Esophageal inlet granuloma. (Laryngoscopic Clinic).

A 41-year-old woman was referred for evaluation of ongoing dysphagia and tracheotomy dependence. Approximately 10 weeks earlier, she had been involved in a motor vehicle accident, which resulted in incomplete quadriplegia. She reported that she had received an indwelling nasogastric tube for approximately 6 weeks prior to the placement of a gastrostomy tube. She had also experienced an 18-day intubation prior to undergoing her tracheotomy. She was unable to swallow solids or liquids, but she was able to manage her own saliva.

On initial evaluation by flexible laryngoscopy at the bedside, a large hypopharyngeal mass was seen obstructing her esophageal inlet and causing some posterior compression of her arytenoids. Her vocal fold mobility was not adequately established because of the mass effect. Computed tomography (CT) of the neck revealed that a 3cm-diameter soft-tissue mass had arisen from the upper cervical esophagus; the mass narrowed the supraglottic airway and deviated the trachea anteriorly (figure 1).

The patient underwent five direct microlaryngoscopy procedures (figure 2). These procedures included serial excisions of the mass in order to reduce the likelihood of subsequent cicatrix. Excision was performed via coldsteel dissection and with a laryngeal microdebrider. Pathology on all specimens was consistent with exuberant pyogenic granuloma. Following the third procedure, the patient was examined via modified barium-swallow imaging, which revealed a patent esophagus. At that point, she was able to resume a full diet. She has subsequently been decannulated from her tracheotomy and gastrostomy tube.

Based on the location of the exophytic process in this patient's esophageal inlet, we believe that these changes were initiated by the 6 weeks of nasogastric intubation. The histologic appearance of her lesions was consistent with granuloma pyogenicum that has been described in other anatomic sites. According to reports of three large series, most cases of granuloma pyogenicum were found in various sites in the oral cavity (especially the gingiva) and on the skin of the face, extremities, and trunk. (1-3)

Granuloma pyogenicum is a benign lesion that was once believed to be infectious in origin but is now believed to be associated with a type of vascular malformntion. Repeated trauma has been implicated as a cause of pyogenic granuloma, and this is consistent with our patient's long history of nasogastric intubation. Gastroesophageal reflux (GER) also might have contributed to her insult; GER is well known to be exacerbated by nasogastric intubation, because it impairs the closure of the lower esophageal sphincter. Nevertheless, Ferrer et al found that GER and microaspiration in intubated patients were not reduced with the use of a small-bore nasogastric tube. (4) They proposed other potential mechanisms, including (1) functional derangement of the upper esophageal sphincter secondary to the pressure of the endotracheal tube cuff and (2) the use of drugs that impair esophageal motility.

We were unable to find any published case report in the English-language literature in which esophageal inlet granuloma formed following nasogastric intubation.

References

(1.) Kerr DA. Granuloma pyogenicum. Oral Surg Oral Med Oral Pathol 195 1;4: 158-76.

(2.) Bhaskar SN, Jacoway JR. Pyogenic granuloma--clinical features, incidence, histology, and results of treatment: Report of 242 cases. J Oral Surg 1966;24:391-8.

(3.) Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: The underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980:4:470-9.

(4.) Ferrer M, Bauer TT, Torres A, et al. Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients. Ann Intern Med 1999:130:991-4.

From the Department of Otolaryngology--Head and Neck Surgery, Northwestern University Medical School, Chicago.