An incidental finding of congenital oesophageal diverticulum
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A baby was born at term (39 6/7 weeks gestation) after premature rupture of membranes, for which she received 3 days of antibiotics. She initially presented floppy with a low respiratory rate and required supplementary oxygen. Biphasic stridor was audible from birth both at rest and when crying. She presented to the ear, nose, and throat (ENT) team at 10 days old with worsening stridor. On examination, she had marked tracheal tug and intercostal recession; cyanotic episodes were noted when feeding and crying with saturations dropping to 80 and 70%, respectively. Flexible nasoendoscopy was performed, which illustrated mild laryngomalacia. Initial management included treatment with steroids and nasogastric feeding.

The patient underwent a computed tomography (CT) scan that illustrated a large left-sided supraglottic cyst (3.5 ×2.4× 2.9 cm) extending from C3 to C7 with the paratracheal extension (Figs 1–3). This was confirmed on microlaryngobronchoscopy (MLB) and the cyst was drained. The patient was managed postoperatively in the pediatric intensive care unit where she remained intubated. Extubation was unsuccessful, secondary to worsening stridor and increased work of breathing; a chest X-ray revealed a collapsed right lung. A second MLB was performed and thick bronchial secretions were found, as well as subglottic inflammation, in keeping with a diagnosis of tracheitis.

The patient later underwent a barium swallow and magnetic resonance imaging (MRI), both of which showed a left lower neck cyst with an opening into the left piriform sinus. Differential diagnoses included a foregut duplication cyst or a third branchial cleft anomaly. Ongoing management of the cyst was discussed with a specialist paediatric ENT team who decided to observe the patient, given she was progressing well clinically. Saturations during this time remained more than 96% during feeding.

At age 8 months, the patient was admitted to the hospital from the clinic due to worsening stridor. She underwent a further MLB that once again illustrated a cyst. An ultrasound scan was performed intraoperatively to aid with the emptying of the cyst, and an incidental finding of a connection between the cyst and the cricopharyngeal region was identified, in keeping with a diagnosis of an oesophageal diverticulum. This was later confirmed on a barium swallow study (Fig. 4). Following the MLB, the patient remained clinically stable; the stridor resolved.

The case has been discussed with the Paediatric, Radiology, and Head and Neck team regarding possible excision of the cyst and management of the oesophageal diverticulum. Ultrasound imaging performed when she was 3 years of age confirmed the presence of a pouch in the cervical esophagus. The patient is now 4 years old—she has been seen regularly in the ENT clinic and remains clinically well. She continues to be asymptomatic from her oesophageal diverticulum and is therefore being managed conservatively at this time.