Laryngopharynx

Oesophagus is the narrowest region of •

.alimentary tract except vermiform appendix
:During its course it has three indentations
At 15 cm from incisor teeth is cricopharyngues –
sphincter (normally closed)
)UES(
At 25 cm aortic arch and left main –
bronchus
At 40 cms where it pierces the –
diaphragm where a physiological
sphincter is sited (LES)
These areas are where most oesophageal foreign
bodies become entrapped
Upper Oesophageal Sphincter: It is a 2-3 mm zone of elevated
pressure between pharynx & oesophagus. It relates to
cricopharyngeal muscle
Lower Oesophageal Sphincter: The LES is located at the junction •
between the esophagus and stomach
normal tone: 10–40 mmHg (achalasia: >40; scleroderma: <10)
Evaluation of Esophagus
The symptoms of heartburn, dysphagia and odynophagia
.almost always suggest a primary esophageal disease
Heartburn: This is sensation of substernal burning
that often radiates to the neck. It is highly indicative of
.gastroesophageal reflux disease (GERD)
GERD
.GERD accounts for 70% of noncardiac chest pain
Gastroesophageal reflux disease refers to damage of esophageal
.mucosa due to abnormal reflux of gastric content
Etiology
Inappropriate function of lower esophageal sphincter LES permits reflux of
gastric contents
into esophagus. The conditions, which decrease LES tone, are
:following
High levels of progesterone in pregnancy .„
Sliding hiatus hernia .„
Fatty foods, chocolate and peppermints .„
Tobacco smoking and alcohol .„
,Drugs, which relax the smooth muscle: Anticholinergic .„
.beta-adrenergic drugs and calcium channel blockers
Clinical Features
Heartburn .
Dysphagia
odynophagia
Angina-like chest pain, which worsens after sublingual
nitroglycerin
torticollis (Sandifer
)syndrome: distinctive neck posture in children that protects against acid reflux
nonproductive cough
hoarseness of voice
asthma-like symptoms and dental erosions

Nonproductive cough: GERD is among the most common

,causes of chronic cough. Other causes include postnasal drip
.asthma and tuberculosis
Asthma-like symptoms: About 70–80% asthma patients
have GERD and treated with PPI. GERD-induced asthma
is suspected in following cases
Adult onset of asthma ––
No family history of asthma or atopy ––
Heartburn precedes onset of asthma ––
Wheezing exacerbated with meals, exercise or ––
supine position
.Nocturnal wheezing ––

‫حمح‬/

‫؛‬/‫؛‬/
Reflux laryngitis or laryngoesophageal reflux
:)Hoarseness of voice(
LPR
Symptoms include hoarseness of voice, throat ––
clearing, dysphagia, increased phlegm and globus
.sensation
Inappropriate function of lower esophageal sphincter UES

Only 40% of LPR patients have Heart burn

Barrett’s esophagus: This potentially serious GERD complication

predisposes to development of adenocarcinoma
of esophagus. Normal stratified squamous epithelium
of distal esophagus is replaced by intestinal columnar
metaplasia
Treatment
,The aims of the treatment include decreasing reflux
improving esophageal clearance and protecting esophageal
.mucosa
Lifestyle modifications: Patient’s instructions include .„
Weight loss
Small and frequent meals
Avoid fats, sweets, chocolate, tomatoes, onions, alcohol
and caffeine at bedtime
Finish dinner 3 hours before going to bed
.Elevation of head end of bed during sleep
Medical treatment: It includes .„
.Antacids
H2 receptor antagonists: H2 receptor antagonist (ranitidine)
.heals 50% cases of reflux esophagitis
Proton pump inhibitors: PPI (such as omeprazole) heals
.cases 80%

.In LPR we give Omeprazol 40mg two times a day

Antireflux surgery: In Nissen’s fundoplication, fundus of .„
.stomach is wrapped around LES
Indication: Patients who do not respond to medical
treatment and
Recent developments .„
Endoscopic suturing
Injection of biopolymers in LES
Radiofrequency delivery to gastroesophageal junction

esophageal Reflux disease

Odynophagia: It is sharp retrosternal pain on swallowing

,indicative of esophagitis due to candida, herpes viruses
Cytomegalovirus (CMV), especially in immunocompromised
patients. The traumatic causes include caustic ingestions and
pill-induced ulcers
esophagitis
The three most common causes of infectious esophagitis are
candida, cytomegalovirus (CMV) and herpes simplex virus
.)HSV(
Treatment
.Management of immunocompromised condition .„
Antifungal .„
.Fluconazole: 100–200 mg/day for 10–14 days
.Clotrimazole and nystatin: Topical 4–5 times a day
Amphotericin B: In cases of granulocytopenia to prevent
.disseminated disease
Antiviral .„
Acyclovir for HSV: Intravenous 5–10 mg/kg every 8 hours
.till patient tolerate oral therapy
Gancyclovir for CMV: Two-week full dose
regimen followed by maintenance therapy for several
.weeks

pill-induced ulcers

Pill-induced esophagitis
Etiology
Factor: Oral medicines not taken in upright position and .„
.without plenty of water or fluid
,Common medicines: Doxycycline, acetylsalicylic acid .„
,nonsteroidal anti-inflammatory drugs (NSAIDs), iron sulfate
.quinidine and alendronate
.Common sites: distal esophagus .„
Clinical Features
.Chest pain and odynophagia occur due to acute esophagitis .„
.Dysphagia indicates development of stricture .„
Diagnosis
Esophagoscopy: Mucosal changes include ulcer, plaques .„
.resembling candida or stricture
Treatment
 .Prevention is the best treatment .„

PERFORATION OF ESOPHAGUS
Early diagnosis is essential, as mediastinitis can rapidly prove
fatal. Perforation of thoracic esophagus is more serious than
cervical esophagus
Instrumental trauma: Esophagoscopy or dilatation of strictures
with bougies. The most common site is just above the
upper sphincter. The lower esophagus perforation near the
.hiatus is uncommon
Spontaneous rupture: This occurs due to vomiting and .„
usually involves lower third esophagus. In Boerhaave’s
syndrome, there occurs postemetic rupture of all the layers
.of esophagus
.Pathological: Malignancy .„
.Penetrating injuries .„
Clinical Features
Cervical esophageal rupture .„
Neck: Pain, local tenderness and surgical emphysema
Fever
.Difficulty in swallowing
Thoracic esophageal rupture .„
Chest pain referred to the interscapular region
Fever 102–104°F (39–40°C)
Signs of shock
Surgical emphysema and pneumothorax
Hamman’s sign: Crunching sound over the heart
.because of air in the mediastinum
Diagnosis
X-rays of the chest and neck findings .„
Widening of the mediastinum
Surgical emphysema, pneumothorax, or gas under the
diaphragm
.Pleural effusion
Treatment
General .„
NG tube
Intravenous fluids for nutrition
Antibiotics: To combat infection
.Management of shock
Perforation is surgically . „
repaired and pleural cavity drained within 6 hours. Repair is
not possible after 6 hours but infected area needs drainage
 Dysphagia: The difficulty in swallowing
The swallow reflex is a complex neurologic event involving
participation of high cortical centers, brain stem centers such as
the tract of the
nucleus solitarius and nucleus ambiguous, and
.cranial nerves V, VII, IX, X, and XII

DYSPHAGIA
Dysphagia refers to difficulty in swallowing. It can be divided
:into two types
oropharyngeal (difficulty in transferring food
bolus from oropharynx to upper esophagus) and
esophageal (difficulty in transporting bolus through the body of
.)esophagus
,Oropharyngeal dysphagia: It is characterized by coughing .„
.choking and regurgitation immediately after initiation of swallowing
.Dysphagia is more with liquid than soft foods
It may be associated with dysphonia, dysarthria, or other neurological
features. The cause may be neurological, muscular, motility or
.structural disorders
,Neurological: Brainstem lesions (pseudobulbar palsy)
.multiple sclerosis, or myasthenia gravis
.Muscular: Myopathies and hypothyroidism
.Structural: Malignancy, surgery and Zenker’s diverticulum
Gurgling noise in the neck or crepitus in the
neck may indicate the presence of Zenker’s
diverticulum
Esophageal dysphagia: It may occur due to mechanical .„
.obstruction or motility disorders
Mechanical obstruction: The dysphagia is primarily for
solids, and is usually continuous and predictable. In
progressive lesions, dysphagia worsens with the progress
:of the lesion. Some of the common causes include
Malignancy: Progressive dysphagia in elderly ––
.people
Peptic stricture: Chronic heartburn and progressive ––
.dysphagia
Schatzki’s ring: Intermittent dysphagia which is not ––
.progressive
Motility disorders: The dysphagia is for both solids and
.liquids. It is episodic, unpredictable and non-progressive
:Some of the common causes include
.Achalasia: Progressive dysphagia ––
Diffuse esophageal spasm (DES): Chest pain and ––
.intermittent non-progressive dysphagia
Scleroderma: Dysphagia associated with chronic ––
.heartburn and Raynaud’s phenomenon
Evaluation
Sudden onset: Foreign body or impaction of food on a stricture
.or malignancy, and neurological lesions
Gradually progressive: Malignancy (short history with weight
loss) and peptic strictures (long history with heartburn
Intermittent: Spasms or spasmodic episodes over an organic
.lesion
Liquids/solids: More with liquids (paralytic lesions), more .„
.with solids, and progressing to liquids (malignancy)
.Intolerance to acid food and fruit juices: Ulcerative lesions .„
:Associated complaints .„
.Regurgitation and heartburn: Hiatus hernia

.Nasal regurgitation: Palatal paralysis

.Aspiration into lungs: Laryngeal paralysis
Physical Examination
,The physical examination should include oral cavity
oropharynx, hypopharynx, larynx, neck, chest and nervous
system including cranial nerves. The lesions of oral cavity
and pharynx can be seen during physical examination
whereas esophageal causes require investigations such as
.barium swallow and esophagoscopy

Investigations
Upper endoscopy, barium swallow, manometry and pH
.recording are the mainstay of dysphagia evaluation
Hemogram: Iron deficiency anemia in Plummer-Vinson .„
.syndrome

,X-ray chest: For advanced esophageal lesions, cardiovascular .„

.pulmonary and mediastinal diseases or pneumomediastinum
,X-ray neck lateral and frontal projections: For cervical osteophytes .„
.lesions of post-cricoid or retropharyngeal region
.a. Useful in children
.b. Shows radiopaque foreign bodies
,c. Saying “e” during exposure brings the tongue anterior
.and shows oropharynx better
.d. Blowing through closed mouth distends hypopharynx
Computed radiography and digital radiography: In this filmless .„
technique, image is captured on an array of digital
.elements, and is read directly into a computer
,Barium swallow: For malignancy, cardiac achalasia, strictures .„
.diverticulum, hiatus hernia or esophageal spasms

BARIUM ESOPHAGOGRAPHY
is gold standard for swallowing disorders
.and esophageal function
Contraindications: Barium swallow is not used when aspiration
&is present or suspected
.perforation of pharynx and esophagus
Video Esophagography
Oropharyngeal dysphagia is best evaluated with this
technique. Low-resolution images are obtained at a high
frame rate. It allows longer exposure with less radiation. It
evaluates equivocal filling defects. Peristalsis is evaluated
.with single swallow
Ultrasound: Transesophageal echosonography can evaluate .„
the depth of malignant ulcer, which helps in staging the
.disease
Manometry and pH studies: For motility disorders, gastroesophageal .„
reflux and esophageal spasm (spontaneous
or acid induced). A pressure transducer along with a pH
electrode and an open-tipped catheter are introduced into
the esophagus. They measure the pressures of esophageal
wall and sphincters. Gastroesophageal reflux disease is
measured by pH electrode, which also measures the effectiveness
.of esophagus to clear the acid load
ES gold standard for assessing esophageal motility
disorderOPHAGEAL MANOMETRY
A small pressure-sensing catheter assembly is passed into
esophagus through nose. It performs manometric study
of upper esophageal sphincter (UES), lower esophageal
.sphincter (LES) and esophageal body
Indications
.To know the exact location of LES for placing a pH probe .„
To study peristaltic function of esophageal body before .„
.antireflux surgery
To confirm the diagnosis of esophageal motility disorders .„
suggested by )achalasia or diffuse esophageal spasm(
.endoscopy or barium swallow

Esophagoscopy (flexible or rigid): For direct examination of .„

.esophageal mucosa and biopsy
Associated investigations: They vary from case to case such .„
as bronchoscopy for bronchial carcinoma, cardiac catheterization
for vascular anomalies, and thyroid scan for
.malignant thyroid
AMBULATORY 24-HOURS ESOPHAGEAL pH
RECORDING

A small pH probe is passed nasally and placed 5 cm above

LES. It is attached to a portable pH device that continuously
record pH for 24 hours. The pH recording tells about the
amount of acid esophageal reflux. The temporal correlations
.between symptoms and reflux can be established
Indications
It is the best way for documenting acid reflux. It is indicated
:in GERD only in the following situations
Preoperative: Before antireflux surgery when endoscopy is .„
.normal
Proton pump inhibitor failures: Symptoms are not responding .„
to proton pump inhibitor (PPI) therapy, and endoscopy is
.normal
Achalasia (Megaesophagus)
Pathophysiology: degeneration of Auerbach’s plexus resulting in •
aperistalsis and increased LES pressure (LES does not relax with
)bolus
SSx: progressive dysphagia, regurgitation, malodorous breath, chest •
pain, aspiration, weight loss
,Dx: esophagram (bird beak appearance, air-fluid levels, aperistalsis •
,failed LES relaxation), manometry (increased LES pressure)
esophagoscopy to rule out mass (carcinoma causing pseudoachalasia)
and esophagitis

,serial esophageal pneumatic dilation (1–5% perforation risk)

wash” meals down with fluids, esophagomyotomy (Heller procedure)“
with fundoplication, Botox to LES
Zenker’s Diverticulum (Pharyngoesophageal Diverticulum)
Pathophysiology: false, pulsion diverticulum typically at Killian’s •
triangle (see previous)
SSx: insidious dysphagia, spontaneous regurgitation of undigested •
food, malodorous breath, aspiration, may become obstructive
Complications: diverticulitis, fistula formation, perforation, bleeding •
Dx: esophagram and endoscopy (80–90% located on the left side) •
Rx: observe if small/asymptomatic; endoscopic esophagodiverticulostomy •
common wall divided with an Endo GIA stapler(
or CO2 laser); larger diverticuli may require open transcervical
diverticulectomy with cricopharyngeal myotomy (must complete
a cricopharyngeal myotomy to prevent recurrence); diverticulopexy
theoretically reduces risk of fistula(
Mallory-Weiss Syndrome: incomplete tear of esophageal
mucosa and laceration of submucosal arteries from increased
abdominal pressure (emesis in alcoholics), presents as an upper
GI bleed; Rx: fluids, usually self-limiting, may decompress
rarely requires endoscopic coagulation or ,)nasogastric tube(
open procedures
Boerhaave Syndrome: increased abdominal pressure results .2
in spontaneous rupture of all 3 layers of the esophagus (usually
,distal, posterior wall), severe symptoms (hematemesis, chest pain
)dyspnea, hypovolemic shock
Dysphagia Lusoria (Bayford Syndrome)
Pathophysiology: anomalous right subclavian artery from descending •
aorta (fourth branchial arch anomaly) has a retroesophageal course
causing dysphagia from extrinsic compression of the esophagus
associated with a right non-recurrent laryngeal nerve, aortic and •
subclavian aneurysms, diverticuli
SSx: intermittent dysphagia (usually presents at middle age with loss •
of elasticity of vessels), weight loss
Dx: barium swallow, arteriogram/CT angiography, esophagoscopy •
)pulsating horizontal bar at obstruction site (
Rx: ligate and reanastomose to right common carotid for severe •
symptoms
Eagle Syndrome (Styloid Process Syndrome)
Pathophysiology: elongated styloid process or ossified stylohyoid •
,ligament causes mechanical irritation of surrounding nerves
associated with prior tonsillectomy or pharyngeal trauma
SSx: odynophagia, unilateral tonsillar pain, pain behind mandibular •
angle, referred otalgia, palpation at site reproduces pain
Dx: CT scan •
Rx: excision from intraoral or external approach •
Plummer-Vinson Syndrome
Pathophysiology: unclear etiology, may be secondary to nutritional •
deficiency (iron)
Risks: young to middle-aged woman, northern hemisphere •
)Scandinavians(
SSx: dysphagia (degeneration of esophageal muscle), cervical •
webs, microcytic hypochromatic anemia )pharyngoesophageal(
,cheilitis (fissures at corners of lips), glossitis ,)iron deficiency(
splenomegaly, achlorhydria
Dx: clinical exam, iron levels, CBC, esophagram •
Complications: increased risk of upper esophageal and •
hypopharyngeal carcinoma
Rx: iron supplements (improves most symptoms), esophageal dilation •
Esophageal Neoplasms
Benign Tumors and Cysts
less common than malignant tumors •
Leiomyoma: most common benign tumor of the esophagus
Adenocarcinoma: most common (incidence has risen), distal
Esophagus
Squamous Cell Carcinoma: usually middle third of esophagus
Salivary Glands