TRACHEA AND ESOPHAGUS

Jeriel John C. Majam, MD, FPSOHNS

Otorhinolaryngology Head and Neck Surgery

TRACHEA

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ANATOMY
Extends from C6 T5/6 vertebrae
Nearly cylindrical, slightly flattened posteriorly 16-20 rings or C-shaped bars, incomplete posteriorly

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ANATOMY
Supplied mainly by the inferior thyroid arteries
Receives branches from the superior thyroid, bronchial, and internal thoracic arteries Drained by the inferior thyroid vein Innervated by the vagus, sympathetic, and recurrent laryngeal nerves
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS
Tracheal Agenesis or Atresia Rare There is no continuity between the larynx and trachea Fatal

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS
Tracheal Webs Thin band of tissue spanning the tracheal lumen without deformity of the underlying cartilage Tx: Dilation, laser transection; resection and anastomosis

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS
Tracheal Stenosis Assoc tracheoesophageal fistula, pulmonary hypoplasia, vascular sling, Trisomy 21 Cartilage is smaller and nonflexible, lacks the posterior membranous portion Dx: endoscopic evaluation Tx: resection and reanatomosis, tracheoplasty
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS
Tracheomalacia Weakness of the tracheal wall resulting in marked exaggeration of movement with respiration Symptoms: Expiratory stridor, wheezing Barking cough Hyperextension of neck Reflex apnea
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS Primary Tracheomalacia Esp in premature infants Dx with rigid endoscopy showing widened posterior wall with expiratory collapse Resolves 18-24 months
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS Secondary Tracheomalacia After surgical repair of tracheoesophageal fistula External compression from vascular anomalies

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

CONGENITAL DISORDERS
1/3000 livebirths Drooling, coughing, cyanosis, abdominal distention, poor feeding

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Clinical Considerations
Foreign body aspiration
More likely to enter right bronchus

Tracheoscopy/bronchoscopy

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Ventilating Bronchoscope

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

TRACHEOSTOMY

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Tracheostomy
Is an opening surgically created through the neck into the trachea through which air may pass to the lungs, by-passing through the upper airway.

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Tracheostomy
Incidence (2002 PGH)
107 referrals 85% adults
Pneumonia and CVD

65 ENT ward tracheostomies

Laryngeal masses Oral cavity tumors Anterior neck masses

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

BACTERIAL TRACHEITIS
Membranous laryngotracheobronchitis Antibiotis directed vs Staph aureus and H. influenza

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ESOPHAGUS
From cricoid cartilage (C6) to stomach (T10)
3 constrictions
Cricopharyngeus Arch of the aorta & left main bronchus Gastro-esophageal junction

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ESOPHAGUS

ANATOMY
Blood supply
inf. thyroid br. of thyrocervical trunk small br. of thoracic aorta bronchial aa. ascending br. of left gastric a ascending br. of left phrenic a.

Venous drainage
Inf thyroid Azygos, hemiazygos Gastric
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ANATOMY
Layers:
Outer longitudinal muscle Inner circular muscle Submucosa Mucosa

Upper 1/3 skeletal muscle, distal portion is smooth muscle

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Congenital
Gastroesophageal reflux
50% of infants; pathologic if it persists beyond 18 months of age Vomiting soon after or up to several hours after feeding Dx: prolonged esophageal pH monitoring Tx: positioning, dietary changes

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

This Is A Piggy Bank

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

This Is A Human Piggy Bank

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

For Practice

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: DIVERTICULA
Caused in part by an area of anatomic weakness 3 areas of constriction Killians dehiscence
Between cricothyroid & cricopharyngeus mm

Laimer-Haeckerman space Killian-Jamieson space

Between cricopharyngeus & circular fibers of esophagus

Lateral dehiscence bet. cricopharyngeus & esophageal muscle fibers through recurrent laryngeal n passes

The only esophageal problem in ENT is laryngopharyngeal reflux (MC)

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: ZENKERS DIVERTICULUM

Zenkers diverticulum (MC) Barium swallow simply xray

Structural: ZENKERS DIVERTICULUM

Due to chronic spasm of the upper esophageal sphincter with resultant high pressures in Killians dehiscence
80% of all diverticula (MC)

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: ZENKERS DIVERTICULUM

Symptoms Dysphagia (MC) Spontaneous regurgitation of undigested food Aspiration & cough Halitosis

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: ZENKERS DIVERTICULUM

Diagnosis Barium swallow Esophagoscopy (flexible is recommended)
Treatment Surgery
Rigid esophagoscopy removal of foreign body, usually used by ENT Flexible esophagoscopy usually used by enterologist

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Barium Swallow

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

AP View

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Barium Swallow

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: ACHALASIA
Zonal reduction in ganglion cells Esophageal aperistalsis and LES dysfxn Xray: absent primary peristalsis, beak-like tapering at the esophageal hiatus

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: DIFFUSE ESOPHAGEAL SPASM

Intermittent abn esophageal motility Manometry: presence of simultaneous contractions and intermittent N primary peristalsis
Can be diagnosed through manometry

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: DIFFUSE ESOPHAGEAL SPASM

Xray: absence of primary peristalsis in the smooth muscle portion, corkscrew appearance

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: PRESBYESOPHAGUS
Abnormal motility associated with aging Decreased primary and increased tertiary contractions Rule out other concomitant illnesses first

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: SCLERODERMA
Aperistalsis of the lower 2/3 of the esophagus Marked decrease in lower esophageal sphincter pressure Normal peristalsis in the upper esophagus 60% with symptomatic dysphagia

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: SCLERODERMA

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: POLYMYOSITIS
Muscle weakness secondary to inflammation and degenerative changes in striated muscle
Peristalsis is diminished and poorly diminished Esophagus may be dilated

Affects lower esophagus

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: HIATAL HERNIA

Portion of stomach passing through the normal esophageal hiatus above the diaphragm Normally associated with obesity, pregnancy etc

Obesity

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: REFLUX ESOPHAGITIS

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: STRICTURES

Caustic ingestion - common

Structural: SCHATZKIS RING

Concentric ring at the gastro-esophageal junction 6-14% of routine barium swallows Only 1/3 are symptomatic Dysphagia if lumen < 13 mm

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Schatzkis Ring

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Structural: ESOPHAGEAL WEBS

Aberrant structure consisting of squamous mucosa located anywhere along the esophagus

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Easy to treat Dilate

Structural: ESOPHAGEAL WEBS

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Others: BOERHAAVE SYNDROME

Results from a tear through all layers of the esophageal wall just above the diaphragm produced by a sudden increase in esophageal pressure

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Others: MALLORY-WEISS SYNDROME Manifest by bleeding from lacerations of the cardia of the stomach as a result of prolonged or forceful vomiting

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

LEIOMYOMA

Most common benign tumor L side smooth border R sight irregular border

Inflammatory: PLUMMER-VINSON
Iron deficient anemia, upper esophageal web, hypothyroidism, glossitis, gastritis, dysphagia 15% increase incidence of postcricoid SCCA
TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

Inflammatory: BARRETTS ESOPHAGUS

Lower portion of esophagus is lined with columnar rather than squamous epithelium Progresses to adenoCA of esophagus in 10-15%

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ESOPHAGEAL CANCER
4% of cancer deaths Male:female = 5:1 Chronic tobacco & alcohol use Lower 1/3 of esophagus 40-50%

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

ESOPHAGEAL CANCER
Fungating in appearance Predisposing alcohol and smoking

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS

TRACHEA AND ESOPHAGUS by JERIEL JOHN C. MAJAM, MD, FPSOHNS