underneath, has been described.3 This is not always feasible if the entire eyelash border is adherent. Care is required when manipulating the cotton bud without visualisation underneath. Other substances such as chlorhexidine gluconate, soap and acetone, which are toxic to the eye, must be avoided. Special care is necessary in all cases of facial lacerations treated with cyanoacrylate TSA. Standardised precautions before application, including tape over the eyelids, positioning of the patient appropriately and the use of high-viscosity TSAs, will minimise cases of iatrogenic eyelid gluing.

Competing interests None declared.

References 1. Singer AJ, Kinariwala M, Lirov R, Thode HC Jr. Patterns of use of topical skin adhesives in the emergency department. Acad. Emerg. Med. 2010; 17: 670–2. 2. Coutts SJ, Sandhu R, Geh VSY. Tissue glue and iatrogenic eyelid gluing in children. Pediatr. Emerg. Care 2012; 28: 810–1. 3. Rouvelas H, Saffra N, Rosen M. Inadvertent tarsorrhaphy secondary to

Dermabond. Pediatr. Emerg. Care 2000; 16: 346. 4. Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. Am. J. Emerg. Med. 2008; 26: 490–6.

Thomas J GIN,1 Jonathan K KAM2 and Carmel CROCK2 1 The Royal Melbourne Hospital, Melbourne, Victoria, Australia, and 2 Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia doi: 10.1111/1742-6723.12169

Delayed presentation and diagnosis of Boerhaave’s syndrome Dear Editor, Boerhaave’s syndrome is a spontaneous rupture of the oesophagus, secondary to a sudden increase in intraoesophageal pressure, which is usually associated with straining or vomiting. A 37-year-old man from eastern Nepal was initially admitted to a peripheral hospital for 4 days with the following history: 3 days of acute epigastric pain, radiating to the back, with no alleviating or aggravating factors. His pain began after several episodes of non-projectile vomiting. The patient also stated that he had consumed several units of alcohol just a few hours before the onset of symptoms. He was diagnosed with acute severe pancreatitis, despite normal serum amylase and lipase levels. His initial CXR was normal. Six days after symptom onset, he developed left-sided chest pain, neck swelling and shortness of breath. He was referred to the ED at Tribhuvan University Teaching Hospital in Kathmandu. There was no history of trauma, fever, cough or similar episodes in the past. There was no history

of pulmonary tuberculosis or abdominal surgery. His vital signs were as follows: BP 120/90 mmHg, PR 116/ min, RR 24/min, SpO2 84% on room air, and he was afebrile. There was subcutaneous emphysema over the upper anterior chest wall and the neck. The patient also had decreased air entry bilaterally with coarse crepitations on the left side. CXR showed bilateral pleural effusions, pneumo-mediastinum and subcutaneous emphysema (Fig. 1). There was a 12 h delay in correct diagnosis following the CXR because of junior medical staff misinterpreting the film and the clinical scenario. CT chest confirmed the (CXR) findings, and also showed an air leak from the oesophagus into the left hemithorax, confirming an oesophageal rupture. The patient underwent an oesophageal resection-oesophagostomy by a cervical approach with feeding jejunostomy. Six weeks later he underwent gastric pull-up with gastrooesophageal anastomosis, with an intial smooth postoperative course. Five months after first admission, he returned with complaints of vague

chest discomfort and left hypochondrial pain. He was diagnosed with an oesphagocele following endoscopy and CT abdomen. Boerhaave’s syndrome is a rare condition with various clinical presentations. It is more common in men, with a mean age between 40 and 60 years. The typical presentation is of Mackler’s triad of vomiting, chest pain and surgical emphysema.1 Atypical presentations, where the diagnosis was not suspected initially, have been described in Nepal. 2 Symptoms can be confused with dyspepsia, myocardial infarction, pancreatitis, dissecting aneurysm, pneumonia or spontaneous pneumothorax. For early diagnosis, the keys are a careful history, high clinical suspicion and the presence of mediastinal and cervical air on CXR. The surgical intervention recommended, irrespective of the duration of the oesophageal rupture, is prompt primary suture closure with reinforcement of the suture line with a well-vascularised pedicled tissue flap.3 Oesophageal resection and diversion is the last resort in patients with sepsis

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine




References 1. Keane M, Gowripalann T, Brodbeck A, Bothma P. A lesson in clinical findings, diagnosis, reassessment and outcome: Boerhaave’s syndrome. BMJ Case Rep. 2012; doi: 10.1136/bcr2012-006485. 2. Gupta RK, Sah PL, Sah S, Sapkota S. Atypical presentation of Boerhaave’s syndrome. BMJ Case Rep. 2012; doi: 10.1136/bcr-2012-006368. 3. Adams BD, Sebastian BM. Honoring the admiral: Boerhaave-van Wassenaer’s syndrome. Dis. Esophagus 2006; 19: 146–51. 4. Rohatagi A, Papanikitas J, Sutcliffe R, Forshaw M, Mason R. The role of oesophageal diverion and exclusion in the management of oesophageal perforations. Int. J. Surg. 2009; 7: 142–4. 5. Haddad R, Teixeira Lima R, Henrique Boasquevisque C, Antonio Marsico G. Symptomatic mucocele after esophageal exclusion. Interact. Cardiovasc. Thorac. Surg. 2008; 7: 742–4. Figure 1.

Pneumo-mediastenium and connection between oesophagus and trachea.

or other comorbidities who are ‘not fit for extended surgery’ to prevent salivary and gastric secretion leakage into the thoracic cavity.4 In this case, it was decided to avoid thoracotomy because of the delayed presentation. A rare complication of oesophagocele after gastrectomy was re-

ported.5 To our knowledge, there are no other reported cases that developed an oesophagocele after the gastric pull-over procedure.

Competing interests

Ajay Singh THAPA,1 Bibhusal THAPA2 and Yogendra SHAKYA1 1 Department of General Practice and Emergency Medicine, Institute of Medicine, Kathmandu, Nepal, and 2Cardio-thoracic and Vascular Surgery, Institute of Medicine, Kathmandu, Nepal doi: 10.1111/1742-6723.12175

None declared.

Nebulised salbutamol challenge confirming life-threatening paradoxical bronchospasm Dear Editor, A 68-year-old otherwise fit and healthy woman with intermittent asthma presented with 3-day history of worsening dyspnoea, which was refractory to her usual budesonide and ipratropium metered-dose inhalers (MDIs). She was admitted for treatment of asthma ex-

acerbation with antibiotics, prednisone and regular formoterol. Her respiratory function returned to baseline by day 4 of admission. The patient was diagnosed with asthma as a teenager, which had been well controlled for many years, with infrequent use of salbutamol MDI.

However, the patient had an in-hospital cardiac arrest at age 53, which was thought possibly associated with salbutamol inhalation. Unfortunately, further details about this incident could not be obtained and the patient never used salbutamol since. The patient had no family history of adverse re-

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Delayed presentation and diagnosis of Boerhaave's syndrome.

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