Introduction
Progressive dysphagia following chemoradiation therapy is the most common complaint of esophageal cancer patients. Common causes for acquired TEF in adults include trauma, prolonged endotracheal intubation, and malignancy. There are sparse data on incidence of acquired malignant TEF as it is very rare. In few studies, incidence of TEF following primary esophageal cancer and lung cancer was reported at 4.5% and 0.3%, respectively. In this case, we report a patient in which distal TEF may have been missed during conventional Videofluroscopic Swallowing Study (VFSS) but was diagnosed only after sequential cup drinking of liquid brim.
Case
67-year-old man was reffered for dysphagia and newly diagnosed as esophageal cancer. He took Ivor-Lewus operation (Esophagectomy and esophagogastrostomy) on October, 2017 and due to anastomtic site leakage, endoscopic foam packing was done. He had been eating soft diet after operation and had no difficulty in swallowing. He readmitted for CCRT to paraesophageal region, regional recurrence and finished RT on July, 2018. At that point, the patient complained of coughing in liquids, especially when he drank in large amounts. A neurological exam showed no abnormalities in this cranial nerve system. At the same time he was diagnosed with aspiration pneumonia and was kept nil per mouth until the cause of aspiration was confirmed. He was referred to our department to find the cause of aspiration pneumonia. A standardized VFSS following the Logemann protocol was performed. He swallowed spoons of liquid barium, subsequent bolus introduction with nectar thin jelly followed by soft and hard solid bolus showed no evidence of oropharyngeal dysphagia. Before leaving, He was asked to swallow a cup of liquid drinking in a sequential manner and after swallowing the liquid barium, he suddenly coughed out the barium liquid that was previously seen to go through the esophagus with no evidence of entrance past the glottis. A scanning of the esophageal and bronchial levels showed barium radiocontrast on his whole trachea and whole brochus. A post VFSS Abdomen showed presence of most barium that the patient had swallowed during the exam. However, a high suspicion of TEF was made. Further evaluation revealed presence of TEF through both chest CT and bronchoscopy. We suspect that due to the small size of the TEF, no aspiration was detected during small amounts of liquid or other thicker boluses and that it was only entrance past TEF during cup drinking that showed the presence of aspiration past TEF.
Conclusion
Patient with esophageal cancer, especially after radiation therapy, may complain of dysphagia related to post radiation changes of the pharyngoesophageal walls. Physicians should be aware of possibility of hidden structural abnormality like TEF when a standardized swallowing protocol of the VFSS failed to capture any positive findings, despite event suspicious symptom of dysphagia. |
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Figure 1. VFSS finding showing normal passage of liquid barium (#1~4) without aspiration, and delayed regurgitation of the swallowed liquid barium via trachea(#5~8). Post VFSS chest and abdomen x-ray findings showing increased haziness in RMLF and RLLF and gastric contents of swallowed barium(A~B).
Figure 2A. Broncoscopy finding showing fistula opening around surgical metal clip lesion proximal to right lower bronchus. 2B. CT scan showing a few tiny air bubbles around the right mainstem(circle), abutting the surgical clippings.
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