ANATOMY & Physiology

ESOPHAGUS
Romulus A. Instrella MD,FPSO-HNS,FPCS,FPSSM,MHA
Otorhinolaryngologist – Head & Neck Surgeon
Sleep Surgeon / Specialist
CMC Sleep Center HEAD
ENT Section HEAD
Capitol Medical Center
CMC , EAMC , AFPMC, LCP , FUMC
ESOPHAGUS
 ESOPHAGUS
• A muscular tube; 25 cm in length
– Collapsed at rest,
– Flat in upper 2/3 & rounded in lower 1/3

• Commences at lower border of the cricoid cartilage.(C6)

• Average Adult swallows ( 600x)
• 35 swallows/hour (awake)
• 6 swallows/hour (asleep)
• Descends along the front of the spine, through the posterior
mediastinum, passes through the Diaphragm, and, entering the
abdomen, terminates at the cardiac orifice of the stomach,
opposite the eleventh dorsal vertebra.
• In the Newborn Upper limit at the
level of 4th or 5th Cervical Vertebrae
• Length at birth: 8-10 cm
• end of Ist Yr: 12cm
• 5th Yr.: 16cm 15th: 19cm
• Diameter: Varies whether bolus of food/ fluid
passing thru or not.
– At rest in adults 20 mm but can stretch up to 30
mm
– At birth it is 5mm at 5 yrs it is 15mm
Blood Supply
U3rd Inf thyroid artery
M3rd Direct branches Thoracic A.
L3rd Esophageal b. L Gastric A.
Lymphatic Drainage
Cervical Esophagus- IJC/paratracheal n.
( Deep Cervical LN )
M3rd-tracheobronchial/ sup &post mediastinal n.
L3rd – n. of L gastric vessels
 Nerve Supply
• Parasympathetic
– Vagus – motor to muscular coats & secretomotor to glands
• Sympathetic
– From cervical & thoracic sympathetic chain
– Contraction of sphincters, wall relaxation, peristalsis
• Intramural
– Combination of all innervation form plexuses & ganglia
– In muscular layers (myenteric or Auerbach’s plexus )
– In submucosa (Meissner plexus )
Several Aspects Inherent Weakness
 Killians Dehiscence
bet inf pharyngeal constrictor muscle
and cricopharyngeus

ZENKER’S
Diverticulum
 Laimer’s/Laimer Haeckerman area
- 2nd potentially weak area in posterior midline, below
cricopharyngeus
- no reports of diverticula
 Killian Jamieson
( lateral dehiscence )
Between cricopharyngeus muscle
& circular esophageal fibers
Esophagus with
PERISTALSIS
 3 Phases of Deglutition

• A. Oral Phase
Preparatory
Voluntary( dependent on the intrinsic muscle
of the tongue)
Tongue
B. Pharyngeal Phase
Passage of the bolus to the oropharynx
Reflex portion
Anterior tonsillar pillar- most sensitive
 C Esophageal Phase
Bolus of food descends into esophagus
Takes 8-12 sec to reach the
Gastroesophageal junction
Much slower than the peristalsis in the
pharynx
Degluttition
Common Congenital Tracheo-esophageal anomalies
• Oesophago-tracheal fistula
– Commonest type
– Newborn has violent fits of
vomiting & coughing on
swallowing
– Polyhydraminos
• Partial Obstruction of
Oesophaugs
– Stricture
– Atresia
– newborn salivates
excessively, becomes
cyanotic and vomits

Source: http://www.nature.com/gimo/contents/pt1/fig_tab/gimo6_F10.html
 MOTILITY DISORDERS

ACHALASIA
Generalized motor disorder
characterized by ;
hypertensive LES (resting tone)
incomplete relaxation of the sphincter w/
swallowing
lack of esophageal peristalsis
Results in delayed esophageal emptying
Leads to dilatation & elongation
etiology; unknown
No Sex Predilection / Genetic Predisposition
 Histology;
loss of or complete lack of ganglion cells
(Auerbach’s Plexus)
3rd & 4th decades of life
Dysphagia( obstruction of LES & peristalsis)
Painless but vary
Regurgitation- aspiration
Halitosis – retained material in the dilated esophagus
Xiphoid process – feel food becoming stuck or hanging up
( valsalva m. washing food down w/ liquids)
 Advanced cases;
severe esophageal dilatation
( laryngeal/tracheal compression)
odynophagia or chest pain
DX; barium study – no peristalsis
manometry
plain chest xray ( air fluid level in dilated esophagus)
“ Birds Beak Deformity “ at LES ( severe cases)
Long standing achalasia= Esophageal CA
Treatment
Endoscopy
Decrease LES pressure
softer diet/keep head elevated
Invasive Procedure- method of choice
Dilation ( mercury tipped bougienage)
( pneumatic dilaton w/ fluoroscopically
placed insufflated bag) Heller
Procedure ( alternative surgical myotomy)
“ Thoracotomy”
Complications
Rupture 2-6 %
Perforation
GERD – 30%
 DIFFUSE ESOPHAGEAL SPASM
repetitive high amplitude contractions of the smooth m.
ETIO : unknown
50 y/o
Histology ;
muscular hypertrophy w/ lymphocytic infiltration
of Auerbach’s Plexus degenerative changes in esophageal
branches of the Vagus Nerve

SX : Chest pain / esophageal colic w/ or w/o swallowing

intermittent dysphagia & odynophagia
Precipitating Factors
emotional stress
hot or cold liquids/ gerd
DX ;
X-ray ( Corkscrew esophagus or beading or curling
of the barium column )
Esophagus is not dilated but diffusely Narrowed
TRT ;
Reassure the pt.
avoiding factors that trigger Sx
treat GERD
Not effective ( Dilation- bougienage)
Surgical Myotomy ( extensive ) but not as
effective as in Achalasia
General patient positioning for
endoscopic techniques.
 3 Important
Anatomic
Narrowing
15 -20 cm Upper Incisor

20-25 cm Upper Incisor

40-45 cm Upper Incisor

 T 10
T 11 Diaphragm

LES
 Unusual! Arterial supply derived from
vessels feeding mainly other organs –
thyroid, trachea & stomach
Cervical Oesophagus: Right &
Left superior & inferior thyroid
arteries.
Thoracic Oesophagus: Upto
tracheal bifurcation Right & Left
inferior thyroid Artery
direct supply from aorta
(tracheo-bronchial tree)
Abdominal Oesophagus 11
branches off L gastric artery and
Branches of splenic artery
posteriorly

Source:
http://www.nature.com/gimo/contents/pt1/fig_tab/gimo6_F2.html
 These areas are where most oesophageal foreign bodies
become entrapped.

• The most common site of oesophageal

impaction is at the thoracic inlet
• Defined as the area between the
clavicles on chest radiograph, this is
the site of anatomical change from the
skeletal muscle to the smooth muscle
of the oesophagus. The
cricopharyngeus sling at C6 is also at
this level and may "catch" a foreign
body.
• About 70% of blunt foreign bodies that
lodge in the oesophagus do so at this
location.
Source:
www.bhj.org/journal/2001_4303_july01/case_442.htm
• Another 15% become lodged at the
mid oesophagus, in the region where
the aortic arch and carina overlap the
oesophagus on chest radiograph.
• The remaining 15% become lodged
at the lower oesophageal sphincter
(LES) at the gastroesophageal
junction. Source: http://emedicine.medscape.com/article/408752-imaging
Foreign Body
 THANK YOU

GOODLUCK