Hypopharyngeal perforation is a rare but potentially life-threatening complication that can follow cervical or aerodigestive procedures. Its deep anatomical location and often subtle symptoms make early recognition difficult, increasing the risk of mediastinitis and sepsis. Massive hematemesis as the initial manifestation is exceptionally uncommon and diagnostically challenging.

A 49-year-old man underwent elective C4–C5 anterior cervical discectomy for degenerative canal stenosis. Shortly after extubation, he developed massive hematemesis. Endoscopy revealed a perforation of the right pyriform sinus, with a Redon suction drain traversing the hypopharyngeal wall into the laryngeal lumen. Emergency direct pharyngolaryngoscopy was performed; the drain was carefully removed and the defect closed endoscopically with interrupted sutures reinforced by biological fibrin sealant. The postoperative course was uneventful, and at three-month follow-up the patient showed complete recovery without stenosis or fistula.

This case describes an exceptionally rare iatrogenic hypopharyngeal perforation caused by a Redon suction drain after anterior cervical discectomy, presenting atypically with massive hematemesis. It highlights the diagnostic challenge and potentially dramatic presentation of hypopharyngeal perforation following anterior cervical spine surgery. The report underscores the importance of meticulous drain placement, intraoperative vigilance, and postoperative airway and swallowing surveillance in preventing aerodigestive complications after cervical or transoral procedures.