Abstract Heterotopic gastric mucosa (HGM) refers to the presence of gastric epithelium outside its normal location, commonly within the gastrointestinal tract. Its presence in the upper aerodigestive tract is exceedingly rare, particularly in neonates. Symptoms vary by location and may include feeding difficulties, aspiration, or airway obstruction. Because these lesions can resemble more common disorders such as laryngomalacia or congenital esophageal anomalies, diagnosis is often delayed. We present a neonate with a hypopharyngeal mass composed of both gastric and small intestinal mucosa who developed severe aspiration and failure to thrive, underscoring the value of early multidisciplinary evaluation. Case A 6-week-old term male with no prior medical history presented with progressive coughing and choking during feeds, poor intake, and weight loss over three weeks. He was afebrile and hemodynamically stable. Laboratory evaluation was unremarkable, but nutritional assessment revealed severe acute malnutrition (weight-for-length Z score −5.0). Chest radiography showed no pneumonia. Additional studies—including echocardiogram, head ultrasound, and abdominal ultrasound—showed no structural cardiac abnormalities, intracranial pathology, or pyloric stenosis. Due to persistent feeding intolerance, he was made NPO and started on nasogastric (NGT) feeds. An esophagram demonstrated no vascular ring but revealed multiple gastric filling defects. Flexible laryngoscopy showed pooled secretions in the hypopharynx without laryngomalacia. Pulmonology recommended a triple endoscopic airway evaluation. Combined flexible bronchoscopy, esophagogastroduodenoscopy, and direct laryngoscopy identified a large pedunculated mass just proximal to the upper esophageal sphincter (Figure 1a). Biopsy led to transient airway compromise requiring intubation and pediatric ICU transfer. Definitive endoscopic excision was performed (Figure 1b), revealing a firm lesion arising from the posterior hypopharyngeal wall. Histopathology demonstrated heterotopic gastric and small intestinal mucosa with mucosal erosion and congestion but no dysplasia. Following excision, tracheomalacia resolved; however, swallow evaluation showed persistent aspiration, requiring continued NGT feeding at discharge. Discussion Hypopharyngeal HGM is extremely rare, and coexistence of gastric and small intestinal mucosa in this location is scarcely described in infants. In this case, the mass likely caused both airway compromise and significant aspiration, resulting in severe malnutrition. Improvement in tracheomalacia after excision suggests an extrinsic mechanical effect on airway stability. Persistent postoperative dysphagia highlights the need for ongoing speech-language therapy and nutritional management. This case emphasizes early endoscopic evaluation in infants with unexplained aspiration or failure to thrive and the importance of recognizing rare congenital anomalies to prevent diagnostic delay. This abstract is funded by: None
Kirkwood et al. (Fri,) studied this question.