Achalasia: a rare cause of stridor

Abstract

Case reportBrian Suffoletto, Kenneth KatzA 56-year-old woman presented to the emergency depart-ment (ED) acutely stridorous. The patient was leaningforward, unable to speak and could not swallow. Thepatient was, however, able to communicate through ges-turing and writing. She confirmed a prior history ofuntreated achalasia, and had eaten a large meal one hourprior to ED presentation.Physical examination (PE) revealed a woman in obviousrespiratory distress. Vital signs included: temperature36.4 C, pulse 92 beats per minute, blood pressure 109/56 mmHg, respiratory rate 30 breaths per minute and aroom air oxygen saturation of 100%. The head, ears, eyes,nose and throat examinations were unremarkable. The neckexamination revealed an audible inspiratory stridor. Pal-pation of the neck did not identify a mass or thyromegaly,however the patient did have tenderness in the anteriorneck. The remainder of the PE was unremarkable.Radiographs were obtained. A cardiothoracic surgeryconsultation was obtained. The insertion of a nasogastrictube (NGT) was attempted to decompress the esophagealdilatation. The NGT repeatedly coiled and was unable to bepassed. An esophagogastroduodenoscopy (EGD) was thenperformed. The endoscope, however, could not be advanceddue to a large impacted food bolus. After 10 l of salinelavage and forceps removal of food pieces the scope wasadvanced through the lower esophageal sphincter (LES),whichwasnotedtohaveincreasedtone.Thepatient’sstridorresolved, and she remained asymptomatic after the EGD.The patient was discharged to home asymptomatic on hos-pital day two to follow up for outpatient surgical myotomy.Comment: Listening to the stridorCamilla Tozzetti, Pietro Amedeo ModestiStridor is rarely encountered in common clinical practice.Even when matched, of all the diagnosis that ever will bemade, achalasia is the most rare. The patient was luckytwice: she had the opportunity to communicate the priorhistory of untreated achalasia, and she met a listeningphysician. Indeed, stridor was a marker of an urgent situ-ation, but the patient history was the real guide to a correctdiagnostic course.Stridor is a loud musical sound of definite and constantpitch (usually about 400 Hz) that indicates upper airwayobstruction. It is identical to wheezing acoustically in everyway except for two characteristics: (1) stridor is confined toinspiration, whereas wheezing is either confined entirely toexpiration (30–60% of patients), or occurs during bothexpiration and inspiration (40–70% of patients) [1, 2]; and(2) stridor is always louder over the neck, whereaswheezing is always louder over the chest [2]. In somepatients with upper airway obstruction, stridor does notappear until the patient breathes rapidly through an openmouth. When stridor is present, an airway diameter lessthan 5 mm can be estimated [3].