Esophageal disorders Congenital

2. DISORDERS OF THE OESOPHAGUS

 

2.1 CONGENITAL

 

ESOPHAGEAL ATRESIA

A  developmental defect is because of incomplete canalisation  of

esophagus. 

The defect is suspected on first feeding of  the  new

born.

 - There is choking coughing and cynosis on feeding.

 - There are five varieties of the observed defects as  shown  in

   Fig The variety C is the most common (85%).

 - The  diagnosis is  established by passage of  rubber  catheter

   through the nose and confirming the obstruction.

 

*  AP & Lat chest Xray will give the level of obstruction.

*  If Xray shows gas in GI Tract or Tracheo-Esophageal fistula is

   suspected .

 

TREATMENT

*   Pump suction of proximal pouch

*   Immediate assessment for other congenital defects

*   Surgical repair of the defect

 

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Esophagus 2 Physiology swallowing

The esophagus is a muscular tube fixed at its upper end to the cricoid cartilage and at its lower end to the diaphragm. This provides it transverse and longitudinal mobility, this mobility allows peristaltic wave to carry the bolus and this mobility also allows of intra thoracic organs to displace the esophogus without altering its food carrying functions.

The tube is lined by sqaumous epithilum with no keratin layer the submucosa contains elastic and fiberous tissue this forms the lamina propria the strongest and dependable layer for stitching in all surgery of esophagus. The lymph flow is not segmental and the submucouslymph plexus allows the lymph to flow long distance up and down, thus upper end cancers may show involvement of superior gastric glands and lower end carcinomas may show mediaitinal glands

1.1 PHYSIOLOGY 

The upper end of the oesophagus acts as a sphincter (UES) and  is

about 3 cm. in length and has a intraluminal resting pressure  of

20-60 mm of Hg.

 - With the act of swallowing this sphincter relaxes for 0.5 to 1

   second  as  the  bolus enters  the  oesophagus  the  sphincter

   contracts  and peristaltic waves of the oesophagus propel  the

   bolus to the lower sphincter (LES)

 - This (LES)  is the last 3 to 5 cm of the oesophagus that  acts

   as  a  sphincter though there is  no  demonstrable  anatomical

   structure like a sphincter.

 - This zone of the oesophagus develops a pressure of 10-20 mm of

   Hg  and  prevents regurgitation of stomach contents  into  the

   oesophagus.

Swallowing physiology

At the end of mastication the semisolid bolus is pushed by the postenor part of the tongue into the posterior oropharynx.

The soft palate (SP) rises to close of the opening of the neso pharynx. The hyoid and larynx move upward and the epiglottis classes of the larynx. These tow (SP+E) close of the nasal air passage and the larynx. The bolus is helped on its way towards the upper opening of the esophagus by the elevation of larynx.

The UES relaxes and the contractions of pharyngeal constrictors push the bolus into the esophagus. During the swallowing the breath is held. Further progress of the bolus is through the peristalsis of the esophagus.

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Esophagus 1 Anatomy

OESOPHAGUS

1. ANATOMY

The oesophagus is a hollow muscular tube that begins at the lower

end  of the pharynx and ends in the stomach, it is 10 inches  (25

cm) in length.

 - Its maximum diameter in an adult is 2.5 cm and it  narrows  at

   its  junction with the pharynx (upper end) and stomach  (lower

   end).

 - It is  also narrow at the level of the 4th  thoracic  vertebra

   where the trachea bifurcates anterior to it .

 - The oesophagus is lined with mucosa (squamous cell) and has an

   inner circular muscular layer and an outer longitudinal layer.

 - In between these muscles, are the ganglion cells of Meissner's

   and  Auerbach plexus,the submucosa has the  Meissner's  neural

   plexus.

 - There is no serosa.

The  blood  supply  of  the  thoracic  oesophagus  is  from   the

oesophageal branches of the aorta, there are in addition branches

from  the  inferior  thyroid,  intercostal,  bronchial,  inferior

phrenic and left gastric arteries.

The   oesophagus  is  supplied  by  both  the   sympathetic   and

parasympathetic nerves.

The  lymphatics  arise  in the mucosa and form a  plexus  in  the

intermuscular  layer and the lymphatics drain to  the  lymphnodes

along the aorta

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HEAD NECK 19 Short notes Epulis -Ludwig's angina

Chapter 14 page 1

Epulis

This  is an abnormal hyperplasia of the gums and is  produced  by

any  cause of chronic irritation (sharp edge of tooth cavity)  or

infection giant cell epulis is also because of inflammation.

Chapter 14 after 2.3

Torticollis

This  is the abnormal position of the head and neck caused  by  a

spasm  of  the  neck muscles. It can be  caused  by  an  abnormal

position while sleeping or an injury at birth. Treatment is  with

physiotherapy  and ultrasound. In the birth injury stretching  of

the muscles can also help.

Chapter 14 after 7.2

Adamantinoma

This is a multilocular cystic swelling usually seen in the  lower

jaw. It causes a bony expansion which can be seen on Xray. It  is

a slow growing tumour but invades tissue locally. The patient  is

20-30 years. Treatment is by local Excision.

Chapter 14 after 4.6

Ameloblastomar

This  tumour takes origen from the enamel organ of the teeth  and

can be seen in the upper or lower jaw also called admantinoma.  A

slow growing low-grade malignat tumour expands the jaw. X-ray  is

a  "soap  bubfle"  multiloculated cystic expansion  of  jaw.  The

lesion has to be excised and replaced with a bone graft.

Chapter 14 after 4.6

Odontoma

There are cysts that origen from ectodermal and mesodermal  teeth

producing tissue in the mouth. These cysts expend the jaw and are

usually benign.

Chapter 14 after 4.2

Ludwig's Angina

This  is  a severe cellulite of the submandibidor region  due  to

tooth  abscess  due to anaerobes and spirochetes the  ocdena  can

cause  respiratory obstruction. The patient needs  admission  and

 hugh dose of antibiotic and metronidazole.

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HEAD NECK 18 malignant parotid

8.6.1 MALIGNANT MIXED TUMOURS

Malignant mixed tumours arise from a neoplastic transformation of

a  benign mixed tumour.  Patients are generally older,  malignant

lesions  are  usually  larger and any mixed  tumour  may  contain

within  it malignant elements and may result in  adeno-carcinomas,

squamous cell carcinoma or malignant spindle cell alternation.

With  the exception of mixed tumours; benign lesions of  salivary

tissues have no malignant potential.

CLINICAL PRESENTATION

Mixed  tumour may grow for years at a slow pace.   The  malignant

component  suddenly develops and there is a marked change in  its

course.

Fixation  of  glands to skin or underlying  structures,  palpable

nodes and involvement of the VIIth nerve are all diagnostic.

Excision of the mass and histologic examination are indicated  in

every case.

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HEAD NECK 17 Parotid tumors

8.5 TUMOURS

8.5.1 MIXED TUMORS

A  common  lesion  of the salivary gland  is  the  mixed  tumours

(pleomorphic adenoma).

*  Eighty  percent of all benign tumours probably originate  from

   the myoepeithelial cells of the ducts.

*  Microscopic examination shows a network of strands of  spindle

   shaped and stellete cells.

*  In  one-third  of  cases loose  myxoid  pattern  predominates. 

   Half, in addition, have pseudocartilaginous structures.

Treatment  is  superficial  Parotidectomy  with  conservation  of

branches of the facial nerve.

8.5.2 PAILLARY CYSTADENOMA LYMPHOMATOSUM (WHARTHIN'S TUMOUR)

The lesion feels firm on examination and represent parotid tissue

sequestered in a lymphnodes.  It is the second most common benign

tumour of salivary tisse

The Histogenesis is unceertain

Treatment is surgical excision.

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HEAD NECK 16 Sialolithisis sialoadenitis

8.4 SIALOLITHIASIS (STONES)

Calculi  sometimes form within the ducts of salivary  glands  and

this occurs because of poor drainage and change of pH.

The symptoms are those of obstruction and distension of the gland

following  the  taking of food.  The gland may  enlarge  and  may

become palpable.

The  stone may be felt in the cheek in the parotid duct  and  the

floor of the mouth in the case of Submandibular duct symptoms are

of pain and swelling.

Treatment is by removal of the stone .

SIALOADENITIS

This occurs most often with invasion by bacteria.

Acute  parotitis occurs, with the symptoms of pain, swelling  and

fever progress is rapidly in these cases .

Obstruction  of the duct plays a causative role  dehydration  and

malnutrition also contribute.

Treatment  is  removal  of  causitive  factors  and  antibiotics. 

Drainage of abscess may be required.

Recurrent sialoadenitis also occur with repeated episodes of pain

and swelling with fever and its complication of orchitis has been

discussed elsewhere.

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