Abstract
- The cervical esophagus extends from the cricopharyngeus muscle into the chest to become the thoracic esophagus.
- The external landmark of the pharyngoesophageal junction is the cricoid cartilage. On esophagoscopy, this is at 15 cm from the upper incisors.
- The esophagus lacks a serosal layer and consists of an outer longitudinal and inner circular muscle layer.
- The cervical esophagus is approximately 5–7 cm long and lies posterior to the cricoid cartilage and trachea and anterior to the longus colli muscles and vertebral bodies. It is flanked by the thyroid gland and carotid sheath on either side.
- Blood supply is primarily from the inferior thyroid artery, although significant collateral circulation exists.
- The recurrent laryngeal nerves lie on either side of the esophagus in the tracheoesophageal groove.
Surgical Anatomy
The cervical esophagus extends from the cricopharyngeus muscle into the chest to become the thoracic esophagus.
The external landmark of the pharyngoesophageal junction is the cricoid cartilage. On esophagoscopy, this is at 15 cm from the upper incisors.
The esophagus lacks a serosal layer and consists of an outer longitudinal and inner circular muscle layer.
The cervical esophagus is approximately 5–7 cm long and lies posterior to the cricoid cartilage and trachea and anterior to the longus colli muscles and vertebral bodies. It is flanked by the thyroid gland and carotid sheath on either side.
Blood supply is primarily from the inferior thyroid artery, although significant collateral circulation exists.
The recurrent laryngeal nerves lie on either side of the esophagus in the tracheoesophageal groove.
General Principles
Esophageal trauma often presents with other associated injuries including carotid, jugular, tracheal, and thyroid injury. As such, neck exploration for suspected injury of any of these structures must always include evaluation of the cervical esophagus.
Early clinical signs and symptoms of cervical esophageal injury include odynophagia, hematemesis, and subcutaneous emphysema. Late signs include fever, erythema, leukocytosis, swelling and/or abscess formation, and ultimately spreading of the infection along the precervical plane leading to mediastinitis.
Workup of a stable patient with potential esophageal injury includes a neck CT, gastrografin, followed by barium swallow study, and/or esophagoscopy.
Management of esophageal injuries hinges on early debridement and repair or, if delayed, drainage, broad-spectrum antibiotics, and nutritional support.
Special Instruments
In addition to a standard instrument tray for the neck exploration, a self-retaining Weitlaner or cerebellar retractor will be necessary.
If there is concern for thoracic extension of the esophageal injury, the surgeon should be prepared to perform a high right thoracotomy to expose the proximal thoracic esophagus.
A rigid and flexible endoscope should be available for intraoperative esophagoscopy, if necessary.
Patient Positioning
Provided cervical spine injury has been ruled out, the patient is positioned in a supine position with the head turned to the right. A bump is placed under the patient’s shoulder to allow gentle neck extension for improved exposure. When possible, the arms are tucked.
Incisions
Standard exposure of the cervical esophagus is through a left-sided oblique neck incision, running along the anterior border of the sternocleidomastoid muscle.
Depending on associated injuries, a collar incision, bilateral sternocleidomastoid incisions, a sternotomy, or a supraclavicular extension may be necessary.
Esophageal Exposure
An incision is made through the skin and dermis, and the platysma is divided.
The sternocleidomastoid muscle is retracted laterally to expose the sternohyoid, omohyoid, and underlying carotid sheath.
Division of the omohyoid muscle allows for exposure of the deep structures of the neck.
