Dysphagia case 2

A 65-year-old man presents to his physician because he has been having increasing difficulty swallowing over the past 2 months. He is still able to swallow liquids, but swallowing solid food now causes severe pain and a sense of fullness behind his sternum. He has lost 18 pounds
since his swallowing difficulties began. The patient is referred to a gastroenterologist, who demonstrates a mass lesion of the distal esophagus, which on biopsy is shown to contain cancer.

Q1

Which of the following is most important in separating the esophagus from the larynx, and must consequently be carefully passed behind
during endoscopy?
/ A. Arytenoids
/ B. Cricoid cartilage
/ C. Epiglottis
/ D. Pharynx
/ E. Vocal cords

Q2
Which of the following nerves provides the efferent impulses necessary for the esophageal actions that occur during swallowing?
/ A. Glossopharyngeal
/ B. Hypoglossal
/ C. Spinal accessory
/ D. Trigeminal
/ E. Vagus

Q3
Which of the following approximately represents the proportion of different esophageal cancer types now being observed in the United States?
/ A. 1/10 adenocarcinoma and 9/10 squamous cell carcinoma
/ B. 1/3 adenocarcinoma and 2/3 squamous cell carcinoma
/ C. 1/2 adenocarcinoma and 1/2 squamous cell carcinoma
/ D. 2/3 adenocarcinoma and 1/3 squamous cell carcinoma
/ E. 9/10 adenocarcinoma and 1/10 squamous cell carcinoma

Q 4
Precancerous metaplasia of the esophageal epithelium gives rise to a mucosa resembling which of the following?
/ A. Mesothelium
/ B. Respiratory epithelium
/ C. Small intestine
/ D. Squamous epithelium
/ E. Stomach

Q5
Frequent use of which of the following has recently been found to probably have a protective effect against development of esophageal
cancer?
/ A. Acetaminophen
/ B. Alcohol
/ C. Aspirin
/ D. Cigarettes
/ E. Codeine

Q 6
Currently, esophageal cancer has which of the following long-term survival rates?
/ A. Less than 5%
/ B. 30%
/ C. 50%
/ D. 70%
/ E. More than 95%

____________________________________________________________________

Dysphagia case 2 answers
A1
The correct answer is C. Endoscopists are very careful when guiding the endoscope past the epiglottis, which is a pear-shaped portion of elastic cartilage that can be moved during swallowing to close the larynx, preventing swallowed material from eventually entering the lungs.
The arytenoids (choice A) are the site of the attachment of the vocal cords (choice E) within the larynx.
The cricoid cartilage (choice B) is in the more distal portion of the larynx.
The pharynx (choice D) is shared by the respiratory and gastrointestinal tracts.


A2
The correct answer is E. The vagus nerve supplies the efferent input into the esophagus that is necessary for swallowing.
The glossopharyngeal nerve (choice A) provides taste and sensation on the palate, but the only muscle it supplies is the stylopharyngeus.
The hypoglossal nerve (choice B) moves the tongue during the initiation of swallowing, but does not innervate the esophagus.
The spinal accessory nerve (choice C) plays no role in swallowing. This nerve mediates head and shoulder movement and innervates laryngeal muscles.
The trigeminal nerve (choice D) provides general sensation to the mouth and motor innervation to the muscles of mastication.

A3
The correct answer is C. More recent statistics indicate that the incidence of adenocarcinoma and squamous cell carcinoma of the esophagus are now roughly equal. Formerly, approximately 2/3 of the esophageal cancers were squamous in origin (choice B). Adenocarcinoma of the esophagus is often found in the distal esophagus.

A4
The correct answer is C. This is an indirect question about Barrett's esophagus, which is an important precursor of adenocarcinoma of the esophagus. While Barrett's esophagus was initially defined to be either gastric-type or intestinal-type metaplasia of the esophagus, more recent studies have shown that the actual problem lesion is more likely to be intestinal metaplasia (diagnosed when isolated goblet cells are seen in the epithelium) rather than gastric metaplasia (choice E).
Metaplasia to mesothelium (choice A) or ciliated respiratory epithelium (choice B) does not usually occur in the esophagus.
The normal epithelium of most of the esophagus is squamous (choice D).

A5
The correct answer is C. An interesting new research observation that may be exploited in the future is that the incidence of esophageal cancer appears to be much lower in people who use aspirin frequently.
Cigarettes (choice D) and alcohol use (choice B) have been implicated as risk factors for esophageal cancer.
Acetaminophen (choice A) and codeine (choice E) have no known effects on the incidence of esophageal cancer.

A6
The correct answer is A. Esophageal cancer is one of the very bad cancers, presently with poor long-term survival. The underlying problem is that the esophagus is only about 3 mm thick, and both metastatic disease and direct spread (often unresectable) to mediastinal structures is common. Active research is presently being undertaken to modify this prognosis by using chemotherapy and radiation therapy prior to surgery, but these modalities have not yet come into widespread use.