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DYSPHAGIA                                        231

visible it may be assumed that no caustic was swallowed, and the oral burns
will heal in time.

In cases where there is no doubt that the substance was swallowed there is
little to gain by passing an oesophagoscope merely to assess the extent of the
burn since the treatment will be unaltered and because there is a real risk of
perforating the oesophagus with the instrument. These cases should have a
nasogastric feeding tube passed. They should immediately be started on
60 mg prgdoisolpne per day for a week, the dose tapering off thereafter over a
further 3-4 weeks. This is given to _jprevent frhro*"^gr>/* subsequent strjdura
formatipa. Antibiotics should also be given systemically during this period,
a combination of penicillin G and streptomycin (Crystamycin) being the drug
of choice.

After 3 or 4 weeks an oesophagoscopy should be done to assess the presence
or absence of stricture formation. At this stage there is less danger of causing
a perforation. If a stricture has formed a programme of dilatation should be


Cancer of the oesophagus has a particularly gloomy prognosis and can occur
in the cervical oesophagus, the middle third and the lower third. While all
three may present to the otolaryngologist in the first instance, he will usually
only be involved in dealing with cancers of the cervical oesophagus. This is
not to be confused with postcricoid cancer, which is higher and forms part of
hypopharyngeal cancer, which is dealt with elsewhere (p. 234).

PATHOLOGY, Most of the tumours are squamous-cell cancers, but at the
lower end of the oesophagus there is a proportion of adenocarcinomata which
take origin from the gastric mucosa or glands. The tumours may be exophytic,
projecting into and filling the lumen of the oesophagus, or they may be

There is a large network of submucosal lymphatics and thus spread up and
down the oesophagus is common. It is typical to find islands of cancer with
apparently ulcerating areas in between—so-called *skip lesions'. Extension
may also occur through the wall of the oesophagus to involve the recurrent
laryngeal nerves, and even the trachea and bronchi with the formation of a
broncho-oesophageal fistula.

SYMPTOMS. Early symptoms are frequently indefinite, a vague discomfort
behind the sternum, a feeling of a 'lump' in the throat and food sticking on
occasion. Late symptoms are marked difficulty in swallowing firstly with solids
and later with fluids. There is loss of weight, dehydration and glandular
enlargement in the left supraclavicular region.


1.  Mirror Examination. In early cases all that may be noticed is some
pooling of saliva in the pyriform fossae. Later on there may be some oedema
of the postcricoid region or the arytenoids, or a vocal cord paralysis.

2.  General Examination. There will often by a node palpable in the left
supraclavicular region. In cancer of the lower end of the oesophagus it may be
possible to palpate an epigastric mass in some cases.

3. Radiological Examination. A barium swallow may reveal a stricture which
is constant and has a slight dilatation above it (Fig. 119). The usual filling