Barium swallow

After completing this article, the reader should be able to: Describe the functional phases and anatomy of swallowing. Detail common underlying causes of dysphagia and their radiographic signs and clinical correlates. List the risk factors for gastroesophageal reflux disease. Differentiate the procedures and goals of barium swallow from those of modified barium swallow. Predict future trends in demand for barium contrast imaging exams related to swallowing dysfunction.     

Videofluoroscopic identification of two types of swallowing

Two forms of swallowing were observed during videofluoroscopy in 166 asymptomatic patients, consisting of an air-containing ("open") pharynx in 120 (72%) and an occluded ("closed") pharynx in 46 (28%). The epiglottis inverted differently in the two forms of swallowing.     

Videofluoroscopic evaluation of complications after laryngeal resection

Summary In past decades, the surgical techniques for treating laryngeal carcinoma have been vastly improved. For circumscribed tumors, voice-conserving resections are possible and for extensive neoplasms, radical laryngectomy, sometimes combined with chemoradiation, has been developed. Postoperative complications regarding swallowing function are not uncommon. Radiologic examinations, especially pharyngography and videofluoroscopy, are most often used to evaluate patients with complications after laryngeal surgery. An optimized videofluoroscopic technique for evaluation of complications is described. The radiologic appearance of early and late complications, such as fistulas, hematomas, aspiration, strictures, dysfunction of the pharyngoesophageal sphincter, tumor recurrence, and metachronous tumors is demonstrated.      

Utilization of the emergent barium swallow

The purpose of this study was to evaluate use of the emergent barium swallow. One hundred thirty-four patients were referred for contrast esophagraphy directly from the emergency department of our hospital and were reviewed retrospectively. Clinical review at the time of the contrast examination revealed that 28 patients actually had features for which gastroduodenal or small bowel pathology was suspected. This left 106 patients with true esophageal studies. Fifty-six patients were suspected of having perforation. Contrast esophagram revealed esophageal disruption in six cases (11%). There were no false-negatives as determined by clinical follow-up. These six patients also had abnormal preliminary chest radiographs. Fifty patients had swallowing difficulties. Of these, 19 were suspected of having an impacted foreign body. A foreign body was detected in four cases (20%), including one impacted at the pylorus. Twenty-seven patients had symptoms of dysphagia. An offending obstruction was found in 10 cases (35%), including four further cases of bolus impaction. Gastric or small bowel disease was identified in three cases. Four patients had odynophagia, and pathology was found in two of these cases (50%). Abnormal motility was noted in seven (14%) of these 50 patients. The emergent contrast esophagram is of value when esophageal pathology is suspected. Perforation is an uncommon occurrence but has a recognized high morbidity and mortality if diagnosis and treatment are delayed. Esophagraphy is able to reliably diagnose or exclude this possibility. If the suspected pathology is not found, consideration should be given to alternative diagnoses, including dysmotility or a downstream lesion. Presented at the 9th Annual Scientific Meeting of the American Society of Emergency Radiology, St. Petersburg, Florida, April 1998.     

以吞咽呛咳为主要症状的多系统淀粉样变临床分析

目的提高对多系统淀粉样变的认识。方法对1例以吞咽呛咳为主要症状的多系统淀粉样变患者的临床资料进行分析,并结合病例复习文献。结果该患者病程10年,病初为皮肤多发性结节,皮肤病变9年后出现口唇增厚、舌肿大、咽反射消失、吞咽困难、呛咳、四肢无力及关节肿痛等,相应累及唇、舌、咽、颅神经、周围神经和骨关节,病变范围不断扩大,实属罕见。皮肤病变属泛发性结节型皮肤淀粉样变,主要表现为全身皮肤多发性结节,呈圆形、类圆形或不规则形,表面光滑,直径约1．5～2．0cm。该病例的另一个特点是发病10年后病变仍未累及心肝肾等重要脏器。诊断主要依靠组织病理学检查。结论多系统淀粉样变发病率低,发生机制不清,易误诊,预后较差。     

Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia

OBJECTIVE: The purpose of our investigation was to determine the relationship between the degree of swallowing dysfunction observed on barium studies and the likelihood of developing pneumonia in a large series of patients. MATERIALS AND METHODS: The findings on videofluoroscopic swallowing studies in 381 patients were used to classify these patients into one of five groups: those with normal swallowing; those with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration; those with laryngeal penetration; those with tracheobronchial aspiration; and those with silent tracheobronchial aspiration. Clinical data were also reviewed to determine how many patients had developed pneumonia during the 6 months before or after the barium studies. The data were then analyzed to determine whether the risk of developing pneumonia increased significantly with each level of swallowing dysfunction seen on barium studies. RESULTS: No significant difference was found in the frequency of pneumonia in patients with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration compared with patients with normal swallowing on barium studies (p = 0.85). In contrast, patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration were approximately four times (p = 0.008), 10 times (p < 0.0001), and 13 times (p < 0.0001), respectively, more likely to develop pneumonia than those with normal swallowing. CONCLUSION: Our findings indicate that the likelihood of developing pneumonia is directly related to the degree of swallowing dysfunction seen on videofluoroscopic studies. Patients with no laryngeal penetration-regardless of whether they had normal or abnormal swallowing-have the lowest risk of developing pneumonia. Patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration are, in increasing order of magnitude, significantly more likely to develop pneumonia than patients with normal swallowing.     

A morphometric analysis of the infant calvarium and dura

Literature addressing the anatomic development of the dura and calvarium during childhood is limited. Nevertheless, histological features of a subdural neomembrane (NM), including its thickness and vascularity, developing in response to an acute subdural hematoma (SDH) have been compared to the dura of adults to estimate when an injury occurred. Therefore, we measured the morphometric growth of the calvarium and dura and the vascular density within the dura during infancy. The mean thicknesses of the calvarium and dura as a function of occipitofrontal circumference (OFC), as well as the mean number of vessels per 25× field, were determined from the right parasagittal midparietal bone lateral to the sagittal suture of 128 infants without a history of head trauma. Our results showed that as OFC increased, the mean thicknesses of the calvarium and dura increased while the vascular density within the dura decreased. Our morphometric data may assist in the interpretation of subdural NM occurring during infancy. We recommend future investigations to confirm and extend our present data, especially by evaluating cases during later infancy and beyond as well as by sampling other anatomic sites from the calvarium. We also recommend morphometric evaluation of subdural NM associated with SDH in infancy and childhood.     

The normal movements of the hyoid bone during swallow

The position of the hyoid bone during quiet breathing and its movement during pharyngeal swallow, as well as its relation to the movement of the epiglottis and the elevation of the rima glottidis were studied with cineradiography in 50 nondysphagial volunteers. The movement of the hyoid bone occurred in either a two-step (40 patients) or a one-step (10 patients) fashion. The findings confirm that pharyngeal swallow is executed with precision and with only small variability in measured parameters.     

早产儿贫血临床分析

目的探讨早产儿贫血发病率与胎龄、体重之间的相关性。方法对近2年来在我院儿科住院的早产儿的贫血发生率进行回顾性总结,对资料进行统计学分析处理,进行对比。结果早产儿贫血发生率随着胎龄、出生体重的增加而逐渐下降,不同胎龄之间及不同出生体重之间的贫血发病率差异均有显著性。结论早产儿胎龄越小、出生体重越低,其贫血的发病率越高。临床上应关注早产儿贫血的发生,并对其进行积极的早期预防。     

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.     

Elevation of the pharynx and the width of the pharyngo-esophageal segment during swallow

The elevation of the pharynx and larynx at swallowing in 10 patients with a defective relaxation of the cricopharyngeal muscle, was compared with that in 10 normals. The pharynx and larynx moved higher among patients with a defective relaxation of the cricopharyngeal muscle. Therefore, it can be concluded that a defective relaxation of the cricopharyngeal muscle at swallowing has no relationship to a defective pharyngo-laryngeal elevation.     

Videofluorography swallow study of patients with systemic sclerosis

Purpose

This study was undertaken to evaluate the role of the videofluorographic (VFG) swallow study in patients with systemic sclerosis.

Materials and methods

Over a 23-month period, 45 women (mean age 58 years, range 27–76 years) with a known diagnosis of systemic sclerosis and a history of dysphagia underwent a dynamic and morphological study of the oral, pharyngeal and oesophageal phases of swallowing with videofluorography. All examinations were performed with a remote-controlled digital C-arm device with 16-in image intensifier, 0.6- to 1.2-mm focal spot range and maximum tube voltage of 150 kVp in fluorography and 120 kVp in fluoroscopy. Cineradiographic sequences were acquired for the swallow study with 12 images per second and matrix 512×512 after the ingestion of boluses of high-density (250% weight/volume) barium. The evaluation of oesophageal peristalsis was documented with digital cineradiographic sequences with six images per second in the upright and supine positions during the swallowing of barium (60% weight/volume), and the water siphon test was performed with the patient in the supine position to evaluate the presence of gastro-oesophageal reflux disease (GORD). All patients subsequently underwent laryngoscopy, endoscopy and pH monitoring, and the data thus obtained were processed and compared.

Results

The VFG swallow study identified alterations of epiglottal tilting associated with intraswallowing laryngeal penetration in 26 patients (57.8%), pooling of contrast agent in the valleculae and pyriform sinuses in 23 (51.1%) and radiographic signs of nonspecific hypertrophy of the lingual and/or palatine tonsils in 18 (40%). The study of the oesophageal phase revealed the presence of altered peristalsis in all patients, and in particular, 36 patients (80%) showed signs of atony. Altered oesophageal clearing mechanisms were evident in all 45 patients, sliding hiatus hernia in 43 (93%) and GORD in 44 (97%).

Conclusions

Our study demonstrated that in patients with systemic sclerosis, there is no primary alteration of the oral or pharyngeal phase of swallowing. In addition, alterations of epiglottal tilting associated with laryngeal penetration of contrast agent were found to be secondary to chronic GORD. Indeed, in 40% of patients, radiographic signs were found that indicated nonspecific hypertrophy of the lingual tonsil and/or palatine tonsils and nonspecific signs of chronic pharyngeal inflammation, and GORD was identified in 93% of patients, which in 40% of cases extended to the proximal third of the oesophagus. The data obtained were confirmed in 85% of cases with pH monitoring and in all cases with laryngoscopy.     

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.     

钡剂灌肠整复婴幼儿肠套叠的体会

肠套叠是一段肠管及肠系膜套入邻近的肠管而引起肠梗阻甚至肠坏死的一种急症，其发病率占婴幼儿肠梗阻的首位，以2岁以下特别是3～12月的肥胖婴儿最多见，男孩比女孩多2倍左右，钡剂灌肠既可以明确诊断又可以及时加压整复。自2000年1月以来，我们采用钡剂灌肠对50例婴幼儿肠套叠患儿进行了X线诊断与整复，取得了很好的效果，现将体会总结如下。