eng Science and Education Publishing American Journal of Medical Case Reports 2374-216X 2020-11-04 9 1 40 44 10.12691/ajmcr-9-1-11 AJMCR20219111 article Abhilash Haridas abhilashsaras@gmail.com 1 Midhun Ramesh 2 Padmavathy Ramadoss 2 Ravi Sreekumaran Nair 2 Sree Gokulam Medical College, and Sree Gokulam GG Hospital, Trivandrum, Kerala State, India SK Hospital, Trivandrum, Kerala State, India Esophageal perforation is a rare complication of foreign body ingestion. The most common foreign bodies causing esophageal perforation in adults are fish and chicken bones. We present the case of an octogenarian man with mild cognitive impairment presenting with respiratory complaints of dyspnoea and orthopnoea in the emergency room. He had hyponatremia induced confusion in addition to his mild cognitive impairment. The diagnosis for his clinical condition was not evident. Evaluation by imaging detected the "missing link" chicken bone as the cause of esophageal double perforation with mediastinitis and bilateral pleural effusion. Following multidisciplinary discussion, the minimally invasive endoscopic approach was decided as the definitive therapy. After medical stabilization in ICU, he underwent endoscopic retrieval of the foreign body followed by fully covered self-expandable metallic stenting. He recovered well and the stent removed after three weeks. Six months down the lane he is doing well and under neurology follow up for mild cognitive impairment. This clinical case shows the atypical, delayed perplexing presentation of esophageal foreign body in the elderly and the need for individualized treatment decision making for a successful outcome. http://pubs.sciepub.com/ajmcr/9/1/11/ajmcr-9-1-11.pdf esophageal perforation chicken bone cognitive impairment endoscopy