Int. Med J Vol. 6 No 1 June 2007
Dysphagia Lusoria From Saccular Aneurysm :A Cause Of: A Case Report
M Irfan, MD Khairi and A Baharudin, MMED
Department of Otorhinolaryngology-Head & Neck Surgery, School of Medical Sciences,
Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan
SUMMARY
Dysphagia is a common symptom in patients presenting to the otorhinolaryngolgy clinic. However, vascular causes (dysphasia lusoria) are relatively rare. W report a case of dysphagia caused by a saccular aneurysm of the descending thoraric aorta. The outline of management is discussed.
Key words: Dysphagia, Aortic aneurysm
Case Report
A 51 years old gentleman presented to the otorhinolaryngology clinic with the complaint of a foreign body sensation in the throat of one month duration. It was associated with intermittent loss of voice . There was dysphagia to both solid and liquid. He did not have any odynophagia. Sometimes he could not even swallow saliva. The sensation resolved after some time by itself.
He has a of motor vehicle accident ten years earlier in where he sustained a Le Fort II fracture and some minor chest injury.
On intra-oral examination, there was a bifid uvula and granular posterior pharyngeal wall. No other positive findings were noted on 70’ laryngoscopy.
A Barium swallow showed an extrinsic compression of the oesophagus at the level of T4-T7 displacing the oesophagus to the right.
Fig. 1: Compression and displacement of the oesophagus as seen in Barium swallow.
Computed tomograph , ( CT ) was done and the lesion was clearly delineated. showing the mass as saccular aneurysm of the descending aorta. There was a circumferential mural thrombus and early mural thrombus in the ascending aorta as well.
Fig. 2: The saccular aneurysm of the descending aorta with circumferential mural thrombus
and early mural thrombus in the ascending aorta.
He was then referred to the National Heart Institute where a hemiarch aorta replacement was done. He waswell post operatively. A repeat CT scan revealed no evidence of leaking or recurrence of the aneurysm
Dysphagia is a sensation of impediment to the normal passage of swallowed material. It can either be oropharyngeal dysphagia (difficulty to initiate a swallowing) or oesophageal dysphagia ( solid or liquid that is hindered in their passage from oral cavity to stomach ). The causes are multiple, the commonest being stroke which is around 50% and the incidence is increased with age.
Dysphagia of vascular origin is uncommon1. When this is so it is known as dysphagia lusoria ( difficulty in swallowing due to vascular abnormalities ). The most common cause is an aberrant right subclavian artery which passes behind the esophagus. This condition is also called arteria lusoria2. This case represents another unusual cause of dysphagia, a saccular aneurysm of the descending aorta.
The descending or thoracic aorta runs in close proximity with the oesophagus in the posterior mediastinum. It starts at the lower border of T4 vertebra, where the arch of the aorta ends, initially to the left of the midline then it slants gradually to the midline and leaves the posterior mediastinum at the level of T12 vertebra, passing behind the diaphragm between the crura. The oesophagus enters the thoracic inlet in the midline (the cervical portion) and normally is crossed by the arch of aorta in the superior mediastinum, 22 cm from the upper incisor before slightly inclining to the left. At T5 vertebra level, it returns to the midline. At T7 vertebral level, it deviates again to the left and curves forward to pass in front of the descending thoracic aorta before piercing the diaphragm at 2.5 cm to the left of the midline. This close anatomical relationships especially in the lower thoracic vertebra level, any abnormalitiy of one of them might affect the other.
In managing patients with symptom of dysphagia, the history and clinical examination are as important as the radiological tools. A careful history may pick up the primary cause in up to 80% of cases3. For example, past medical history of chest injury in this case might lead us to some pathology related to the thoracic part of aorta and the oesophagus. Indeed a barium swallow showed an external compression of the oesophagus at T4 to T7 level.
Barium swallow remain the most single most important imaging modality in dysphagic patient whenever the source of obstruction is beyond the level of oropharynx.
The external compression of the oesophagus was clearly demonstrated in this contrasted imaging. It was confirmed by computed scan tomograph findings that the obstructing mass was a saccular aneurysm of the descending aorta.
CONCLUSION
Every dysphagic patient should be investigated and treated with an individual approach. Some may present with a straight forward mass in the oral cavity or oropharynx while in others the obstructive mass could be in a ‘hidden area’ such as in the mediastenum or intraabdominal. A multidisciplinary team of an ORL surgeon, a radiologist and cardiothoracic surgeons in this case achieve a good theraputic outcome.
REFERENCES
Windfuhr JP, Schubert D, Remmert S. Aneurysm of the subclavian artery. An unusual cause of dysphagia. HNO. 2004 Dec;52(12):1097-102.
Alper F, Akgun M, Kantarci M, Eroglu A, Ceyhan E, Onbas O, Duran C,Okur A. Demonstration of vascular abnormalities compressing esophagus by MDCT: special focus on dysphagia lusoria. Eur J Radiol. 2006 Jul;59(1):82-7. Epub 2006 Mar 2.
.Lind CD. Dysphagia : Evaluation and treatment. Gastroenterol Clin North Am. 2003 Jun;32(2):553-75.
Correspondence
Dr Irfan bin Mohamad
Department of Otorhinolaryngology-Head & Neck Surgery
School of Medical Sciences
Universiti Sains Malaysia Health Campus
16150 Kota Bharu,
Kelantan