section epub:type=”chapter” role=”doc-chapter”>

7 Esophagus and Swallowing

Diseases of the esophagus encompass several disciplines. This chapter discusses the otolaryngologic aspects involved, particularly endoscopy and the clinical aspects and treatment of esophageal disorders.

7.1 Applied Anatomy

The esophagus begins at the caudal border of the cricoid cartilage, at the level of the sixth cervical vertebra, and ends at the cardia, at the level of the eleventh thoracic vertebra. In adults, the opening of the esophagus lies ≈15 cm from the upper incisor teeth and the cardia at ≈35 to 41 cm from the incisors. The full length of the esophagus is thus ≈20 to 26 cm ( ▶ Fig. 7.1a).

The wall of the esophagus is capable of expanding and contracting and is resistant to considerable mechanical stress. The internal lining consists of stratified nonkeratinizing squamous epithelium. The outer longitudinal musculature and inner circular muscle form two separate layers of the wall ( ▶ Fig. 7.1b). There are also muscle fibers running spirally.

The esophageal musculature is striated in the upper third; consists of both mixed smooth-muscle fibers and striated fibers in the middle third; and is almost exclusively smooth muscle in the lower third.

The esophagus has three physiologic constrictions ( ▶ Fig. 7.1):

• 
  

  The upper constriction is formed by the cricopharyngeus muscle, the upper esophageal sphincter (UES).

  
  
• 
  

  The middle constriction, ≈27 cm from the incisors in the adult, is caused by the crossing of the esophagus by the aortic arch and the left main bronchus. Sometimes these two structures form two separate constrictions.

  
  
• 
  

  The lower constriction is at the level of the lower esophageal sphincter (LES), the esophageal hiatus, the cardia.

The cervical and thoracic parts of the esophagus are located above the diaphragm. The abdominal part is located below it. The blood supply is segmental, as is the lymphatic drainage.

Innervation: The nerves are derived from the vagus nerves and from the sympathetic trunks. Together, they form a plexus between the two layers of the muscular coats, and also a second plexus in the submucous tissue. Striated muscle in the upper third is supplied by somatic fibers from the vagus nerve. Autonomic supply from the vagus to smooth muscle is provided in the middle to lower third. The significance of the segmental sympathetic supply from blood vessels is uncertain.

7.2 Physiology and Pathophysiology

The esophagus has its own active mobility, as well as a passive form of mobility produced by respiration and the movements of the neighboring major vessels and the heart. The act of swallowing can be divided into an oral phase, which is under voluntary control, and pharyngeal and esophageal phases. The pharyngeal and esophageal phases are under autonomic control and depend on stimulation of the posterior pharyngeal wall. This is associated with involuntary elevation of the larynx (see ▶ p. 261).

The entrance to the esophagus and the gastric cardia are usually closed. The entrance to the esophagus opens during swallowing, and the cardia opens in response to the oncoming peristaltic wave.

The sphincter and transport functions of the esophagus can be investigated using the following procedures: contrast radiography, video fluoroscopy, cineradiography, and manometry (intraluminal measurement of pressure in the esophagus; see ▶ p. 398).

Disorders of peristalsis and tone may result from mechanical obstruction and narrowing or from paralysis of the muscles or nerves.

In presbyesophagus, the coordination of the various phases of motility is disturbed, with increased tertiary contractions and atonic phases. This prolongs the transit time of food.

7.3 Investigation Methods

7.3.1 Clinical Examination

Inspection and palpation of the external part of the neck may demonstrate redness, swelling, and tenderness (e.g., over the carotid sheath) as well as venous congestion and lymphadenopathy in cases of inflammatory processes. Transnasal fiberendoscopy should be performed to inspect the pharynx and larynx. Retention of saliva or chyme in the hypopharynx is suspicious for esophageal or swallowing disorders. Paralysis of cranial nerves IX, X, and XII should be excluded.

Many clinics now offer transnasal esophagoscopy (TNE) with a distal video chip in the tip. This procedure can be performed without sedation, in the outpatient clinic, and offer an immediate accurate diagnosis and assessment of function without the need for hospitalization.

7.3.2 Diagnostic Imaging

A contrast swallow with Gastrografin (Sodium amidotrizoate/Amidotrizoate meglumine) is commonly used to demonstrate the mucosa and lumen. Typical findings are shown in ▶ Fig. 7.2.

Radiologic investigations include contrast administration, computed tomography (CT; with dual-source and 64-line techniques), and magnetic resonance imaging (MRI) to analyze the composition, distribution, and propulsion of esophageal contents during swallowing. Scintigraphy and video fluoroscopy are noninvasive procedures that have been used to observe and record bolus transit. However, the techniques require access to specialized laboratories and involve radiation exposure.

7.4 Esophagoscopy

Two methods are available for examining the esophagus. Each method has its own indications, and the two may need to be combined.

Rigid esophagoscopy ( ▶ Fig. 7.3) is undertaken under general anesthesia in combination with muscle relaxant and endotracheal intubation. Light is transmitted to the distal end of the scope through glass fibers inside a rigid rod. Telescopes or optical forceps allow magnification. In addition, continuous lavage and suction can be used. A range of instruments are available for extraction, excision, and coagulation, as well as injection. Pneumatic pressure can be increased in the esophagus to expand a particular part. Rigid esophagoscopy and endoscopes facilitate photographic and video records. Laser surgery is also possible for malignant strictures.

With the patient under general anesthesia with a muscle relaxant, the rigid esophagoscope is introduced into the esophagus with direct visualization of the oropharynx, hypopharynx, and postcricoid area. The instrument is then advanced to the cardia ( ▶ Fig. 7.4). The diameter of the scope provides ample space for procedures inside the lumen or on the walls of the esophagus. The procedure also makes it possible to assess the elasticity, stiffness, and mobility of the esophageal wall. The indications are listed in ▶ Table 7.1 .

Flexible esophagoscopy has specific indications and can be performed with the patient under local anesthesia with mild sedation. Flexible endoscopes typically have a fiberoptic core. However, a newer generation of endoscopes provides very high-quality images from a video chip camera in their tip. Flexible endoscopes offer several advantages that include a narrow caliber, maneuverability, a working channel that facilitates the use of miniaturized instruments, and a fiber for laser treatment.

Gastroscopy and duodenoscopy can also be carried out during the same session ( ▶ Table 7.1 ). ▶ Fig. 7.5 shows a fiberoptic esophagoscope.

7.4.1 Esophageal Manometry and Esophageal pH-Metry (Ambulatory pH-Monitoring)

Intraluminal pressure is measured at various levels in the esophagus. Various methods are used:

• 
  

  Conventional manometry involves the continuous recording of pressure using sensors at separate measurement points with 3 to 5 cm intervals.

  
  
• 
  

  High-resolution manometry (HRM) has sensors that are typically spaced 1 cm apart along the length of the manometric assembly. Catheters with up to 36 sensors distributed longitudinally and radially in the esophagus allow for simultaneous pressure readings spanning both sphincters and the interposed esophagus.

  
  
• 
  

  Multichannel intraluminal impedance (MII) depends on changes in the resistance to alternating current between two metal electrodes produced by the presence of a bolus inside the esophageal lumen. Liquid-containing boluses have a higher conductivity and will lower the impedance to a nadir value. The impedance stays at its nadir as long as the bolus is present in the segment, returning to baseline once the bolus is cleared by a contraction.

  
  
• 
  

  Combined multichannel intraluminal impedance with esophageal manometry (MII-EM) is a test of esophageal function. It provides information about both pressures and bolus transport within the esophagus.

  
  
• 
  

  Radiomanometry combines radiography and manometry.

  
  
• 
  

  Pharmacomanometry is manometry with the administration of autonomic drugs.

pH-metry (ambulatory pH Monitoring) is carried out using special pH electrodes, which are connected to a data storage device. Simultaneous pH recording and manometry are possible with a pressure-measuring device. Patients are free to carry on with daily activities and data is generally recorded over a 24-hour period. This method helps evaluate reflux and motility disorders, as well as other clinical syndromes such as globus sensation and upper chest pain. It is also important for assessing the efficacy of drug therapy and surgery.

7.5 Clinical Aspects

7.5.1 Trauma

7.5.1.1 Button Battery Ingestion

Button batteries are the ideal shape for small children to insert in their mouths and swallow. However, once swallowed they may lodge in the esophagus and cause tissue erosion leading to perforation and serious illness or death. A child with suspected or known ingestion must be treated as a medical emergency. While children often present with a history of swallowing a coin, it is important to exclude the possibility of battery ingestion. There are several types of button batteries, with varying chemical compositions, such as cadmium, lithium, manganese, and zinc, but all are dangerous. Mercury batteries are now banned under European Law.

Pathogenesis: The danger from button batteries is that a live battery with charge will produce a current when adjacent to moist soft tissues, and a chemical reaction produces sodium hydroxide (caustic soda) adjacent to the cathode. The sodium hydroxide is erosive and rapidly causes soft tissue trauma with ulceration and perforation through the esophageal wall, with ongoing erosive change in any other tissue adjacent to the esophagus.

Diagnosis: A high incidence of suspicion should be maintained in any suspected case of button battery ingestion. Symptoms include drooling, airway compromise, vomiting, choking, coughing, chest/abdominal pain, or unexplained gastrointestinal bleeding. Radiographs of the neck, chest, and abdomen will help confirm the diagnosis and identify the site of the battery.

Treatment: A button battery in the esophagus requires urgent esophagoscopy and removal. If the battery is below the diaphragm, the child should be assessed urgently by the pediatric surgical team, who will then decide on whether to observe and monitor or intervene and remove.

7.5.1.2 Caustic Ingestion

Clinical features: Ingestion of caustic substances causes severe pain in the mouth, pharynx, behind the sternum, and in the epigastric region, accompanied by gagging, vomiting, sialorrhea as well as occasionally glottic edema and dyspnea. White corrosive crusts and burned areas are found in the mouth and the surrounding area. Shock becomes progressive, with falling blood pressure and a rising pulse rate, cyanosis and pallor, cold sweats, and circulatory collapse. After 24 to 48 hours, there are increasing signs of intoxication such as renal damage, hematuria, evidence of liver damage, hemolysis, disturbance of electrolyte and water metabolism, and occasionally involvement of the central nervous system (CNS). There is an increasing risk of perforation or mediastinitis, pleuritis, peritonitis, and tracheoesophageal fistula. Rapid wasting occurs. In the longer term, patients develop a long esophageal stricture, with progressive dysphagia.

Pathogenesis: Coagulation necrosis due to acids and liquefactive necrosis due to alkaline substances penetrate to varying depths. The corrosive scars in the mouth and pharynx may be minimal due to the rapid passage of the agent, but severe damage extending into the esophagus and possibly the stomach and intestine is possible. The esophagus is more severely affected than the stomach in alkaline burns, due to reflex cardiospasm, while acid burns cause more severe damage to the stomach.

Events usually take the following course: (1) primary local necrosis in the mouth, pharynx, esophagus, stomach, and intestine; (2) generalized intoxication; (3) acute, subacute, and chronic corrosive esophagitis; (4) healing of the esophagitis with scarring or stricture; (5) late complications such as late or recurrent stenosis and possibly malignant degeneration. Scar tissue stenosis begins around the third week.

Diagnosis: This is based on the typical history of an accident or attempted suicide and typical local findings. The corrosive substance must be identified. Radiographs are taken of the chest and abdomen. If the corrosive burns appear to be mild, contrast views of the esophagus are taken and careful esophagoscopy can be carried out to assess the esophagus and stomach and insert a feeding tube. Contraindications include shock and suspected perforation. Immediate esophagoscopy is only performed if the degree and extent of the corrosive burn are uncertain.

Treatment: If possible, the patient should drink large quantities of fluids (water). Analgesics and sedatives are given, and the patient is admitted to intensive care for intravenous management of shock, fluid administration, parenteral nutrition, broad-spectrum antibiotics, and, if necessary, gastrotomy and tracheotomy. High-dose steroids are given intravenously, and these are continued for at least 4 weeks, with the dosage being adjusted according to the endoscopic findings (granulations).

The first careful esophagoscopy is performed after 6 to 8 days. Dilation can start at the end of the second week if radiography and endoscopy demonstrate stricture formation. Follow-up esophagoscopies are performed at 10-day intervals until mucosal defects have epithelialized. The patient is then followed up with radiography and esophagoscopy after 1, 3, 6, and 12 months.

Two methods of bougienage can be used:

• 
  

  Early bougienage, approximately 8 to 12 days after the burn injury, using a thick bougie of ≈40 Fr in adults, 20 Fr in children, and 30 Fr in adolescents, with the caliber being increased daily until the patient is able to swallow without difficulty. The intervals are then prolonged until radiography no longer demonstrates a stenosis.

  
  
• 
  

  Late bougienage is only used if an organic stenosis develops despite steroid administration. This may only occur several weeks later. Bougienage must never be done blindly, but must always be performed using esophagoscopy or over a thread or stylet.

Bougienage is started with a bougie of the appropriate caliber, with visualization using an esophagoscope. Bougies are again introduced in sequentially increasing sizes ( ▶ Fig. 7.6). Contrast radiographs should be taken first to localize the stricture and exclude intraluminal neoplasms or multiple stenoses.

Bougienage over a thread ( ▶ Fig. 7.7) can be used to save the patient from daily esophagoscopy and to ensure that the bougie is correctly introduced through the stenosis and reaches the distal part of the esophagus. Fenestrated bougies are used. First, the patient swallows a perforated lead shot attached to several meters of silk suture. The thread is let out daily and the metal shot reaches the intestine via the stomach and can be verified by radiography. The thread is then securely anchored. Fenestrated bougies of increasing caliber can now be introduced safely over the thread and through the stricture. Bougienage may take several weeks. When it is no longer needed, the end of the thread is then cut off at the mouth and the sphere and thread are passed normally.

Pneumatic dilatation or balloon dilatation is another measure to dilate esophagus strictures. At the time of fiberendoscopic esophagoscopy a deflated balloon is inserted into the area of narrowed stricture (through-the-scope technique). By inflation of the balloon with air or fluid a circumferential pressure is set to the wall of the stricture ( ▶ Fig. 7.8).

The goal of a bougienage treatment is to achieve an esophageal lumen of ≈45 Fr (i.e., a diameter of 15 mm) in adults; ≈30 to 35 Fr in children up to 10 years; and 30 to 40 Fr in adolescents.

The risks in bougienage include perforation of the esophageal wall. The risk is reduced when bougienage is carried out over a thread, guidewire, or by balloon dilatation. Perforations tend to occur particularly in the area of the necrotic stricture (e.g., when there are blind pouches) and cause mediastinitis, pleuritis, or peritonitis, which require external drainage.

If bougienage treatment is unsatisfactory, surgical treatment of the stricture, partial esophageal resection, and replacement with a segment of stomach or bowel must be considered. Due to the tendency for recurrent stenosis and malignant degeneration to develop in the elderly, patients with esophageal strictures must be kept under medical supervision with radiography and endoscopy at increasing intervals.

7.5.1.3 Blunt Injuries

These traumatic injuries to the esophagus occur especially in road traffic accidents, when the impact of the chest against the steering wheel produces tears in the esophageal wall. Traumatic esophagotracheal fistulas, often delayed, can also occur as a result of localized necrosis of the wall.

The main symptom is coughing on swallowing. Rupture in the lower third of the esophagus is usually the result of blunt trauma to the thorax.

7.5.1.4 Open Penetrating Injuries

These injuries usually lie in the cervical segment and occur as a result of sharp forces to the neck and upper chest. The main symptoms are the escape of saliva or food from the wound.

Every traumatic injury to the esophagus should be examined using esophagoscopy. Minor damage to the mucosa can be controlled for 4 to 6 days using a feeding tube, and large open penetrations with injury to the muscle should be treated surgically, with thoracotomy and open exploration.

7.5.1.5 Foreign Bodies

These mainly involve unintentionally swallowed objects of various types. Children, usually under the age of 3, swallow objects such as coins ( ▶ Fig. 7.9) or toys, whereas adults swallow fish bones, glass splinters, parts of false teeth, nails, needles, large fruit stones, or even cutlery (e.g., among prison inmates).

Clinical features: These include considerable dysphagia (difficulty in swallowing), odynophagia (pain on swallowing) localized to the neck or retrosternal area and rarely the epigastric region, and attacks of coughing. Life-threatening symptoms include severe pain in the back between the shoulder blades and behind the sternum, and indicate early mediastinitis.

Pathogenesis: Foreign bodies usually become lodged in the upper constriction, the esophageal orifice, and rarely at the second or third constrictions. Retained or impacted foreign bodies cause necrosis of the esophageal wall, and, depending on the site, lead to mediastinitis, pleuritis, or peritonitis, with paraesophageal abscess formation and, on occasion, surgical emphysema.

Diagnosis: This is based on the history. Initially, pain on swallowing is localized to a specific area, and the neck and cervical spine are held rigid. There may be swelling of the neck or surgical emphysema, or crepitation on palpation of the neck and the supraclavicular fossae. Lateral radiographs of the neck and chest are taken to determine the position of radiopaque foreign bodies. Air shadows in the esophagus above a foreign body are also shown, as is mediastinal emphysema after perforation. Gastrografin is used for foreign bodies that are radiolucent. Esophagoscopy is performed, both to establish the diagnosis and for treatment.

Differential diagnosis: This includes persistent mucosal lesions caused by a foreign body that has already been passed, and early obstructive tumor.

Treatment: If the foreign body is soft and unlikely to perforate, a period of observation is acceptable. These foreign bodies may pass with observation and administration of a sedative that has muscle-relaxant properties (diazepam). Agents that induce esophageal motility such as hyoscine butylbromide (buscopan) may also be given. Hard and large foreign bodies with sharp edges and hooks are managed using rigid esophagoscopy with the patient under general anesthesia. If this is not successful, cervical esophagotomy is performed, or thoracotomy for a more distal foreign body. Perforations are treated by suturing the defect and administering high-dose antibiotic cover. Periesophagitis and abscesses are treated by drainage.

Course and complications: There may be no sequelae if the foreign body is removed rapidly and without complications. If it is retained for a long period, pressure and perforation occurs, leading to mediastinitis with symptoms of rapidly increasing pain behind the sternum or between the shoulder blades. Lateral neck and chest radiographs show gas emphysema (appearing as a “cloudy” prevertebral shadow), widening of the prevertebral stripe, and possible fluid retention. Oral gastrografin demonstrates the perforation site. Small foreign bodies often reach the stomach initially and have a 95% chance of being passed spontaneously. The feces should be checked for up to 8 days or even longer to ensure that the foreign body has been passed.

7.5.1.6 Perforation and Rupture

Iatrogenic esophageal perforation is most likely to occur during esophagoscopy, particularly if there is a stricture that requires dilation. There is also a risk of perforation with feeding tubes, nasogastric tubes, and endotracheal tubes, particularly if they are passed blindly. The sites of predilection are the three constrictions, stenotic areas, and the piriform sinus.

Esophageal perforation is a risk during endoscopic surgery of Zenker diverticulum/pharyngeal pouch. The procedure entails dividing the septum between the esophageal lumen and the pouch, but failure to seal the entirety of the division will leave a potentially dangerous defect and a risk of mediastinitis.

It is vitally important for an esophageal perforation to be explored and repaired as soon as possible using mediastinotomy, thoracotomy, or laparotomy, depending on the site of the perforation.

Spontaneous rupture of the esophagus (Boerhaave syndrome) is caused by a sudden increase in intraesophageal pressure due to vomiting or cicatricial stenosis, and is relatively common in patients with habitual vomiting or alcohol abuse. The symptoms are dramatic and include bloodstained vomit, hematemesis, severe pain behind the sternum and between the shoulder blades, pain in the left upper quadrant and in the renal area, pallor, a rapid fall in blood pressure, dyspnea, and rapid circulatory collapse.

Diagnosis: This is based on the simultaneous appearance of surgical emphysema of the neck, acute abdominal signs, pneumothorax, and dyspnea.

Differential diagnosis: This includes rupture of the diaphragm, incarcerated hiatus hernia, perforation of a gastric or duodenal ulcer, acute pancreatitis, and myocardial infarction.

Treatment: Open surgical intervention with thoracotomy, primary closure of the defect and pleura, drainage of the pleura and mediastinum, and additional broad-spectrum antibiotic administration are necessary.

7.5.2 Esophageal and Swallowing Disorders

The following conditions all have typical clinical signs and symptoms of dysphagia:

• 
  

  Esophageal diverticulum.

  
  
• 
  

  Gastroesophageal reflux disease (GERD).

  
  
• 
  

  Hiatus hernia.

  
  
• 
  

  Achalasia.

  
  
• 
  

  Barrett Esophagus

  
  
• 
  

  Mallory-Weiss syndrome.

  
  
• 
  

  Cricopharyngeal incoordination.

  
  
• 
  

  Diffuse esophageal spasm.

  
  
• 
  

  Infectious esophageal disorders.

  
  
• 
  

  Eosinophilic esophagitis.

  
  
• 
  

  Obstructive disorders of the esophagus

  
  
• 
  

  Dysphagia lusoria.

  
  
• 
  

  Esophageal rupture.

The most common diagnoses are described below.

7.5.2.1 Esophageal Diverticulum

Esophageal diverticulum is an out-pouching or sac of the epithelial-lined tissue of the esophagus. It may be a true diverticulum, involving all layers of the esophagus, or a false diverticula, involving only the mucosa and submucosal layers that protrude into the circular and longitudinal muscle of the esophagus. An esophageal diverticulum is usually acquired and can affect any part of the esophagus ( ▶ Fig. 7.10).

Stay updated, free articles. Join our Telegram channel

Join