Achalasia esophagus; presenting as acute air way obstruction

Acute airway obstruction from mega-esophagus is a rare presentation of achalasia. Mega-esophagus is generally considered when the transverse width of the esophagus is more than 7 cm. A 78 year old lady presented with longstanding history of productive cough and nocturnal dyspnoea. She was seen in the emergency department with acute exacerbation of dyspnoea after a bout of vomiting, containing semi-solid food with foetid smell. Her respiratory status deteriorated rapidly with onset of stridor, and cyanosis. Chest x-ray showed widening of mediastinum due to dilated esophagus with air-fluid level. Prompt, repeated, upper respiratory tract suction was carried out. A wide bore nasogastric tube was introduced, esophagus was decompressed with a gush of air and fluid, relieving the respiratory distress. This case illustrates an unusual presentation of achalasia underscoring the need for urgent, life-saving esophageal decompression. Hypotheses, regarding the mechanism of airway compromise, as well as, treatment options are reviewed.