Hiding in Plain Sight: An Unusual Case of Progressive Dysphagia, Dyspnea and Dysphonia
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CLINICAL CONUNDRUM
Hiding in Plain Sight: An Unusual Case of Progressive Dysphagia, Dyspnea and Dysphonia Stephanie D. Mes1 · Tjouwke A. van Kalkeren2 · Rutger J. Jacobs3 · Inez M. J. H. Coene2 · Antonius P. M. Langeveld1 · Heiko Locher1 Received: 28 June 2020 / Accepted: 24 August 2020 © The Author(s) 2020
Clinical Conundrum An 87-year-old woman presented with progressive solid food dysphagia that had been on-going for over 10 years. Her medical history included sarcoidosis, atrial fibrillation, hypertension, and a right-sided hemicolectomy for cecal adenocarcinoma. During gastroenterological consultation in a secondary setting, a barium swallow test revealed severe dilation of the proximal and distal esophagus, stasis of the bolus at the level of the aortic arch, and a “rat-tail” appearance of the esophagogastric junction (Fig. 1). Subsequent gastroscopy showed atony, esophageal dilation, and a narrowed tortuous segment in the distal esophagus (Fig. 2). Dilation was performed with Savary bougies up to 16 mm; however, this did not improve her swallowing. Although no definitive diagnosis could be made, a long-standing nonspecific esophageal motility disorder was suspected. As her symptoms were mild, the patient agreed to conservative management with observation. Two years later, the patient developed additional symptoms of dyspnea and dysphonia. During meals, she became increasingly short of breath. She also developed a dorsal articulation that was progressive during the day. At this time, the patient was referred for tertiary ENT consultation. Fiberoptic laryngoscopy revealed a non-solid bulging of the posterior pharyngeal wall, which was present at rest (Fig. 3a) and expanded over the larynx upon valsalva, swallowing, * Heiko Locher [email protected] 1
Department of Otorhinolaryngology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
2
Department of Otorhinolaryngology, Alrijne Hospital, Houtlaan 55, 2334 CK Leiden, The Netherlands
3
Department of Gastroenterology, Alrijne Hospital, Houtlaan 55, 2334 CK Leiden, The Netherlands
and phonation (Fig. 3b). CT scanning revealed a severely dilated esophagus (Fig. 4). As the findings did not explain the pharyngeal posterior wall swelling, and since her symptoms had progressed, a second evaluation in a multidisciplinary setting was arranged.
Teaching and Clinical Points The multidisciplinary evaluation included a gastroenterologist, radiologist, and otorhinolaryngologist. This group re-evaluated the neck CT scan. Adjustment of the contrast settings revealed a giant mid-esophageal diverticulum, rather than the supposed severely dilated esophagus. The diverticulum expanded in the retropharyngeal space all the way up to the level of the epiglottis tip—measuring 78 mm in the lateral, 38 mm in the antero-posterior, and 140 mm in the cranio-caudal direction (Fig. 5). The posterior pharyngeal wall bulging corresponded to the most cranial part of the airfilled diverticulum. This phenomenon explained her dyspnea and dysphonia dur
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