脊椎・大動脈弓部間の食道狭窄から口側食道の拡張を来して気道閉塞を起こした1例(Airway obstruction caused by esophageal stricture due to compression between the spine and the aortic arch)

要旨 今回，拡張した食道が気管を圧迫して気道閉塞を来した症例を経験したので報告する。症例は出生直後の脳性麻痺による精神発達遅滞，ならびに高度の脊椎側弯のある53歳の女性。食事中にチアノーゼが出現したため救急要請となり，救急隊により半座位の状態から臥位へと変更しバッグバルブマスク換気を行ったところチアノーゼは消失し，当センターに搬入となった。搬入時，呼吸状態は安定しており，胸部CT検査で食道は大動脈弓部と弯曲した脊椎で挟まれ，口側の食道は拡張し，内容物で充満していた。また，気管は拡張した食道により背側から圧排されていた。内視鏡的に貯留した食物残渣を吸引除去した。第4病日に水溶性造影剤を服用し，造影剤の胃への移行を認め，経口摂取は可能であると判断した。その後は食事内容のコントロールで呼吸困難の再発なく，良好に経過した。本症例では，食道が弯曲した脊椎と大動脈弓部に挟まれ，食物の通過障害を来し，食道は慢性的に拡張していたと考えられた。食道は完全閉塞の状態ではなかったことから，ある程度の食道内圧で食物は通過していたと思われる。しかし，何らかの理由（固形物の大量摂取など）を契機に口側食道の内圧が高まり，それにより背側から気管を圧排し，気道閉塞の症状が出現したと推測された。我々が検索した限り類似の病態は散見されるが，本病態は過去に報告例がなく，非常に稀な症例であった。脊椎側弯症に合併する呼吸不全の鑑別診断として，食道拡張による気道閉塞も念頭に置くべきである。 ABSTRACT We herein report a case of airway obstruction caused by the compression of the trachea due to dilated esophagus. The patient was a 53–year–old female with a history of scoliosis and cerebral palsy from birth. Emergency medical assistance was required due to an occurrence of cyanosis during a meal. The ambulance service changed the patient's position from fowler to the recumbent position before administering ventilation using a bag valve mask. She was admitted to our center without cyanosis. On admission, the patient's respiratory state was stable. Chest CT showed the esophagus to be compressed between the aortic arch and the curved spine, the adoral esophagus was dilated, and that the esophagus was filled with food residue. The trachea was found to be compressed by the dilated esophagus from the dorsal side. The food residue was removed by suction using an endoscope. Ingestion was determined to be possible on the 4th day, because a water–soluble contrast agent was taken and observed to move into the stomach. The patient's dyspnea was not recurrent and was thereafter successfully controlled. The patient's clinical course was uneventful. The difficulty associated with allowing the passage of food led to the chronic dilation of the esophagus. The food residue could pass through the esophagus with some esophageal pressure because the esophagus was not completely obstructed. However, some factors (e.g. a large amount of solid food) had increased the patient's esophageal pressure. The esophagus was thought to have compressed the trachea from the dorsal side and thus had caused tracheal obstruction. To the best of our knowledge, there have been no identical case reports, although we were able to find some similar studies. An airway obstruction caused by a dilated esophagus should therefore be considered in the differential diagnosis