, but may cause a more severe inflammatory reaction, therefore water-soluble contrast media with minimal mediastinal irritation is preferred [7, 21,22,23].

Computed tomography with oral or intravenous contrast has a high sensitivity. CT with contrast media should be considered as the first imaging test for PP [24, 25].

Our study shows that computed tomography was initially performed for diagnosis in 29 patients (80.5%), whereas contrast esophagography with a water-soluble contrast agent was not used as initial diagnosis. Contrast esophagography with a water-soluble contrast agent was only performed as control imaging. Computed tomography was used not only for initial diagnosis but also for follow-up in 25 patients (69.4%).

A quick and correct diagnosis is very important, a delayed diagnosis leads to a delayed therapy and a therapy delayed more than 24 h can lead to a higher morbidity [26,27,28,29]. A delay in treatment of 12–24 h allows sufficient leakage of saliva and bacteria surrounding loose areolar tissue to produce a purulent infection and an intensifying inflammatory response [30]. This inflammation in the fascial spaces of the head and neck may allow rapid downward spread of infection into the mediastinum under gravity and negative intrathoracic pressure [31].

In our study, the interval between perforation or event that caused perforation and diagnosis was between 0 and 6 days. The interval was between 1 and 6 days in 13 patients (36%), in other 23 patients (63.88%) perforation was identified on the same day.

Due to a lack of sufficient studies, the treatment method for perforations is still controversial today. After an adequate diagnosis, it is important to start therapy quickly. Whether conservative therapy or surgical therapy, the nasogastric feeding tube is one of the most important procedures for therapy of PP, which can also be inserted during panendoscopy [9]. The most commonly used antibiotics in the treatment of PP are cefuroxime and metronidazole as well as imipenem and meropenem [2]. Cefuroxime is effective against most gram-negative and gram-positive aerobes and metronidazole is highly effective against anaerobes [32, 33].

According to our data, all 36 patients (100%) were treated surgically. The most frequently performed procedure was transcervical mucosal suture (n = 19/52.78%). Surgical intervention as a first and repeat procedure together was performed in 4 (11%) patients using transcervical mucosal sutures with flap closure techniques such as pectoralis and free flap procedures. Despite initial adequate surgical and antibiotic therapy as well as feeding via nasogastric tube, surgical interventions should have been performed again in 15 patients (41.66%). The number of surgical interventions performed varied from 1 to 10, depending on the complications after the initial surgery. Cephalosporins in combination with metronidazole were used in 22 patients (61%). A total of 35 patients (97%) were treated with antibiotics.

Depending on localization perforations smaller than 2 cm can be treated conservatively with observation, gastric tube and intravenous antibiotics; however, if lesions are larger than 2 cm, surgical therapy, if necessary, neck exploration with drainage is recommended [8].

After approximately 5–21 days after insertion of the gastric tube in the case of surgical or conservative therapy before removal of a gastric tube, a contrast esophagography with a water-soluble contrast medium is recommended to exclude extravasation [34].

Our retrospective study showed that mortality was rather low compared to other studies. However, the management of PP is still controversial until now. Collaborative efforts, prospective studies, and multicenter investigations are essential to develop more accurate concepts and recommendations for the diagnosis and treatment of pharyngeal perforations.