The ingestion of a caustic substance can lead to severe damage to the esophagus. Currently, esophagoscopy is recommended for all patients with a history of caustic substance ingestion because clinical criteria have not proved to be reliable predictors of esophageal injury. The records of 79 consecutive patients younger than 20 years who were first seen with a history of corrosive ingestion were reviewed. The presence or absence of three serious signs and symptoms--vomiting, drooling, and stridor--as well as the presence and location of oropharyngeal burns were compared with the findings on subsequent esophagoscopy. Fifty percent (7/14) of the patients with two or more of these serious signs and symptoms (vomiting, drooling, and stridor) had serious esophageal injury as compared with no positive endoscopic results in the group with none or only one of these clinical findings. The presence of oropharyngeal burns did not identify patients with serious esophageal injury. These results suggest that the presence of two or more signs or symptoms in patients with a history of caustic substance ingestion may be a reliable predictor of esophageal injury.