An Unusual Case of Dysphagia: A Supraglottic Venous Malformation

Abstract

Dysphagia can be classified into oropharyngeal and esophageal dysphagia. The distinction between both types based on history alone can be challenging. An esophagogastroduodenoscopy (EGD) is the most utilized tests to investigate the etiology of dysphagia. Even though the EGD exam is more directed to look for esophageal causes of dysphagia, an inspection of the supraglottis or hypopharynx during the exam can be helpful in ruling out obvious structural lesions in those areas. A 45-year-old male with chronic gastroesophageal reflux disease presented with a three-year history of intermittent chocking and dysphagia. His dysphagia was more to solids than liquids and had worsened over the last year. On physical exam, no lesions in the oral cavity were seen. The neck exam revealed a 1.5 cm mobile mass located on the right lateral side. The trachea was midline; no thyromegaly was noted. The patient was referred for an EGD. On EGD, a fusiform lesion with a bluish hue most consistent with a venous structure was seen in the supraglottic region. It was estimated at 5-7 mm in diameter. Otherwise, the EGD revealed a small hiatal hernia. No esophageal lesions were identified. The patient was referred for evaluation by Otolaryngology (ENT). Laryngeal endoscopic examination revealed a cystic lesion with a bluish hue located on the right aryepiglottic fold measuring around 5- 7 mm. No further abnormalities were identified. A computed tomography (CT) scan of the neck showed multiple soft tissue hypoenhancing masses with intrinsic vascularity and punctate calcifications suggesting venous/venolymphatic malformations; it also showed a round lesion along the aryepiglottic fold. The patient underwent a direct laryngoscopy with aspiration of the lesion on the right aryepiglottic fold yielding frank blood confirming the diagnosis of venous malformation. The patient reported resolution of his dysphagia after the procedure without recurrence. Although uncommon, vascular malformations of the supraglottis or hypopharynx should be considered in the differential diagnosis of a patient presenting with dysphagia. These have the potential to bleed and compromise the airway. Procedures such as an EGD can potentially lead to this serious event. As such, vigilance and careful examination of the supraglottic region are important while evaluating patients with dysphagia. When venous malformations are suspected, imaging with CT or MRI should be done along with referral to ENT for evaluation.Figure: Endoscopic View of Supraglottic Venous Malformation.Figure: Endoscopic View of Supraglottic Venous Malformation.