esophagus

 The esophagus starts at the lower border of the cricoids cartilage (at C6) to the cardiac orifice at (T11)
 Total length 20-25 cm
 Its diameter 20 mm & distends during swallowing into 30 mm
 In newborn diameter 5mm
 Esophageal course:
 follow the curvature of the spine posteriorly
 deviates to the left initially
 return to the midline in the posterior mediastinum.
 A second bend to the left occurs as the oesophagus crosses the descending thoracic aorta to pierce the diaphragm.
 It has 3 divisions:
1. Cervical division: same nerve supply as trachea (recurrent laryngeal nerve) (from cricopharyngeus-sternal notch)
2. Thoracic division: it is crossed by the left main bronchus (note bifurcation of the trachea is at T4-5)
3. Abdominal division: 1.25 cm long
 It has 3 layers:
1. Mucosal layer:
A. Epithelium: Stratified squamous epithelium lines the majority of the
esophagus, with only the distal 1 to 3 cm lined by columnar epithelium.
B. Lamina propria
C. Muscularis propria
2. Submucosal layer
3. Muscular layer:
a) Inner: circular
b) Outer: longtiduinal
 The upper 1/3 of muscles are striated
 The lower 2/3 of muscles are smooth
 It does not has serosa which leads to:
 Loss of important anatomic barrier to the spread of infection and neoplastic disease.
 It is more susceptible to perforations
 It has less structural integrity to aid in surgical repair or anastomoses.
 nerve supply of the esophagus:
 upper 1/3:
 striated muscle
 supplied by the recurrent laryngeal nerve
 lower 2/3:
 smooth muscle
 supplied by:
A. parasympathetic which their nucleus is
located in the vagus nerve
B. sympathetic chain
 relation of vagus to esophagus: left vagus is anterior to esophagus, right vagus is posterior to the esophagus
 meissner's plexus: submucosal layer
 auerbach's plexus: between the longitudinal & circular muscles
 blood supply:
 inferior thyroid vein into brachiocephalic trunk
 azygous into the IVC
 esophageal into coronary then into portal system
 In addition, the esophagus maintains a complete network of vessels within the wall, allowing for mobilization over a
long distance
It has 3 constrictions: (distance from incisior teeth)
A. Cricopharyngeal constrictions: 15 cm
B. Constriction where aortic arch & left main bronchus: 25cm
C. Gastroesophageal sphincter: 40cm
 cricopharyngeal sphincter:
 length of the sphincter: 1cm
 it has the greatest pressure during manometery
 narrowest part of the GIT and a common site for:
 food & F.B impaction
 Instrumental perforation
 lower esophygeal sphincter :
 Not histologically demonstrated
 No thickening of the circular muscular layer
 It is a physiological sphincter
 Mucosal folds at the lower end of the esophagus may form a valve
 The sling which is formed by the oblique muscles of the stomach encircling
the lower esophagus does not contributes to the sphincteric effect
The esophageal hiatus:
 Situated within the crura (striated muscles) while IVC goes through central tendon
 At the level of T10
 Transmits: vagal nerve; esophageal branches of the left gastric artery
 Resting pressure of the upper esophageal sphincter (cricopharyngeus resting
pressure) is: A-P: 100 mm Hg; laterally: 50mm Hg
 Resting pressure of the lower esophagus is : 40 mmHg
 Beta adrenergic blocker: increase lower esophageal pressure
 Pinch cock effect is produced by the right crus of the diaphragm
Upper esophageal sphincter
Killian’s dehiscence:
 Triangular dehiscence between the 2 parts of the inferior constrictor muscle
(thyropharyngeus & cricopharyngeus muscle)
 More on the left
 Note that:
 the cricopharyngeus is the most inferior part of the inferior constrictor
separated from it by killian’s dehiscence
 Through which Zenker’s diverticulum/pharyngeal pouch can form
 Risk of perforation during endoscopy
Zenker's diverticulum :
 Pulsion diverticulum: herniation of the pharyngeal mucosa through Killian's
dehiscence from the posterior part of the hypopharynx
 Cause:
 Normally the cricopharyngeus muscle must relax during contraction of pharynx
 if incoordinated contractions of inferior constrictor parts occur it will contract
instead of relaxing which will increase intrapharyngeal pressure that will cause
mucosal bulging through the structurally weak point Posteriorly
 cause failure of normal swallowing
 symptoms:
 dysphagia: early symptom
 dyspnea: late due to aspiration pneumonia
Killian jamieson space:
 Lateral dehiscence between the oblique & transverse fibers of the
cricopharyngeus
 Through which the branches of inferior thyroid artery & recurrent laryngeal
nerve enter
 The sphincter relaxes during swallowing
 It is actively dilated during swallowing by laryngeal elevation
laimer-haeckerman space:
Triangular space between the posterior cricopharyngeus & most superior circular esophaygeal muscle
Lateral Pharyngeocele: variable location above and lateral to the cricopharyngeus
tracheoesophageal fistula: the most common type is blind proximal pouch & fistula from the distal esophagus
 Swallowing
The idea behind swallowing:
 Swallowing involves the passage of a bolus of food or liquid from the oral cavity to the stomach via the pharynx and
oesophagus, passing over the entrance to the laryngeal vestibule
 The basic musculature of swallowing controls: Jaw, tongue, degree of constriction, length of the pharynx , closure of
the laryngeal inlet.
Note: airway protective mechanisms are activated in advance of those of passing the bolus
The central pattern generator for swallowing is located in the caudal nucleus of the solitary tract
Swallowing stages/phases:
1. oral phase:
1) preparatory phase: the food is taken into the mouth and broken down (occurs in the oral cavity)
2) oral proper phase: the bolus is moved into the back of the tongue (occurs in the oropharynx)
2. pharyngeal reflex phase (occurs in part of the oropharynx & the hypopharynx)
3. esophageal phase
Estimated transient time:
 transit from the mouth to the oropharynx takes 1-2 seconds
 the bolus to traverse the pharynx to the cricopharyngeal sphincter: less than 1 second
 esophageal transient time: 10-15 seconds
Oral phase: This phase is voluntary and involves: V (trigeminal), VII (facial), and XII (hypoglossal).
Moistening: by saliva from the salivary glands (parasympathetic). (VII: chorda tympani and IX: lesser petrosal)
Mastication: Food is mechanically broken down by the action of the teeth controlled by the muscles of mastication (Vc)
acting on the temporomandibular joint.
 This results in a bolus which is moved from one side of the oral cavity to the other by the tongue (glossopharyngeal).
 Buccinator (VII) helps to contain the food against the occlusal surfaces of the teeth.
 The bolus is ready for swallowing when it is held together by (largely mucus) sali va, sensed by the lingual nerve of the
tongue (Vc).
 Any food that is too dry to form a bolus will not be swallowed.
 Trough formation (a longitudinal concave fold at the back of the tongue) formed by the intrinsic muscles (XII) with
contribution from the contraction of the genioglossus and styloglossus (both XII) also contributes to the formation of
the central trough.
 The trough obliterates against the hard palate from front to back, forcing the bolus to the back of the tongue.
 The tongue is then elevated to the roof of the mouth by:
 mylohyoid (mylohyoid nerve Vc)
 genioglossus, styloglossus and hyoglossus (the rest XII))
 Such that the tongue slopes downwards posteriorly.
 Elevation of the hyoid bone reduces the size of oral cavity, this
ensures that elevation of the tongue from before backward
forces the food bolus Posteriorly into the pharynx.
Movement of the bolus posteriorly
 The food bolus is moved (by the muscles in the back of the
tongue) along the palate and into the esophagaeal passage.
 Mylohyoid (Vc) lifts the tongue and styloglossus (XII) pulls it
back.
 The palatoglossal arches are opened by relaxation of
palatoglossus (pharyngeal plexus IX, X).
 Once the bolus reaches the palatoglossal arch and the oropharynx, the pharyngeal phase, which is reflex and
involuntary, then begins.
 Receptors initiating this reflex are proprioceptive (afferent limb of reflex is IX and efferent limb is the pharyngeal
plexus- IX and X).
 These proprioceptive receptors are scattered over: base of the tongue, palatoglossal arches , palatopharyngeal arches,
tonsillar fossa, uvula, posterior pharyngeal wall.
 Stimuli from the receptors of this phase then provoke the pharyngeal phase.
 In fact, it has been shown that the swallowing reflex can be initiated entirely by peripheral stimulation of the internal
branch of the superior laryngeal nerve.
Note the most important neuromuscular events in the:
Preparatory oral phase: Lateral rolling motion of the tongue
Oral proper phase: Elevation of the tongue tip & blade toward the hard palate by the action of the intrinsic muscles &
genioglossus; Elevation of the soft palate to protect the nasaopharynx

Pharyngeal phase
 This phase is passively controlled reflexively and involves cranial nerves V, X (vagus), XI (accessory) and XII
(hypoglossal).
 The vagal nerve palsy main clinical effect is on the pharyngeal phase
 Lasting less than 1 sec
Sequence of events is initiated that ensures that the airways are protected during bolus transport:
1) diaphragmatic contraction is inhibited
2) soft palate is elevated to ensure a sphincteric closure of the nasopharynx
3) Vocal cords start to close to protect the airways.
As the bolus enters the oropharynx and touches key trigger points, a reflex is initiated in which:
1) constrictors relax to dilate the pharynx
2) Pharynx and larynx are raised by the longitudinal muscles.
The trigger point for the pharyngeal phase:
 contact of the food with the faucial arches or with the mucosa overlying the posterior pharynx in the region that is
innervated by the glossopharyngeal nerve
For the pharyngeal phase to work properly:
a) all other egress from the pharynx must be occluded this includes: the nasopharynx and the larynx.
b) other activities such as: chewing, breathing, coughing and vomiting are concomitantly inhibited.
Closure of the nasopharynx (velopharyngeal closure)
1- The soft palate:
a) tensed by tensor palati (Vc)
b) elevated by levator palati (pharyngeal plexus IX, X)
2- simultaneous approximation of the walls of the pharynx to the posterior free border of the soft palate by:
a) palatopharyngeus (pharyngeal plexus—IX, X)
b) Upper part of the superior constrictor (pharyngeal plexus—IX, X).
c) Passavan's bar assist closure of the nasopharynx:
o Some of the uppermost fibers of the superior constrictor and of the palatopharyngeus form a muscular
band which, during swallowing, raises a transverse ridge (Passavant's ridge) on the posterior pharyngeal
wall with accompanying elevation of the soft palate; it closes off the nasal part of the pharynx from the oral
part.
o It must be noted that the ridge only becomes evident during the act of swallowing; it is not seen in the
living pharynx at rest or in the cadaver.
So the velopharyngeal sphincter is made of: Tensor palate muscle, Levator palate, Palatopharyngeus, Upper part of the
superior constrictor, Muscularis uvulae
The pharynx prepares to receive the bolus
 The pharynx is pulled upwards and forwards to receive the bolus by:
1) suprahyoid
2) longitudinal pharyngeal muscles:
a) stylopharyngeus (IX)
b) salpingopharyngeus (pharyngeal plexus IX, X)
c) palatopharyngeus(pharyngeal plexus IX, X).
 The palatopharyngeal folds on each side of the pharynx are brought close together through the superior constrictor
muscles, so that only a small bolus can pass.
Closure of the oropharynx
The oropharynx is kept closed by:
1) palatoglossus (pharyngeal plexus: IX, X)
2) intrinsic muscles of tongue (XII)
3) styloglossus (XII).
Laryngeal closure
Laryngeal closure sphincters
1. laryngeal aditus (inlet):
a. adduction of the aryepiglottic folds
 b. retroversion of the epiglottis take place.
c. The aryepiglotticus muscle contraction
2. false vocal fold adduction
3. true Vocal cord adduction

Explanation:
Glottis closure reflex:
 Mediated by superior laryngeal nerve
 Reflex loop involves nucleus ambigus
 Result in closure of true vocal cord
 Excessive stimulation causes laryngospasm
True vocal cord adduction:
 The primary laryngopharyngeal protective mechanism to prevent aspiration during swallowing is true vocal fold
adduction
 The adduction of the vocal cords are effected by the contraction of the lateral cricoarytenoids and the oblique and
transverse arytenoids (recurrent laryngeal nerve of vagus).
 Since the true vocal folds adduct during the swallow, a finite period of apnea must necessarily take place with each
swallow. When relating swallowing to respiration, it has been demonstrated that swallowing occurs most often during
expiration.
 The clinical significance of this finding is that patients with a baseline of compromised lung function will, over a period
of time, develop respiratory distress as a meal progresses.
The aryepiglotticus muscle action:
 causing the arytenoids to appose each other so it closes the laryngeal aditus by bringing the aryepiglottic folds together
and drawing the epiglottis down to bring its lower half into contact with arytenoids, thus closing the aditus
 innervated by recurrent laryngeal nerve of vagus
Retroversion of the epiglottis:
 while not the 1 mechanism of protecting the airway from laryngeal penetration & aspiration, acts to anatomically direct
the food bolus laterally towards the piriform fossa.
Laryngeal elevation:
 note that laryngeal inlet closure is effected by the elevation of the larynx under the shelter of the tongue base & fixed
thyroid cartilage will allow aspiration
 The larynx is elevated 2cm with the pharynx under the tongue by:
 Longtidunal muscles of the pharynx:
1. stylopharyngeus (IX)
2. salpingopharyngeus (pharyngeal plexus IX, X)
3. palatopharyngeus (pharyngeal plexus IX, X)
 inferior constrictor (pharyngeal plexus IX, X).
 The respiratory centre of the medulla is directly inhibited by the swallowing centre for the very brief time that it takes
to swallow. This means that it is briefly impossible to breathe during this phase of swallowing and the moment where
breathing is prevented is known as deglutition apnea.
Hyoid elevation
 The hyoid is elevated superiorly anteriorly by: digastric (V & VII) and stylohyoid (VII)
 Lifting the pharynx and larynx up even further.
Bolus transits pharynx
 The bolus moves down towards the esophagus by pharyngeal peristalsis which takes place by sequential contraction of
the superior, middle and inferior pharyngeal constrictor muscles (pharyngeal plexus IX, X).
 The lower part of the inferior constrictor (cricopharyngeus) is normally closed and only opens for the advancing bolus.
 Gravity plays only a small part in the upright position—in fact, it is possible to swallow solid food even when standing
on one’s head. The bolus moves through the pharynx at a speed of (8 m/s).
Esophageal phase
 Esophageal peristalsis
 Like the pharyngeal phase of swallowing, the esophageal phase of swallowing is under involuntary neuromuscular
control. However, propagation of the food bolus is significantly slower than in the pharynx . The bolus enters the
esophagus and is propelled downwards first by striated muscle (recurrent laryngeal, X) then by the smooth muscle (X)
at a rate of 3 – 5 cm/sec.
Opening of the auditory tube
The actions of:
 levator palati (pharyngeal plexus IX, X)
 tensor palati (Vc)
 salpingopharyngeus (pharyngeal plexus IX, X)
in the closure of the nasopharynx and elevation of the pharynx opens the auditory tube, which equalises the pressure
between the nasopharynx and the middle ear. This does not contribute to swallowing, but happens as a consequence of it.

 Note:
 peristalitic wave starts in the top of the pharynx as the bolus enters the esophagus
 it travel caudally to:
1. clear food behind the bolus
2. produces contraction of the
cricopharyngeaus to prevent regurgitation
Note that 2 of swallowing stages are under voluntary
control:
1. Oral preparation
2. Oral phase
Relaxation phase
 Finally the larynx and pharynx move down with
the hyoid mostly by elastic recoil.
 Then the larynx and pharynx move down from
the hyoid to their relaxed positions by elastic
recoil

Physiology of swallowing

Nerves involved in swallowing

1. CN. V The Trigeminal Nerve
2. CN. VII The Facial Nerve
3. CN. IX The Glossopharygeal Nerve
4. CN. X The Vagus Nerve
5. CN. XI The Spinal Accessory Nerve
6. CN. XII The Hypoglossal Nerve
Valve Function for Deglutition
There are six valves that operate during swallow within the
upper digestive tract:
1) Lips
2) Tongue
3) glossopalatal valve
4) velopharynx (velum to posterior pharyngeal wall)
5) Larynx
6) upper esophageal (cricopharyngeal) sphincter
Operation valve

1) lips (orbicularis oris muscle):

 the first and most anterior valve
 Lip closure is maintained throughout the oropharyngeal stages of swallow.
 It permits:
a) mastication without loss of food from the mouth
b) the generation of pressure in the oral cavity to propel the bolus posteriorly during the oral stage of swallow
2) tongue:
 The edges of the tongue begin the oral stage by making anterior and lateral contact with the anterior and lateral
alveolar ridge.
 Vertical midline tongue-to-palate contact progresses anterior-posteriorly, propelling the bolus ahead of it toward
the pharynx
 The pressure of the tongue against the palate increases as bolus viscosity increases.
 All of this lingual control during oral preparation and the oral stage of swallow is thought to be under voluntary
cortical control
3) Glossopalatal valve:
 an operative valve while holding a bolus in the mouth before beginning the oral stage of swallow
 the soft palate is actively pulled down and forward by the palatoglossus muscle to contact the back of the tongue,
which is elevated slightly
 Closure of this posterior glossopharyngeal valve prevents premature loss of food or liquid into the pharynx and
widens the nasal airway to ensure easy nasal breathing during chewing and oral manipulation of food
4) velopharyngeal valve:
 closes during the pharyngeal phase
 prevent the entry of food or liquid into the nasal cavity
 may be accomplished using:
a. velar elevation (levator muscle) and retraction (palatopharyngeal muscle) alone or
b. In combination with anterior movement of the posterior pharyngeal wall (superior pharyngeal constrictor
Passavant pad) or mesial movement of the lateral pharyngeal walls (superior constrictor).
c. So the superior constrictor assists in lateral pharyngeal closure
d. The adenoid pad may also contribute to velopharyngeal closure.
passavant ridge: visible constriction of the superior end of the superior constrictor where the palatopharyngeal
muscle intergigitate
5) Larynx:
 All laryngeal sphincter (at 3 different levels) undergo reflex contraction during the pharyngeal phase to prevent the
entry of food or liquid into the airways
 1ST: true vocal folds close
 2nd: false vocal folds with anterior tilting of the arytenoids cartilage to contact the base of the epiglottis and
close the laryngeal entrance
 3rd: aryepiglottic fold sphincter: epiglottis is folded over the top of the airway biomechanically
 the epiglottis is folded to a horizontal position:
1. As the larynx and hyoid elevate
 2. Tongue base retraction brings the tip of the epiglottis backward and in contact with the posterior pharyngeal
wall and continues to squeeze the epiglottis down against the posterior pharyngeal wall, bringing the epiglottis
to its most inferior position.
3. As the bolus envelops the epiglottis, the downward pressure of the bolus contributes to this epiglot tal descent.
Note that the epiglottis per se is not essential in preventing aspiration & can be removed surgically without
complications

 As the bolus passes through the pharynx and the tongue base moves anteriorly toward its rest position, the
epiglottis elevates and moves anteriorly with the tongue base. When the tip of the epiglottis is no longer in contact
with the posterior pharyngeal wall, the elasticity in the cartilage causes it to spring back to its vertical position
within 0.03 to 0.06 second
Note:
 The false V.C Sphincter cannot be closed independently of the true vocal cords
 The laryngeal airflow ceases completely during swallowing
 Epiglottis backward tilting helps deflection of food into the pyriform fossa
6) The cricopharyngeal valve or upper esophageal sphincter (UES):
 musculoskeletal sphincter made of:
a. cricopharyngeal muscle
b. cricoid cartilage.
 Serves to prevent the entry of air into the esophagus during respiration.
 During swallow, the UES opens to allow bolus passage into the esophagus
 During the pharyngeal swallow, as the bolus head (leading edge) leaves the valleculae, the UES opens
 Opening of the UES is a complex event;
a. cricopharyngeal muscle relaxes:
 this muscle relaxation does not open the sphincter.
 It is considered to be an enabling event, allowing the larynx to move up and forward.
b. the UES is opened by anterior movement of the hyolaryngeal complex:
 Opening occurs as the larynx and hyoid move anteriorly and the cricoid lamina is jerked anteriorly away
from the posterior pharyngeal wall.
c. Bolus pressure:
 As the bolus passes through the sphincter, the pressure of the bolus increases the width of UES opening

Pharyngeal Pressure generator

pharynx is shortened by:
1. approximately 2 cm or
2. 1/3 of its total length during the pharyngeal swallow in younger adults
narrowing the pharyngeal diameter sequentially from top to bottom:
 The pharyngeal constrictors contract, moving the posterior pharyngeal wall anteriorly and the lateral pharyngeal walls
medially
bolus pressure:
 When the tail of the bolus reaches the valleculae, the tongue base retracts and the pharyngeal walls contract anteriorly,
applying pressure to the bolus in the pharynx.
 Tongue base retraction acts like a piston during the swallow, moving the bolus through a chamber (the pharynx) of
decreasing size and into the esophagus.
Clinical application:
 If the tongue base fails to retract sufficiently to make complete contact to the inward moving pharyngeal walls, residual
food or liquid will remain in the valleculae after the swallow.
 If there is a unilateral pharyngeal weakness, food will remain in the piriform sinus on the damaged side of the pharynx
after the swallow.
 If both sides of the pharynx fail to contract, food will be left on both sides of the pharynx in the piriform sinuses
Nerve stimulation during swallowing:
 The region stimulated by the bolus and tongue movement is innervated by the glossopharyngeal nerve, which sends
afferent input to the medullary swallow center.
 As the leading edge of the bolus reaches the pit of the valleculae and the oropharynx, sensory input is carried to the
medullary swallow center by the vagus nerve.
When the pharyngeal swallow triggers:
1. hyoid and larynx begin to elevate and move anteriorly: airway closes as the larynx achieves approximately 50% of
its elevation
2. pharynx shortens
3. velopharyngeal valve closes
 Airway closure and cricopharyngeal opening always occur within 0.03 second of each other unless the airway is closed
voluntarily at an earlier time.
 Thus, the airway is closed and protected as the esophagus is opened to receive the bolus that is being driven through
the pharynx under pressure.
 This entire sequence of pharyngeal events takes place in less than 1 second

Effects of Bolus Characteristics on the Oropharyngeal Swallow

Increase in Viscosity of the bolus increases the following:
1. Lingual palatal pressures
2. intrabolus pressures
3. oral transient time
4. pharyngeal transient time
5. Airway closure duration
6. cricopharyngeal opening duration
However, Airway closure duration & cricopharyngeal opening duration generally occur within 0.03 second of each other,
regardless of bolus volume
increase in the volume of the bolus increases the following:
1) oral transient time
2) pharyngeal transient time
3) change The temporal relationship of the oral and pharyngeal stages of swallow also changes:
 On swallows of small volumes (1 to 5 mL), the oral stage proceeds first, followed by the pharyngeal stage.
 On swallows of larger volumes (10 to 20 mL), the oral and pharyngeal stages occur essentially simultaneously.
 It has been hypothesized that afferent input from the oral cavity, particularly from the tongue as it manipulates
the food or liquid and shapes around it to initiate the oral stage of swallow, to the cortex and medullary
swallow center modulates these physiologic changes, because many of these systematic changes in the swallow
begin while the bolus is still in the oral cavity