Case02

A 5 year old patient is brought into your clinic complaining of a sore throat with pain and difficulty when swallowing. Their parent describes that the child accidentally swallowed a small lego that was later expelled after vomiting one day ago. A CT scan with oral barium contrast which shows extraluminal (i.e. outside the lumen of the esophagus) collection of contrast posterior to the esophagus against the vertebral body of T6 to T7.

Question 3/3 - What nervous structure(s) in this region are at risk of irritation?

Correct! The esophageal plexus is a set of nerves around the esophagus and in close proximity to the deduced perforation. Thus, with leakage of food or vomit from the perforation these nerve might become irritated or inflamed.

Correct! The posterior vagal trunk runs along the posterior side of the esophagus (the right vagus branches out posteriorly as part of the esophageal plexus before coalescing into a distinct trunk inferiorly to pass through the diaphragm, but often a distinct trunk is present along the full posterior side of the esophagus). Thus, with leakage of food or vomit from the perforation these nerve might become irritated or inflamed.

Incorrect. The anterior vagal trunk runs along the anterior, not the posterior, side of the esophagus (the left vagus branches out anteriorly as part of the esophageal plexus before coalescing into a distinct trunk inferiorly to pass through the diaphragm, but often a distinct trunk is present along the full posterior side of the esophagus). Thus, the anterior location is not consistent with the barium leak location.

Correct! The greater splanchnic nerve arises from levels T5-9 running medially from the sympathetic chain across the vertebral bodies. This is in close proximity to the described barium leak so food or vomit from the perforation might irritated or inflame the nerves.

Incorrect. The lesser splanchnic nerve arises from levels T10-11, more inferior than the described perforation at T6/7 and would be at reduced risk unless there is considerable spread from the leakage point.

Incorrect. The least splanchnic nerve arises from levels T12, more inferior than the described perforation at T6/7 and would be at reduced risk unless there is considerable spread from the leakage point.

Possible! While the sympathetic chain runs along the lateral aspects of the vertebral bodies from the location of the esophagus, it is possible for material leaking into the posterior side of the esophagus to work a little laterally from the leakage point and irritate the chain.

Unlikely. The intercostal nerve emerges from the intervertebral foramen located quite lateral and posterior from the location of the esophagus. It is unlikely for leak contents work their way that laterally. Additionally, the nerve travels between the internal and innermost intercostal muscle groups, so an muscle/membrane layer would also need to be penetrated to reach the nerve.

Incorrect. The right recurrent laryngeal nerve loops around the right subclavian artery, which is located at the root of the neck to superior to be affected by a perforation at T6/7.

Incorrect. The left recurrent laryngeal nerve loops around the aorta, which is located in the superior mediastinum, a location superior and anterior to the esophagus perforation at T6/7.