Cough is the most common complaint for which patients seek medical attention. Cough can be classified as acute (less than 3 weeks) or chronic (3 to 8 weeks or longer). The most common causes of chronic cough in nonsmokers include asthma, gastroesophageal reflux disease (GERD) and postnasal drip syndrome (PNDS). Lesions that compress the upper airway remain a rare cause of chronic cough.
We report the case of a 50-year-old housewife, who presented to the pulmonary clinic for evaluation of a non-productive cough. The cough had been present for approximately 1 year. It was described as slow in onset, worse at night with frequent awakenings and was accompanied with pleuritic chest pain. No aggravating factors or relationship to food or body position. The cough was refractory to prescription and over-the-counter cough suppressants. The patient and her husband were both lifelong non-smokers and denied any exposure to chemicals, irritants or pets. They also denied any recent travel. Laboratory data, pulmonary function tests (PFT) and chest radiographs were unremarkable. The patient had already been adequately treated for allergic rhinitis and gastroesophageal reflux disease. Neither resolved her cough. Computed tomography (CT) of the chest showed a 1.7 cm low-density mass posterior to the carina. Bronchoscopy revealed an extrinsic compression without obstruction proximal and posterior to the carina. Barium swallow showed minimal extrinsic compression of the esophagus. Magnetic resonance imaging (MRI) was compatible with an esophageal duplication cyst (EDC). The patient underwent open thoracotomy with complete excision of the cyst. Pathology revealed a cyst that was multilocular and lined with cuboidal to cilliated columnar epithelium. It had a smooth muscle coat with no evidense of mucous glands, cartilage or neoplasia. The findings were consistent with an EDC. The patient’s cough subsequently resolved.DISCUSSION: This case demonstrates a rare presentation of an EDC as an etiology of chronic cough. EDCs are congenital anomalies of the embryonic foregut commonly located in the posterior mediastinum. They are common in children, may be single or multiple and present as respiratory or gastrointestinal symptoms. One third of patients remain asymptomatic throughout childhood. In adults, EDCs are usually found incidentally. When present, dysphagia is the most common complaint. Complications include infection, hemorrhage, obstruction and neoplastic transformation. EDC’s can be detected by numerous modalities including chest CT, esophageal ultrasound or MRI. Often these are incidentally detected on chest radiographs or upper gastrointestinal examinations. Needle aspiration to confirm the benign diagnosis may be performed in conjunction with endoscopy or with CT guidance. Pathology usually reveals a variety of mucosa including squamous, columnar, cuboidal or pseudostratified. The recommended treatment is complete excision either with conventional or muscle-sparing posterolateral approach as well as though newer modalities like video assisted thorascopic surgery (VATS). Recurrences are rare.
Cough is the most common complaint for which patients seek medical attention. Though rare, extrinsic compression of the trachea can be a cause of chronic cough. EDC’s mostly present as dysphagia in adults. Though benign, complete excision is recommended.
L.O. Bravo, Department of Defense.The views presented in this case do not represent that of the Department of Defense