Double D – Dysphagia and Dysphonia in a Patient with Esophageal Achalasia: A Case Report

Achalasia is an esophageal motility disorder characterized by insufficient relaxation of the lower esophageal sphincter and impaired esophageal peristalsis. Although its exact etiology remains unclear, degeneration of inhibitory neurons in the lower esophageal sphincter is evident. Patients typically present with dysphagia for solids and liquids, vomiting, and weight loss.

This case report describes a 32-year-old male with a delayed achalasia diagnosis, leading to significant complications. The patient was admitted to the outpatient clinic due to worsening symptoms of vomiting and dysphagia. He had undergone Heller’s myotomy six years earlier, following a ten-year diagnostic delay. Subsequent treatments, including two peroral endoscopic myotomies and balloon dilation, proved ineffective, ultimately necessitating esophagectomy due to esophageal exhaustion. Postoperatively, he developed dysphagia and dysphonia.

A multidisciplinary team - including an otolaryngologist, a speech-language pathologist (SLP), and a gastroenterologist - conducted a fiberoptic endoscopic evaluation of swallowing (FEES). The assessment revealed aspiration during swallowing of liquids, while solid food intake remained intact. Additionally, left-sided unilateral vocal cord paresis was observed, due to recurrent laryngeal nerve injury. Objective voice analysis using Praat indicated reduced and variable voice intensity, increased perturbation measures of jitter and shimmer, and a low harmonics-to-noise ratio. The GRBAS scale was used for the perceptual evaluation of voice. Results on the Voice Handicap Index indicated the moderate impact of dysphonia on quality of life.

This case underscores the challenges of delayed achalasia diagnosis and management. Despite multiple interventions, the patient ultimately required esophagectomy, resulting in significant swallowing and voice complications. It highlights the essential role of a multidisciplinary approach, including gastroenterologists, otolaryngologists, and SLPs. While SLPs are not traditionally involved in achalasia management, this report emphasizes their crucial role in assessing and addressing swallowing and voice impairments in these patients.