We describe the case of a 20-month-old girl with a gastrostomy tube who presented with strider, daily emesis, stertor, and mild neck retractions. Endoscopic and radiologic investigations revealed a dilated esophagus, an associated tracheal compression, and a paraesophageal hernia secondary to a slipped Nissen fundoplication. The patient underwent a revision fundoplication, and her stridor, stertor, and neck retractions subsided significantly. She tolerated tube feeding without emesis and was discharged home. We recommend a careful evaluation of fundoplication in patients who have undergone the procedure who present with stridor and frequent emesis. Esophageal dilation and associated tracheal compression should be considered in the differential diagnosis, and in such a case, revision of the gastric wrap should alleviate the problem.

Stridor is a common indication for referral to an otolaryngologist. If the cause is not identified on physical examination or flexible laryngoscopy, direct Iaryngoscopy and bronchoscopy are often indicated to evaluate for subglottic and tracheal pathology causing turbulent airflow. Stridor is often characterized as biphasic or expiratory in these situations.

Tracheal compression can be the result of a variety of extrinsic causes. In the pediatrie population, the most common cause is a vascular lesion. ' Esophageal dilation causing compression of the trachea has been described in the literature, usually as a result of achalasia.2'4 We report the case of a young child who was found to have esophageal dilation after a slipped Nissen fundoplication caused trachéal compression with stridor and respiratory distress.

Case report

A 20-month-old African- American girl was referred to the Otolaryngology service for evaluation of stridor and daily emesis. The patient had a history of cortical atrophy, blindness, epilepsy, and gastroesophageal reflux disease that had required a Nissen fundoplication and placement ofagastrostomytube. Despite theprocedure, she was still receiving metoclopramide and ranitidine via the tube.

On examination, the patient exhibited intermittent biphasic stridor, as well as some stertor and mild neck retractions. Her mother said that this breathing pattern was typical. No perioral cyanosis was evident, and the patient's pulse oximetry level was 99%.

The patient was taken to the operating room for endoscopie investigation. Laryngoscopy and bronchoscopy detected evidence of laryngomalacia (mild arytenoid collapse), a normal subglottis, andmildleft posterolateral extrinsic trachea! compression. Because the trachéal compression appeared to be somewhat pulsatile, the patient was sent for computed tomography (CT) of the chest to rule out a vascular abnormality.

CT demonstrated significant esophageal dilation and mild trachea! compression, as well as a paraesophageal hernia (figure 1). Contrast- enhanced radiography showed a malfunctioning Nissen fundoplication with reflux into the dilated esophagus (figure 2). The hernia likely occurred as a result of the slipped Nissen fundoplication.

The patient was admitted, and eventually the Nissen fundoplication was revised with a hernia reduction. The procedure resulted in less prominent stridor, stertor, and retractions, as well as resolution of the daily emesis. The patient eventually required a second fundoplication revision, and she subsequently did well.

Discussion

The earliest report of trachea! compression as a rare presentation of achalasia was published in 1950 by Bello et al.2 To the best of our knowledge, no report of tracheal compression from esophageal dilation after a slipped Nissen fundoplication has been previously published in the literature. It appears that in our patient, the enterai wrap came loose and entered the mediastinum to cause the paraesophageal hernia. The esophageal dilation was likely related to a failure of the upper esophageal sphincter to relax, although the precise mechanism is not clear.

As with other causes of extrinsic tracheal compression, treatment is directed at the causative process. Bansal et al reported a case of paraesophageal hernia occurring after a failed Nissen fundoplication that was initially mistaken for a lung abscess.5 The paraesophageal hernia in their patient, as well as the one in our patient, resolved with revision surgery.

In patients with a history of antireflux surgery who present with stridor and emesis, a slipped Nissen fundoplication should be considered in the differential diagnosis. Even if tracheal compression is not present, reflux/emesis can cause inflammation of the larynx or even aspiration, causing respiratory distress. If such a situation is found, revision of the fundoplication should resolve the problem.

From the Department of Otolaryngology-HeadandNeckSurgery, Emory University School of Medicine, Atlanta (Dr. Rajan); and the Department of Otolaryngology, University of Tennessee Health Science Center, Memphis (Dr. Thompson).