A 38-year-old male was involved in a motor-vehicle collision and found with a Glasgow Coma Scale (GCS) of 3/15 outside his vehicle. He was intubated by the emergency medical services (EMS) at the scene before being transferred to the level 1 trauma center. On arrival to the emergency department (ED), the patient was hemodynamically unstable with a left-sided tension pneumothorax and a positive Focused Assessment with Sonography for Trauma (FAST) test. An emergency thoracostomy tube (TT) was inserted, and the patient was taken to the operating room (OR) for emergent laparotomy. Splenectomy was performed for ruptured spleen. The abdomen was closed, and the patient underwent pan-computed tomography (CT) scan.
Further investigation revealed a traumatic brain injury (TBI) with brainstem contusion, traumatic mydriasis of the right pupil, a right ear laceration, mandibular fractures, and fracture of the spinous process of C6 and T6 and T7 vertebral bodies. Fractures of left ribs 1-11 and 6-12 on the right side were associated with a left hemopneumothorax. Of note, no mediastinal abnormalities were noted on admission CT imaging (Figure 1).
Further management included feeding via a 16 French gauge OGT, the position of which had been confirmed by X-ray (Figure 2), and auscultation as per trauma intensive care unit (ICU) protocol. Later, he was started on Jevity  (Abbott Nutrition) enteral feeding at 80 ml/hour for 24 hours, providing 1,920 kcal/day in accordance with our ICU protocol. Jevity  is a 1 kcal/ml enteral feed with fiber for patients with, or at risk of developing, disease-related malnutrition; it contains a mix of fiber and fructo-oligosaccharides.
A repeat head CT on day 7 revealed a brainstem contusion. A decision was made to insert a percutaneous tracheostomy on the 8th day of admission. Furthermore, 1 liter of transudative pleural effusion was drained via a right-sided 32 French chest drain (inserted using an open technique). The OGT was kept in place during this period. However, the OGT side hole was higher in position (Figure 2).
On day 10, the oral and maxillofacial (OMF) team performed an open reduction and internal fixation (ORIF) of the mandibular para-symphyseal fracture with upper and lower arch bars. During the surgery, the oral endotracheal tube was changed to nasal intubation to facilitate the facial surgery, and the OGT was removed at the same time. Difficultly was encountered by the anesthetist during OGT removal. Video-laryngoscopy revealed whitish solid cheesy material at the upper esophageal orifice, which was manually fragmented and removed using a McGill's forceps. The material was described as "cheesy", calcified feeding substance formed around the tube and taking the shape of the esophagus. An attempt was made to re-introduce a nasogastric feeding tube (NGT) under direct video-laryngoscopic guidance, but resistance was encountered, and the procedure was abandoned.
On the following day, the patient's oxygen saturation readings dropped to 94-96%, accompanied by tachycardia. A new 16 French NGT was inserted smoothly (one attempt), and the left TT was removed.
After 2 days, a CT scan pulmonary angiogram was requested to rule out pulmonary embolism due to persistent tachycardia; this revealed pulmonary embolism in the right main pulmonary artery and left upper lobe. Incidentally, a localized area of heterogeneous air and fluid density was noted along the left upper paraoesophageal region with minimal pneumomediastinum, raising the suspicion of an esophageal injury (Figure 3). The gastroenterology team decided to manage the injury conservatively without endoscopy but with antimicrobial cover, as the patient was hemodynamically stable. No organic gastrointestinal pathology was present. The patient made an uneventful recovery from the esophageal injury, without the development of mediastinitis or further complications. However, his functional recovery from the TBI was poor.