Professional Documents
Culture Documents
CH 46
CH 46
BRONCHOESOPHAGOLOGY
Jane Y. Yang, MD
Ellen S. Deutsch, MD
James S. Reilly, MD
BRONCHOLOGY
Bronchology combines the history and physical examination
with the knowledge of the pathologic possibilities and the
findings of the radiologic evaluation and the specular exami-
nation of the airway to provide the patient with an accurate
diagnosis and the best therapeutic option.
Tracheobronchial Conditions
Acute bronchiolitis, usually caused by respiratory syncytial
virus, occurs in children under 2 years of age. Inflammatory
airway obstruction has a greater impact on young children
with narrower airways. Bacterial tracheitis may cause life-
threatening sudden airway obstruction, particularly in chil-
dren less than 3 years of age. Thick, copious secretions
complicate mucosal swelling at the level of cricoid carti-
lage; Staphylococcus aureus is the most commonly isolated
pathogen.
Initial management of pneumonia includes appropriate
empiric antibiotic therapy based on the type of pneumonia
and the patient’s immunologic status. Bronchoscopy allows
directed aspiration of secretions for culture; bronchoalveolar
lavage and bronchoscopy-protected specimen brushing
can retrieve specimens adequate for quantitative analysis.
Bronchoscopy is indicated for lung abscesses unresponsive
to postural drainage and chest physiotherapy to rule out an
underlying carcinoma or foreign body, to obtain secretions
for culture, and to drain the abscess.
Bronchoesophagology 551
Malignant Neoplasms
Bronchogenic carcinoma is the most common malignancy in
the United States; approximately 87% of all cases of lung
cancer are attributable to long-term tobacco use. Bronch-
oscopy has emerged as an integral tool for the diagnosis and
staging of lung cancer. Bronchogenic carcinomas are divided
Bronchoesophagology 553
Radiologic Evaluation
Specialized radiographic examinations, such as barium swal-
low, computed tomography, and magnetic resonance imag-
ing or magnetic resonance angiography, may be useful to
define airflow dynamics, distal anatomy, or the relationship
between the airway and adjacent structures or masses.
Tracheobronchography, with superimposition of three-
dimensional anatomy, provides a unified view of the airway
rather than a planar slice image. Radiographic tracheo-
bronchial three-dimensional reconstruction and “virtual”
endoscopy are being developed. Radiographic procedures
can provide information about dynamic processes that is dif-
ficult to obtain by other methods but cannot provide tactile
information or tissue samples.
Anomalies of the great vessels can affect the trachea
and the esophagus. The anomalous innominate artery may
obliquely compress the anterior tracheal wall. In addition, three
typical patterns are demonstrated in patients with congenital
vascular anomalies. A large posterior esophageal indentation
554 Otorhinolaryngology
ESOPHAGOLOGY
Within the last few decades, improvements in lenses and illu-
mination have allowed esophagoscopes to evolve into pri-
mary diagnostic and therapeutic tools for managing many
esophageal disorders. Open-tube esophagoscopes are used to
examine and treat esophageal disease; flexible fiberoptic
upper gastrointestinal endoscopes also allow examination of
the stomach and duodenum.
Therapeutic Esophagoscopy
Esophageal strictures may occur in patients with a history of
caustic ingestion, Plummer-Vinson syndrome, Behçet’s syn-
drome, gastroesophageal reflux, and Crohn’s disease or as a
result of tracheoesophageal fistulae or malignancies or their
management. Rigid or fiberoptic esophagoscopes can be used
to visualize the esophageal lumen for direct dilatation or to
pass a guidewire or a stent.
Foreign bodies that become lodged in the esophagus
require surgical removal. Meat is the most common
esophageal foreign body found in adults, and coins are the
most common in children. Patients may be asymptomatic, or
they may have dysphagia or emesis or develop stridor, fever,
or a cough aggravated by eating. Lodgment occurs most
commonly just below the cricopharyngeus muscle and in the
thoracic esophagus at the compression of the esophagus by
the aortic arch or left bronchus or at a stricture.
Button batteries, sharp objects, and objects causing bleed-
ing, acute or severe airway compromise, or significant pain
or dysphagia should be removed emergently. Endoscopic
removal of foreign bodies allows evaluation of any esopha-
geal injury and visualization of multiple or radiolucent for-
eign bodies. Although some foreign bodies can be safely
removed using a fiberoptic esophagoscope, rigid esophago-
scopes with Hopkins rod telescopes remain the gold standard
for evaluation and removal of esophageal foreign bodies.
Complications of esophageal foreign bodies include edema,
esophageal laceration, erosion or perforation, hematoma,
granulation tissue, aortoesophageal or tracheoesophageal
fistula, mediastinitis, paraesophageal or retropharyngeal
abscess, migration of the foreign body into the fascial spaces
of the neck, arterial-esophageal fistulae with massive
hemorrhage, respiratory problems, strictures, and proximal
esophageal dilation; fatalities have been reported.
556 Otorhinolaryngology
Caustic Ingestion
Patients who ingest caustic substances are at risk of serious
esophageal injury, even in the absence of oropharyngeal burns.
Most ingestions occur in young children and are accidental;
ingestions in adolescents and adults are often suicide gestures
or attempts. Acid ingestion produces coagulative necrosis.
Alkaline products, which produce liquefactive necrosis,
account for the majority of ingestions and for the greatest
number of serious injuries. Most authors report that the pres-
ence or absence of symptoms is an unreliable predictor of
esophageal injury and advocate esophagoscopy to evaluate
the extent and severity of injury for virtually all patients with
caustic ingestions, to the upper limit of any full-thickness
burn. Esophagoscopy is contraindicated in the presence of a
severe burn with evidence of laryngeal edema and in patients
who have been on high doses of corticosteroids. Management
remains controversial and may include hospitalization, antibi-
otics, corticosteroids, analgesics, sedation, and antireflux ther-
apy. Observation and selective esophagoscopy are reasonable
for patients who ingest bleach or hair relaxers.
Esophageal Diseases
Achalasia is a motor disorder characterized by loss of peristal-
sis of esophageal smooth muscle and dysfunction of the lower
esophageal sphincter causing incomplete relaxation. The esoph-
agus eventually becomes dilated and retains food; at this point,
barium contrast may demonstrate esophageal dilatation, with a
smooth tapered bird-beak appearance of the lower esophageal
sphincter because of incomplete relaxation. Histologically, the
ganglion cells in Auerbach’s plexus are significantly reduced
in quantity or absent; esophageal cancer eventually develops in
2 to 8% of patients. Management options include dilation, sur-
gical myotomy, or injection of botulinum toxin.
Patients with amyloidosis often have neural or muscular
involvement, resulting in abnormal or absent peristalsis and
Bronchoesophagology 557
Benign Tumors
Benign esophageal tumors are less common than malignant
esophageal tumors. Squamous papillomas are the only benign
epithelial tumor. More than half of benign nonepithelial
Bronchoesophagology 559
Malignant Tumors
Squamous cell carcinoma is the most common malignant
esophageal tumor. Screening endoscopy should be performed
in patients with known risk factors such as alcohol and tobacco
abuse, achalasia, Plummer-Vinson syndrome, tylosis (palmar
and plantar keratoderma), chronic stricture from ingestion of
lye or corrosive substances, and celiac disease. Symptoms
include dysphagia, aspiration pneumonia, hoarseness, unilat-
eral neck mass, cough, fever, or a choking sensation. Endo-
scopically, polypoid, ulcerative, or infiltrating lesions are
usually found in the middle and lower third of the esophagus.
Adenocarcinoma is the second most common esophageal
epithelial malignancy, usually occuring in the distal esopha-
gus in association with Barrett’s metaplasia. Other malignant
epithelial tumors are rare and include variants of squamous
cell carcinoma such as spindle cell carcinoma, verrucous
carcinoma or pseudosarcoma, adenoid cystic carcinoma,
mucoepidermoid carcinoma, argyrophyl cell carcinoma, and
melanoma. Nonepithelial malignant esophageal tumors
include leiomyosarcoma, rhabdomyosarcoma, and fibrosar-
coma. Direct esophageal infiltration or compression may be
caused by thyroid, lung, or lymphatic malignancies.
Hematemesis
Esophageal varices, usually limited to the distal half of the
esophagus, develop as a result of portal hypertension. The
principal clinical manifistation of esophageal varices is bleed-
ing. Other causes of bleeding from the esophagus include the
Mallory-Weiss syndrome and the Boerhaave’s syndrome.
Mallory-Weiss tears develop in the gastric cardia and gas-
troesophageal junction after an episode of retching, vomit-
560 Otorhinolaryngology