© U.S. Cancer Pain Relief Committee, 1998 0885-3924/98/$19.00Published by Elsevier, New York, New York PII S0885-3924(98)00083-9

254 Journal of Pain and Symptom Management Vol. 16 No. 4 October 1998

Original Article

Esophageal Stents May Interfere with the Swallowing Reflex: An Illustrative Case History

Angel Lee, MRCP (UK), and Karen Forbes, MRCP (UK)

Department of Palliative Medicine, Bristol Oncology Centre, Horfield Road, Bristol, United Kingdom

Abstract

Dysphagia is an important and distressing symptom which has a significant impact on the quality of life of patients with carcinoma of the esophagus. Although endoscopic palliation of dysphagia due to unresectable or recurrent esophageal carcinoma can be provided by esophageal dilatation and intubation, laser ablation, injection of alcohol or sclerosants, or brachytherapy, these techniques are often unsuitable for the palliation of high esophageal tumors. We present a patient with recurrent carcinoma of the proximal esophagus who developed an inability to swallow as a complication of intubation with an esophageal stent. The dysphagia improved dramatically after the stent was removed.

J Pain Symptom Manage 1998;16:254–258.

© U.S. Cancer Pain Relief Committee, 1998.

Key Words

Deglutition disorder, esophageal neoplasm, stents, palliative care

Introduction

Surgical resection offers the best chance oflong-term survival and palliation of symptomsin patients with carcinoma of the esophagus.However, up to two-thirds of patients are notamenable to surgery at the time of presenta-tion, either because of the extent of disease orother coexisting medical conditions.

1

In thesepatients, the goal of management is the effec-tive palliation of dysphagia and odynophagia,usually by reestablishing the patency of theesophageal lumen.

Esophageal stents are often used as palliativetherapy in patients who have failed or are notsuitable for other forms of palliative treatment,

such as surgery, radiotherapy, or laser therapy.Stents can be successfully placed in more than90% of cases

2

and the procedure is relativelysimple and safe. Recognized complications in-clude esophageal perforation (5–19%), tubemigration (10–15%), and tube obstruction(6%).

3-5

Dysphagia is not well recognized as a compli-cation of placement of esophageal stents. Wepresent a patient who developed inability toswallow after stent insertion.

Case Report

The patient was a 77-year-old man who hadan esophagectomy for a poorly differentiatedadenocarcinoma of the esophagus. He was wellfor 2 months, but over the following 8 months,he required 19 endoscopic dilatations for ananastomotic stricture at 21 cm from the inci-sors. Biopsy at the stricture was suspicious of re-

Address reprint requests to:

Angel Lee, MRCP, PalliativeCare Service, Tan Tock Seng Hospital, MoulmeinRoad, Singapore 308433, Singapore.

Accepted for publication: January 26, 1998.

Vol. 16 No. 4 October 1998 Esophageal Stents and Swallowing Reflex 255

current disease. In view of the frequency of di-latations, he was admitted for elective insertionof a Celestin tube. Following this procedure hedeveloped dysphagia even to fluids. His prog-nosis was judged to be short and he was re-ferred to our hospital palliative care team forsymptom control.

On examination, he was frail and cachectic.He had no cervical lymphadenopathy and noother physical signs of metastatic disease. Hehad a hoarse voice and a weak cough, whichhad developed after stent insertion, and wascontinually spitting out saliva. All attempts atswallowing induced distressing laryngospasmwith stridor.

Hyoscine butylbromide (60 mg) was givensubcutaneously in a syringe driver over 24hours to dry secretions. Hyoscine butylbro-mide was chosen over hydrobromide becauseof its lesser sedative effect. Despite this, thedose had to be subsequently decreased to 40mg over 24 hours because the patient becamesleepy.

Endoscopy showed that the top of the stentwas at 18 cm from the incisors. This wasthought to be just below the cricopharyngeusmuscle, with the distal end of the stent at 30cm. There was no evidence of any obstructionof the Celestin tube. Both vocal cords werenoted to be paralyzed in the adducted posi-tion. Chest radiography (Fig. 1) and lateralneck radiography (Fig. 2) showed the top ofthe stent just below the level of the sixth cervi-cal vertebra, generally taken to be the level ofthe upper esophageal sphincter.

6

Swallowing assessment by a speech therapistrevealed a normal oral phase but poor laryn-geal lift. Swallowing resulted in violent chokingwith stridor. Videofluoroscopy was unsuccess-ful since the patient was too fearful of chokingto swallow during the procedure.

It was feared that removal of the stent mightlead to esophageal rupture. Nonetheless, be-cause the patient’s dysphagia did not improveafter 2 weeks the stent was removed. This wasfollowed by gradual improvement of both the

Fig 1. Chest radiograph showing position of Celestin tube.

256 Lee and Forbes Vol. 16 No. 4 October 1998

patient’s swallowing and his voice. He toler-ated a liquid diet by the third day and pro-gressed to a soft diet a few days later. Hysoscinewas discontinued as his swallowing improved.

The patient was discharged home and re-quired another esophageal dilatation for re-current dysphagia 4 weeks later. His generalcondition continued to deteriorate and hedied at home 2 weeks following this.

Discussion

Patients often need increasingly frequent dila-tations for recurrent dysphagia when this is usedas the primary therapy.

7

The usual indicationsfor placement of esophageal stents are a require-ment for frequent and/or difficult dilatationsto minimize dysphagia, and the persistence ofdysphagia despite dilatation. Esophageal stent-ing is also considered to be the definitive treat-ment for tracheoesophageal fistulae.

Alternative methods for palliating dysphagiain patients with carcinoma of the esophagusare laser therapy and injection of ethanol. Un-fortunately, neither of these methods wouldhave been suitable in this patient. Ethanol in-jection is best for exophytic tumors and laser

therapy is generally only suitable for relativelyshort tumors (less than 6 cm), which are exo-phytic, noncircumferential and in the mid ordistal esophagus.

8

The upper esophageal sphincter has vari-ously been considered a pharyngeal or anesophageal structure. The position of thepharyngoesophageal sphincter is usually takento be at about 20 cm when measured fromthe incisors endoscopically. The muscular ele-ments of this sphincter are made up of thecricopharyngeous muscle, the inferior pharyn-geal constrictor, and adjacent portions of thecervical esophagus. High esophageal strictures,i.e., within 2 cm of the pharyngoesophagealsphincter, are considered unsuitable for in-tubation. A stent at this site is not usually tol-erated because of the sensation of foreignbody; stridor from laryngeal obstruction andproximal migration of the prosthesis may alsooccur.

Swallowing is a complex sequence of eventsallowing propulsion of food into the stomachand prevention of food passing down the tra-chea or up into the nasopharynx. It is dividedinto oral, pharyngeal, and esophageal phases.During the oral phase, the food bolus is movedbackwards by the tongue. Stimulation of the

Fig 2. Lateral radiograph of the neck showing the upper end of the Celestin tube just below the level of the sixthcervical vertebra.

Vol. 16 No. 4 October 1998 Esophageal Stents and Swallowing Reflex 257

pharyngeal wall by the food bolus or apposi-tion of the soft palate against the pharynx re-sults in reflex pharyngeal peristalsis. Muscularcontractions then traverse the oropharynx andhypopharynx, and reach the upper esophagealsphincter in less than 1 second. The pharyn-geal and parapharyngeal muscles then con-tract in a coordinated sequence, pushing thefood bolus ahead. At the same time, to preventfood from going up the nose or down the tra-chea, the palatopharyngeal folds come to-gether as the vocal cords adduct, the larynxmoves upward and the epiglottis covers the lar-ynx. As the wave of contraction reaches the up-per esophageal sphincter, it relaxes and a se-ries of peristaltic waves helps to bring the foodto the stomach. This primary wave of peristalsisis assisted by secondary contractions stimulatedby esophageal distention.

9,10

Laryngeal movement is crucial to a success-ful swallowing mechanism because the laryn-geal inlet must be closed and physically re-moved from the path of the food bolus duringthe swallow. Because sphincteric musculaturehas a single insertion anterior to the cartilageof the larynx, the sphincter and the larynx areobliged to move together during the act ofswallowing. The presence of a prosthesis splint-ing the movement of the larynx can lead to apicture similar to oropharyngeal dysphagiawith a primary neurological cause.

Our patient developed inability to swallow,discomfort in the upper chest, audible stridor(especially after attempts at swallowing), andhoarseness of the voice following stent inser-tion. Both vocal cords were observed to be ad-ducted at endoscopy. It is not known whetherthe patient’s cords were moving normally be-fore or after the esophagus was stented, how-ever the patient’s hoarse voice, stridor, anddysphagia all improved after stent removal. It ispossible that trauma during stent insertioncaused edema and recurrent laryngeal nervepalsies due to compression, which resolved fol-lowing stent removal. Clinically, it seems thatalthough the stent was observed endoscopicallyto be distal to the cricopharyngeous muscle, itwas proximal enough to lead to laryngeal com-pression with splinting of movement.

Successful stenting in patients with highesophageal strictures close to the cricopharyn-geus has been reported,

11,12

for example, withmodified Celestin tubes with a soft funnel de-

signed to sit above the cricopharyngeus.

13

Ex-panding metal stents may provide a less trau-matic and better tolerated method of stentingwith fewer complications for the majority of pa-tients with carcinoma of the esophagus.

2,14

Therole of the latter devices in patients with suchproximal lesions is uncertain.

Conclusion

This case provides an insight into the com-plex mechanism of swallowing and how it canbe disturbed. Stent removal provided a simplesolution to the acute dysphagia in this patient.Patients with dysphagia due to recurrent dis-ease with high, circumferential esophagealstrictures remain difficult to palliate despite re-cent advances in endoscopic palliation and pros-theses.

Acknowledgment

With thanks to Professor D. Alderson for per-mission to report on his patient.

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