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224 THE LARYNX, BRONCHI AND OESOPHAGUS
If there is a total block in the oesophagus the patient will immediately vomit
everything he eats or drinks. This type of picture must be differentiated from a
later regurgitation of undigested food seen with a pharyngeal pouch. If food
builds up and collects in the oesophagus, such as occurs above a stricture, a
tumour or an achalasia, then it will eventually overflow, enter the larynx, and
cause at first coughing fits, and later inhalation pneumonia.
The age of presentation of the patient gives some idea of the pathology.
Children may have congenital problems such as tracheo-oesophageal fistula,
web, congenital vascular anomalies or hiatus hernia and they are prone to
foreign bodies and corrosive burns. In middle age, while cancer must always
be considered, the most likely causes are achalasia, oesophagitis from reflux
and hiatus hernia, globus hystericus, Paterson-Brown Kelly syndrome and
pharyngeal pouch. In the elderly the cause of dysphagia is cancer of the
oesophagus until proved otherwise, although it may be due to osteophytes
impinging on the oesophagus, diverticula, or strictures from long-standing
Enquiry must be made into precipitating factors such as the effect of
position, various types of food, worry, etc. and alleviating factors such as
antacids or tranquillizers.
Associated symptoms such as voice change may signify recurrent laryngeal
nerve involvement or pachydermia due to reflux of acid burning the inter-
arytenoid area. A large thyroid or a retrosternal thyroid, an aortic aneurysm
or a bronchial carcinoma can cause extrinsic pressure, as can osteophytes.
In the past history one must find out about any accidental ingestion of
corrosives in childhood, treatment for indigestion or peptic ulcer, and irradia-
tion for thyroid or chest conditions.
1. General. There are few external signs of oesophageal disease. The patient
must be weighed and assessed for weight loss. The neck should be carefully
palpated for supraclavicular nodes on the left side and also for thyroid
nodules or enlargement. The patient should be asked to swallow some water,
and the swallowing efforts should be observed, and the neck palpated at the
same time. The larynx should be examined for evidence of vocal cord paralysis
or pooling of saliva in the pyriform fossa signifying hold-up. Note is taken of
the state of the tongue, the corners of the mouth and nails as these are
changed in the Paterson-Brown Kelly syndrome. The abdomen should be
palpated for any epigastric tenderness.
2. Laboratory Investigations. All patients should have a full haematological
examination and where the haemoglobin is low or the film confirms a micro-
cytic anaemia, a serum iron and iron-binding capacity test should be done. If
it is indicated the thyroid function tests should be performed and if there
has been vomiting or loss of weight the urea and electrolytes ought to be
3. Radiography. This forms the keystone to the examination of oesophageal
disease. A barium swallow with or without a barium meal must be done in
every case of dysphagia. If any abnormality is seen then it is usually followed
up by oesophagoscopy. This is best performed by the person who is going to
carry out the future definitive treatment. If no radiographic abnormality is