Case Presentation: A 74-year-old man presented with chronic complaints of dysphagia to solids for 20 years associated with choking, regurgitation, postprandial cough and shortness of breath. Clinical evaluation revealed tolerance to liquids with persistent globus sensation, and difficulty swallowing solids, requiring concomitant liquid intake. Video-fluoroscopic modified barium swallow did not show evidence of aspiration. Considering his smoking history, an upper gastrointestinal endoscopy was obtained to rule out esophageal cancer. It revealed a small area of extrinsic compression in the upper third of the esophagus with no diagnostic abnormalities on biopsies. CT angiogram of the neck with contrast revealed an aberrant right subclavian artery (RSA) behind the esophagus, diagnostic of dysphagia lusoria. It was further confirmed by fluoroscopic esophagogram which demonstrated a smooth, rounded, extrinsic compression of the posterior esophagus. Management was symptomatic, consisting of dietary recommendations and lifestyle modifications including smaller bites and pureed meals with water to facilitate the swallowing.
Discussion: Dysphagia lusoria is a rare entity resulting from esophageal compression by an aberrant RSA that arises directly from the aortic arch distal to the left subclavian artery, and travels behind the esophagus in about 80% of cases [1]. It was first defined in 1794 as “dysphagia lusus naturae”, the Latin translation of “freak of nature” [2]. With a prevalence ranging between 0.16 to 4.4%, an aberrant RSA is more common in women, and mostly asymptomatic, with only 20-40% incidence of dysphagia due to esophageal compression [3, 4]. Although uncommon, our patient’s late-onset presentation with dysphagia and recurrent chest pain was likely the result of vascular changes in the RSA leading to compression. Swallow evaluations are suitable for early dysphagia evaluation, with barium esophagogram being key to reveal the extrinsic esophageal compression [5]. Upper endoscopies are not necessarily required and usually are grossly normal but helpful to rule out malignancies or, in our case, reveal the extrinsic esophageal compression. CT or MRI are the definite imaging studies to confirm the vascular anatomy. Treatment is largely based on symptom severity and, in our case, conservative with lifestyle and dietary modifications. Surgical interventions and esophageal dilatation are reserved for severe presentations or cases refractory to conservative strategies [6].
Conclusions: Through this case report, we aim to increase awareness of the rare diagnosis of dysphagia lusoria. Although rare, this condition should be considered in patients presenting with dysphagia with normal swallowing studies, in order to prevent unnecessary repeat testing, as well as delay in diagnosis and management.