Pharyngeal dysfunctions and their interrelationship in patients with dysphagia

Cineradiographic examination of the pharynx is a valuable tool for evaluation of patients with swallowing complaints. The direct functional imaging is the essence of cineradiography of the pharynx during swallowing. In this way the motor function of the pharynx can be monitored. The kind and number of specific dysfunction can give a valuable information about the severity of pharyngeal impairment. Using a scoring system compensation and decompensation of pharyngeal function can be assessed, thereby offering an understanding of the patients' swallowing ability.     

Morphological findings in dynamic swallowing studies of symptomatic patients

The aim of this study was to assess the role of videofluoroscopy in the detection of structural abnormalities of the pharynx and esophagus in patients with different symptoms of impaired deglutition. Dynamic radiographic recording of deglutition was performed in 3193 consecutive patients (1578 men, 1615 women; mean age 54 years) suffering from dysphagia, suspicion of aspiration, globus sensation, and non-cardiac chest pain. We assessed different structural lesions from the oral cavity to the esophagus and classified them into eight categories. Their frequency and association with the different clinical symptoms were evaluated. Videofluoroscopy revealed 1040 structural abnormalities in 833 patients (26%) including mass lesions from the oral cavity to hyoid/larynx ( n=66), pharyngeal diverticula ( n=181), pharyngeal masses ( n=78), other pharyngeal narrowings ( n=71), webs ( n=98), masses ( n=39), and other narrowings ( n=73) of the upper esophageal sphincter, esophageal diverticula ( n=80), esophageal webs, rings and strictures ( n=194), and intrinsic and extrinsic esophageal lesions ( n=160). There was a considerable variance of findings for different symptoms. In a large proportion of symptomatic patients videofluoroscopy detects morphological abnormalities along pharynx and esophagus often combined with functional disorders. This fact underlines the role of videofluoroscopy as a diagnostic test for function as well as morphology.     

咽部正常形态和结构性病变的MRI观察

目的：研究MRI对咽部结构性病变的诊断价值．材料和方法：对189例健康成人咽部正中矢状面磁共振图像分析，观察正常人的软腭、咽后壁，会厌、喉及食管环咽段的形态、位置、厚度、长度以及在MRI上的信号强度，对11例有吞咽困难症状的咽部异常者进行MRI对比观察．结果：正常人咽部形态(与吞咽活动有关结构)在MRI矢状面上显示较好．T1加权和质子加权图像上咽部结构解剖清晰。T2加权图像上虽结构轮廓模糊，但有助于咽部肿瘤病灶的定性．结论：MRI对咽部软组织病变的显示远优于常规X线和CT，并可作出正确的定位、定性诊断。     

Radiology of the pharynx and oesophagus in young adults

The indication for and results of radiological examination of the pharynx in 195 young adults (83 men, 112 women; age 13-40 years) were analysed retrospectively. A total of 99 patients were examined because of a suspected foreign body. In only seven was a foreign body revealed; two patients had mucosal tears. Five other emergency examinations were normal. Eighty-seven patients were examined because of long-standing upper oesophageal dysphagia. One had a diverticulum in the pharyngooesophageal segment and another had oesophageal achalasia. Nineteen other patients had pharyngeal dysfunction. Eighteen patients were examined because of retrosternal pain on swallowing. One had a pedunculated pharyngeal cyst while two had pharyngeal dysfunction. The other examinations were normal. Our results show that a careful radiological examination of the pharyngeal function is of value in young adults with swallowing complaints. Even in acute dysphagia a foreign body is seldom revealed. In patients who had undergone cineradiography, 21 of 90 (23%) had some form of pharyngeal dysfunction which could account for the patients' symptoms.     

Swallowing dysfunction in the postpolio syndrome: a cinefluorographic study.

Twenty patients with a remote history of poliomyelitis and recent or progressive dysphagia were evaluated with cinefluorography. Radiographic abnormalities were present in the pharynx in varying degrees in all but one of the patients. Findings included atrophy of the prevertebral soft tissues, unilateral or bilateral weakness of the tongue or soft palate, paresis or paralysis of the pharyngeal constrictor muscle, incomplete or absent epiglottic tilt, poor laryngeal elevation, poor laryngeal closure with laryngeal penetration, aspiration (often without a cough), and luminal narrowing at the cricopharyngeal level. Other structural lesions included a Zenker diverticulum in one patient, bilateral pharyngeal pouches in five, and a unilateral pouch in one. Additional structural lesions contributing to dysphagia were found in two other patients, including a focal stricture in the cervical esophagus in one patient and two stenotic rings in the distal esophagus in another. In four patients (one of whom had the Zenker diverticulum), the inferior constrictor muscle contracted forcibly above a prominent cricopharyngeus muscle, perhaps contributing to the formation of the diverticulum. It is important to examine postpolio patients with dysphagia carefully with dynamic imaging to assess the severity of decompensation and to detect other lesions that may be treatable. The information derived can be used to guide management.     

Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

OBJECTIVE: The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery. MATERIALS AND METHODS: From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted. RESULTS: Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration. CONCLUSION: Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.     

Pharynx: value of oblique projections for radiographic examination

The utility of oblique views for augmenting standard posteroanterior and lateral double-contrast radiography of the pharynx was examined. Over an 8-month period, two oblique views were added to the standard posteroanterior and lateral views of the pharynx during routine upper gastrointestinal studies in 102 patients divided into two groups. Group 1 consisted of 81 patients without suspected pharyngeal or esophageal disease who demonstrated what was considered to be normal anatomy on all radiographic views. Group 2 consisted of 21 patients who were known or suspected to have pathologic abnormality of the pharynx. The members of this latter group each demonstrated various abnormal pharyngeal anatomy on the standard views. In just over half of these cases the oblique projection contributed significant information not obtained with conventional views. Therefore, the authors conclude that oblique images are a beneficial addition to the diagnostic evaluation of patients highly suspected of having pharyngeal disease.     

Esophageal lesions after total laryngectomy

Clinical and endoscopic evaluation of the post-total laryngectomy patient with dysphagia may be limited by postoperative fibrosis or strictures. The barium esophagogram is a valuable adjunctive tool in further assessing these patients, as both functional and anatomic abnormalities can be evaluated. A 10-year retrospective review yielded 204 patients who had had total laryngectomies for squamous cell carcinoma of the larynx; 85 of these patients had postoperative barium esophagograms. Dysphagia was the chief complaint in 73 of these 85 patients. The studies were reviewed for anatomic abnormalities of the surgically deformed pharynx (neopharynx) and the esophagus distal to it. While most patients (51%) with dysphagia had abnormalities in the neopharynx, 17 (23%) had abnormalities distal to the neopharynx; these included four esophageal carcinomas and 13 benign esophageal strictures. These results emphasize the importance of evaluating the entire esophagus and maintaining a high index of suspicion for distal esophageal disease in the total laryngectomy patient with dysphagia.     

Globus sensation: findings on videofluoroscopic examinations.

OBJECTIVE: To determine the findings on videofluoroscopy of the pharynx and esophagus in patients with a globus sensation and compare them with a similar group of patients with dysphagia. METHODS: A computerized search of radiology files revealed 83 patients with a globus sensation who had videofluoroscopic examinations of the pharynx and esophagus during a 10-year period from 1989-1999. A computerized search was also performed to generate an age- and sex-matched group of 83 patients with dysphagia who also had videofluoroscopic examinations during this period. Original radiologic reports were reviewed to determine the frequency of morphologic and functional abnormalities of the pharynx and esophagus in these 2 groups. RESULTS: Early closure of the cricopharyngeus was found in 13 (16%) patients with globus versus 2 (2%) with dysphagia (p < 0.01). Enlarged pharyngeal tonsils were found in 31 (37%) patients with globus versus 17 (21%) with dysphagia (p < 0.05). Enlarged lingual tonsils were characterized on barium studies by nodularity or lobulation of the posterior-inferior base of the tongue and valleculae in all patients, and the palatine tonsils were symmetrically enlarged in all but 2 patients. No other radiographic findings were significantly associated with a globus sensation. CONCLUSION: Early closure of the cricopharyngeus and enlarged lingual or palatine tonsils may contribute to the development of a globus sensation, but the pathophysiologic basis for this association remains unclear.     

Digital cineradiographic swallow study: our experience

PURPOSE: Swallowing disorders can be secondary to different types of diseases in which, at least initially, patients succeed in establishing voluntary or involuntary compensatory mechanisms that enable them to maintain a sufficient nutritional state. When the compensatory mechanisms become insufficient massive food aspiration into the airways can occur and suffocation may prove to be the main pathology. It has been calculated that in the USA about 8,000-10,000 people die each year due to suffocation. The dynamic radiological examination of swallowing is considered important not only for diagnosis, but also for planning a rehabilitation therapy and type of nutrition for the patient and for verifying the results of the therapy. The aim of this study is to analyse the results of our experience in the use of the digital cineradiography system to evaluate patients with normal and pathological swallowing. MATERIALS AND METHODS: We reviewed the digital cineradiography of 220 patients that at no time had undergone surgery and presented no organic pharyngeal or oesophageal disease (excluding hiatus hernia). All the exams followed a standard protocol that included the dynamic evaluation of the larynx, soft palate, pharynx, and gastro-oesophageal junction with a cineradiographic sequence of 12 frames/second with a 512x1024 matrix. There was also an archive of the film in a post-processing console. The patients received single photograms (printed on laserfilm), videotape recordings or CD-ROM of the dynamic exam. RESULTS: 137 (62%) of the patients did not present swallowing alterations although only 7 patients had a negative examination. In 35 cases hiatus hernia was appreciable while in 69 cases the hernia was associated with gastro-oesophageal reflux. In 23 cases aspecific functional disorders of the oesophagus were demonstrated and in 3 cases achalasia. The remaining 83 patients (38%) (37 males and 46 females, average age 57.02 yrs) presented alterations of the oral and/or pharyngeal stages of swallowing: reduction in soft-palate motility (2 cases), unilateral paralysis of the vocal chords (1 case), incontinence of the bolus during the oral stage (8 cases), lingual movement anomalies (4 cases), subepiglottic penetration (62 cases), asymmetric epiglottic tilt, aspiration of the contrast medium in the airway (17 cases), reduction of laryngeal and hyoid bone movement (9 cases), bolus retained in the valleculae and pyriform sinus (13 cases), cricopharyngeal spasm (6 cases), pharyngeal paralysis (1 case); hiatus hernia was also evident in 20 cases and gastro-oesophageal reflux was associated in 13 of them. Overall, 36% of the cases presented an isolated form while 64% of the cases presented a complex dysfunction with several simultaneous alterations. DISCUSSION AND CONCLUSIONS: The videofluorographic swallow study is an important step in the diagnostic evaluation of a dysphagic patient not only as regards the analysis of the main alteration and its capacity to confirm the presence or absence of contrast medium aspiration in the airway, but also because it provides important information on rehabilitation and nutritional orientation (oral/no oral), as well as on the results of the therapy. The recent diffusion of the digital X-ray equipment has made possible its use for the study of the organic and functional diseases of the upper alimentary tract. Currently a standard protocol for the study of swallowing with digital fluorography is not available. The technique we applied, already verified in a significant number of dysphagic patients, has allowed us to distinguish patients with normal swallowing from those with disorders of the oral and pharyngeal stage, and thus to identify disturbance and establish an appropriate rehabilitation treatment.     

Deglutition after near-fatal choking episode: radiologic evaluation

Acute airway obstruction during oral intake is a relatively common event that may be fetal if not relieved immediately. Deglutition was studied in 75 individuals who had experienced a near-fatal choking episode (NFCE) or sudden inability to breathe during food intake that was promptly relieved by means of a Heimlich maneuver, suctioning, or intubation. Videofluoroscopy supplemented by static imaging revealed abnormal stages of deglutition in 58 individuals: oral, 32; pharyngeal, 19; pharyngoesophageal segment (PES), 28; and esophageal, 23. Forty individuals aspirated a liquid bolus; this was more often due to oral dysfunction (bolus leakage, n = 17; delayed initiation, n = 18) than pharyngeal abnormality (defective closure, n = 13; incomplete transport, n = 9). Oral-stage dysfunction was common in those with neurologic disease, a history of dysphagia, and structural or motor abnormalities of the PES or esophagus. Fourteen patients were able to vocalize during the NFCE, and each demonstrated an abnormality of the PES or esophagus that could obstruct a solid bolus, suggesting that symptoms were not due to airway obstruction. A variety of unsuspected deglutition abnormalities were documented, indicating the usefulness of radiographic evaluation after NFCE.     

Correlation between the radiologic study of deglutition and the clinical picture in systemic sclerosis (scleroderma)

Fifty-one patients with systemic sclerosis (scleroderma) were studied by means of videofluoroscopy in order to evaluate the abnormalities in the oropharyngeal and esophageal phases of deglutition and to correlate the radiological patterns with the clinical features of the disease. Thirteen patients (25.5%) exhibited swallowing disorders such as oral leakage, retention, penetration, mild or moderate aspiration and abnormal upper esophageal sphincter behavior. These dysfunctions were more evident in patients with esophageal motility abnormalities. A normal radiological pattern in the esophagus was not associated with swallowing alterations. Remarkably, patients with oral-pharyngeal disorders had a higher incidence of lung diseases. Forty-five patients (88%) exhibited disorders of the esophageal phase of deglutition, such as mild or severe motility abnormalities or hiatal hernia, gastro-esophageal reflux, reflux esophagitis, and stricture. Radiological findings in the esophagus can be abnormal in the early stages of the disease. On the other hand, the radiological pattern of esophageal motility can be occasionally negative in advanced or extensive disease. This indicates a discrepancy between clinical symptoms and radiological picture of the esophagus. The radiological examination of the oral-pharyngeal and esophageal phases of deglutition is important in patients with scleroderma in order to evaluate visceral involvement, motility disorders, and risk of aspiration. Such radiological information can be useful in preventing esophagitis and pulmonary complications.     

Epidermolysis bullosa: radiographic findings in 16 cases

Epidermolysis bullosa is a group of dermatologic disorders with varied inheritance patterns having the common manifestation of blister or bulla formation after minor trauma. Sixteen patients with the disease had the following radiographic manifestations: esophageal stricture (16), fecal impaction (six), vaginal stenosis (one), epithelial bridging and fusion of the digits (six), and aspiration changes in the lungs (two). Esophageal strictures involved the pharynx or cervical esophagus in eight cases and were multiple in five; they ranged in length from 2 mm to 15 cm and tended to progress over time. The findings of esophageal stricture, particularly when multiple and involving the proximal esophagus, and/or the presence of distal phalangeal atrophy with soft-tissue webbing suggest the diagnosis of epidermolysis bullosa.     

The width of the pharyngo-esophageal junction area

In order to elucidate the pharyngo-esophageal segment in normal and abnormal conditions the width of the pharyngo-esophageal junction area on three different levels: hypopharynx, infracricoid segment of the cervical esophagus (ICCO) and cervical esophagus was measured in 150 non-dysphagial volunteers and in 252 dysphagial patients examined with cineradiography during barium swallowing. The result indicates that a narrow ICCO in absolute figures reflects the size of the swallowed bolus and is not a predictor of pharyngeal abnormality, per se. However, when the width of the ICCO in a.p. projection is less than 3/4 of the width in lateral projection this can indicate a narrow ICCO and should lead to endoscopy for further evaluation.     

The feasibility of pretherapeutic diagnosis of malignant pharyngeal processes using high-frequency cineradiography

The differentiation between stage T3 and stage T4 pharyngeal tumors is of crucial importance for the proper therapeutic approach (surgery, surgery with consecutive radio- or radiochemotherapy, chemotherapy). The clinical relevance of the additional information provided by cineradiography was evaluated in combination with the endoscopic and computed tomographic results. We performed static and dynamic pharyngography with mono- and double-contrast-methods in four planes, including pharyngeal distension (Valsalva's and Müller's maneuver) and phonation. For the dynamic study, high-speed cineradiography (35 mm film, 50 frames/s) was used. Twenty-three patients with histologically proven neoplasms were examined. It was determined that surgery was technically feasible in 4 out of 14 patients who were previously presumed to have inoperable tumors. In 2 cases, an extension of the tumor mass was seen by cineradiography (results proven intraoperatively).     

Cineradiography in closed and open pharyngeal swallow

The pattern of swallowing by which the oral bolus reaches an air-containing oropharynx is called an 'open swallow' whereas the sequence in which the oropharynx is collapsed on the arrival of the bolus is called a 'closed swallow'. The significance of this distinction was further analyzed by a correlation with other laryngeal and pharyngeal functions during swallowing in a cineradiologic study in 75 dysphagic patients and 50 asymptomatic volunteers. The relative incidence of open and closed type swallows was similar in the two groups. The maximum elevation of the pharynx and larynx was the same in open and closed swallow, although in individuals with an open swallow the elevation occurred later than in individuals with a closed swallow. Epiglottic movement disturbances, defective closure of the laryngeal vestibule, pharyngeal constrictor muscle paresis, cricopharyngeal incoordination, cervical esophageal webs and Zenker diverticula were significantly more common in individuals with an open pharyngeal swallow than in those with closed swallowing.     

Value of pharyngography in patients without suprasternal symptoms

The purpose of the present paper was to determine if pharyngeal or cervical oesophageal lesions may present with distal symptoms. All patients presenting for barium swallow underwent examination of the pharynx and oesophagus. The pharyngeal examination included spot films of the pharynx as well as views of the pharyngo-oesophageal segment filmed at three frames per second. During the 18-month period of the present study interrogations were carried out to identify patients without symptoms in the cervical or suprasternal region. One hundred and twelve patients were identified; 58 were male and 54 were female. The age range was 18-84 years. Examinations revealed abnormalities within the pharynx in 42 patients (38%); of this group of 42, 34 also had an oesophageal abnormality. The majority of the pharyngeal findings were minor. There were, however, three patients who each had a pharyngeal abnormality (pharyngeal carcinoma, obstructive cricopharyngeal narrowing, pharyngo-oesophageal junction stricture) as well as an oesophageal lesion (hiatal hernia, achalasia, reflux oesophagitis), either of which may have been the source of the symptoms. The remaining eight patients (7%) of this group of 42 with detected pharyngeal abnormality had normal oesophageal examinations. Most of these were again minor changes and were unlikely to be significant. There was, however, one patient in whom the only abnormality was an infiltrative cancer of the posterior wall of the pharyngo-oesophageal junction. In conclusion, the identification of patients in the present study with pharyngeal lesions and without distal abnormal findings indicates that a proximal lesion may present with downstream symptoms. Furthermore, there were also patients in whom the examination found abnormalities in multiple segments of the pharynx and oesophagus. We suggest that examination of the pharynx is warranted as part of the barium swallow in patients without cervical or suprasternal symptoms.     

Imaging of the pharynx and the esophagus.

In the past year there have been an unusual number of new concepts developed concerning the pharynx and the esophagus. The normal swallowing mechanism has been studied in detail using a variety of techniques that have increased our understanding of the normal and abnormal swallowing mechanism. In the esophagus, simultaneous barium swallows and esophageal manometry have created new insights into esophageal peristalsis. Based on this material, new recommendations have been developed for a standard barium swallow for the evaluation of esophageal motility. Also, findings previously considered to be abnormal, such as mild tertiary contractions, have now been demonstrated to be within normal limits. For the first time, detailed criteria for abnormal esophageal peristalsis have been described. This article reviews the literature, emphasizing those areas in which new concepts will affect the practicing radiologist.     

Barium and meat. A comparison between pharyngeal swallow of fluid and solid boluses

The influence of bolus consistency on pharyngeal swallow was radiologically studied in 24 individuals by comparing liquid barium and solid meat after chewing. Pharyngeal function was apparently performed synchronously and symmetrically on both boluses. No definite conclusion about the influence on epiglottic mobility, closure of the laryngeal vestibule and relaxation of the cricopharyngeal muscle could be drawn from this study. There was no difference in the elevation of the pharynx and larynx. The transit time for a solid bolus was shorter compared with that of a fluid bolus. The transit time for the apex of the bolus was shorter than for the tail. A more marked elevation of the pharynx and larynx was followed by a shorter transit time. The width of the pharyngo-esophageal segment was larger in the transverse than in the sagittal diameter during the passage of the bolus and larger on solid compared with fluid swallow. Our results reflect the ability of pharyngeal swallow to be executed with precision and with few alterations due to variable bolus consistency.     

颈段高位食管恶性梗阻的介入治疗

目的：探讨介入微创技术在颈段高位食管恶性梗阻治疗中的可行性。方法：颈段高位食管梗阻病例39例，梗阻部位近端分别位于食管环咽段至以下12mm区间。经用扩张管进行耐受性扩张试验后，在X线影像监视下经口置入用单丝编制的网管状镍钛合金支架疏通食管腔，并经供血动脉介入化疗抑制肿瘤。结果：39例患者共放置46枚高位食管支架。支架放置后所有病例均能进食细渣饮食。除轻微疼痛和可耐受性不适外未产生其他不良反应。接受介入化疗患者的平均生存时间较单纯支架治疗患者长。结论：颈段高位食管恶性梗阻并非内支架治疗禁区，介入化疗对颈部恶性病变也能起到有效的抑瘤作用。