A 38-year-old female patient presented to our fast-track ENT clinic with persistent left-sided throat discomfort and pain for several months. The throat pain lateralised to the left and radiated to her left ear. She also reported positive reflux symptoms with heartburn. At the time of review, medical management had been implemented (with high-dose oral proton pump inhibitor and raft-forming alginate); however, this yielded no symptomatic relief. Voice Handicap Index (VHI) was 11 and Eating Assessment Tool (EAT-10) score was 1. She was a non-smoker, and her past medical history was insignificant.\nOffice examination of the neck, oral cavity and oropharynx was unremarkable. Flexible nasendoscopy was performed, which revealed some post-cricoid oedema consistent with laryngopharyngeal reflux (Figure ). A contrast-enhanced magnetic resonance imaging (MRI) scan of the neck was normal. As symptoms continued to persist, a transnasal oesophagoscopy (TNO) under local anaesthetic was performed as an office procedure where a proximal oesophageal lesion was identified (Figure ). The lesion appeared small (approximately 3 mm in diameter), exophytic, non-ulcerating and papillomatous. It was located on the left side of the upper oesophageal mucosa, 23 cm from the nasal sill. Multiple punch biopsies were taken.\nHistological examination of the specimen revealed squamous cell papilloma of benign appearance with prominent papillae and acanthotic stratified squamous epithelium without cellular atypia. The specimen tested positive for human papilloma virus (HPV). Oesophageal manometry and 24-hour oesophageal pH monitoring indicated borderline pathological reflux with some proximal penetration (DeMeester score [DMS] = 15.9).\nThe patient then underwent complete endoscopic excision of the lesion. Histology confirmed HPV-positive squamous papilloma. Anti-reflux treatment, including lifestyle changes, was continued. Following excision, the patient’s symptoms resolved and a yearly follow-up confirmed their complete remission. It is yet uncertain whether symptomatic relief was a result of excision, continued anti-reflux treatment, or even a placebo effect associating the procedure.
A 67-year-old Caucasian man visited his primary care physician with complaints of hematemesis and continuous dysphagia. He had history of cigarette smoking and social alcohol consumption. Previous medical history included hypertension and hyperlipidemia. An initial EGD showed multiple verrucous lesions extending from 30 cm to 39 cm from his incisors. Pathological examination of the multiple biopsies showed squamous papillomatosis.\nThe patient was referred for evaluation at our hospital and a new EGD showed the same extensive verrucous lesions with three large growths on the distal esophagus causing significant stenosis. He repeated the biopsies and maintained the previous histological diagnosis. A thoracoabdominal CT-Scan revealed large esophageal lesions apparently superficial with thickening of the esophageal wall. Endoscopic Ultrasound showed that these changes were almost all limited to the mucosa and submucosa except in one area where they appeared to penetrate deeper.\nAt this time, the patient’s dysphagia got worse and there was substantial suspicion of potential malignancy. After a multidisciplinary discussion, he was proposed for surgery. He underwent a minimally invasive Ivor-Lewis Esophagectomy (laparoscopy + right lateral thoracoscopy) with a mechanical termino-lateral esophago-gastric upper thoracic anastomosis (at approximately 24/25 cm from the incisors) (Figs. , ). The postoperative (PO) period was uneventful and the patient was discharged at the 9th PO day.\nThe examination of esophagectomy specimen () showed a squamous cell carcinoma in situ (verrucous type) of the distal esophagus with areas of high dysplasia and extensive diffuse squamous papillomatosis. There were no signs of lymphatic or perineural invasion and margins were clear. The eighteen lymph nodes excised were all negative for malignancy. The TNM stage (8th edition) was Tis N0. One year later, at the follow-up consultation, there were no signs of recurrence.