S4204 An Unusual Cause of Dysphagia

Introduction: Differentiating oropharyngeal from esophageal dysphagia refines the diagnostic strategy. This case highlights an unusual etiology for dysphagia following remote anterior cervical discectomy and fusion (ACDF). Revision cervical spine surgery with hardware removal, replacement and myofascial repair or flap reconstruction are the standard of care for this condition. Case Description/Methods: A 79-year-old man with atrial fibrillation, CKD-3, diabetes, and remote ACDF (1997) presented with weeks of dizziness, hyper-secretions, and a “choking” sensation during swallowing of both solids and liquids. Fiber-optic endoscopic evaluation of swallowing showed metallic hardware protruding into the posterior pharyngeal wall at the epiglottis, limiting laryngeal elevation and causing penetration to the vocal cords. Non-contrast computed tomography neck confirmed an anterior fixation plate breaching the posterior pharyngeal wall at C4–5. Esophagogastroduodenoscopy demonstrated erosion of the same plate into the proximal esophagus; a gastrostomy tube was placed for nutrition before transfer for combined neurosurgical and thoracic repair. Discussion: Pharyngoesophageal perforation after ACDF is estimated at 0.02–1.52% of cases, yet may present decades after surgery, long after transient postoperative dysphagia has resolved. Late or progressive symptoms or any alarm feature (progression, weight loss, anemia, age >60 y) should prompt endoscopy to exclude malignancy. Diagnostic algorithms begin with videofluoroscopic swallow study for suspected oropharyngeal disease and endoscopy plus barium esophagram—supplemented by high-resolution manometry when necessary—for esophageal pathology. Management targets the underlying lesion: speech-language therapy for neurogenic dysphagia, dilation or resection for strictures or tumors, pneumatic or botulinum therapy or peroral endoscopic myotomy/Heller myotomy for achalasia, proton-pump inhibitors for reflux, topical steroids for eosinophilic esophagitis, and revision spine surgery with hardware removal and myofascial or flap reconstruction for migrated implants. This case reminds clinicians to retain migrated cervical hardware in the differential diagnosis of late-onset dysphagia and highlights the importance of early multidisciplinary assessment. Portions of this abstract were drafted with assistance from generative AI; all text was reviewed, revised, and approved by the authors, who assume full responsibility for the final content.