Coughing up a Polyp: A Rare Cause of Dysphagia!

Abstract

Fibrovascular polyps are rare, benign intraluminal lesions composed of fibrous, vascular and adipose tissues. They tend to be large and pedunculated and most commonly arise in the proximal esophagus. The incidence is higher in men and typically present in the 6th or 7th decade of life. A 74-year-old male presented with intermittent symptoms of dysphagia and episodes of choking in which he would cough up a mass and then swallow it again. He denied any odynophagia or respiratory distress between the episodes. There were no reports of weight loss or anemia. Upper endoscopy showed a proximal cervical submucosal lesion. A CT scan revealed a low-density lesion within the superior esophagus and a barium swallow showed a large pedunculated filling defect with a visible stalk extending superiorly within the upper esophagus. Further examination by endoscopic ultrasound showed a long esophageal polyp from the area immediately below the vocal cords extending down about 5cm. The polyp was estimated to be at the level of the upper esophageal sphincter area/hypopharynx (Figure 1). The patient was ultimately referred to ENT for endoscopic resection of the hypopharyngeal mass. The polyp, measuring about 6cm in length and 3cm in width, was resected en bloc (Figure 2). The patient tolerated the procedure well and was discharged the following day with only moderate odynophagia that soon resolved. Pathology was benign with the polyp described as a fibroepithelial lesion with focal surface erosion, reactive epithelial changes, and marked vascular congestion. Fibrovascular polyps are rare, benign polyps. While the exact etiology is unknown, it is thought that these types of polyps arise from redundant mucosal folds that slowly elongate over time due to constant traction from peristaltic activity. They tend to be slow growing and are often able to reach a large size before discovery. The most common presentation is dysphagia followed by globus sensation, but they can also cause anemia, weight loss and odynophagia. The most severe complication is regurgitation of the polyp into the oral cavity which can lead to asphyxiation. Despite different imaging modalities, these polyps are often misdiagnosed or missed, especially on EGD where they can resemble normal mucosa or lay flat against the lumen. Prompt removal by endoscopic or surgical resection is important to prevent potentially fatal complications.1815_A Figure 1. Imaging1815_B Figure 2. fibrovascular polyp