Case Study: Differential Diagnosis of UES Disorders

Here is a case example illustrating the differential diagnostic process one might encounter when a patient complains of food sticking in the cervical region. Such a complaint might implicate a disorder of the upper esophageal sphincter (UES).

Patient Evaluation

A 50-year-old woman with a history of well-controlled rheumatoid arthritis complained of progressive discomfort when swallowing solid and liquid foods. She localized her problem to the lateral neck.

It’s important to make a note of the rheumatoid arthritis as it is a systemic disease and may be part of an “overlap syndrome,” when connective tissue disorders appear together. We should also understand that the solid food complaint may indicate an obstruction in the UES, and the localization to the throat may also be inaccurate. The problem also appears to be progressively worse. With these factors in mind, what additional information do we need to diagnose the issue?

Seeing the Problem

To gain visibility and potentially find the origin of the problem, a modified barium swallow using a slightly thickened material (connoted by the number 2 in the video below) was given in normal volume amounts. In the video below we see both the lateral view of the oropharynx and a view of the esophagus:

Interpreting the Results

The patient’s complaint was confirmed as there was considerable residual left above the upper sphincter. However, hyoid excursion was judged to be normal, ruling out a traction (mechanical) disorder. Other considerations to explain her disorder include a neurologic origin (failure to relax), an anatomic disorder (less likely from the history), or an esophageal-based disorder.

Diagnosis

The swallowing study continued with the patient standing and swallowing a normal amount of barium. We stood her up and used a thicker bolus because the lateral view did not necessarily explain the etiology of her complaint. This view can be seen at 0:54 in the video above.

The total lack of esophageal motility seemed to be the most likely source of her complaint. The upper sphincter did not open normally due to the primary failure of the body of the esophagus to clear the swallowed material below the level of her complaint. Treatment, therefore, should be focused on the primary esophageal disorder under the direction of the gastroenterologist.