Achalasia cardia presenting with tracheal compression

A 37-year-old man presented with difficulty in swallowing for the past 3 years. He initially had dysphagia to liquids only; however, for the past year, he had difficulty in taking solids as well. He started having a cough associated with exertional dyspnoea for 3 months and had lost 8 kg weight. He had been taking over-the-counter antacids and oral pantoprazole with symptomatic relief. On examination, he had pallor, and the rest of the physical examination was unremarkable. He was planned for a barium swallow examination. The chest X-ray was normal. Spirometry was done for the evaluation of shortness of breath. The flow–volume loop [Figure - 1]a showed flattening of the expiratory limb of the loop suggesting intrathoracic variable airway obstruction. Subsequently, a contrast CT scan of the thorax was done [Figure - 1]b, which showed a large dilated oesophagus causing compression of the trachea. The patient’s symptoms were consistent with an oesophageal motility disorder, and on barium swallow, he was diagnosed as achalasia cardia with a large dilated oesophagus.

Figure 1: (a) Flow-volume loop obtained during spirometry showing flattening of expiratory limb; (b) mediastinal section (axial) of CT thorax showing deformed trachea due to compression from the dilated oesophagus

Airway compression in achalasia can occur due to pressure exerted by the massively dilated oesophagus over the posterior tracheal wall but is an uncommon presentation. This patient underwent endoscopic treatment for achalasia. The patient did not give consent for bronchoscopic examination to assess for placement of a silicone stent to stabilize the airway. He had marked relief in his dysphagia at 6 months of follow-up although no relief was reported in his cough.

Conflicts of interest. None declared