Dysphagia lusoria: A late onset presentation

Dysphagia lusoria is a term used to describe dysphagia secondary to vascular compression of the oesophagus. The various embryologic anomalies of the arterial brachial arch system often remain unrecognised and asymptomatic, but in 30%-40% of cases can result in tracheo-oesophageal symptoms, which in the majority of cases manifest as dysphagia. Diagnosis of dysphagia lusoria is via barium swallow and chest Computed tomography scan. Manometric abnormalities are variable, but age-related manometric changes may contribute to clinically relevant dysphagia lusoria in patients who present later in life. Our report describes a case of lateonset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria. The patient had proven additional oesophageal dysmotility with solid bolus only and a clinical response to dietary modification.     

Lusoria dysphagia in a patient with retroperitoneal fibrosis and Riedel's thyroiditis

The case history of a 68-year-old woman with progressive dysphagia caused by extrinsic compression of the oesophagus by an aberrant right subclavian artery or arteria lusoria is presented. Previous history mentioned a Riedel's thyroiditis, idiopathic retroperitoneal fibrosis and an aortic sclerosis. The authors want to report the case because it is an example of an association between lusoria dysphagia and retroperitoneal fibrosis, the connective tissue disease responsible for Riedel's thyroiditis, and perhaps, aortic sclerosis. This is the first report of this particular association.     

Dysphagia after arteria lusoria dextra surgery: Anatomical considerations before redo-surgery

Aberrant right subclavian artery(arteria lusoria) is the most common congenital root anomaly, remaining asymptomatic in most cases. Nevertheless, some of the 20%-40% of those affected present tracheo-esophageal symptoms. We report on a 6-year-old previously healthy girl presenting with progressive dysphagia over 4 wk. Diagnostics including barium swallow, echocardiography and magnetic resonance angiography(MRA) revealed a retro-esophageal compression by an aberrant right subclavian artery. Despite the successful, uneventful transposition of this arteria lusoria to the right common carotid via right-sided thoracotomy, the girl was suffering from persisting dysphagia. Another barium swallow showed the persistent compression of the esophagus on the level where the arteria lusoria had originated. As MRA showed no evidence of a significant re-obstruction by the transected vascular stump, we suspected a persisting ligamentum arteriosum. After a second surgical intervention via left-sided thoracotomy consisting of transecting the obviously persisting ligamentum and shortening the remaining arterial stump of the aberrant right subclavian artery, the patient recovered fully. In this case report we discuss the potential relevance of a persisting ligamentum arteriosum for patients with leftaortic arch suffering from dysphagia lusoria and rational means of diagnosing, as well as the surgical options to prevent re-do surgery.     

Adult dysphagia lusoria. Treatment by arterial division and reestablishment of vascular continuity

The case of a 27-year-old woman with dysphagia secondary to esophageal compression by an anomalous right subclavian artery is presented. Division of the anomalous vessel at its origin and revascularization of the right upper extremity by direct end-to-side anastomosis to the ascending aortic arch was accomplished through a right anterolateral thoracotomy. We believe this is the preferred surgical treatment of dysphagia lusoria in the adult.     

Dysphagia lusoria and segmental aperistalsis in the upper third of the esophagus

An aperistaltic zone located in the upper third of the esophagus was present in a young woman with dysphagia, who had undergone surgical treatment for dysphagia lusoria 3 months before. The segmental absence of contraction in the upper third of the esophagus was the most probable cause for the persistence of dysphagia, and could have resulted from damage related to compression or to surgical intervention in the area.     

Dysphagia lusoria caused by persistent right aortic arch with aberrant left subclavian artery and diverticulum of kommerell

Sammary It requires a high index of suspicion to make the diagnosis of dysphagia lusoria. Clinically, these adults will present with symptoms of intermittent solid food dysphagia, and a mediastinal abnormality may be seen on chest x-ray. Noninvasive imaging of the chest with either computerized tomography or magnetic resonance scanning are excellent methods for evaluating the mediastinum for solid tumors or vascular anomalies that can cause extrinsic esophageal compression. Dysphagia lusoria caused by a persistence of the right embryologic aortic arch and diverticulum of Kommerell with an aberrant left subclavian artery may be satisfactorily managed by dietary modification when the symptoms are mild.The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official policy or reflecting the views of the Army or the Department of Defense.     

Dysphagia lusoria caused by a right-sided aorta

We report a case of an 80-year-old female with dysphagia lusoria caused by oesophageal compression by a right-sided atheromatous aorta. The relationship between aortic root vascular anomalies and dysphagia has been clearly established in literature and can be diagnosed by a barium swallowing study, followed by CT or MRI. Aortic anomalies and variations in aortic branches are caused by embryonic malformations and are mostly described in association with congenital heart lesions. In this pauci-symptomatic patient, the preferred treatment is a conservative management.     

Late-onset dysphagia lusoria assessed by 3-dimensional computed tomography of an aortic arch abnormality

Symptomatic vascular rings causing late-onset dysphagia (dysphagia lusoria) are quite unusual in adults. We present a 42-year-old woman with a 1-year history of dysphagia from a right-sided aortic arch with an aberrant left subclavian artery and left-sided ligamentum arteriosum. Using a helical CT scan of the chest and a three-dimensional reconstruction software, her anatomic abnormality was completely delineated. Arch aortogram confirmed the anomaly. The patient underwent a left posteriolateral thoracotomy. Intraoperative findings correlated precisely with the preoperative reconstruction data. Division of the ligamentum resulted in a complete decompression of the esophagus and resolution of the patient's symptoms.     

Aberrant right subclavian artery (arteria lusoria) as a rare cause of dysphagia and dyspnea in a 79-year old women with right mediastinal and retrotracheal mass, and co-existing coronary artery disease

A rare case of a 79-year old women with dysphagia and dyspnea secondary to compression of the esophagus by an aberrant right subclavian artery (ARSA, A. lusoria) is presented. This abnormality is generally silent and often an incidental x-ray finding. Computed tomography and intraarterial angiography, including direct catheterization of the ARSA, established the diagnosis. The interdependence with a co-existing coronary artery disease is discussed. Thus, ARSA has to be taken into account in patients with abnormal x-ray findings presenting with dysphagia and dyspnea.     

Arteria lusoria aneurysm with truncus bicaroticus: surgical resection without restoring blood supply to the right arm

Arteria lusoria, an aberrant or anomalous right subclavian artery, is the most common anomaly of the aortic arch. It may be associated with other congenital anomalies of the heart and great vessels-including, rarely, truncus bicaroticus (a common trunk of both common carotid arteries), and, even more rarely, aneurysmal formation.Herein, we report the case of a 72-year-old man who had both an atherosclerotic aneurysm of an aberrant right subclavian artery and truncus bicaroticus. We resected the aneurysm through a posterolateral thoracotomy and did not restore the distal pulsatile blood supply to the right arm. During long-term clinical follow-up, the patient experienced no arm ischemia or cerebrovascular insufficiency.Aneurysm of arteria lusoria should be suspected in the presence of a right superior mediastinal mass on chest radiographs and should be considered as a cause of new-onset dyspnea, chest pain, or dysphagia. Symptomatic right arteria lusoria aneurysm should be removed promptly after diagnosis. Despite disagreement among investigators regarding the need to restore pulsatile blood flow to the right arm, we recommend reconstructing that flow, when possible.     

Hybrid Repair of an Aberrant Right Subclavian Artery with Kommerell's Diverticulum

This publication describes a hybrid endovascular and open surgical approach to treating a large aneurysm of an aberrant right subclavian artery (Kommerell's diverticulum). A 76-year old man presented with dysphagia lusoria due to a 3.5 × 3.0 cm aneurysm involving an aberrant right subclavian artery. The patient was treated by a thoracic aortic endograft, left subclavian artery de-branching (by its transposition to the left common carotid artery) and right subclavian artery revascularisation. This approach avoids the requirement for a thoracotomy or sternotomy needed with open surgical repair. At a 6 months follow-up assessment the aneurysm was shown to be thrombosed with no evidence of endoleak.     

Symptomatic aberrant retro-esophageal subclavian artery: considerations about the surgical approach, management and results

Ten case histories of patients with symptomatic aberrant retro-esophageal subclavian artery are presented. The diagnosis was made on a clinical basis in 8 cases because of symptoms of tracheo-esophageal obstruction, and confirmed by barium meal. All patients were investigated by angiography. Six patients with right abnormal retro-esophageal subclavian artery (arteria lusoria) and its mirror image were treated by transection of the aberrant subclavian artery and reimplantation into the common carotid artery through a single midline sternal splitting incision which gave ample access. Three patients with left abnormal subclavian artery (right aortic arch) were operated by transection of the patent ductus arteriosus or ligamentum arteriosum through a left lateral thoracotomy. After a follow-up of from one to 10 years (mean 6.4 years), 9 patients are free of symptoms like dysphagia, dyspnea or subclavian steal and normal pulses are present on both upper extremities in 8 cases.     

EUS imaging of the arteria lusoria: case series and review

BACKGROUND: The arteria lusoria is an aberrant right subclavian artery that passes dorsally between the esophagus and spine after branching off from the aortic arch. The role of endoscopic ultrasonography (EUS) in the diagnosis of the arteria lusoria has not been established. The possibility of demonstrating this vascular anomaly with EUS and estimating its prevalence was assessed. METHODS: From December 1991 to September 1998, EUS of the upper gastrointestinal tract was performed in 3334 consecutive patients for various reasons. After imaging of the target organ(s), the echoendoscope was slowly pulled back while imaging the mediastinum proximally to the superior aspect of the aortic arch. In every patient, the area of the aortic arch was carefully inspected and special attention was given to vessels crossing from left to right between the esophagus and spine. RESULTS: During the study period, an arteria lusoria was discovered in 12 of 3334 patients (0.36%: 95% CI [0.16%, 0.56%]). There were 6 men and 6 women; mean age was 64+/-14.7 years. In all 12 patients the arteria lusoria passed between the esophagus and spine. In none of the patients could symptoms be attributed to the presence of this anatomic variant. CONCLUSIONS: An arteria lusoria can be detected with upper gastrointestinal EUS and was found in 0.36% of patients. EUS can accurately demonstrate this vascular anomaly.     

Neurologic causes of dysphagia

Pharyngeal dysphagia may be caused by any of a wide variety of neurologic diseases, but the possibility of neurologic disease is often over-looked in the evaluation of dysphagia. This is especially unfortunate because some of the neurologic causes of dysphagia are treatable. This review organizes the neurologic causes of dysphagia into a simple framework that facilitates consideration of these diseases. Methods of evaluating neurogenic dysphagia, including history taking, physical examination, and laboratory testing, are to be considered separately in a subsequent article.     

Relationship of cervical spine disorders to dysphagia

Extrinsic esophageal compression by cervical osteophytes as a cause of dysphagia was first reported by Zahn in 1905. Yet, despite the high incidence of osteophytes of the cervical spine, dysphagia secondary to degenerative disease of the cervical spine is very uncommon. In a review of 116 cases of degenerative arthritis of the cervical spine requiring therapy, dysphagia was documented in only 7 (Saffouri and Ward 1974). In a review of 1,200 patients with dysphagia, none demonstrated dysphagia due to cervical spine disease (Leroux 1962). The attribution of dysphagia to a cervical spine abnormality should therefore be made with extreme caution. Objective evidence of impairment of pharyngeal function by the cervical abnormality should always be sought. Critical evaluation of dynamic studies of swallow by motion recording radiographic techniques can provide such evidence. This report presents our findings in a series of patients with cervical spine disorders evaluated in the Johns Hopkins Swallowing Center over a 2 year period.     

Neurologic evaluation of dysphagia

Unexplained dysphagia is often caused by unrecognized neurologic disease. A previous article (Buchholz 1987) discussed the many neurologic diseases that may cause dysphagia. This article reviews a neurologist's approach to dysphagia of possible neurologic origin. As with most medical problems, a careful history provides more information about dysphagia than any other data-gathering technique. Therefore, history-taking is discussed first, followed by review of pertinent aspects of the general and neurologic examinations and ancillary testing.     

Clinical and Radiologic Evaluation Reveals High Prevalence of Abnormalities in Young Adults with Dysphagia

The purpose of this study was to retrospectively evaluate the radiologic findings in young adults with dysphagia undergoing barium swallow and to compare these with the final clinical diagnosis. Clinical history, barium swallow, endoscopy (21 patients), manometry (18 patients), 24 h pH monitoring (4 patients), and outcome of treatments were studied and compared in 43 patients aged 14–30 years (mean 24 years). There were 26 men and 17 women. Duration of symptoms varied between 2 weeks and 22 years and included globus (n = 22), obstruction (n = 31), water brash (n = 6), classic reflux symptoms (n = 10), atypical reflux symptoms (n = 9), slow eating (n = 6), and vomiting (n = 11). The final diagnosis was achalasia (n = 2), arteria lusoria (n = 1), esophagitis (n = 1), esophageal dysfunction (n = 11), esophageal stricture (n = 5), gastroesophageal reflux disease (n = 8), and pharyngeal dysfunction (n = 2). Thirteen patients were assessed to be normal. The result of the barium swallow was in agreement with the final diagnosis in all but 3 patients who were assessed as normal, and the final diagnosis was esophagitis (n = 1), dysmotility (n = 1), and reflux disease (n = 1). Anatomic and functional abnormalities are common in young adults with dysphagia. Barium swallow reveals the explanation of the symptoms in 70% of such patients. Radiology therefore should be the method of choice for the investigation of dysphagic young adults.     

Dysphagia Associated with Cervical Spine and Postural Disorders

Difficulties with swallowing may be both persistent and life threatening for the majority of those who experience it irrespective of age, gender, and race. The purpose of this review is to define oropharyngeal dysphagia and describe its relationship to cervical spine disorders and postural disturbances due to either congenital or acquired disorders. The etiology and diagnosis of dysphagia are analyzed, focusing on cervical spine pathology associated with dysphagia as severe cervical spine disorders and postural disturbances largely have been held accountable for deglutition disorders. Scoliosis, kyphosis–lordosis, and osteophytes are the primary focus of this review in an attempt to elucidate the link between cervical spine disorders and dysphagia. It is important for physicians to be knowledgeable about what triggers oropharyngeal dysphagia in cases of cervical spine and postural disorders. Moreover, the optimum treatment for dysphagia, including the use of therapeutic maneuvers during deglutition, neck exercises, and surgical treatment, is discussed.     

Incidental finding of arteria lusoria during transradial coronary catheterization: Significance in interventional cardiology

Arteria lusoria is the most common anomaly of the aortic arch with an incidence of 0.5%–2.5%. It is mostly diagnosed incidentally while performing imaging for evaluation of other unrelated medical conditions. The aberrant right subclavian artery arises beyond the origin of the left subclavian artery from the aortic arch. This results in a complex right‐subclavian‐aortic anatomy which leads to difficulty in transradial coronary angiography. This can lead to prolonged procedure time and increased use of catheters by unaware interventionists. This is even more important if this is encountered in the setting of an acute myocardial infarction. Our review takes into account clinical significance of this uncommon anomaly in the field of interventional cardiology.     

Nutrition Support and Therapy in Patients with Head and Neck Squamous Cell Carcinomas

Head and neck squamous cell carcinomas (HNSCC) present a unique set of challenges in both the treatment of the disease and in support of the patient afflicted with the cancer. A major challenge is the nutritional support of these patients. Often, patients with HNSCC are malnourished at baseline due to an underlying dysphagia. Many others develop dysphagia as a result of their surgical resection and external beam radiation therapy. This dysphagia further exacerbates the chronic dehydration and malnutrition. This article will review strategies to provide nutritional support to HNSCC patients and also to review nutritional strategies that may decrease the morbidity and mortality associated with HNSCC treatment.