Oral Sex can be hazardous to your health

From one of my attendings via email while working at another ER in the city:

he presenting complaint was “sore throat”.

the patient was very up front about what happened: 38yo female with past medical history significant for daily alcohol use (she was drunk at noon when i saw her) complaining of sore throat since the night before. while performing oral sex on her fiance, she felt a sudden sharp pain and started “bleeding like my period” from her mouth and nose. she kept spitting the blood out and it subsided about 20mins later. she then went to sleep. when she woke up in the morning, she noted severe throat pain and could not turn her head due to the pain.

vitals were normal. exam, aside from a subtle soft tissue abnormality in the posterior oropharynx (ed note: basically where your mouth meets your throat) and her resistance of essentially all head/neck movement, was unremarkable. CBC (ed note: complete blood count measure your white cells, red cells, etc) was normal, except for her platelets of 55k (ed note: this is very low and makes you more susceptible to bleeding). pain meds did nothing, in fact her pain was getting worse. that’s when i got the plain films (ed note: aka x-rays). broad-spectrum antibiotics and a CT scan rapidly followed. attached are some images from her ct.

she had free air from the base of the skull down into the mediastinum (ed note: middle of the inside of your chest/thorax inbetween the lungs). there was fluid as well, but no abscess (ed note: abscess is a pocket of infection that can be extremely dangerous). she started having worsening pain and started retching. her next stop was the ICU (intensive care unit). i don’t have follow-up yet but ENT (Ear Nose and Throat Surgery) planned to observe her initially given that, at the time, her airway was fine and there was no abscess.

bummer of a hummer indeed…

That may be the greatst email I’ve ever recieved.  Just a bit of background in case your lost, as I’ve sent this to several non-medical friends and they were a bit confused by the significance of the story.  Many alcoholics can develop severe thinning of their esophagus from chronic vomiting.  Because of the thinning it’s quite easy for them to tear their esophagus during an episode of retching.  We even have a name for it in medicine: a Mallory-Weiss tear.  Once the esophagus is torn, it obviously will bleed like a stuck pig, which is often not good as most alcoholics have low platelet counts like our patient above.  A platelet count of around 50K is pretty low and can lead to poor clotting of blood, which will cause excessive bleeding.

The other thing that can happen is that a torn esophagus will allow air into places it shouldn’t go.  The danger of this is that air irritates the body and causes exceptional pain and swelling when it tracks into undesired areas.  This frequently happens in the abdomen when a stomach ulcer perforates through the wall of the stomach.  Air then tracks into the stomach and causes very severe pain.  We consider air in the abdomen a surgical emergency and air found in any other part of the body where it shouldn’t be is also an emergency.

The other danger in tearing part of your GI tract open is that there’s a lot of bacterial flora that hang out naturally in the GI tract.  That bacteria can track along with the air to places it shouldn’t be.  They can collect and make a walled-off area of infectiona and inflammation called an abscess.  Our patient here didn’t have one but we worry a great deal about that, because abscesses can lead quickly to sepsis.  Sepsis is a state of extreme badness.  The body is overwhelmed by bacterial infection that is now in the bloodstream.  As your body attempts to fight this overwhelming infection, your immune cells are pouring out special proteins and enzymes to help recruit other cells to kill off bacteria.   Some of these proteins cause very high fever and can often raise your heart rate and drop your blood pressure to very dangerous levels.  When that happens we call it ’septic shock’.

Fortunately, that didn’t happen above, likely because it had been caught relatively early, but if left alone it would have been a very likely outcome.  She was pretty lucky in the long run.

This is a pretty unique story though.  There’s no case reports in the medical literature of any patient ever having an esophageal rupture/tear after performing oral sex.  The CTs and X-rays are pretty impressive also, but to an untrained eye they don’t look like too much so I won’t bore you with them here.  My attending is hoping to have this published in a journal or at least present the case at a few conferences in the upcoming year.  If that happens I’ll be sure to link to them.

Stay safe out there folks.