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Spasmodic Stenosis Of The Esophagus

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Etiology - The functional activity of the esophagus is dependent upon

reflex action. The food is propulsed in a peristaltic wave by the same

mechanism as, and through an innervation (Auerbach and Meissner

plexus) similar to that which controls intestinal movements. The vagus

also is directly concerned with the deglutitory act, for swallowing is

impossible if both vagi are cut. Anything which unduly disturbs this

arc may serve as an exciting cause of spasmodic stenosis.

Bolting of food, superficial erosions, local esophageal disease, or a

small foreign body, may produce spasmodic stenosis. Spasm secondary to

disease of the stomach, liver, gall bladder, appendix, or other

abdominal organ is clinically well recognized. A perpetuating cause in

established cases is undoubtedly nerve cell habit, and in many cases

there is an underlying neurotic factor. Shock as an exciting cause has

been well exemplified by the number of cases of phrenospasm developing

in soldiers during the World War.

Cricopharyngeal spasmodic stenosis usually presents the subjective

symptom of difficulty in starting the bolus of food downward. Once

started, the food passes into the stomach unimpeded. Regurgitation, if

it occurs, is immediate. The condition consists in a tonic

contraction, ahead of the bolus, of the circular fibers of the

inferior constrictor known as the cricopharyngeus muscle, or in a

failure of this muscle to relax so as to allow the bolus to pass. In

either case the disorder may be secondary to an organic lesion. Local

malignant disease or foreign bodies may be the cause. Globus

hystericus, lump in the throat, and the sense of constriction and

choking during emotion are due to the same spasmodic condition.

Diagnosis - At esophagoscopy there will be found marked exaggeration

of the usual spasm which occurs at the cricopharyngeus during the

introduction of the tube. The lumen may assume various shapes, or be

so tightly closed that the folds form a mammilliform projection in the

center. If the spasm gradually yields, and a full-sized esophagoscope

passes without further resistance, it may be stated that the esophagus

is of normal calibre, and a diagnosis of spasmodic stenosis can be

made. Considerable experience is required to distinguish between

normal and pathologic spasm in an unanesthetized individual. To the

less experienced esophagoscopist, examination under ether anesthesia

is recommended. Deep anesthesia will relax the normal cricopharyngeal

reflex closure as well as any abnormal spasm, thus assisting in the

differentiation between an organic stricture and one of functional

character. Under deep general anesthesia, however, it is impossible to

differentiate between the normal reflex and a spasmodic condition,

since both are abolished. Many cases of intermittent esophageal

stenosis supposed to be spasmodic are due to organic narrowness of

lumen plus lodgement of food, obstructive in itself and in the

esophagitis resulting from its presence. The organic narrowing,

congenital or pathologic, is readily recognizable esophagoscopically.

Treatment.--The fundamental cause of the disturbance of the reflex

should be searched for, and treated according to its nature. Purely

functional cases are often cured by the passage of a large

esophagoscope. Recurrences may require similar treatment.