Clinical Challenges

What is your diagnosis?

Figure A

A 70-year-old woman with a past medical history of gastroesophageal reflux disease presented for evaluation of difficulty swallowing. She described trouble with solid food bolus transition, but denied difficulty swallowing liquids or episodes of choking. Concurrently, she reported progressive symptoms of retrosternal burning and epigastric pain despite adhering to twice-daily proton pump inhibitor therapy.


Figure B

Her physical examination revealed a soft abdomen with mild tenderness to deep palpation over the epigastrium. Laboratory studies showed no evidence of anemia or leukocytosis. She underwent a video-swallow study that demonstrated a normal swallowing mechanism without evidence of pooling of contrast or aspiration. An esophagogastroduodenoscopy was performed that showed a 7-cm hiatal hernia without evidence of erosive esophagitis or stenosis at the gastroesophageal junction. Upon careful withdrawal, a polypoid lesion was noted in the oropharynx (Figure A). Neck computed tomography scans revealed a 13-mm, well-circumscribed, round mass in the right piriform sinus (Figure B). What is the lesion responsible for this patient's oropharyngeal dysphagia?


 

Fibroepithelial polyp of the hypopharynx

Our patient underwent an upper endoscopy to evaluate symptoms of refractory gastroesophageal reflux disease and was found to have a large hiatal hernia. Upon careful endoscopic withdrawal, the polyp was briefly visualized as it was pulled back into the oropharynx. The patient was referred for flexible laryngoscopy that confirmed a polypoid mass involving the right lateral piriform wall. She subsequently underwent direct laryngoscopy with harmonic scalpel-assisted excision of the lesion leading to resolution of her symptom of oropharyngeal dysphagia. The surgical specimen measured 3 × 1.4 × 0.4 cm. Pathology demonstrated benign overlying squamous mucosa with submucosa composed of bland spindle cells and fat, consistent with a benign fibroepithelial polyp (Figure C, original magnification × 100; stain: hematoxylin and eosin).

Figure C

Fibroepithelial polyps are rare benign lesions of the hypopharynx and proximal esophagus that can lead to oropharyngeal dysphagia.1 Larger hypopharyngeal polyps have been associated with aspiration and airway compromise.1 Owing to their proximal location, these lesions are more readily identified under flexible laryngoscopy, but can also be observed with esophagogastroduodenoscopy. Cross-sectional imaging of the neck can be considered for patients with oropharyngeal dysphagia and a normal video-swallow study. Although the underlying pathogenesis remains unclear, inflammation or infection may play a role, especially in smokers.2 The rate of recurrence after resection is low.1

Further evaluation for her symptomatic hiatal hernia was performed and the patient ultimately underwent a laparoscopic Nissen fundoplication with wedge gastroplasty, leading to improvement in her symptoms of gastroesophageal reflux disease. This case illustrates that, although esophagogastroduodenoscopy is not considered the first step in the evaluation of patients with oropharyngeal dysphagia, a careful examination can sometimes reveal the diagnosis.

References

1. Caceres M, et al. Large pedunculated polyps originating in the esophagus and hypopharynx. Ann Thorac Surg. 2006;81:393-6.

2. Maskey AP, et al. Endobronchial fibroepithelial polyp. J Bronchology Interv Pulmonol. 2012;19:313-4.

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