Giant midesophageal diverticulum presenting as food impaction: case report and review of the literature

doi:10.1016/j.amjoto.2006.06.014

American Journal of Otolaryngology

Volume 28, Issue 2, March–April 2007, Pages 122-125

https://doi.org/10.1016/j.amjoto.2006.06.014 Get rights and content

Abstract

A giant midesophageal diverticulum is a medical rarity that is usually asymptomatic, and discovered incidentally. We report a case of a giant midesophageal diverticulum that revealed itself secondary to food impaction. A literature review on epidemiology, etiology, clinical presentation, investigations, and management of giant midesophageal diverticula will be highlighted.

Introduction

A midesophageal diverticulum is a saclike bulging of the midesophageal wall into the periesophageal space. It is a rare entity, usually asymptomatic, and mostly an incidental finding during routine radiological examination performed for other unrelated indications. Although rare, its potential complications may be quite debilitating. We report a case of a giant midesophageal diverticulum that presented with food impaction and clinically simulated a foreign body aspiration, with choking, dyspnea, and wheezing.

Section snippets

Case report

A 78-year-old woman presented with difficulty in breathing, dysphagia, and excess salivation of 1-day duration, which initially started after an episode of choking while eating. She reported having had 2 previous similar episodes in the past that resolved spontaneously and had not been investigated.

On physical examination, inspiratory stridor, wheezing, and rhonchi were heard. Flexible laryngoscopy revealed pooling of excessive secretions in the piriform sinuses. Chest radiograph and arterial

Discussion

Since the first report of a midesophageal pulsion diverticulum around 90 years ago, fewer than a dozen cases have been reported in the literature, most of which being 3 cm or smaller [1]. In particular, a giant midesophageal diverticulum is a medical rarity. A review of the literature since 1925 shows clearly that there are only few scattered reports of giant midesophageal diverticula [2].

Esophageal diverticula in general have been classified according to their etiology as either “traction” or

Conclusion

Giant midesophageal diverticula are a medical rarity. Several direct and indirect clues can help the clinician identify this entity. We reported a case of a giant midesophageal diverticulum that presented as food impaction. Therefore, suspicious cases of food impaction with no other evident etiology should prompt a full investigation and search for any underlying esophageal pathology and, in particular, a diverticulum or an esophageal motility disorder.

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Unlike distal esophageal diverticula which are often associated with gastroesophageal reflux disease, they are classically associated with chronic mediastinal inflammation and result from traction forces on the esophageal wall [1–4]. However, it is not unusual for midesophageal diverticula to be asymptomatic and discovered incidentally [5]. Fibrovascular polyps (FVP) of the esophagus are similarly rare.
Esophageal diverticula and esophageal fibrovascular polyps are uncommon clinical entities. While an asymptomatic presentation is possible, symptoms, when present, may be dissimilar in their gastrointestinal or respiratory characteristics. Additionally, these findings typically occur in different segments of the esophagus, with polyps occurring most frequently in the cervical esophagus and the midesophagus being the predominant location of pathologic diverticula.
We report the case of a 55-year-old patient who presented with a two-year history of progressive dysphagia secondary to a large proximal to midesophageal mass. Workup included esophagography, computed tomography, and endoscopy with ultrasound and was initially consistent with a diagnosis of a large esophageal fibrovascular polyp. Upon operative exploration, the mass was found to be a midesophageal diverticulum associated with a leading lipoma. The patient was successfully treated with transthoracic stapled diverticulectomy. At postoperative follow-up the patient was tolerating oral intake with no symptoms of dysphagia.
Esophageal diverticula are typically found in the midesophagus and are thought to arise from radial traction secondary to mediastinal inflammation. Esophageal fibrovascular polyps may result from tracheobronchial compression, and esophagography typically identifies a mobile intraluminal mass.
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The natural course of progression for asymptomatic esophageal diverticula is unknown [2,5] which presents a therapeutic quandary for determining definitive treatment. Controversy exists regarding treatment of asymptomatic esophageal diverticula [2,5,7]. Asymptomatic esophageal diverticula have been safely observed without progression at long-term follow up in adults [5].
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We interpreted the false lumen as the result of a probable trauma tear, in a blistered esophageal mucosa leading to superficial dissection. The blind pouch was unlikely to be a congenital esophageal duplication, considering the upper extremity location and the age at diagnosis, since this rare disorder presents in 70 to 90% of the cases before 2 years of age, especially with respiratory symptoms.1,2,6,7 The patient was empirically started on proton pump inhibitors, because GERD is a theoretical complication that could further damage the fragile esophageal mucosa.6,8,9
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We present an unusual case of EB simplex involvement of the esophagus with spontaneous resolution of a false lumen, with clinical improvement of the patient.
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se presenta un caso de EA simple con afectación inusual del esófago y resolución espontánea de una falsa luz, que condujo a la mejoría clínica de la paciente.
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Direct diverticular peroral endoscopic myotomy for the treatment of thoracic esophageal diverticula: technique and outcomes
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Case reportGiant midesophageal diverticulum presenting as food impaction: case report and review of the literature

Abstract

Introduction

Section snippets

Case report

Discussion

Conclusion

Med Hypotheses

Ann Thorac Surg

Gastroenterology

Gastroenterol Clin North Am

Lancet

Am J Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Spindleformige erweiterung der speisrohre

Med Jahrb kais k Österr Staates

Tuberculous diverticula of the esophagus

Acta Otolaryngol

Case report
Giant midesophageal diverticulum presenting as food impaction: case report and review of the literature