The Videofluorographic Swallowing Study in Rheumatologic Diseases: A Comprehensive Review
Esophageal dysphagia associated with sarcoid has been attributed to dysmotility from neuropathy, dysmotility from myopathy, mechanical obstruction from esophageal mural involvement, and mechanical obstruction from extrinsic compression by subcarinal lymphadenopathy. The relative importance of these etiologies has not been evaluated because of variable and nonstandardized analysis. In particular, manometry has not been performed to exclude esophageal dysmotility in dysphagia attributed solely to extrinsic compression. A 42-yr-old male with chronic sarcoid for 20 yr presented with mild dysphagia to solids. An upper gastrointestinal series revealed smooth narrowing of the esophageal lumen and transient hang-up of the barium column and a 1.3-cm diameter radiopaque pill at the level of the carina. Chest computerized tomography revealed esophageal narrowing at the level of the carina and splaying of the two mainstem bronchi from compression by subcarinal lymphadenopathy. Esophagogastroduodenoscopy revealed elliptical esophageal narrowing due to multiple, smooth, and nodular deformities at 29-32 cm from the incisors. Pathological examination of deep biopsies of the nodules revealed normal mucosa and submucosa without granulomas. Esophageal manometry revealed a highly localized high pressure zone of 39.8 +/- 6.1 mm Hg at 29-31 cm from the incisors (lab normal about -5 mm Hg). Esophageal muscle contractions were peristaltic and of normal amplitude above, within, and below this high pressure zone. This case report demonstrates that extrinsic compression from subcarinal lymphadenopathy is a sufficient mechanism for dysphagia with sarcoid, but it does not exclude a role for other mechanisms, such as nerve injury, in some cases.