Ba swallow shows limited leak of contrast in the supraaortic segment of the esophagus anteriorly, with a smooth extrinsic impression on the retrocardiac segment of the esophagus.

 Here is the CT of the patient, which shows Extraesophageal air in the supraaortic segment with multiple mediastinal lymph nodes

Esophageal tuberculosis

TB of the esophagus may be primary or secondary. Mechanisms of secondary tubercular involvement of the esophagus are

(1) swallowed sputum in patients having advanced open TB;

(2) direct involvement from tuberculosis involving the lungs, mediastinal lymph nodes or thoracic spine;

(3) retrograde lymphatic spread and

(4) blood borne.

 

Mid-esophagus is the commonest site of involvement, near bifurcation of trachea, due to close proximity to mediastinal lymph nodes.

Abnormalities seen in \'barium swallow\' are extrinsic compression, traction diverticula, strictures, sinus/ fistulous tracts, kinking and pseudo-tumor mass of esophagus - in decreasing order of frequency.

Diminished motility and mucosal irregularity may also be seen.

CT gives most complete delineation of the tuberculous mediastinal lymphadenopathy and the fistulous tract extending from the esophagus into the nodal mass.

On esophagoscopy ulcer with undermined edges is a common finding, and esophageal sinus or fistulous opening may be seen.

 Treatment

Majority of the patients respond well to antitubercular treatment. Few may require surgery, but as the last option. The surgery consists of paraesophageal drainage of the mediastinal abscess and esophageal diversion.