3 anatomy & physiology of esophagus

1. Zou Hua
ENT Depart.
The Second Affiliated Hospital
Sun Yat Sen University
Email: [email protected]

2. overviewoverview
Anatomy & physiology of esophagus
(gullet)
Anatomy & physiology of trachea,
Tracheotomy
Anatomy of cervical part
Neck masses
Neck Dissection

3. Anatomy & physiology Anatomy & physiology
of esophagusof esophagus

4. Esophageal AnatomyEsophageal Anatomy
Muscular tubeMuscular tube
connecting the connecting the
pharynx to the pharynx to the
Stomach, channelStomach, channel
for the transport of for the transport of
foodfood
18 to 26 cm in 18 to 26 cm in
lengthlength
Back: vertebra Back: vertebra
(C6---T11)(C6---T11)
Front: larynx & Front: larynx &
lower airwaylower airway

5. Esophageal AnatomyEsophageal Anatomy
Upper EndUpper End : C6 : C6 (the (the
inferior pharyngeal constrictor inferior pharyngeal constrictor
merges with the cricopharyngeusmerges with the cricopharyngeus) )
____ Upper esophageal Upper esophageal
sphincter (UES)sphincter (UES)
Lower EndLower End: T11 : T11
(thickened circular smooth (thickened circular smooth
muscle)muscle) __ __ Lower Lower
esophageal sphincter esophageal sphincter
(LES) (LES)

6. Esophageal AnatomyEsophageal Anatomy
38-40cm from incisors38-40cm from incisors

7. Esophageal AnatomyEsophageal Anatomy
It is divided into three parts
Cervical parts
Thoracic parts
Abdominal parts

8. Esophageal ConstrictionsEsophageal Constrictions
The esophagus has 3 areas of narrowing:
Superiorly: level of cricoid cartilage, juncture with pharynx
Middle: crossed by aorta and left main bronchus
Inferiorly: diaphragmatic sphincter

9. Esophageal ConstrictionsEsophageal Constrictions
These narrowing areas have
important clinical significance
where most esophageal foreign
bodies become entrapped.

10. Esophageal AnatomyEsophageal Anatomy
Innervation mainly by celiac ganglia
(Vagus n.)

11. Esophageal physiologyEsophageal physiology
1. swallow (Esophageal
Transport by Gravity)
The oropharyngeal phase : Swallowing
begins when a food bolus is propelled into
the pharynx from the mouth. It is
voluntary.
The esophageal phase. It is involuntary.
It takes approximately 8 to 10 seconds
from initiation of the swallow to entry into
the stomach .
In rapid sequence and with precise
coordination, the larynx is elevated and the
epiglottis seals the airway.

12. Esophageal physiologyEsophageal physiology
2.Secretion (submucosal mucous
glands)
3.Protection : Gastroesophageal
reflux (machenic , secretion )

13. Gastroesophageal reflux (GER)Gastroesophageal reflux (GER)
The gastric content (acid, pepsin, bile
salts, and pancreatic enzymes) refluxed into
the esophagus.
 It can damage the mucosa through
the presence of hydrochloric.

14. TestsTests
1.X-ray
Plain X-ray : mental or some foreign bodies
Barium X-ray :As the oesophagus, stomach
and duodenum are soft tissue structures, they are not
usually seen on a plain X-ray. By using barium to
coat the inner lining of these areas, the Radiologist
can see them clearly on the X-ray screen; and can
watch the way the organs function during this study.
Barium is a chalky substance that can be suspended
in water and is visible on X-rays

15. TestsTests
a plain X-ray Barium X-ray

16. Barium X-rayBarium X-ray

17. TestsTests
X-ray barium test indications
Difficulty or pain in swallowing;
Be troubled by indigestion or acid reflux;
An ulcer or blockage in the stomach is
suspected.

18. TestsTests
Endoscopy (Rigid & flexible telescope-under sedation)
Rigid Endoscopy

19. TestsTests
flexible telescope

20. Anatomy & physiology of Anatomy & physiology of
the Respiratory tractthe Respiratory tract

21. The Respiratory tractThe Respiratory tract
The airway begins at the mouth or nose, and
accesses the trachea via the pharynx through
which air flows, to get from the external
environment to the alveoli.
Upper respiratory passages filter and humidify
incoming air
Lower passageways include delicate conduction
passages and alveolar exchange surfaces

22. The Components of the Respiratory SystemThe Components of the Respiratory System
the mouth or nose, the
pharynx. the larynx
(cricoid cartilage), the
trachea, the left and
right main bronchi ,
large bronchioles,
clusters of alveoli.

23. The Components of the Respiratory SystemThe Components of the Respiratory System
The cricoid
cartilage, or simply
cricoid ("ring-
shaped"), is the
only complete ring
of cartilage around
the trachea. It is
very important to
support the airway.

24. The Anatomy of the TracheaThe Anatomy of the Trachea
The trachea is a tubular
structure which is located
at the front of the neck
Begins: the level of the
C6 ( the thyroid
cartilage).
Bifurcating: into right and
left main bronchi (the
level of the T5)
Length: 10 to 15cm
Diameter :16-18 mm

25. The Anatomy of the TracheaThe Anatomy of the Trachea
Structure of the Trachea
wall
Anterior wall:
cartilaginous rings

(16 to 20 C-shaped )
Posterior wall:
fibromuscular sheet

(ligaments)
Posterior : esophagus

26. Physiology of the TracheaPhysiology of the Trachea
Respiration: air moving in and out of the
lungs
Filter particulate matter, humidify inspired
air, and aid in expectoration of secretions.
Physiology of Airway Protection: coughing
reflex

27. Physiology of the TracheaPhysiology of the Trachea
The hyaline cartilage in the tracheal wall
provides support and keeps the trachea from
collapsing.
The posterior soft tissue allows for
expansion of the esophagus, which is
immediately posterior to the trachea.

28. Tracheotomy

29. DefinitionDefinition
An opening surgically created
through the neck into the trachea
(windpipe). A tube is usually
placed through this opening
(tracheostomy tube also trach
tube)
to provide an airway and to allow
removal of secretions from the
lungs.
It provides an alternative
airway, by passing the upper
passages .

30. Tracheostomy tubesTracheostomy tubes
Inserted through
the tracheostomy
to maomtaom a
patent airway
Secured in place
by tapes tied
around the neck

31. PurposePurpose
A tracheotomy is performed if enough air is not
getting to the lungs, if the person cannot breathe .
The conditions in which a tracheotomy may be used
1. Acute setting
Maxillofacial injuries
Large tumors of the head and neck, congenital tumors, e.g.
branchial cyst
Acute inflammation of head and neck
2. Chronic / elective setting - when there is need for long term
mechanical ventilation to pump air into the lungs for a long
period of time and tracheal toilet
comatose patients,
surgery to the head and neck.

32. Operative procedures
Emergency tracheotomy
(cricothyroidotomy)
Surgical tracheotomy
(nonemergency tracheotomy )

33. (A). An incision is made in the skin just above the sternal
notch Just below the thyroid,
(B). The membrane covering the trachea is divided
(C). The trachea itself is cut
(D). A cross incision is made to enlarge the opening
(E). A tracheostomy tube may be put in place
Completed
tracheotomy

34. Operative procedures
Completed tracheotomy
1 - Vocal cords
2 - Thyroid cartilage
3 - Cricoid cartilage
4 - Tracheal cartilages
5 - Balloon cuff

35. ComplicationsComplications
 Bleeding. In very rare situations, the need for blood
products or a blood transfusion.
 Need for further and more aggressive surgery.
 Infection.
 Impaired swallowing and vocal function.
 Scarring of the neck.
 Air trapping in the surrounding tissues (subcutaneous
emphysema) or chest (Pneumothorax). In rare situations, a
chest tube may be required.
 Need for a permanent tracheostomy. This is most
likely the result of the disease process which made
the a tracheostomy necessary, and not from the
actual procedure itself.

36. Complications Complications (rare) (rare)
Damage to the larynx (voice box) or
airway with resultant permanent change
in voice
Airway obstruction (tube obstruction) and
aspiration of secretions/ accidental
decannulation –the most common cause of
death.
Scarring of the airway or erosion of the
tube into the surrounding structures

37. Postoperative carePostoperative care
Objective : ensure patent airway.
Prevent the complications
Chest x- ray
Antibiotics
Suctioning and clearing the
tracheotomy tube
Humidifying the air

38. Postoperative carePostoperative care
Normally nasal breathing
Humidifies, filters and warms air
before it enters the lungs
The tracheostomy bypasses these
mechanisms so that the air is
cooler, dryer, and not as clean. In
response to these changes the
body produces more mucous,
which may require
humidification to aid expulsion.

39. Postoperative carePostoperative care
Tracheostomy tube changs
Tracheostomy tubes are changed
weekly or any time a blockage is
suspected.
To prevent build up of secretios
on the wall of the tube

40. Postoperative carePostoperative care
Some precautions with a Tracheostomy
Water is a serious threat
No swimming
No showering
Avoid clothing that blocks the
Tracheostomy
Accidental decannulation -most
common cause of death.

41. Postoperative carePostoperative care
The tube will be removed if the tracheotomy
is temporary. Then the wound will heal
quickly and only a small scar may remain.
Weaning is a gradual decrease in the tube
size and ultimate removal of the tube.
If the tracheotomy is permanent, the hole
stays open.

42. Anatomy of neckAnatomy of neck

43. Introduction Introduction
The neck contains important
communications between the head and
the body, including air and food
passages, major blood vessels and
nerves, and the spinal cord. Many vital
structures are compressed into a narrow
area which is engineered for maximal
mobility to permit variation in head
position relative to body.

44. Anatomy of neckAnatomy of neck
Skeleton: vertebral
column,hyoid bone,
and laryngeal and
tracheal cartilages
Muscles
Nerves
Major Vascular
Structures
Visceral Column
- pharynx,
larynx, trachea,
and esophagus.
Thyroid Gland
Between Mandibular notch and Clavicle

45. Anatomic trianglesAnatomic triangles
The neck can be divided
into two major triangles
(anterior and posterior
triangles) by the
sternocleidomastoid
(SCM), with multiple smaller
triangles
Anatomic triangles

46. Anatomic trianglesAnatomic triangles
Two major triangles
Anterior triangle -
bordered by the
anterior border of the
SCM, midline of the
neck, and the mandible
Posterior triangle -
bordered by the
posterior border of the
SCM, trapezius, and
clavicle
 A: muscular triangle, carotid triangl,
esubmental triangle, submandibular triangle
P: supraclavicular triangle,
occipital triangle

47. MusclesMuscles of neck of neck

48. Major VascularMajor Vascular

49. Major VascularMajor Vascular
Major Vascular
Structures bifurcates
into:
Internal (intracranial) - no
branches in the neck
External (extracranial)
Thyrocervical trunk
Vertebral artery
Internal jugular vein (within
carotid sheath)

External jugular vein

50. Lymphatic drainageLymphatic drainage
Lymphatic drainage: major
head and neck lymph node
groups. The lymph nodes of
the neck can be divided into
six levels within the defined
anatomic triangles.
I--Submental and
submandibular nodes
II--Upper jugulodigastric
group
III--Middle jugular nodes
IV--Inferior jugular nodes
V-- Posterior triangle group
VI--Anterior compartment
group

51. Lymphatic drainageLymphatic drainage
These groups and the areas that
they drain are particularly
important when locating and
working up a "neck mass" or
possible malignancy. The groups
and drainage areas are as follows.

52. Lymphatic drainageLymphatic drainage
Individual Lymph Nodes in the Head and Neck

53. Lymphatic drainage (Lymphatic drainage (Level I)Level I)
Submental triangle (Ia)
Anterior digastric
Hyoid
Mylohyoid
Submandibular triangle
(Ib)
Anterior and posterior
digastric
Mandible.

54. Lymphatic drainageLymphatic drainage
Ia
Chin
Lower lip
Anterior floor of
mouth
Mandibular incisors
Tip of tongue
Ib
Oral Cavity
Floor of mouth
Oral tongue
Nasal cavity
(anterior)
Face

55. Lymphatic drainage (Lymphatic drainage (Level Level IIII))
Upper Jugular Nodes
Anterior  Lateral border of
sternohyoid, posterior digastric
and stylohyoid
Posterior  Posterior border of
SCM
Skull base
Hyoid bone (clinical landmark)
Carotid bifurcation (surgical
landmark)

56. Lymphatic drainage (Lymphatic drainage (Level Level IIII))
Oral Cavity
Nasal Cavity
Nasopharynx
Oropharynx
Larynx
Hypopharynx
Parotid

57. Lymphatic drainage (Level III)Lymphatic drainage (Level III)
Middle jugular nodes
Anterior  Lateral border of
sternohyoid
Posterior  Posterior border
of SCM
Inferior border of level II
Cricoid cartilage lower border
(clinical landmark)
Omohyoid muscle (surgical
landmark)
Junction with IJV

58. Lymphatic drainage (Level III)Lymphatic drainage (Level III)
Oral cavity
Nasopharynx
Oropharynx
Hypopharynx
Larynx

59. Lymphatic drainage (Level IV)Lymphatic drainage (Level IV)
Lower jugular nodes
Anterior  Lateral border of
sternohyoid
Posterior  Posterior border of
SCM
Cricoid cartilage lower border
(clinical landmark)
Omohyoid muscle (surgical
landmark)
 Junction with IJV
Clavicle

60. Lymphatic drainage (Level IV)Lymphatic drainage (Level IV)
The thoracic duct:
Conveys lymph from the entire
body back to the blood
Exceptions:Right side of head and
neck, RUE, right lung right heart
and portion of the liver
Begins at the cisterna chyli
Enters posterior mediastinum
between the azygous vein and
thoracic aorta
Courses to the left into the neck
anterior to the vertebral artery and
vein
Enters the junction of the left
subclavian and the IJV

61. Lymphatic drainage (Level IV)Lymphatic drainage (Level IV)
Hypopharynx
Larynx
Thyroid
Cervical esophagus

62. Lymphatic drainage (Level V )Lymphatic drainage (Level V )
Posterior triangle of neck
Posterior border of SCM
Clavicle
Anterior border of trapezius
Va Spinal accessory nodes
Vb  Transverse cervical
artery nodes
Radiologic landmark: Inferior
border of Cricoid
Supraclavicular nodes

63. Lymphatic drainage (Level V )Lymphatic drainage (Level V )
Nasopharynx,
Oropharynx, Posterior neck and
scalp

64. Lymphatic drainage (Level VI )Lymphatic drainage (Level VI )
Thyroid
Larynx(glottic and subglottic)
 Pyriform
 sinus apex
Cervical esophagus

65. A Neck MassA Neck Mass

66. Introduction Introduction
Neck masses are very common
Inflammatory and infectious causes :
cervical adenitis
Congenital masses : branchial anomalies and
thyroglossal duct cysts
Neck masses resulting from trauma:
hematomas firm masses because of fibrosis.
Neoplasms (benign and malignant)
Malignancy is the greatest concern in a patient with
a neck mass.

67. Normal AnatomyNormal Anatomy
The central portion : the hyoid bone,
thyroid cartilage, and cricoid
cartilages, the thyroid gland .
Carotid arteries are pulsatile and can
be quite prominent if atherosclerotic
disease is present.
The sternocleidomastoid muscles
should be palpated along their
entirety

68. DiagnosisDiagnosis
Normal variations in anatomy can be
distinguished from true pathology without the
need for additional diagnostic testing
The only easy way to diagnose a neck mass is to
know exactly what the patient has before you
begin.
your only challenge is to prove it
The next most challenging is to have some idea of
what the patient has, perform a few tests, narrow
the differential, and then prove the final diagnosis.

69. DiagnosisDiagnosis
The patient's age and the size and
duration of the mass are the most
significant predictors of neoplasia
Malignancy is the greatest concern
in a patient with a neck mass.

70. DiagnosisDiagnosis
The occurrence of symptoms and their
duration must also be determined.
Acute symptoms, such as fever, sore throat, and
cough, suggest adenopathy resulting from an upper
respiratory tract infection.
 Chronic symptoms of sore throat, dysphagia, change
in voice quality, or hoarseness are often associated
with anatomic or functional alterations in the
pharynx or larynx.

71. Diagnostic StepsDiagnostic Steps
History: A careful medical history can provide
important clues to the diagnosis of a neck mass.
Developmental time course
Associated symptoms (dysphagia, otalgia, voice)
Personal habits (tobacco, alcohol)
Previous irradiation or surgery
Physical Examination
Complete head and neck exam (visualize &
palpate)
Emphasis on location, mobility and consistency
endoscopic evaluation, with possible excisional biopsy
or neck dissection.

73. Fine needle aspiration biopsy Fine needle aspiration biopsy (FNAB)(FNAB)
Diagnostic yields
reach as high as 90%
for both infection and
neoplasm.

74. Imaging techniquesImaging techniques
Computed tomography (CT) or with
contrast
Magnetic resonance imaging (MRI)
or with contrast
Ultrasonography
Nuclear scanning
Positron emission tomography (PET)
the metabolic activity of the tissues

76. BiopsyBiopsy
Biopsy should be considered for neck masses
with progressive growth, location within the
supraclavicular fossa, or size greater than 3
cm.
Biopsy also should be considered if a patient
with a neck mass develops symptoms
associated with lymphoma. Frozen-section
examination of the mass followed by neck
dissection should be performed if the mass
proves to be metastatic carcinoma.
The risk of having a malignant neck mass
becomes greater with increasing age.

77. Lymph node groups with the
most likely sites of the primary
lesion.
Diagnosis Diagnosis (metastatic lymph node)(metastatic lymph node)

78. algorithm

80. Evaluation and management of a neck mass in the adult patient. (PPD = purified protein derivative)
Algorithm

81. ManagementManagement
Many inflammatory lymph nodes resolve with
no treatment, although close observation is
required.
A single course of therapy with a broad-
spectrum antibiotic and reassessment in one to
two weeks is a reasonable treatment choice
when a patient with a neck mass has signs and
symptoms of an inflammatory process (i.e.,
fever, painful mass, erythema) or a history of
recent infection

82. ManagementManagement
Benign neoplasm: surgical treatment

83. Neck DissectionNeck Dissection

84. overviewoverview
Anatomy
Nodal levels
Common nodal drainage patterns
Staging
Classification
Sentinel Lymph Node

85. IntroductionIntroduction
The neck dissection is a surgical procedure for
control of neck lymph node metastasis from
squamous cell carcinoma (SCC) of the head and
neck.
The aim of the procedure is to remove lymph
nodes from one side of the neck into which cancer
cells may have migrated.
The metastases may originate from SCC of the
upper aerodigestive tract, including the oral
cavity, tongue, nasopharynx, oropharynx,
hypopharynx, and larynx, as well as the thyroid,
parotid and posterior scalp.

86. IntroductionIntroduction
Lymph node metastasis reduces the survival
rate of patients with squamous cell carcinoma
by half.
The survival rate is less than 5% in patients
who previously underwent surgery and have a
recurrent metastasis in the neck.
Therefore, the control of the neck is one of
the most important aspects in the successful
management of these particular tumors.

87. AnatomyAnatomy
Lymph Node Levels: To describe the lymph nodes of the neck
for neck dissection, the neck is divided into 6 areas called Levels

88. Common Nodal DrainageCommon Nodal Drainage
Level I: Chin, Lower lip,
Anterior floor of mouth,
Mandibular incisors, Tip of
tongue, Oral Cavity, Floor of
mouth, Oral tongue, Nasal cavity
(anterior), Face
Level II: Oral Cavity, Nasal
Cavity, Nasopharynx,
Oropharynx, Larynx,
Hypopharynx, Parotid
Level III: Oral cavity,
Nasopharynx, Oropharynx,
Hypopharynx,Larynx

89. Common Nodal DrainageCommon Nodal Drainage
Level IV: Hypopharynx,
Larynx,
Thyroid, Cervical esophagus
Level V: Nasopharynx,
Oropharynx, Posterior neck and
scalp
Level VI: Thyroid, Larynx
(glottic and subglottic), Pyriform
sinus apex, Cervical esophagus

90. ClassificationClassification
Radical Neck Dissection (RND)
Gold standard operation
Modified Radical Neck Dissection (MRND)
Preservation of non lymphatic structures
Selective Neck Dissection (SND)
Preservation of lymph node groups
Extended Neck Dissection
Removal of additional lymph node groups or
non lymphatic structures

91. Radical Neck DissectionRadical Neck Dissection
Removes
all ipsilateral cervical lymph node
groups I-V
SCM, IJV, XI
Submandibular gland, tail of parotid
Preserves
Posterior auricular
Suboccipital
Retropharyngeal
Periparotid
Perifacial
Paratracheal nodes

92. Modified Radical Neck DissectionModified Radical Neck Dissection
Removes
Nodal groups I-V
Preserves
SCM, IJV, XI (any
combination)
Notate according to
which structures are
preserved

93. Selective Neck DissectionSelective Neck Dissection
Remove high risk
lymph node groups
based on tumor site.
For oropharyngeal,
hypopharyngeal and
laryngeal cancers,
SND (II-IV) is the
procedure of choice.

94. Extended Neck DissectionExtended Neck Dissection
To removal of one or more additional
lymph node groups or nonlymphatic
structures, or both, not encompassed by
the RND
Notated by naming the structure(s)
removed.

95. Operative TechniqueOperative Technique
Limited incision guided by
lymphoscintigraphy and
gamma probe
Frozen section analysis
(incised margin )

96. ComplicationsComplications
Nerve injury: Shoulder dysfunction (the
accessory nerve )
Vessel injury : Bleeding
Infections: Wound infections may also occur
and can usually be managed in the clinic with
antibiotics and minor wound care.

97. ComplicationsComplications
Lymphatic Leak
Major lymph channels are encountered at the
lower aspect of the neck, especially on the left
side.
Occasionally a lymphatic leak occurs despite
these efforts.
Food in the stomach can increase the amount of
lymphatic flow. A diet change and a pressure
dressing can usually control this problem,
Return to the operating room for repair if
necessary .

98. EmphasisEmphasis
Anatomy features of the trachea and
physiology .
What is tracheotomy? What is the
indications?
What important structures in the neck?
 Esophageal three Constrictions. What are
the clinic significance?

99. EmphasisEmphasis
Two major triangles of the neck
How many levels of Lymphatic
drainage of the neck
Neck masses classification and
algorithm of diagnosis
Classification of the neck dissection

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