More superiorly, in the root of the neck, the right vagus nerve gives off the right recurrent laryngeal nerve, which “hooks” around the right subclavian artery as it passes over the cervical pleura. If a patient has a hoarse voice and a right vocal cord palsy is demonstrated at laryngoscopy, chest radiography with an apical lordotic view should be obtained to assess for cancer in the right lung apex (Pancoast’s tumor).
In the clinic
When patients present with esophageal cancer, it is important to note which portion of the esophagus contains the tumor because tumor location determines the sites to which the disease will spread (Fig. 3.100).
Esophageal cancer spreads quickly to lymphatics, draining to lymph nodes in the neck and around the celiac artery. Endoscopy or barium swallow is used to assess the site. CT and MRI may be necessary to stage the disease.
Once the extent of the disease has been assessed, treatment can be planned.
In the clinic
The first case of esophageal rupture was described by Herman Boerhaave in 1724. This case was fatal, but early diagnosis has increased the survival rate up to 65%. If the disease is left untreated, mortality is 100%.
Typically, the rupture occurs in the lower third of the esophagus with a sudden rise in intraluminal esophageal pressure produced by vomiting secondary to an uncoordination and failure of the cricopharyngeus muscle to relax. Because the tears typically occur on the left, they are often associated with a large left pleural effusion that contains the gastric contents. In some patients, subcutaneous emphysema may be demonstrated.
Treatment is optimal with urgent surgical repair.
A 65-year-old man was admitted to the emergency room with severe central chest pain that radiated to the neck and predominantly to the left arm. He was overweight and a known heavy smoker.
On examination he appeared gray and sweaty. His blood pressure was 74/40 mm Hg (normal range 120/80 mm Hg). An electrocardiogram (ECG) was performed and demonstrated anterior myocardial infarction. An urgent echocardiograph demonstrated poor left ventricular function. The cardiac angiogram revealed an occluded vessel (Fig. 3.114A,B). Another approach to evaluating coronary arteries in patients is to perform maximum intensity projection (MIP) CT studies (Fig. 3.115A,B).
This patient underwent an emergency coronary artery bypass graft and made an excellent recovery. He has now lost weight, stopped smoking, and exercises regularly.
When cardiac cells die during a myocardial infarction, pain fibers (visceral afferents) are stimulated. These visceral sensory fibers follow the course of sympathetic fibers that innervate the heart and enter the spinal cord between the TI and TIV levels. At this level, somatic afferent nerves from spinal nerves T1 to T4 also enter the spinal cord via the posterior roots. Both types of afferents (visceral and somatic) synapse with interneurons, which then synapse with second neurons whose fibers pass across the cord and then ascend to the somatosensory areas of the brain that represent the T1 to T4 levels. The brain is unable to distinguish clearly between the visceral sensory distribution and the somatic sensory distribution and therefore the pain is interpreted as arising from the somatic regions rather than the visceral organ (i.e., the heart; Fig. 3.114C).
The patient was breathless because his left ventricular function was poor.
When the left ventricle fails, it produces two effects.
First, the contractile force is reduced. This reduces the pressure of the ejected blood and lowers the blood pressure.