Isolated Dysphagia: An Unusual Presentation of a Lateral Medullary Lesion

Abstract

Dysphagia is a complex symptom often attributed to mechanical obstruction, dysmotility, or a neurologic origin. Thus, the process of eliciting the etiology may poise a diagnostic challenge in atypical presentations. A 60-year-old male who presented with a sudden onset of dysphagia and feeling of food bolus impaction in the absence of other symptoms. The patient has had trouble swallowing any fluids, pills, or food for five days. He has not had any prior episodes of dysphagia. His past medical history includes transient ischemic attacks, hypertension, hyperlipidemia, diabetes mellitus type 2, and hypothyroidism. On presentation, the patient had elevated blood pressure, severe dysphagia, mild right facial droop, hypernatremia, and elevated serum glucose levels. Initial barium swallow showed narrowing in subglottic esophagus and subsequent Esophagogastroduodenoscopy (EGD) revealed a cricopharyngeal web dilated up to 51 Fr without any resistance. There was no improvement in the patient's symptoms after the procedure. Initial neurological assessment was unremarkable. However, further neurological evaluation was needed after profound pharyngeal muscular weakness and nearly absent swallow initiation was shown on a modified barium swallow. Magnetic resonance imaging (MRI) of the brain was inconclusive, so digital subtraction angiography (DSA) of head and neck was done and suggested subacute infarct of right pontomedullary junction due to terminal segmental right vertebral artery occlusion. Due to the severity of dysphagia, the patient underwent a percutaneous endoscopic feeding gastrostomy (PEG) placement, tolerated tube feeds, and was discharged nine days later. Five weeks after discharge, dysphagia was significantly improved from initial evaluation and overall swallow was safe for oral intake. This case illustrates that subacute lateral medullary lesions can present with dysphagia as the main symptom at the onset. The initial EGD showed a cricopharyngeal web which shifted the thinking towards a gastrointestinal cause for dysphagia. However, having a strong clinical suspicion of a neurogenic origin led us to this diagnosis. The neurogenic etiology of an acute or subacute oropharyngeal dysphagia should be suspected in the practice of gastroenterology or emergency department, especially if the history is not typical for food impaction that occurs during swallowing and when the patient has risk factors conducive to neurovascular disease.1832_A Figure 1. Endoscopic image showing cricopharyngeal web1832_B Figure 2. Modified barium swallow showing pharyngeal dysphagia with essentially absent swallow initiation1832_C Figure 3. CT angiogram of the neck showing focal high-grade narrowing of the dominant right vertebral V3 segment artery