Akute Kompression der Luftwege bei Achalasie

Respiratory distress, dysphagia, and neck swelling developed in a 72-year-old woman who was known to have achalasia. Symptoms developed immediately after vomiting, and the patient presented with worsening breathlessness, stridor, and hoarseness of voice. Examination revealed a left-sided uncompressible neck mass and signs of respiratory distress. The most recent surveillance endoscopy had shown a baggy esophagus, 35 cm to the esophageal-gastric junction, without esophageal obstruction.
Chest x-ray (A) confirmed the presence of a tortuous, dilated, and baggy esophagus (A, arrows show outline of the dilated esophagus). Lateral neck x-ray (B) showed a distended esophagus compressing the trachea (bottom arrow) and displacing the laryngeo-tracheal complex anteriorly (B, top arrow). CT scan revealed herniation of the distended esophagus posteriorly behind the oropharynx to the level of the nasopharynx, deviating the trachea, and compressing the upper part of the esophagus. CT scan also showed distal esophageal complete obstruction at the gastroesophageal junction. There was no evidence of pneumothorax or esophageal rupture.

Fiberoptic laryngoscopy was used to negotiate the acute shift of larynx, and to intubate the trachea. Because of increased risk of perforation, esophageal catheterization was not attempted. A repeat x-ray (C), 4 days later, revealed spontaneous decompression of esophagus. Endoscopic balloon dilation was chosen as the treatment for this patient. The patient refused esophageal resection and replacement, so endoscopic dilation and surveillance was continued.

Achalasia, left untreated, causes progressive stasis, esophageal dilation, and formation of mega-esophagus. Airway obstruction is a rare complication, and in most cases decompression of the esophagus is achieved with esophageal catheterization after securing the airway. Nitrates and nifedipine have been used with some response because these dilate the lower end of the esophagus and allow the air to escape.1 For definitive treatment of symptomatic achalasia, laparoscopic myotomy provides an attractive choice for younger patients and those with a large-diameter esophagus, while graded pneumatic dilation is usually the treatment of choice for patients older than 40 years of age.2

References
1 M.S. Wagh, D.S. Matloff and D.L. Carr-Locke, Life threatening acute airway obstruction in achalasia, Med Gen Med 6 (2004), p. 12.
2 V. Annese and G. Bassotti, Non-surgical treatment of oesophageal achalasia, World J Gastroenterol 12 (2006), pp. 5763–5766.

M Aslam, Ch Sutton, and D Hunter

Journal of the American College of Surgeons Volume 205, Issue 6, December 2007, Page 813