A 73-year-old man with several weeks of progressive dysphagia, cough, and hoarseness presented with difficulty tolerating oral intake, with coughing immediately after ingestion of solids and liquids. He denied hematemesis, hemoptysis, or weight loss. He had several hospitalizations for recurrent pneumonia, requiring intermittent antibiotics, inhalers, and steroids. He also had a large empyema requiring video-assisted thoracoscopic surgery several months prior to presentation. He was a former 10 pack-per-year smoker who quit 20 years prior; he had worked as a dental technician with significant exposure to silica. He served in the Navy and was stationed in Cuba for several years, where he worked in the shipyards. His medical history included obstructive lung disease requiring home oxygen, bronchiectasis, gastroesophageal reflux, and silicosis.
On physical exam, the patient was afebrile and in no acute respiratory distress. His vital signs were blood pressure 108/66 mm Hg, heart rate 107 beats per minute, respiratory rate 20 breaths per minute, with oxygen saturation 95% on 3 L nasal cannula. He was a slender, well-appearing male, with no oropharyngeal findings, halitosis, tracheal deviation, or elevated jugular venous pressure. He had a notably hoarse, soft-spoken voice, and rales were auscultated throughout both lung fields. Abdominal exam was unremarkable with no abdominal distension, tenderness on palpation, masses, or hepatosplenomegaly. The rest of the physical exam and labs were unremarkable. Tuberculosis and human immunodeficiency virus tests were also negative.
A swallowing evaluation was performed initially with a modified barium-swallow test, which showed moderate oropharyngeal dysphagia to solids. Aspiration occurred after the completed swallow, triggering cough and reflux of materials into the oral cavity. On chest radiograph, there were bilateral calcified hilar lymph nodes and opacities in the mid to upper lung fields consistent with his diagnosis of silicosis (Figure 1). Esophagogastroduodenoscopy revealed no esophageal abnormalities or a fistulous tract. A formal barium upper GI swallow study demonstrated a widely patent fistula between the mid-esophagus and bronchus intermedius, with contrast extending into the right lower-lobe bronchi (Figure 2). Mediastinal calcifications were also seen, consistent with silicosis. Chest computed tomography confirmed an 8-mm fistula extending from the subcarinal region into the esophagus, with progressive massive fibrosis and traction bronchiectasis in the upper lobes (Figure 3).
Esophageal stenting of the fistula was performed via endoscopy but was complicated by stent migration and eventual removal. An open partial esophagectomy was performed as definitive management. A month after surgery, the patient was tolerating small amounts of food by mouth without dysphagia or cough.