Individual case: A complete esophageal lumen obstruction

A patient with head and neck cancer presented with a fever and dry mouth.


The patient

A 74-year-old man with a moderately differentiated squamous-cell carcinoma of the larynx that had spread locally to surrounding tissues and lymph nodes (stage IVA) presented with one day of fever and no associated symptoms except for dry mouth of several months' duration. He had been diagnosed with head and neck cancer 12 months before presentation and had been treated with a cisplatin-based chemotherapy and 7,4-Gy radiation dose. The patient had a tracheostomy and a percutaneous endoscopic gastrostomy tube placed before the treatment, relied completely on enteral feedings for nutrition, and had had a failed swallow evaluation three months earlier.

On physical exam, he had a temperature of 99.6 °F, a heart rate of 122 beats/min, and a respiratory rate of 22 breaths/min. He had a 2×2-cm hard mass below the right jaw and decreased breaths sounds on the right anterior hemithorax with no egophony.

Figure CT scan of the chest with IV contrast coronal view showing residual barium in the distal esophagus red arrows assumed to be from the earlier swallow study
Figure. CT scan of the chest with IV contrast, coronal view, showing residual barium in the distal esophagus (red arrows), assumed to be from the earlier swallow study.

A chest CT scan with IV contrast showed a right-middle-lobe pneumonia and residual barium in the distal esophagus (Figure). An esophagogastroduodenoscopy confirmed the presence of small amounts of barium and a complete esophageal stricture with no obvious lumen. No dilatation was attempted given the absence of an esophageal lumen endoscopically and/or radiologically. The patient went home after completing antibiotics for the aspiration pneumonia. He died a year later when the neck mass eroded into the carotid artery.

The diagnosis

The diagnosis is complete esophageal lumen obstruction due to esophageal toxicity following chemoradiation. Esophageal toxicity is a common occurrence with head and neck cancer treated with radiation and/or chemotherapy. Almost all patients develop some degree of acute superficial mucositis, and about half experience dysphagia. Long-term toxicities include chronic dysphagia (50%), symptomatic strictures that limit intake of either solids or liquids (37%), and complete strictures that limit any type of intake (7% to 37%), according to a 2013 review published by The Lancet Oncology.

Acute esophageal mucositis is believed to be the initial tissue damage that leads to the dysphagia and to the stricture formation. The actual mechanism of tissue damage is poorly understood but includes direct tissue toxicity, proinflammatory cytokines and pathways, reactive oxygen species, second messengers, and metabolic byproducts or microorganisms that colonize the mucosa. The hypopharynx is the anatomical area most vulnerable to strictures given the natural narrowing and presence of the pharyngeal constrictor muscles. Other important risk factors include the chemotherapy regimen administered, the dose of radiation and the fractionation scheme, patient's age and gender, and preservation of oral intake.

Pearls

  • Clinically significant dysphagia is a common complication of radiation and/or chemotherapy for head and neck cancer.
  • The pathophysiology of dysphagia resulting from radiation and/or chemotherapy is poorly understood but includes direct toxicity, proinflammatory cytokines and pathways, reactive oxygen species, second messengers, and metabolic byproducts of microorganisms that colonize the mucosa.

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