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Objectives/Hypothesis Presentation of a case of esophageal perforation caused by ingestion of a foreign body that was difficult to visualize endoscopically, and systematic review of the current literature with a focus on available diagnostic modalities and missed diagnoses. Data Sources MEDLINE (1946-2014) Review Methods We conducted a systematic review of MEDLINE for cases and studies of esophageal perforation due to foreign bodies. Results A systematic review of esophageal perforations caused by foreign bodies revealed 40 studies that included 168 patients. Neck/chest pain, odynophagia, and dysphagia were the most common presenting symptoms-each occurring in the majority of patients. Where reported, diagnostic sensitivity of lateral neck X-rays was 56%, and computed tomography (CT) scan was 100%. Nine of 168 cases specifically mentioned a missed diagnosis. Very few studies reported a failure to visualize the foreign object at the time of primary rigid or flexible esophagoscopy. No studies reported nonvisualization of the foreign body at the time of open surgery. Conclusion Esophageal perforations due to foreign bodies are rare but carry potentially devastating complications. Delays in diagnosis are common, and no standard diagnostic algorithm exists. Lateral neck X-rays are an easy but insensitive screening test. Laryngoscopy is an excellent screening test but not always diagnostic. CT is a more sensitive diagnostic method, which can also help guide management based on the detection of complications. Although seldom described, if an object is not visualized at the time of endoscopic or surgical intervention, follow-up CT may be useful in determining the persistence of effects of the perforation or the foreign body. Laryngoscope, 125:371-378, 2015 [ABSTRACT FROM AUTHOR]