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DR MANPREET SINGH NANDA
ASSOCIATE PROFESSOR ENT
MMMC&H SOLAN
U_tell_me_80@yahoo.co.in
 Etiology
 Iatrogenic – instrumental trauma during
oesophagoscopy/biopsy/dilatation
 Malignancy
 Penetrating injuries ...
 Hamman’s sign – Crunching sound over heart
because of air in mediastinum
 Diagnosis
 X Ray Chest/Neck – surgical emphy...
 Thoracic – surgical repair if within 6 hrs,
after 6 hrs – no repair possible
 Drainage of pleural cavity
 Complication...
 Etiology
 Accidental – children
 Suicidal/alcoholic/psychiatric – adults
 Acids/alkalies (more destructive,penetrate
...
 C/F
 Burns on lips, oral cavity, oropharynx
 Dysphagia/odynophagia
 Drooling of saliva
 Hoarseness/stridor
 Shock
...
 Treatment
 Immediate
 ICU/NBM/IV fluids
 RT feed/gastrostomy
 Wash and irrigate eyes and mouth with cold
water
 Ant...
 Delayed
 Oesophagoscopy within 2 days and repeat
every 2 weeks – to know site and extent.
Perforation
 Dilatation of s...
 Etiology – when muscular layer is damaged
 Trauma – FB/ injury
 Iatrogenic – surgery, RT, NG tube, pills
 Corrosive b...
 C/F
 Impaction of FB
 Dysphagia 1st with solids
 Pain
 Regurgitation/coughing
 Malnourished/anaemia
 Diagnosis – b...
 Treatment
 NBM
 Gastrostomy
 Oesophagoscopy and repeated endoscopic
dilatation with bougies under direct vision
 Che...
 Hypermotility disorders
 Cricopharyngeal spasm – failure of UES to
relax
 Diffuse oesophageal spasm – non peristaltic
...
 Hypomotility disorder with abnormal reflux
of gastric contents through oesophagus into
laryngopharynx causing laryngeal ...
 C/F
 Heart burn
 Regurgitation
 Dysphagia/odynophagia
 Angina like chest pain worsens after
sublingual nitroglycerin...
 Types
 Non erosive reflux – only symptoms, no signs
 Reflux oesophagitis- mucosal changes
 Barrett’s oesophagus
 Dia...
 Treatment
 Life style modifications
 Antacids – liquid
 Proton pump inhibitors – rabeprazole (80%)
 H2 receptor anta...
 Pre cancerous condition affecting distal
oesophagus due to change in its normal
stratified epithelium to intestinal colu...
 Pathology
 Absence of peristalsis in body of oesophagus
 High resting pressure in LES which dont relax
 Spasm of LES ...
 C/F
 Age gp 30-60 yrs, both sexes equal
 Dysphagia more for liquids than solids (as solids
pass due to weight)
 Regur...
 Diagnosis
 Barium swallow with fluoroscopy
 Smooth and regular narrowing of lower
oesophagus – rat tail appearance/ bi...
 Treatment
 Endoscopic pneumatic dilatation – tears LES
muscle hence reduces LES pressure. Can
cause perforation
 Modif...
 Rare
 Seen in younger age gp
 Leiomyomas – 66%. Treatment – external
surgical excision with thoracotomy. No
endoscopic...
 Common
 Types and etiology
 SCC (93%) – mostly involves upper and middle 1/3rd
of oesophagus
 Age 50-70 yrs
 Males
...
 Spread
 Direct – trachea, left bronchi, subglottis, RLN
 Lymphatic – supraclavicular LN
 Blood – lung, liver, bone, b...
 Diagnosis
 Barium swallow – irregular narrowing and
ulcerated edges. Rat tail appearance
 Oesophagoscopy with biopsy
...
 Patterson brown kelly syndrome
 Etiology
 Iron def/ vitamin def
 Autoimmune
 Atrophy of mm of alimentary tract in lo...
 Prognosis – can lead to ca buccal mucosa,
tongue, pharynx, oesophagus, stomach, post
cricoid region
 Diagnosis
 Haemog...
 Hypopharyngeal diverticulum/ upper
oesophageal diverticulum
 Etiology
 Age > 60 yrs
 Hypopharyngeal mucosa herniates ...
 Regurgitation of food
 Halitosis
 Voice change
 Gurgling sound on swallowing
 Loss of weight
 Aspiration pneumonia
...
 Treatment
 Excision of pouch (diverticulectomy)
 Cricopharyngeal myotomy (cervical
approach)
 Dohlman’s procedure – e...
 Displacement of stomach into chest through
diaphragm
 Age > 50 yrs
 Types
 Sliding (mc) 85% - reflux oesophagitis, he...
 Diagnosis
 Barium swallow
 X Ray Chest – gas shadow behind heart
 Treatment
 Conservative – reduce reflux
 Surgical...
 Larynx, trachea, bronchi
 Large (supraglottis), small (trachea/bronchi),
sharp (any site)
 Predisposing factors
 Age ...
 Nature of F B
 Non vegetative – plastic, glass, metals. Can
remain asymptomatic, non irritating,
granuloma formation
 ...
 C/F
 Inhalation phase – choking 1st symptom, dry
cough, sudden dyspnoea, wheezing (U/L, B/L),
cyanosis, fever, stridor,...
 Bronchial FB – right mc (shorter, wider,
vertical)
 Total obstruction – atelectasis (collapse)
 Partial obstruction – ...
 Diagnosis
 X Ray Neck AP and lateral – radio opaque FB
 X Ray Chest PA and lateral at end of
inspiration and expiratio...
 Hemlich’s maneuver
 Indication – large FB completely completely
obstruction the larynx with total aphonia and
asphyxia
...
 Pharynx
 Tonsil, base of tongue, vallecula, pyriform fossa
 Tonsil – fish bone, needle – tongue depressor and
forceps....
 Risk factors
 Children – tendency to put
 Oesophageal strictures, carcinoma
 Psychosis
 Loss of consciousness – seiz...
 Diagnosis
 X Ray Neck AP and Lateral – radio opaque
 Radiolucent – prevertebral widening,
displacement of trachea
 X ...
 Treatment
 Oesophagoscopy and removal under GA
 Cervical oesophagotomy – impacted FB
 Trans thoracic oesophagotomy
 ...
 Rigid/flexible
 RIGID BRONCHOSCOPY
 Indications
 Diagnostic
 Symptoms like wheeze, dyspnoea, chronic
cough, unexplai...
 Therapeutic
 FB removal
 Suction clearance of secretions, mucus plug in
head injury, chest trauma, major thoracic or
a...
 Bronchoscope
 Chevalier Jackson – distal illumination
 Openings (vents) at distal end for aeration
 Size as per age –...
 Anaesthesia
 GA using ventilatory part of bronchoscope
 Jet ventilation (using jet instrument for ventilation
called v...
 Steps
 Lubricate the scope
 Protect teeth , lips
 Hold in right hand, introduce through right side
of tongue, move to...
 Post op care
 IV antibiotics and steroids
 NBM till out of anaesthesia
 Coma position to prevent aspiration
 If resp...
 Flexible fibre optic bronchoscopy
 Advantages
 Better magnification and illumination
 Documentation
 Small size – su...
 RIGID OESOPHAGOSCOPY
 Indications
 Diagnostic
 Dysphagia, odynophagia, regurgitation
 FB throat
 Oesaphageal disord...
 C/I
 Coagulopathy/bleeding disorder
 Perforation of oesophagus/acute burns
 Cervical spine/mandible lesions/severe tr...
 Oesophagoscope
 Chevalier Jackson – distal illumination
 Negus – oblique light
 The handle at proximal end indicate
d...
 Anaesthesia – GA
 Position – Boyce’s position- head extended at atlanto
occipital joint, neck flexed on chest
 Once cr...
 Post op care
 Look for features of oesophageal perforation – pain in
intrascapular region, surgical emphysema, high fev...
 Advantages
 OPD procedure
 LA – spray/SLN block
 Less morbidity
 Can be done in jaw, spine disorders
 Can examine s...
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Diseases of oesophagus Slide 1 Diseases of oesophagus Slide 2 Diseases of oesophagus Slide 3 Diseases of oesophagus Slide 4 Diseases of oesophagus Slide 5 Diseases of oesophagus Slide 6 Diseases of oesophagus Slide 7 Diseases of oesophagus Slide 8 Diseases of oesophagus Slide 9 Diseases of oesophagus Slide 10 Diseases of oesophagus Slide 11 Diseases of oesophagus Slide 12 Diseases of oesophagus Slide 13 Diseases of oesophagus Slide 14 Diseases of oesophagus Slide 15 Diseases of oesophagus Slide 16 Diseases of oesophagus Slide 17 Diseases of oesophagus Slide 18 Diseases of oesophagus Slide 19 Diseases of oesophagus Slide 20 Diseases of oesophagus Slide 21 Diseases of oesophagus Slide 22 Diseases of oesophagus Slide 23 Diseases of oesophagus Slide 24 Diseases of oesophagus Slide 25 Diseases of oesophagus Slide 26 Diseases of oesophagus Slide 27 Diseases of oesophagus Slide 28 Diseases of oesophagus Slide 29 Diseases of oesophagus Slide 30 Diseases of oesophagus Slide 31 Diseases of oesophagus Slide 32 Diseases of oesophagus Slide 33 Diseases of oesophagus Slide 34 Diseases of oesophagus Slide 35 Diseases of oesophagus Slide 36 Diseases of oesophagus Slide 37 Diseases of oesophagus Slide 38 Diseases of oesophagus Slide 39 Diseases of oesophagus Slide 40 Diseases of oesophagus Slide 41 Diseases of oesophagus Slide 42 Diseases of oesophagus Slide 43 Diseases of oesophagus Slide 44 Diseases of oesophagus Slide 45 Diseases of oesophagus Slide 46 Diseases of oesophagus Slide 47 Diseases of oesophagus Slide 48 Diseases of oesophagus Slide 49 Diseases of oesophagus Slide 50 Diseases of oesophagus Slide 51 Diseases of oesophagus Slide 52 Diseases of oesophagus Slide 53 Diseases of oesophagus Slide 54 Diseases of oesophagus Slide 55
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Diseases of oesophagus

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Diseases of oesophagus

  1. 1. DR MANPREET SINGH NANDA ASSOCIATE PROFESSOR ENT MMMC&H SOLAN U_tell_me_80@yahoo.co.in
  2. 2.  Etiology  Iatrogenic – instrumental trauma during oesophagoscopy/biopsy/dilatation  Malignancy  Penetrating injuries – pointed FB, cut throat, gun shot  Spontaneous rupture – mostly lower 1/3rd during vomiting. Boerhave’s syndrome – all layers  C/F  Cervical oesophagus rupture – pain in neck, supraclavicular region, dysphagia, odynophagia, emphysema, fever  Thoracic oesophagus rupture – more dangerous. Retrosternal pain,chest pain, high fever, shock , emphysema
  3. 3.  Hamman’s sign – Crunching sound over heart because of air in mediastinum  Diagnosis  X Ray Chest/Neck – surgical emphysema/ widening of mediastinum/ pneumothorax/ gas under diaphragm/ pleural effusion  Barium swallow – 3-4 days laterto localise  Treatment  NBM  RT feed/ gastrostomy  IV antibiotics  Cervical – conservative, drainage if suppuration
  4. 4.  Thoracic – surgical repair if within 6 hrs, after 6 hrs – no repair possible  Drainage of pleural cavity  Complication  Death due to mediastinitis/septicaemia  If treatment delayed more than 24 hrs - > 50% mortality due to mediastinitis
  5. 5.  Etiology  Accidental – children  Suicidal/alcoholic/psychiatric – adults  Acids/alkalies (more destructive,penetrate deep)  Severity depends on nature, amount, concentration and duration  Stages – acute necrosis -> granulations -> strictures
  6. 6.  C/F  Burns on lips, oral cavity, oropharynx  Dysphagia/odynophagia  Drooling of saliva  Hoarseness/stridor  Shock  Mediastinitis  Diagnosis  X Ray chest/neck  Barium /oesophagoscopy (not immediate but 2 days)
  7. 7.  Treatment  Immediate  ICU/NBM/IV fluids  RT feed/gastrostomy  Wash and irrigate eyes and mouth with cold water  Antibiotics/steroids/analgesics – parentral  Tracheostomy if stridor  Only for mild burns – neutralize with weak acid or alkali (within 6 hrs)
  8. 8.  Delayed  Oesophagoscopy within 2 days and repeat every 2 weeks – to know site and extent. Perforation  Dilatation of strictures  Oesophageal reconstruction
  9. 9.  Etiology – when muscular layer is damaged  Trauma – FB/ injury  Iatrogenic – surgery, RT, NG tube, pills  Corrosive burns  Infections  Ulcers – reflux, diptheria, typhoid  Drugs – anti diuretic, anti arthritic  Congenital – lower 1/3rd
  10. 10.  C/F  Impaction of FB  Dysphagia 1st with solids  Pain  Regurgitation/coughing  Malnourished/anaemia  Diagnosis – barium swallow/ oesophagoscopy / Chest X Ray
  11. 11.  Treatment  NBM  Gastrostomy  Oesophagoscopy and repeated endoscopic dilatation with bougies under direct vision  Chevalier Jackson bougies  Balloon dilatation/wire guided rigid dilatation  Excision and reconstruction – excise the stricture segment and reconstruct with stomach/colon/jejunum
  12. 12.  Hypermotility disorders  Cricopharyngeal spasm – failure of UES to relax  Diffuse oesophageal spasm – non peristaltic contractions of oesophagus due to degeneration of nerve process.  Barium swallow – rosary bead or cork screw type of appearance  Nut cracker oesophagus – peristaltic contractions of oesophagus
  13. 13.  Hypomotility disorder with abnormal reflux of gastric contents through oesophagus into laryngopharynx causing laryngeal and pharyngeal symptoms  Mc cause of laryngitis, non productive cough and non cardiac chest pain  Etiology  Inappropriate functioning of LES (low tone)  Tobacco/alcohol/fatty food/chocolates/drugs  Pregnancy  Hiatus hernia/ post nasal drip/ psychological
  14. 14.  C/F  Heart burn  Regurgitation  Dysphagia/odynophagia  Angina like chest pain worsens after sublingual nitroglycerine  Extra oesophageal reflux symptoms – FB sensation throat, hoarseness of voice, dental erosion, throat clearing  Signs – post laryngitis – congested arytenoids, interarytenoids, nasal congestion
  15. 15.  Types  Non erosive reflux – only symptoms, no signs  Reflux oesophagitis- mucosal changes  Barrett’s oesophagus  Diagnosis  Clinical  Oesophagoscopy/laryngoscopy  24 hrs double ph monitoring of pharynx and oesophagus  Barium swallow  Chest X Ray
  16. 16.  Treatment  Life style modifications  Antacids – liquid  Proton pump inhibitors – rabeprazole (80%)  H2 receptor antagonists - ranitidine (50%)- healing  Pro kinetic drugs – domperidone (increase clearance)  Surgery – nissen’s fundoplication  Complications – oesophagitis, laryngitis, OME, aspiration pneumonia, carcinoma
  17. 17.  Pre cancerous condition affecting distal oesophagus due to change in its normal stratified epithelium to intestinal columnar epithelium  Can lead to adenocarcinoma (if > 8 cm long)  Seen in GERD due to severe inflammation  Smokers  Diagnosis – barium swallow/oesophagoscopy  Treatment – anti reflux/ regular endoscopy to detect adenocarcinoma early
  18. 18.  Pathology  Absence of peristalsis in body of oesophagus  High resting pressure in LES which dont relax  Spasm of LES leading to retention of food  Etiology  Hereditary  Infective – chagas disease due to trypanosomiasis (cardiomegaly, megacolon, achalasia)  Auto immune  Degeneration of auerbach’s plexus
  19. 19.  C/F  Age gp 30-60 yrs, both sexes equal  Dysphagia more for liquids than solids (as solids pass due to weight)  Regurgitation  Chest pain / retrosternal or epigastric fullness  Weight loss  IDL – pooling of saliva  Complications – nutritional deficiency/ pulmonary complications/ oesophageal malignancy
  20. 20.  Diagnosis  Barium swallow with fluoroscopy  Smooth and regular narrowing of lower oesophagus – rat tail appearance/ bird beak appearance/ pencil tip appearance  Loss of peristalsis in distal oesophagus  Dilated oesophagus  Manometry  Low pressure at body of oesophagus, high pressure at LES  Flexible endoscopy
  21. 21.  Treatment  Endoscopic pneumatic dilatation – tears LES muscle hence reduces LES pressure. Can cause perforation  Modified Heller’s operation – incision of circular muscle fibres of lower oesophagus  Inj botulinum toxin in LES  Calcium channel blockers – relax smooth muscles.  Nitrates
  22. 22.  Rare  Seen in younger age gp  Leiomyomas – 66%. Treatment – external surgical excision with thoracotomy. No endoscopic removal as can cause perforation...  Lipomas/fibromas/haemangiomas  Mucosal polyps/cysts
  23. 23.  Common  Types and etiology  SCC (93%) – mostly involves upper and middle 1/3rd of oesophagus  Age 50-70 yrs  Males  Smoking/alcohol/paan/supari  Hot and spicy food  Oesophageal conditions – strictures, corrosive injury, cardiac achalasia  Premalignant – plummer vinson syndrome (females), HPV  Adenocarcinoma – lower 1/3rd – gerd/barrett’s oesophagus
  24. 24.  Spread  Direct – trachea, left bronchi, subglottis, RLN  Lymphatic – supraclavicular LN  Blood – lung, liver, bone, brain  C/F  Retrosternal discomfort  Gradually progressive dysphagia for solids first then liquids  Odynophagia  Iron def anaemia  Loss of weight  IDL – pooling of saliva (ca upper 1/3rd ), paramedian vc (RLN)
  25. 25.  Diagnosis  Barium swallow – irregular narrowing and ulcerated edges. Rat tail appearance  Oesophagoscopy with biopsy  CT Scan  Chest X Ray  Treatment – poor prognosis as late presentation  SCC – RT / if early in upper 1/3rd – total laryngo pharyngo oesophagectomy with gastric pull up  Adeno – surgery – oesophagogastrectomy with reconstruction (radioresistant)  Late stage – palliative – pain killers/gastrostomy
  26. 26.  Patterson brown kelly syndrome  Etiology  Iron def/ vitamin def  Autoimmune  Atrophy of mm of alimentary tract in lowest part of laryngopharynx  C/F  Gradually progressive dysphagia first for solids  Microcytic hypochromic anaemia  Angular stomatitis/ glossitis  Koilonychia (spooning of nails)  Web formation in cricopharynx/ splenomegaly
  27. 27.  Prognosis – can lead to ca buccal mucosa, tongue, pharynx, oesophagus, stomach, post cricoid region  Diagnosis  Haemogram  Barium swallow  Oesophagoscopy – web formation in post cricoid region  Treatment  Oral/parentral iron  Vit B6, B12  Oesophageal dilatation of web with bougies........
  28. 28.  Hypopharyngeal diverticulum/ upper oesophageal diverticulum  Etiology  Age > 60 yrs  Hypopharyngeal mucosa herniates through killian’s dehiscence (weak area between thyropharyngeus and cricopharyngeus)  Sac formed has mouth wider than oesophageal opening so food gets collected in it  C/F  Dysphagia – increases after few swallows as pouch filled with food
  29. 29.  Regurgitation of food  Halitosis  Voice change  Gurgling sound on swallowing  Loss of weight  Aspiration pneumonia  O/E  Swelling on left side of ant triangle of neck which is soft and gurgles on palpation (Boyce’s sign)  IDL – pooling of saliva  Diagnosis – Barium swallow.  Oesophagoscopy C/I as risk of perforation
  30. 30.  Treatment  Excision of pouch (diverticulectomy)  Cricopharyngeal myotomy (cervical approach)  Dohlman’s procedure – endoscopic diathermy to divide partition wall between oesophagus and pouch  Endoscopic laser treatment with CO2 laser using operating microscope to divide partition wall between oesophagus and pouch
  31. 31.  Displacement of stomach into chest through diaphragm  Age > 50 yrs  Types  Sliding (mc) 85% - reflux oesophagitis, heart burn – in line of oesophagus  Paraoesophageal 5% - no reflux, external dyspnoea – by side of oesophagus  Mixed 10%
  32. 32.  Diagnosis  Barium swallow  X Ray Chest – gas shadow behind heart  Treatment  Conservative – reduce reflux  Surgical – reduction of hernia and repair of diaphragmatic opening
  33. 33.  Larynx, trachea, bronchi  Large (supraglottis), small (trachea/bronchi), sharp (any site)  Predisposing factors  Age – 1-4 yrs, tendency to put, accidental  Unconsciousness – alcohol, anaesthesia, head injury  During swallowing – coughing, laughing, tapping on back  IX, X CN – larynx and pharynx paralysis  Psychiatric
  34. 34.  Nature of F B  Non vegetative – plastic, glass, metals. Can remain asymptomatic, non irritating, granuloma formation  Vegetative – peanuts, beans, seeds. Reactive cause congestion and oedema, can swell up causing airway obstruction, short latent period, cause chemical irritation and infection
  35. 35.  C/F  Inhalation phase – choking 1st symptom, dry cough, sudden dyspnoea, wheezing (U/L, B/L), cyanosis, fever, stridor, tachycardia, tachypnoea  Latent – symptom free interval (adaptation)  Manifestation  Laryngeal FB – if large fatal, change in voice, croupy cough, inspiratory stridor, aphonia, dyspnoea  Tracheal FB – sharp – cough and hemoptysis, small can move up and down – audible click, biphasic stridor
  36. 36.  Bronchial FB – right mc (shorter, wider, vertical)  Total obstruction – atelectasis (collapse)  Partial obstruction – check valve – obstructive emphysema  Small – wheeze  Complications – bronchiectasis, lung abscess, empyema, pneumothorax  D/D – acute LTB, pulmonary TB, pneumonia, bronchiectasis, lung abscess
  37. 37.  Diagnosis  X Ray Neck AP and lateral – radio opaque FB  X Ray Chest PA and lateral at end of inspiration and expiration – radiolucent FB  CT Scan  Fluoroscopy/ videofluoroscopy  Laryngoscopy and bronchoscopy  Treatment  IV antibiotics/steroids/oxygen  Laryngeal FB – DL Scopy/laryngofissure  Tracheostomy/cricothyrotomy
  38. 38.  Hemlich’s maneuver  Indication – large FB completely completely obstruction the larynx with total aphonia and asphyxia  C/I – partial obstruction  Method  Stand behind the standing patient – place arms around his lower chest – give 4 sudden upward and backward thurst below the epigastric region – squeezing of lungs occurs so residual air can dislodge the FB  Bronchoscopy – rigid/flexible  Thoracotomy/bronchotomy  Lobectomy/pneumonectomy – old impacted FB
  39. 39.  Pharynx  Tonsil, base of tongue, vallecula, pyriform fossa  Tonsil – fish bone, needle – tongue depressor and forceps........  Base of tongue/vallecula – fish bone, needle – IDL  Pyriform fossa – fish bone, needle, dentures, meat bone – rigid endoscopy  Oesophagus – coin (mc), meat bone (adults), dentures, safety pin , battery (tissue necrosis)  Sites – cricopharyngeal sphincter (mc), broncho aortic constriction and lower sphincter
  40. 40.  Risk factors  Children – tendency to put  Oesophageal strictures, carcinoma  Psychosis  Loss of consciousness – seizures, alcohol, deep sleep  C/F  Choking/gagging at time of ingestion  Pain/discomfort  Dysphagia/odynophagia  Drooling of saliva  Resp distress/hoarseness/stridor – if compresses trachea  IDL – pooling of saliva  Laryngeal crepitus absent
  41. 41.  Diagnosis  X Ray Neck AP and Lateral – radio opaque  Radiolucent – prevertebral widening, displacement of trachea  X Ray Chest lateral and PA view  X Ray Neck to pelvis – children to rule out multiple FB  Barium study – full study can disfigure the oesophagus. So a small cotton pledget soaked in barium can be swallowed and it get stuck at FB – for radiolucent FB
  42. 42.  Treatment  Oesophagoscopy and removal under GA  Cervical oesophagotomy – impacted FB  Trans thoracic oesophagotomy  Thoractomy/external approach  IV antibiotics  Stomach – passes with stools so watch, normal diet, no purgatives. Operate if pain and tenderness in abdomen, no progress, if FB > 5 cm in a child < 2 yrs age  Complication – resp obstruction/oesophageal perforation, stenosis, strictures/TOF/ cellulitis and abscess in neck/perforation of aorta
  43. 43.  Rigid/flexible  RIGID BRONCHOSCOPY  Indications  Diagnostic  Symptoms like wheeze, dyspnoea, chronic cough, unexplained hoarseness of voice, pulmonary infection > 4 weeks  Abnormal radiological findings – atelectasia, empysema, opacity, pneumonia  Vc paralysis  Collection of bronchial secretions  Malignancy/ tuberculosis  Difficult intubation
  44. 44.  Therapeutic  FB removal  Suction clearance of secretions, mucus plug in head injury, chest trauma, major thoracic or abdominal surgery, coma  Removal of benign neoplasm  Drainage of lung abscess  Excision of strictures  Dilatation of bronchial stenosis  C/I  Trismus/cervical spine lesions/ aortic aneurysm/ unstable angina, recent MI/ coagulopathy, bleeding disorders/recent URTI in children (oedema)
  45. 45.  Bronchoscope  Chevalier Jackson – distal illumination  Openings (vents) at distal end for aeration  Size as per age – length adults 40 cm, children 30 cm, infants 25 cm
  46. 46.  Anaesthesia  GA using ventilatory part of bronchoscope  Jet ventilation (using jet instrument for ventilation called venturi)  Procedure not longer than 20 min to prevent subglottic oedema mainly in children  Position  Boyce’s position – neck flexed on thorax, head extended at atlanto occipital joint  Technique  Direct  Through laryngoscope – infants and children, short neck, thick tongue  Select proper size scope, no force
  47. 47.  Steps  Lubricate the scope  Protect teeth , lips  Hold in right hand, introduce through right side of tongue, move to midline to view epiglottis  Lift the base of tongue to identify tip of epiglottis  Lift the epiglottis to enter glottis  Rotate the scope 90 degree to bring its tip in axis of glottis and enter trachea  Rotate the scope back to its position......  For examining bronchi turn the head to opposite side
  48. 48.  Post op care  IV antibiotics and steroids  NBM till out of anaesthesia  Coma position to prevent aspiration  If resp distress, cyanosis due to laryngeal spasm – may need tracheostomy  Complications  Injury to teeth, lips  Bleeding – use topical adrenaline  Laryngeal spasm/oedema – steroids/oxygen  Bronchospasm – steroids  Pneumothorax  Hypoxemia - oxygen
  49. 49.  Flexible fibre optic bronchoscopy  Advantages  Better magnification and illumination  Documentation  Small size – sub segmental bronnchioles  Topical anaesthesia  Can be done in neck or jaw lesions  Can be passed through ET/tracheostomy tube  Bed side  Can take biopsy of upper lobe  Disadvantage – limited use in children because of problem of ventilation
  50. 50.  RIGID OESOPHAGOSCOPY  Indications  Diagnostic  Dysphagia, odynophagia, regurgitation  FB throat  Oesaphageal disorders  Haematemesis  Metastatic neck node  As part of panendoscopy  Therapeutic  Removal of foreign body  Removal of benign neoplasm/ treatment of diverticulum  Dilatation of oesophagus – stricture, webs, stenosis  TEP after total laryngectomy  Injection sclerosing agent for oesophageal varices
  51. 51.  C/I  Coagulopathy/bleeding disorder  Perforation of oesophagus/acute burns  Cervical spine/mandible lesions/severe trismus  Aneurysm of aorta  Advance heart, kidney, liver disease  Pre op  BT, CT  Stop NSAID – 2 to 5 days before  Stop aspirin – 7 to 10 days before  NBM 6-8 hours  Barium swallow  Antibiotic
  52. 52.  Oesophagoscope  Chevalier Jackson – distal illumination  Negus – oblique light  The handle at proximal end indicate direction of bevel at distal end
  53. 53.  Anaesthesia – GA  Position – Boyce’s position- head extended at atlanto occipital joint, neck flexed on chest  Once cricopharyngeal sphincter reached all extended  Technique  Lubricate – protect lips and teeth – hold in right hand and introduce through right side of tongue- identify epiglottis and arytenoids  Lift the scope with left thumb to open hypopharynx  Slow gentle pressure on tip at cricopharyngeal sphincter opening. If sphincter dont open give a muscle relaxant or 4% lignocaine drops through scope  Guide the scope into oesophagus. Now hands switched over and hold with left hand  Advance to see cardiac end . extension  Inspect the oesophagus while withdrawing
  54. 54.  Post op care  Look for features of oesophageal perforation – pain in intrascapular region, surgical emphysema, high fever  Complications  Injury to lips, teeth, pharynx  Oesophageal perforation – cricopharyngeal sphincter  Injury to arytenoids  Bleeding  Rupture of aortic aneurysm  Injury to cervical vertebra  Compression of trachea in children leading to resp obstruction – immediately withdraw the scope
  55. 55.  Advantages  OPD procedure  LA – spray/SLN block  Less morbidity  Can be done in jaw, spine disorders  Can examine stomach and duodenum  Good illumination and magnification  Disadvantages  Limited removal of FB  Cant examine laryngopharynx  Need voluntary swallowing to advance scope  Procedure  Air or water insufflation is done to open the lumen of oesophagus
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A LECTURE ON DISEASES OF OESOPHAGUS FOR MBBS STUDENTS

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