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Full text of "Diseases Of The Nose Throat And Ear"

226            THE LARYNX, BRONCHI AND OESOPHAGUS

Any site may be affected, but due to the nature of the above conditions it is
usually found in the middle or lower thirds of the oesophagus.

SYMPTOMS. The symptoms are a gradually increasing dysphagia with some
discomfort at the site of the stricture. On occasion the patient may present as
an acute emergency with total dysphagia due to a bolus of meat becoming
stuck in the stricture. If the condition is of long duration there will be weight
loss.

TREATMENT. In the non-malignant conditions, attempts should be made to
alleviate the condition by dilatation. The initial dilatations are done via
oesophagoscopy using Jackson bougies. Dilatations should be done until the
stricture becomes tight. On no account should the stricture be dilated until it
bleeds because this leads to more fibrous tissue formation. The dilatations are
done at weekly or fortnightly intervals until the maximum lumen is achieved.
At this point the patient should be taught to swallow a Hurst mercury bougie
before meals to maintain the dilatation. If this regime is unsuccessful the
stricture should be excised surgically and an end-to-end anastomosis
performed. This is easier if the stricture is in the lower third than in the middle
third where the results are unrewarding.

PATERSON-BROWN KELLY SYNDROME

AETIOLOGY. In the United States this is known as the Plummer-Vinson
syndrome and it consists of dysphagia, hypochromic microcytic anaemia,
angular stomatitis, glossitis and koilonychia. It is more common in females
than in males, and also more common on the West coast of Britain than the
East coast. The cause of the syndrome is unknown, but since there is an
atrophy of all the mucous membranes of the alimentary tract an auto-immune
basis must be presumed.

SYMPTOMS. The dysphagia may be very marked, but it is not usually severe.
The angular stomatitis, glossitis and koilonychia (Fig. 113) may be slight. The
characteristic blood picture is a low haemoglobin and a hypochromic
microcytic anaemia. All cases will have a low serum iron and a consequently
high iron-binding capacity. A small, but significant, proportion of patients
with this condition progress to the stage of postcricoid carcinoma. The
relationship is not close enough to label the Paterson-Brown Kelly syndrome
as a pre-malignant condition. A curious radiographic finding of unknown
cause is a web at the postcricoid region (Fig. 114). This can often be seen at
oesophagoscopy and may indeed be a firm diaphragm requiring dilatation,
but sometimes a well-marked radiological web may not be visualized at
oesophagoscopy.

TREATMENT. Iron should be given orally at first until the haemoglobin is
within normal limits. From then on, a check should be kept on the serum
iron and the iron-binding capacity. When the haemoglobin has been restored
to normal the serum iron will still be low and, due to absorption problems,
may stay low in spite of oral iron administration. While the serum iron is low,
dysphagia will continue, and so if oral iron fails to raise it to the normal level
then the patient will require to be given parenteral iron. A check on the course
of the disease during follow-up should always be by means of the serum ir
rather than the haemoglobin.