Laryngo - Broncho Esophagology

The Upper Aerodigestive Tract

Frederick Mars B. Untalan, M.D.

Anat Infant

Anatomical protection of airway Can be fed supine Chubby cheeks Small oral space Short neck

As the infant grows, the neck elongates

Larynx (vocal cords and epiglottis) moves downward. Eustachian tubes angle

Fatty tissue decreases in cheeks Oral space becomes larger Requires more control and coordination

Dance between neurological and anatomical maturation.

Comparison infant/adult

As the infant grows, the neck elongates; Larynx (vocal cords and epiglottis) moves downward; Eustachian tubes angle Fatty tissue decreases in cheeks; Oral space becomes larger; Requires more control & coordination; Dance between neurological & anatomical maturation.

Pockets

Anatomy/Physiology
Tube Sphincters

UES LES

No Serosa Cranial nerves V, VII, IX, X, XII

Anatomy reminder
The esophagus is a muscular tube main function is to move ingest from the oral cavity to the stomach 3 main components: a) Upper Esophageal Sphincter (UES) Cricopharyngeal muscle-striated b) Body- Striated and smooth muscle c) Lower Esophageal Sphincter

Innervation from branches of the vagus nerve

Pharynx

Esophagus - mid

Esophagus - distal

Sequence of swallowing

(Morris & Klein, 2000)

Swallow Physiology Oral Stage & Oral Preparation stage

Lip closure Cheek muscles Elevation of tongue tip Posterior movement of the tongue Nasopharyngeal closure

Swallow Physiology Oral pharyngeal stage

Posterior tongue retracts Posterior pharyngeal wall contraction Start of laryngeal contraction Vocal fold adduction Maintenance of nasopharyngeal contraction

Swallow Physiology Pharyngeal Stage

Tongue Base retracts Contraction of the pharyngeal constrictors is complete to reach the tongue base as it fully retracts Laryngeal elevation & anterior movement reaches its height Vocal folds remain adducted Epiglottis is in an inverted position over the supra larynx.

Oral Phase

Pharyngeal Phase

Pharyngeal & Esophageal Phase

Swallowing & Respiration

Most people swallow mid way through expiration Airway closure occurs at the level of the vocal folds, the level of the arytenoids, the epiglottis and tongue base Difficulties with respiration alone can create swallowing difficulties

Plain Film

Uses:
Suspected infectious cause of dysphagia with gross displacement of structures.
Advantages Disadvantages Radiation Poor anatomic detail

cheap Fast

No assessment of swallow

Plain Film

Epiglottitis

Barium Esophagram

Uses: structural disorders, e.g. dysphagia for

solid foods. Can use air contrast. Disadvantages Radiation Logistics in bedridden pts. Cannot detect dynamic disorders.

Advantages Good anatomic detail

Air Contrast Barium Esophagram

Normal

Fungal Plaques

Modified Barium Swallow

Uses excellent to evaluate dynamic (e.g. neuromuscular, aspiration) swallow disorders.

Disadvantages

Advantages
Gives good anatomic detail

Radiation
Does not directly test sensitivity Logistics

Evaluates all phases of swallowing

Flexible vs rigid endoscope

Equal successful results Complications:

Flexible: 5.1% Rigid: 10%

Berggreen PJ et al. Gastrointest Endosc 1993

Rigid scope considered having better

view

Commonly used by ENT & thoracic surgeons

Fiberoptic Endoscopic Evaluation of Swallowing

Cricopharyngeal Achalasia

Achalasia

Cricopharyngeal Achalasia
Cricopharyngeal Myotomy:

Zenkers Diverticulum

Zenkers Diverticulum

MOTILITY DISORDERS

Oropharyngeal
Zenkers diverticulum Neurological Muscle Disorders Local structural lesions

Cervical Spine Disease

Esophageal Webs & Rings

Diffuse Esophageal Spasm

Cancer

Systemic Disorders that Cause Dysphagia

Stroke present in up to 47% Amyotrophic Lateral Sclerosis Parkinsons Disease Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis

Autoimmune Disorders

Systemic Sclerosis Systemic Lupus Erythematosis Dermatomyosits Mixed Connective Tissue Disease Mucosal Pemphigoid, Epidermolysis Bulosa Sjogrens Syndrome (xerostomia) Rheumatoid Arthritis (cricoarytenoid joint fixation)

Aging
Dysphagia is present in 2% > 65 Poor dentition Loss of tongue connective tissue Increased pharyngeal transit time

Dysphagia in Children
Nasal obstruction Oral lesions clefts, ranulas, mucoceles Laryngomalacia, laryngeal clefts, TE fistula Vascular rings, Foregut malformations Tumors hemangiomas, lymphangiomas, papillomas, leiomyomas, neurofibromas

Globus Hystericus
Imagined dysphagia Somatization

Caustic Ingestion
Esophagus, pharynx, larynx Bases

Drain cleaners Electric dishwasher soap Hair relaxant

Acids Bleaches

Strictures / Caustic Ingestion

Caustic Ingestion

Alkalis pH > 7
Liquefaction necrosis

Acids pH < 7
Coagulation necrosis

Bleaches pH = 7
Irritants

Caustic Ingestion

Bleach ingestion
5-6% sodium hypochlorite Produce ulceration Normal oropharynx barium swallow Burned oropharynx - esophagoscopy

Caustic Ingestion
Esophagoscopy in virtually all patients at 24-48 hours post-ingestion < 24 hours underestimation of injury > 48-72 hours with risk of iatrogenic perforation barium swallow Rigid vs. flexible debatable Endoscopy to upper limit of severe burn

Caustic Ingestion
Goal
Preventing permanent injury or stricture in esophagus

Caustic Ingestion
Antibiotics

Pro
Decrease bacterial counts Reduction in granulation

Con
Influx of gram negatives Mask infection No reduction in strictures

Ampicillin 50 mg/kg/day

Caustic Ingestion
Steroids Prednisone 2 mg/kg/day x 21 days then taper Most effective for grade 2 injuries Strictures easier to manage Anderson no benefit

Caustic Ingestion

Prevention of acid reflux

H2 blockers

Proton pump inhibitors

Caustic Ingestion
Strictures develop in 10-15% Dilation

Prograde Retrograde Balloon catheters

Esophageal replacement

Caustic Ingestion
Esophageal carcinoma 1,000x increased risk 13 to 71 years after injury Better prognosis than usual esophageal cancer

Caustic

Ingestion

Caustic Ingestion

Caustic Ingestion
Esophageal replacement Colonic interposition Jejunal interposition Gastric pull-ups

Ingestion injuries causing perforation Foreign bodies

Management is similar of iatrogenic perforation

Corrosive agents
Acid/ alkali

Foreign Bodies
Foreign body ingestion Foreign body aspiration Toddlers

Oral exploration Lack posterior dentition Easy distractibility Cognitive development (edible?)

Clinical features
History of swallowing FB Dysphagia, odynophagia, regurgitation, excessive salivation, drooling Respiratory symptoms especially in children High index of suspicion in paediatric & mentally ill patients 17% FB impactions in children have no symptoms

Hodge D III et al. Ann Emerg Med 1985

Investigations

Neck & chest X-ray ( AP & lateral)

esophagus vs trachea Overlying vertebral on AP view

Contrast swallow X-ray

Barium is preferred ( risk of aspiration!) May make endoscopy difficult

Endoscopy

Foreign Bodies

Foreign Body Ingestion

Coins 75% Meat Vegetable matter Less than 24 hours in most

Foreign Body Ingestion

Parental suspicion Symptoms

Choking, coughing, dysphagia, odynophagia Physical exam Drooling

Respiratory compromise

Foreign Body Ingestion

Common locations
Cricopharyngeus Aorta/left mainstem bronchus Gastroesophageal junction

Foreign Body Ingestion

Radiopaque
Coins Cartilage/bones

Radiolucent
Hot dogs

Ba swallow

Foreign Body Ingestion

Ba Swallow

Foreign Body Ingestion

Removal
GA Esophagoscopy Examine for ulceration & perforation

Foreign Body Ingestion

Disc batteries
Emergency NaOH, KOH, mercury
1 hour mucosal damage 2 to 4 hours muscular layers 8 to 12 hours perforation

Esophagoscopy Observation for gastric location for 4-7 days

Foreign Body Ingestion

Postoperative management NPO for 4-12 hours Perforation

Tachycardia Tachypnea Fever Chest pain

Foreign Body Ingestion

Balloon Catheter Extraction

Effective in 90% Endoscopy for failures Complications
Emesis Epistaxis Tracheal placement Laryngospasm Airway compromise

Foreign Body Aspiration

Vegetable matter in 70-80%

Peanuts & other nuts (35%) Carrot pieces, beans, sunflower & watermelon seeds

Metallic objects Plastic objects

Foreign Body Aspiration

Bronchi 80-90%
Right mainstem most common
Carina Less divergent angle Greater diameter

Trachea Larynx

Larger objects, irregular edges Conforming objects

Foreign Body Aspiration

History
Choking Gagging Wheezing Hoarseness Dysphonia

Can mimic asthma, croup, pneumonia A positive history must never be ignored, while a negative history may be misleading

Foreign Body Aspiration

Choking episode with coughing, gagging or wheezing Asymptomatic interval

20-50% not detected for one week

Complications
Cough Hemoptysis Pneumonia Lung abscess Fever

Foreign Body Aspiration

Physical exam
Larynx/cervical trachea
Inspiratory or biphasic stridor

Intrathoracic trachea
Prolonged expiratory wheeze

Bronchi
Unequal breath sounds Diagnostic triad - <50%
Unilateral wheeze Cough Ipsilaterally diminished breath sounds

Fiberoptic laryngoscopy

Foreign Body Aspiration

Radiography
PA & lateral views of chest & neck Inspiration & expiration Lateral decubitus views Airway fluoroscopy

25% have normal radiography

Foreign Body Aspiration

Foreign Body Aspiration

Foreign Body Aspiration

Foreign Body Aspiration

Complete airway obstruction

Respiratory distress Inability to speak or cough

Partial airway obstruction

Coughing Gagging Throat clearing Back blows/probing hypopharynx not recommended

Foreign Body Aspiration

Complete

airway obstruction

< one year

Back blows

> one year

Gentle abdominal thrusts while supine

Older children/adults
Heimlich maneuver

Foreign Body Aspiration

Usually NOT A DIRE EMERGENCY

Trained personnel Instruments assembled and checked Await for emptying of stomach Find duplicate FB to test instruments and techniques

Foreign Body Aspiration

General anesthesia Spontaneous ventilation Laryngoscopes Bronchoscopes Suction Forceps Rod-lens telescopes

Foreign Body Aspiration

Complications
Pneumonia
Antibiotics, physiotherapy

Atelectasis
Expectant management, physiotherapy

Pneumothorax Pneumomediastinum

esophageal obstruction

Benign obstruction
Foreign body obstructions Achalasia Reflux strictures

Malignant obstruction

Foreign bodies obstructions

esophagus is the commonest site of FB impaction- 75% of all FB obstruction of GIT

Web WA Gastrointest Endosc 1995

Paediatric population 6 mon 3 years

Toys, coins

Adults
Meat, bone

Sites of obstruction

Cervical oesophagus: 80%

Cricopharyngeus

Middle oesophagus: 10%

Aortic arch Left main bronchus

Lower oesophagus: 10%

Diaphragmatic hiatus
Nandi P et al Br J Surg 1978

Predisposing factors
Schatzki ring Peptic stricture

Cancer uncommonly causes FB or food impaction.

Specific management

Urgent endoscopy for

Sharp objects Batteries Coins in proximal oesophagus Complete dysphagia

Endoscopy:
Removal or push onward ( only if known normal distal oesophagus) Assessing underlying pathology

Other conservative tricks

No role of glucagon or diazepam

Tibbling L et al. Dysphagia 1995

No control study of the efficacy of gasforming drinks

May cause oesophageal perforation

Proteolytic agents ( papain)

Digests oesophageal wall Haemorrhagic APO if aspirated

Investigations
Barium swallow Oesophageal manometry

Incomplete relaxation of the LES in response to swallowing High resting LoS pressure Absence of oesophageal peristalsis

Prolonged oesophageal pH monitoring

To rule out gastro-oesophageal reflux disease (GORD) To determine if abnormal reflux is being caused by treatment

Medical management

Calcium channel blockers and nitrates are used to decrease LOS pressure.
10% benefit from this treatment. used primarily in elderly patients who have contraindications to either pneumatic dilatation or surgery

Medical management

Endoscopic intra-sphincteric injection of botulinum toxin

30% patients remains free dysphagia after one year cause an inflammatory reaction, making a subsequent myotomy very difficult.

Lower Esophageal Sphincter

Pinch-Cock Action Intraabdominal Esophagus Angle of His Mucosal Rosette High Pressure Zone Abdominal Pressure