Endgames Spot Diagnosis

Mild dysphagia and globus sensation in an older man

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2106 (Published 18 May 2017) Cite this as: BMJ 2017;357:j2106
  1. Subramanian Nachiappan, radiology registrar,
  2. David C Howlett, radiology consultant
  1. Eastbourne District General Hospital, Eastbourne, UK
  1. Correspondence to s.nachiappan{at}nhs.net

A 72 year old man presented with a three to four month history of non-progressive difficulty in swallowing and a globus sensation at the cervicothoracic level. Nasoendoscopy was normal. A chest radiograph was performed (fig 1). What does it show?

Answer

The radiograph shows a right sided aortic arch (fig 2, arrows) and unfolding of the ascending aorta: an example of a vascular ring.

Figure2

Fig 2 Chest radiograph. White arrows show right sided aortic arch

Discussion

Aortic arch abnormalities, also known as vascular rings, are often diagnosed in infancy or childhood and it is rare for patients to present with symptoms in late adulthood.

There are several variants of vascular rings in the literature, almost half of them being double aortic arch and the second most common variant being an aberrant right sided aortic arch. The trachea and oesophagus are surrounded by these vascular structures in the mediastinum and can become compressed, leading to symptoms.1

The incidence of vascular rings is less than 0.2% annually and even lower in the adult population. There have been only isolated case reports of adults presenting with symptoms, and less so in the older population.234

In adults, dysphagia is the most common presenting complaint. It has been postulated that symptoms in late adulthood are the result of age related changes such as aortic dilatation secondary to atherosclerosis and hypertension, thoracic kyphosis, and oesophageal dysmotility.25

Barium swallow (fig 3) can be used to investigate older patients with non-progressive dysphagia, for motility problems, and for where oesophagogastro-duodenoscopy is not tolerated or is unsafe to perform. If there are red flag signs for oesophageal malignancy, upper gastro-intestinal endoscopy is the technique of choice. Extrinsic impression on the oesophagus might not be appreciated or diagnosed on endoscopy, and a barium study should be considered where symptoms persist after a normal oesophagogastro-duodenoscopy.

Figure3

Fig 3 Barium swallow: smooth extrinsic impression of right sided aortic arch on the oesophagus (arrows)

Patients with non-progressive and mild symptoms might be managed conservatively. Where symptoms are more extreme and surgery is considered, contrast enhanced computed tomography is indicated for more detailed evaluation of the mediastinum.

Learning points

The presence of atypical impressions on barium swallow should alert the clinician to possible rare pathologies. Although common presenting complaints, globus sensation and non-progressive dysphagia might be caused by rare unexpected pathologies such as aortic arch congenital abnormalities, even in the older population.

Extrinsic oesophageal impressions might not be appreciated endoscopically. Barium swallow retains a role in investigation of upper gastro-intestinal symptoms and can be useful in older patients or if there is suggestion of motility problems, or if symptoms persist despite a normal oesophagogastro-duodenoscopy.

Footnotes

  • We have read and understood BMJ policy on declaration of interests and declare no competing interests.

  • Patient consent obtained.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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