What is the "dreaded" complication associated with this esophageal mass?

Maria Flynn, MD

Suffolk Radiology Associates

Suffolk, VA

Case report

A 52-year-old man presented to the hospital due to increasing shortness of breath and significant weight loss over the previous 3 to 4 months. The patient could not lie on his back secondary to his shortness of breath. Posteroanterior and lateral chest radiographs were performed, followed by contrast-enhanced computed tomography scans of the neck and thorax (Figures 1-4). The mass was determined to be a fibrovascular polyp.

Challenge: What is the "dreaded" complication associated with this esophageal mass?

1. Asphyxiation due to laryngeal obstruction
2. Recurrence if the mass is not completely resected
3. Regurgitation of the mass into the mouth
4. Dysphagia

Answer

a—Asphyxiation due to laryngeal obstruction

A fibrovascular polyp is a rare, benign, intraluminal esophageal tumor. It is composed of a varying amount of fibrous tissue, adipose fat, and vascular structures, and is covered with squamous epithelium. Several terms have been used throughout the literature to describe these lesions, depending on their composition. Terms include lipomas, fibromas, fibrolipomas, fibromyxomas, and fibroepithelial polyps.^1,2

Fibrovascular polyps can result in all of the complications listed in the question; however, the most dreaded is asphyxiation from impaction in the larynx.^1-4 These lesions are typically asymptomatic until they become large. The average length of a fibrovascular polyp at diagnosis is 15 cm, and the average duration of symptoms is 17 months.² Other reported symptoms include dysphagia, respiratory complications, and regurgitation of the polyp into the mouth.^1,2

Fibrovascular polyps can be challenging to diagnose, and up to 30% are misdiagnosed.¹ These lesions can be missed on imaging studies and during endoscopy because they are soft, covered by normal mucosa, and can be displaced easily.

In a review by Levine and colleagues of 16 patients with fibrovascular polyps, chest radiographs demonstrated a right-sided superior mediastinal mass, anterior bowing of the trachea, or both in 44% of the cases.² Barium studies demonstrated a lobulated intraluminal mass originating from the lower cervical esophagus, and computed tomography (CT) demonstrated an intraluminal esophageal mass that was heterogeneous to soft tissue and fat density, depending on the tissue content.²

Figure 5

Figure 6

In our patient, the chest radiograph demonstrated an upper esophageal mass with an air fluid level suggesting esophageal obstruction (Figures 5 and 6). Consolidation in the left perihilar/lingular lobe from obstructive atelectasis was also visible. The contrast-enhanced CT scan confirmed a heterogeneous intraluminal mass with near complete esophageal obstruction (Figures 3 and 4). The patient was in a lateral position because his shortness of breath prevented him from laying supine.

Surgical resection is the treatment of choice. Care should be taken to completely resect the stalk so that recurrence can be avoided.¹

References

1. Ozcelik C, Onat S, Dursun M, et al. Fibrovascular polyp of the esophagus: diagnostic dilemma. Interact Cardiovasc Thorac Surg. 2004;3(2):260-262.
2. Levine MS, Buck JL, Pantongrag-Brown L, et al. Fibrovascular polyps of the esophagus: clinical, radiographic, and pathologic findings in 16 patients. AJR Am J Roentgenol. 1996;166(4):781-787.
3. Cochet B, Hohl P, Sans M, et al. Asphyxia caused by laryngeal impaction of an esophageal polyp. Arch Otolaryngol. 1980;106(3):176-178.
4. Carrick C, Collins KA, Lee CJ, et al. Sudden death due to asphyxia by esophageal polyp: two case reports and review of asphyxial deaths. Am J Forensic Med Pathol. 2005;26(3):275-281.