Oral Regurgitation of a Large Esophageal Mass

Question: A 57-year-old man presented to the outpatient clinic with a 1-month history of worsening globus sensation and intermittent transoral mass regurgitation. The patient reported that the mass had developed gradually over the past 2 weeks. He had no significant dysphagia and had mild transient dyspnea when the mass regurgitated. He could induce nausea and freely vomit a smooth mass of 3-cm diameter into his mouth and swallow it back (Figure A, Video). A contrast-enhanced computed tomography scan of the neck revealed a 10-cm hypodense lesion originating in the cervical esophagus at the C6 level and extending distally to T3 (Figure B, C). Esophagogastroduodenoscopy showed a large, broad-based, pedunculated polypoid mass rooted at the meatus of the esophagus and extending up to 28 cm distal to the incisor (Figure D). The mass partially obstructed the laryngeal opening while prolapsing from the esophagus (Figure E). Transoral resection was successfully performed under general anesthesia with endotracheal intubation. The patient recovered uneventfully after surgery and had complete resolution of his presenting symptoms. He remained asymptomatic, and upper gastrointestinal endoscopy performed 3 months after the surgery showed no evidence of recurrence. What is the diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Examination after surgical removal showed a sausage-shaped smooth mass measuring 10 × 2.2 × 1 cm (Figure F). Histological examination of a sample of the mass revealed an admixture of massive mature adipose tissue and minimal fibrous and vascular components covered with normal squamous epithelium, characteristic of esophageal fibrovascular polyps (Figure G). Fibrovascular polyps of the esophagus are a rare, benign condition that typically arise from the cervical esophagus.1Fernandes C. Proenca L. Carvalho J. Recurrent regurgitation of a spongy mass into the mouth.Gastroenterology. 2015; 148: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Although they have also been described and reported as fibromas, fibrolipomas, myxofibromas, and pedunculated lipomas based on the major pathological presence, the World Health Organization recommends the name for these neoplasms grouped together as esophageal fibrovascular polyps.2Goto A. Suzuki M. Iizuka K. et al.Regurgitation of a mass into the mouth: a fibrovascular polyp of the esophagus.Endoscopy. 2010; 42: E248-E249Crossref PubMed Scopus (2) Google Scholar Large and pedunculated fibrovascular polyps of the esophagus >4 cm in size may prolapse and can obstruct respiration, as seen in this case, and even cause sudden choking owing to complete obstruction of the laryngeal opening1Fernandes C. Proenca L. Carvalho J. Recurrent regurgitation of a spongy mass into the mouth.Gastroenterology. 2015; 148: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Goto A. Suzuki M. Iizuka K. et al.Regurgitation of a mass into the mouth: a fibrovascular polyp of the esophagus.Endoscopy. 2010; 42: E248-E249Crossref PubMed Scopus (2) Google Scholar; it also predicts difficult airways before intubation because the esophageal mass resection of such size usually necessitates general anesthesia with endotracheal intubation.3Tang W. Wei P. Huang J. Li J. Securing and mobilizing an esophageal mass before and after endotracheal intubation.Anesthesiology. 2021; 135: 152-153PubMed Google Scholar Traditionally, endoscopic dissection is advocated for esophageal fibrovascular polyps with a thin stalk that are <2 cm in size, and large polyps resection usually necessitates open surgery considering the volume and hemorrhage risk.1Fernandes C. Proenca L. Carvalho J. Recurrent regurgitation of a spongy mass into the mouth.Gastroenterology. 2015; 148: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Recent technological advancements have enabled endoscopic resection, including flexible endoscopy and rigid endoscopy, to be frequently performed in large and pedunculated fibrovascular polyps.1Fernandes C. Proenca L. Carvalho J. Recurrent regurgitation of a spongy mass into the mouth.Gastroenterology. 2015; 148: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Goto A. Suzuki M. Iizuka K. et al.Regurgitation of a mass into the mouth: a fibrovascular polyp of the esophagus.Endoscopy. 2010; 42: E248-E249Crossref PubMed Scopus (2) Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwMzViNDQ1ZTE3NDlkZWNmNzUzZDVlNzEyNzNjMDJmMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyMjIyNjc2fQ.Hf_lp4uyuoDnAGwwQS8_eCM0ixmPVZLec9uohpsQ9qbt7uLsF5wOLV3UAKl-hjvLdjodh-ujyvcLTdWC8H-PdOBNeyLKz6EGINzwg_2KZybv7NLWOPogoUCXh4LUMszWfwBsuwZQl5BF7ZPlsN1BaA9dvFmNdOMxgdWOOYndpjElhtc26BVsuFVQIV4Lk3rIfD1Nq56qJfZFvRYcXqrtaLUkiDGR91gFC8aSqWkhsknpWApICENOQ8IdkwAj08xJJQozraxxAr8lGM8BAtb3-RVia7h5yWxUpptgucTDCEQy3uhIW_0nxVDLm3ol6fecdLEM_regK32dQlEA_Fqg1g Download .mp4 (2.95 MB) Help with .mp4 files Video