Delayed Dysphagia After Removal of Foreign Bodies Near Upper Esophageal Sphincter

Abstract

A 70-year-old male presented to the emergency department with sudden onset of dysphagia. He had medical history of hypertension for 10 years and cerebral infarction in the territory of the middle cerebral artery 7 year ago. Lateral neck radiography revealed foreign bodies in the upper esophagus (Fig. 1A) and an upper endoscopy was performed. Two seashells with sharp edge were impacted near the upper esophageal sphincter and they were removed using hard straight cap and grasping forceps (Fig. 1B). Figure 1 Radiograph of a 70-year-old man who presented with dysphagia. Foreign bodies were lodged in the upper esophagus (blue arrow) (A) and 2 seashells were removed with endoscopic grasping forceps (B). Although white blood cell was elevated and small laceration with periesophageal inflammation was suspected at CT scan, his condition improved with non-operative management including broad spectrum antibiotics. However, dysphagia continued for 10 days after removal of foreign bodies. Modified barium swallowing showed large volume of valecular residue with tracheal aspiration despite improvement of inflammation on follow-up CT scan. High-resolution impedance manometry (HRIM) was performed to rule out esophageal motility disorder. HRIM revealed a failure of upper esophageal sphincter relaxation with impaired bolus transit (Fig. 2). Two days later, he refused to receive further treatment and was discharged.When he visited outpatient clinic 4 days after discharge, dysphagia was improved and he could take soft diet. Figure 2 High-resolution impedance manometry (HRIM) findings with 30 mmHg isobaric contour. HRIM presents a failure of upper esophageal sphincter relaxation (red arrow) with impaired bolus transit and intrapharyngeal saline pooling (yellow arrow). Recently, HRIM system was used to develop the clinical parameters of deglutitive upper esophageal sphincter relaxation and normal range values were acquired from healthy volunteers.1 In the near future, more accurate diagnosis of dysphagia might be possible based on the objective manometric findings in swallowing difficulty.