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Imaging of the Pharynx
and the Esophagus
Often neglected or wrongfully discarded as obsolete, barium swallows are still a staple of the
daily routine of radiology departments worldwide, serving as an important tool to support
the clinical and endoscopic diagnosis of the upper gastrointestinal tract. Like other imaging
methods, barium radiography and uoroscopy have also undergone radical technological
changes and upgrades. This book constitutes a seminal volume on the subject, easily accessible
to junior graduate students and specialists, showcasing that before being a diagnostic tool of
utmost importance, it is a form of art worth preserving and passing on to future generations.
Covering sections such as oral and pharyngeal anatomy and an overview of clinical disorders, the
basics of pharyngoesophageal endoscopy, CT, and MR imaging, as well as the art of interpreting
the images, this book provides an extensive and well-illustrated guide to the morphodynamic
imaging of the pharynx and esophagus.
Key Features
◾
Underscores the value of the barium swallow study in the evaluation of the upper
gastrointestinal tract in both routine and complex diagnostic scenarios
◾
Illustrates the technological advancements in imaging, such as radiographic and uoroscopic
techniques supplemented by digital imaging and improved contrast media
◾
Caters to both early career learners and experienced clinicians and offers a structured
exploration of anatomy, pathology, and radiologic techniques
Imaging of the Pharynx
and the Esophagus
Giovanni Fontanella MD FRSA MBSImPc
Designed cover image: Giovanni Fontanella
First edition published 2026
by CRC Press
2385 NW Executive Center Drive, Suite 320, Boca Raton, FL 33431
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2026 Giovanni Fontanella
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any
legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear
that any views or opinions expressed in this book by individual editors, authors or contributors are personal to
them and do not necessarily reect the views/opinions of the publishers. The information or guidance contained
in this book is intended for use by medical, scientic or health-care professionals and is provided strictly as a
supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history,
relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in
medical science, any information or advice on dosages, procedures or diagnoses should be independently veried.
The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device
or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the
drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is
appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional
to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and
publishers have also attempted to trace the copyright holders of all material reproduced in this publication and
apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material
has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted,
or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microlming, and recording, or in any information storage or retrieval system, without written
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For permission to photocopy or use material electronically from this work, access www .copyright .com or contact
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are not available on CCC please contact mpkbookspermissions @tandf .co .uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for
identication and explanation without intent to infringe.
ISBN: 978-1-032-83166-4 (hbk)
ISBN: 978-1-032-79178-4 (pbk)
ISBN: 978-1-0 03- 50 811-3 (ebk)
DOI: 10.1201/9781003508113
Typeset in Palatino
by Deanta Global Publishing Services, Chennai, India
“La vita non nisce, è come il sonno;
la nascita è come il risveglio.
...
Torneremo ancora, ancora, e ancora.”
F. Battiato
A mio padre Eugenio, ora in una dimensione senza dolore
A mia madre Mirella, esempio di vita e di coraggio
A Simona, futura moglie, che condivide con me ogni giorno pane e sogni
Ad Ivana, glia mia, che mi mantiene bambino come lei
“Life does not end, it is like sleep;
birth is like awakening.
...
We will return again, and again, and again.”
F. Battiato
To my father Eugenio, now in a dimension free from pain.
To my mother Mirella, a true example of life and courage.
To Simona, my future wife, who shares her daily bread and dreams with me.
To Ivana, my daughter, who keeps my inner child alive, a child like her.
Contents
Foreword by Bonnie Martin-Harris .................................................viii
Foreword by Francesco Giuseppe Biondo ...........................................ix
Acknowledgments ...................................................................x
Author .............................................................................. xi
Introduction ........................................................................xii
1 Oral, Pharyngeal, and Esophageal Anatomy ...........................................1
2 Physiology of Deglutition ..........................................................32
3 Clinical Evaluation of Pharyngoesophageal Disorders .................................50
4 Basics of Pharyngoesophageal Endoscopy ............................................54
5 Typical Fluoroscopic Results ........................................................59
6 Evolution of Fluoroscopy and Barium Swallow ........................................93
7 Imaging Technique ...............................................................100
8 Contrast Media ..................................................................109
9 Approach to Image Interpretation .................................................. 118
10 Pharyngeal Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4
11 Esophageal Disorders .............................................................152
12 Basics and Use of CT and MRI of the Pharynx and Esophagus .........................191
Index ............................................................................... 199
vii
Foreword by Bonnie Martin-Harris
The modied barium swallow study (MBSS) stands as one of the most enduring, informative tools
in the evaluation of swallowing physiology. With its origins in structural imaging, the procedure
has evolved to capture dynamic events at the intersection of anatomy, physiology, and functional
health. Through decades of renement, the MBSS has become not only a diagnostic procedure but a
platform for interdisciplinary understanding, linking image-based impairment with clinical management, patient goals, and outcome prediction.
This volume by Dr. Giovanni Fontanella is a timely and vital contribution to that evolution. It
reects the discipline, clinical empathy, and integrative thinking that high-delity uoroscopic evaluation demands. It is not enough to capture images in shades of black, white, and gray. True clinical
impact requires interpreting those images within the context of the patient, bringing together their
physiology, their symptoms, their environment, and their care team. That synthesis is at the heart
of this book.
Dr. Fontanella’s work is particularly meaningful at a time when radiology trainees are often distanced from the functional implications of what they image. This book bridges that divide. It offers
detailed anatomic and physiologic exposition while grounding those details in real clinical relevance. It trains the eye to see impairment not in isolation but as part of a complex, dynamic system.
It elevates the role of the radiologist to that of a full participant in the management of dysphagia,
highlighting the neural underpinnings of function and the translational value of imaging ndings.
This book exemplies an integrative approach to uoroscopic imaging, one that emphasizes standardized protocols, physiologic detail, and clinical interpretation grounded in reproducibility and
relevance. It advances a broader ethos: that methodological rigor is not an academic exercise but
a foundation for responsible, impactful patient care. Excellence in this eld demands more than
image acquisition; it requires the ability to interpret ndings with precision, to communicate across
disciplines with clarity, and to act with shared purpose.
Comprehensive in scope and thoughtful in execution, this text offers essential insight for the
full team of clinicians engaged in the management of oropharyngeal and esophageal swallowing
disorders. Its strength lies in its clarity, its clinical applicability, and its insistence on seeing patients,
rather than images, as the central focus of practice.
Dr. Fontanella has crafted more than a procedural guide; he has created a teaching companion
and a clinical reference. It belongs in the hands of every resident, fellow, and practicing clinician
committed to pursuing this work with delity, transparency, and compassion.
viii
Bonnie Martin-Harris, PhD, CCC-SLP, BCS-S
Foreword by Francesco Giuseppe Biondo
Every signicant scientic work is born from a question, a conict, an act of resistance.
This book was conceived in precisely this way—as a response to the hasty tendency to dismiss
uoroscopy as an “outdated” technique, in an era where technological innovation has profoundly
transformed the diagnostic and therapeutic approach to pharyngeal and esophageal diseases.
This volume, beyond offering exceptional clinical and scientic value, powerfully reafrms that
uoroscopy is far from obsolete; rather, it remains a modern clinical frontier, maintaining its diagnostic dignity—and even a humanistic dimension.
Dr. Giovanni Fontanella, whom I had the pleasure of knowing and appreciating during our
clinical and scientic collaboration when I served as Director of the Department of General and
Specialist Surgery at the “Sacro Cuore di Gesù—Fatebenefratelli” Hospital in Benevento, Italy, presents a work that goes well beyond describing the morphology, pathophysiology, and dynamic imaging of the pharyngoesophageal tract. It highlights, with rigor and depth, the irreplaceable role of the
radiologist in the multidisciplinary management of patients with functional and organic pharyngoesophageal disorders.
Such an approach restores to the patient a precise, dynamic, and integrated diagnostic language—
where technique becomes a tool for connection, understanding, and ultimately, care.
The clinical acumen and human sensitivity that permeate each page of the book reect the
author’s mature approach, shaped by extensive eld experience and deep reection on the very
meaning of our profession.
This is not merely a technical manual. It is an act of awareness—of the history of medicine, and of
attentive listening to patients and to the human body, which speaks beyond words.
In my 40 years of experience as a surgeon of the esophagus and pharynx—at the University
of Naples, the “Moscati” Hospital of Avellino, and the “Sacro Cuore di Gesù—Fatebenefratelli”
Hospital in Benevento—I have witnessed tools and methodologies evolve. Yet, the value of clinical
interpretation and observation—guided by sensitivity, scientic curiosity, interpretative skill, and
technical precision—has never diminished.
The author invites us to “speak with patients” before, during, and after the examination.
A simple phrase—yet profoundly revolutionary in a medical context increasingly at risk of
becoming procedural and depersonalized. I fully share this vision.
Like surgery, uoroscopy is not merely technique: it is presence, it is language, it is relationship.
Imaging of the Pharynx and the Esophagus is a complete, scholarly yet accessible volume, intended
not only for radiologists, surgeons, and gastroenterologists, but for all those who recognize dysphagia as not only a clinical, but also an existential concern.
I therefore consider this volume an important reference—not only to be studied and consulted,
but also to be lived, as knowledge lives when it meets experience. It is a book that informs, guides,
and inspires.
Francesco Giuseppe Biondo, MD
Specialist in General and Thoracic Surgery
Professor of Thoracic Surgery
Head of the General Surgery Unit
Avellino, Italy
ix