A 72-year-old woman with longstanding achalasia of the esophagus developed acute-onset nausea and vomiting. After a period of particularly intense retching, she complained of sudden-onset dyspnea. On arrival to the emergency department, she was in respiratory distress, and examination revealed a large anterior neck swelling (Figure 1A, arrow) and stridorous breath sounds. The remainder of examination results were unremarkable.
Figure 1. A, Photograph of anterior neck swellling. B, Anterior-posterior neck and chest radiograph. C, Lateral neck radiograph. Used with permission of Neil Ruparelia, MBBS, MRCP, Department of Cardiology and General Medicine, John Radcliffe Hospital, Headley Way, Oxford, England.
Diagnosis
Acute airway obstruction as a result of esophageal herniation. Anterior-posterior and lateral radiographs of the chest and neck revealed a large loop of esophagus had herniated into the neck, with subsequent anterior displacement of the trachea and larynx (Figure 1B, arrow; Figure 1C, arrow). Esophageal herniation into the neck causing significant respiratory compromise is uncommon and we could not find any reported cases. Although the patient remained well oxygenated, ongoing distress and discomfort led to the insertion of an endotracheal tube under direct visualization, with the aid of nasal endoscopy. After a period of ventilation, the esophageal herniation was reduced with an endoscope. The patient made a full recovery and subsequently underwent laparoscopic surgery to prevent recurrence. Although an uncommon cause of acute respiratory distress presenting to the emergency physician, extratracheal causes of airway compromise should be considered when one is faced with a patient with a history of persistent vomiting. The immediate management should ensure oxygenation, and reduction of the hernia should be considered in the emergency setting under direct visualization to ensure that risks such as esophageal perforation are minimized. Long-term management includes laparoscopic repair to prevent recurrence.
Department of Cardiology and General Medicine, John Radcliffe Hospital, Headley Way, Oxford, England
For the diagnosis and teaching points, see page 593.
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