Severe distal esophageal stricture.

A 58-year-old man presented for endoscopy and biopsy of an esophageal mass. His medical history was significant for squamous cell carcinoma (SCC) of the tongue 7 years earlier; the SCC had been treated with a total glossectomy, epiglottidectomy, and bilateral neck dissections followed by chemotherapy and radiation. A tracheostomy was performed, and the defect was reconstructed with a free flap. A percutaneous endoscopic gastrostomy (PEG) was created, through which the patient had received all his nutrition during the intervening 7 years.

Esophagoscopy detected the mass 25 cm from the incisors (biopsy subsequently identified it as a second primary SCC). During further examination at 40 cm, a thin, diaphragm-like stricture was encountered; the stricture almost completely obstructed the lumen of the esophagus and prevented passage of the endoscope into the stomach (figure). Biopsy of the stricture identified squamous mucosa but no evidence of cancer.

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Esophageal strictures usually occur as a result of gastroesophageal reflux. Recently, Lee et al reported that symptomatic upper esophageal strictures are more likely to occur in patients with hypopharyngeal tumors who have been treated with concurrent chemotherapy and radiation. (1) These authors hypothesize that the location of these primary tumors predisposes these patients to concentric scar formation. They further state that patients with a PEG may be at increased risk of stricture formation. Inactivity of the esophageal musculature with poor motility may contribute to poor esophageal acid clearance and thereby lead to the formation of these strictures. Also, radiation therapy decreases saliva production and can result in a lack of salivary bicarbonate, which hinders the neutralization of gastric refluxate. These risk factors might have been partly responsible for the severe distal esophageal stricture in our patient.

Reference

(1.) Lee WT, Akst LM, Adelstein DJ, et al. Risk factors for hypopharyngeal/upper esophageal stricture formation after concurrent chemoradiation. Head Neck 2006;28:808-12.

Sheldon R. Brown, MD

From the Ear, Nose, and Throat Section, Department of Surgery, Carl T. Hayden VA Medical Center, Phoenix, Ariz.