TITLE OF
CASE
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Megaoesophagus presenting as
stridor
AUTHORS
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SK Drever 1, V Thirumal 1, F Cooper
1, D McAteer 2
1 Department of Otolaryngology, Aberdeen Royal
Infirmary, Aberdeen, Scotland
2 Department of Radiology, Aberdeen Royal Infirmary,
Aberdeen, Scotland
Corresponding author:
Sara Drever, Department of Otolaryngology, Aberdeen Royal Infirmary,
Aberdeen
Email: katharinedrever@live.co.uk
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DESCRIPTION
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A female presented to the
Emergency Department with a four-day history of progressive
breathlessness and intermittent coughing episodes followed by stridor.
She reported no dysphagia or odynophagia. Examination revealed a marked
inspiratory stridor but no respiratory compromise. Flexible
nasolaryngoscopy showed no obvious supraglottic swelling; however, the
larynx was rotated towards the right, which corresponded with her neck
examination which revealed a soft palpable swelling along the left-hand
side. Her past medical history included hypothyroidism, atrial
fibrillation, and small bowel ischaemia requiring laparotomy and small
bowel resection 4 years prior.
A chest X-ray showed a markedly dilated oesophagus throughout its length
which was shown to be chronic when compared to previous X-rays (Figures
1 & 2). Computed tomography revealed oesophageal dilatation causing
mass-effect and compression upon the tracheobronchial tree and larynx.
Tracheal narrowing was noted to be 3–4 mm in the upper mediastinum
(Figure 3).
She was treated with nebulised adrenaline and intravenous dexamethasone
in the Emergency Department, which settled her stridor. She was admitted
to the Otolaryngology Ward for observation overnight.
Upon discharge, she underwent a barium swallow (Figure 4), demonstrating
marked cricopharyngeal spasm causing significant luminal narrowing but
no significant holdup of barium. The remainder of the oesophagus was
chronically dilated and appeared atonic but there was prompt emptying
into the stomach. The findings were atypical of achalasia, there were no
obstructing lesions identified and it was felt that chronic dysmotility
was most likely.
She was followed up at 6 months and reported no further symptoms. A
gastroenterology review suggested that the patient’s presentation was
due to an atonic hypo-motile oesophagus with a degree of dysmotility.
The patient declined further investigations.
One year following her initial presentation, she attended the Emergency
Department with biphasic stridor and signs of respiratory distress.
Flexible nasolaryngoscopy again identified a large swelling in the left
hypopharyngeal compressing the larynx (Video 1). She was transferred to
theatre for intubation +/- tracheostomy; however, during transfer, her
stridor settled and compression on the larynx lessened (Video 2),
allowing safe insertion of a wide-bore nasogastric tube under flexible
nasolaryngoscopic visualisation via the non-compressed right pyriform
fossa. Aspirating the air from the dilated oesophagus resulted in
complete decompression of her larynx (Video 3) and the stridor
disappeared. Following observation overnight, the nasogastric tube was
removed, the patient commenced a soft diet and was discharged home. An
alert has been put on her electronic patient record so that if she
presents again with this problem, the team are aware of the successful
management method described above which avoided the need for intubation
or front of neck access. The patient has opted out of surgery to address
her oesophageal condition as she is asymptomatic between episodes.
Megaoesophagus is rare, most frequently presents with dysphagia and
regurgitation of food and is most commonly caused by achalasia. A
literature search identified only one previous case of obstructing
megaoesophagus secondary to idiopathic dysmotility disorder; however,
this case revealed the stridor to be secondary to an impacted food
bolus, whereas our case did not demonstrate any obstructing
lesions.1-4
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LEARNING
POINTS
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Acute airway obstruction is a rare presentation of
megaoesophagus
Megaoesophagus is commonly caused by achalasia; however, we
present a case of megaoesophagus caused by idiopathic dysmotility
disorder
Decompression with a wide bore nasogastric tube avoided a
scenario of difficult intubation or emergency front of neck access
CONSENT
STATEMENT
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Approval from an ethics committee was not required in
this case; however, verbal and written informed consent was obtained
from the patient prior to submission for
publication.
ACKNOWLEDGEMENTS
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None. |