Abstract
Background
Dysphagia is the sensation of difficulty swallowing and is a common clinical problem that warrants prompt evaluation, diagnosis, and management. Dysphagia has a large differential diagnosis including mechanical obstruction and neurological pathology.
Aims
We aim to report a series of unusual cases of dysphagia to remind readers to have an index of suspicion for atypical etiologies of dysphagia.
Methods
Three cases were identified in clinical practice and included in this case series.
Results
Case 1
A 61-year-old male presents with a 4-month history of progressive solid and liquid oropharyngeal dysphasia and 20-pound weight loss. Nasopharyngeal laryngoscopy and gastroscopy did not reveal structural abnormality. CT neck and chest showed diffuse idiopathic skeletal hyperostosis (DISH).The C3-4 osteophyte formed a shelf-like projection anteriorly measuring up to 1.8 cm which compressed the posterior hypopharynx at the level of the epiglottis, likely impeding epiglottic inversion (Fig. 1a). The patient tolerated percutaneous endoscopic gastrostomy tube insertion with no complications and will seek surgical consultation for treatment of DISH.
Case 2
A 30 year-old female snowboarder fell 15 feet onto hard-packed snow and sustained soft tissue injuries to her left hip and chest wall. Forty-eight hours later, she developed retrosternal pleuritic chest pain and progressive dysphagia and odynophagia. CT chest/abdomen showed no abnormalities; however, gastroscopy revealed several partial-thickness esophageal tears with visible muscle fibers just above the gastroesophageal junction (Fig. 1b). She was treated conservatively for 3 days with NPO, intravenous pantoprazole and intravenous piperacillin-tazobactam with no complications.
Case 3
A 72-year-old female presented with dysphagia, odynophagia and melena stool. She had a thoracic stent graft exclusion of a ruptured thoracic aneurysm 2 months ago, which was complicated post-operatively by methicillin-susceptible Staphylococcus aureus bacteremia and thoracic epidural abscess. CT angiography showed type 1 endoleak at the inferior margin of the thoracic aortic stent. Gastroscopy showed a bleeding aortoesophageal fistula (Fig. 1c). Due to patient frailty no further surgery was recommended and she was offered palliative treatment.
Conclusions
Dysphagia is a non-specific clinical symptom that has a broad differential diagnosis. The workup of dysphagia must be focused to the patient’s history; in these three cases, a rare diagnosis was considered in the clinical context and appropriate management was promptly initiated. In order to make these diagnoses, there must be an index of suspicion for uncommon causes of dysphagia. This case series reminds the clinician that patients can present with time-sensitive and life threatening disease with a primary symptom of dysphagia, and consideration for uncommon etiologies is crucial in delivering prompt management to these patients.
Figure 1. a) 61-year-old male with DISH presents with oropharyngeal dysphagia due to prominent C3-4 osteophyte projecting anteriorly and compressing the posterior hypopharynx. b) 30 year-old female with dysphagia and odynophagia due to isolated partial-thickness esophageal tears from deceleration injury. c) 72-year-old female with dysphagia and odynophagia secondary to aortoesophageal fistula due to infected thoracic aortic stent graft.
Funding Agencies
None