Endgames Picture Quiz

A man with absolute dysphagia after eating a steak

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5462 (Published 10 September 2014) Cite this as: BMJ 2014;349:g5462
  1. Max S Osborne, specialist trainee year 2, surgery1,
  2. Tom Saunders, specialist trainee year 2, surgery2,
  3. Fiona Fuerstenberg, specialist trainee year 2, anaesthetics3,
  4. Declan Costello, ear, nose, and throat consultant4,
  5. Balraj Dhesi, specialist trainee year 2, radiology5
  1. 1Princess Royal Hospital, Telford TF1 6TF, UK
  2. 2Department of Cardiothoracics, University Hospital of North Staffordshire, Stoke on Trent, UK
  3. 3Department of Anaesthetics, Royal Shrewsbury Hospital, Shrewsbury, UK
  4. 4Ear, Nose, and Throat Department, University Hospital Birmingham, Birmingham, UK
  5. 5Department of Radiology, University Hospital Coventry, Coventry, UK
  1. Correspondence to: M S Osborne maxosborne{at}doctors.org.uk

A 52 year old man presented to the emergency department with a complete inability to swallow (absolute dysphagia) and pain in his throat. He described an acute onset of pain while eating “a nice piece of steak” three hours earlier. After this time he could not swallow without pain in the middle of his throat and was unable to manage fluids without regurgitation. He arrived in the emergency department carrying a bowl and was spitting out his own saliva. He reported no changes to his voice and no difficulty with breathing. He was otherwise fit and well, with no recent trauma, weight loss, or history of a similar presentation. Neck examination in the emergency department was unremarkable except that he regurgitated test drinks of water. Radiography was performed (fig 1).

Questions

  • 1. What radiographic view is shown?

  • 2. What does the radiograph show?

  • 3. What is the diagnosis?

  • 4. What would your initial treatment plan be?

  • 5. What further management may be needed?

Answers:

1. What radiographic view is shown?

Short answer

A lateral soft tissue radiograph of the neck.

Long answer

Figure 1 shows a lateral soft tissue radiograph of the neck.

2. What does the radiograph show?

Short answer

An opacity consistent with soft tissue in the upper oesophagus measuring about 2 cm in width, lying anterior to the C5-C6 vertebrae with air below. There is also mild loss of lordosis.

Long answer

Within the distal pharynx-proximal oesophagus at the level of C5-C6, there is a soft tissue opacity measuring 2 cm in width (fig 2), which may represent a wedged food bolus at about the level of the cricopharyngeus muscle. There is mild loss of lordosis (due to muscular spasm) and air below the mass in the oesophagus. No prevertebral soft tissue swelling or surgical emphysema (suggestive of perforation) is visible.

Fig …

View Full Text

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe