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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5509_Библиотеки_им_академика_М_И_Перельмана.pdf
ImagI ng of the Pharynx and t he esoP hagus
9.6.9 Anterior Hyoid Excursion
This component evaluates the forward movement of the hyoid bone during swallowing. Anterior
excursion of the hyoid is essential for effective epiglottic inversion and opening of the UES. We
study the angle of the thyroid cartilage relative to the position of the hyoid bone, at the height of
the pharyngeal swallow or maximal anterior displacement of the hyoid bone. Limited movement
can result in pharyngeal residue and increased aspiration risk due to incomplete airway protection
(Fig u r e 9.9a–d).
Figure 9.9 Component 9: Anterior Hyoid Excursion. 0 = Complete anterior movement. Acute
ang le (45° or less) between the thyroid cartilage and hyoid bone at the height of anterior hyoid move-
ment. 1 = Partial anterior movement. Thyroid cartilage is more in a direct line (greater than 45° but
less than 90°) with the hyoid at the height of anterior hyoid movement. 2 = No anterior movement.
No appreciable anterior movement of the hyoid bone. The hyoid does not deviate from the 90° angle
with the thyroid cartilage.
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0: Complete anterior movement.
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1: Partial anterior movement.
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2: No anterior movement.
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9.6.10 Epiglottic Movement
This component assesses the degree of inversion of the epiglottis over the laryngeal inlet during
swallowing.
Complete epiglottic inversion provides critical protection against aspiration. Insufcient inversion exposes the airway to bolus entry during the swallow. We evaluate laryngeal elevation and
anterior traction of the hyolaryngeal complex resulting in inferior displacement of the epiglottis, at the height of the pharyngeal swallow or maximal anterior displacement of the hyoid bone
(Figure9.10a–d).
Figure 9.10 Component 10: Epiglottic Movement. 0 = Complete inversion. Complete inferior displacement of the epiglottis. 1 = Partial inversion. Movement of the epiglottis up to a horizontal position, but with no progression beyond this point. A score of (1) would also be given if the epiglottis
moves inferiorly but does not reach a horizontal position. 2 = No inversion. Minimal to no movement of the epiglottis.
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0: Full inversion over the laryngeal inlet.
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1: Partial inversion.
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2: No inversion.
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ImagI ng of the Pharynx and t he esoP hagus
9.6.11 Laryngeal Vestibular Closure
This component evaluates the closure of the laryngeal vestibule during swallowing, which includes
the supraglottic and glottic structures that form the nal protective barrier to the airway.
Effective closure of the laryngeal vestibule prevents penetration and aspiration. Incomplete closure may allow the bolus or residue to enter the airway, increasing the risk for aspiration pneumonia.
This is scored during the late closure of the laryngeal vestibule, at the height of the pharyngeal
swallow or maximal anterior displacement of the hyoid bone (Figure 9.11a–d).
Figure 9.11 Component 11: Laryngeal Vestibule Closure. 0 = Complete; no air/contrast in laryngeal vestibule. Complete closure with no air or contrast in the laryngeal vestibule. 1 = Incomplete;
narrow column of air/contrast in laryngeal vestibule. Characterized by a narrow column of air or
contrast in the laryngeal vestibule. 2 = None; wide column of air/contrast in laryngeal vestibule. No
closure with a wide column of air or contrast in the laryngeal vestibule.
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0: Complete closure; no air or contrast enters the laryngeal vestibule.
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1: Incomplete closure with a narrow column of contrast or air.
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2: No closure; wide column of contrast or air enters the vestibule.
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9.6.12 Pharyngeal Stripping Wave
The pharyngeal stripping wave refers to the sequential contraction of the pharyngeal constrictor
muscles that clears the bolus through the pharynx into the esophagus.
A diminished or absent stripping wave may result in pharyngeal residue, prolonged swallow
time, and secondary aspiration from pooled material. This component evaluates the progressive
contraction of the pharyngeal constrictors, at the full length of the posterior pharyngeal wall from
the nasopharynx to the pharyngoesophageal segment (PES), during the full duration of the pharyngeal swallow (Fig ure 9.12 a–d).
Figure 9.12 Component 12: Pharyngeal Stripping Wave. 0 = Present—complete. Full contraction from the nasopharynx to the level of the PES at the time of collapse. 1 = Present—diminished.
Diminished pharyngeal stripping wave along any portion of the pharyngeal wall. 2 = Absent.
Complete absence of the pharyngeal stripping wave along the entire pharyngeal wall, often represented by a straight line of the posterior pharyngeal wall throughout the swallow.
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0: Complete and coordinated stripping wave.
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1: Incomplete or reduced stripping wave.
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2: Absent stripping wave.
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ImagI ng of the Pharynx and t he esoP hagus
9.6.13 Pharyngeal Contraction
This component assesses the inward and upward movement of the pharyngeal walls during swallowing. It is typically best visualized in the anteroposterior (AP) view, observing the pharyngeal
walls both at rest and during maximum movement. Adequate pharyngeal contraction contributes
to effective bolus clearance. Impaired contraction can lead to pharyngeal residue, inefcient swallowing, and potential post-swallow aspiration (Figu r e 9.13a–e).
Figure 9.13 Component 13: Pharyngeal Contraction. 0 = Complete. Symmetrical shortening and
complete inward compression of the pharynx. Lateral walls are relatively straight during shortening and compress against the bolus tail through the pharynx, bilaterally. 1 = Incomplete (pseudodiverticulum). Incomplete contraction represented by dynamic pouches. Typically unilateral and in
the high to mid-pharynx, lateral to the valleculae. 2 = Unilateral bulging. Unilateral bulging of one
pharyngeal wall extends the full length of the pharynx. May be distinguishable at rest. 3 = Bilateral
bulging. Outward bulging of both pharyngeal walls.
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0: Complete contraction with medial movement of the pharyngeal walls.
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1: Incomplete contraction with visible pseudodiverticulae.
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2: Unilateral bulging of the pharyngeal wall.
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3: Bilateral bulging with signicantly reduced contraction.
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9.6.14 Pharyngoesophageal Segment Opening
The component evaluates the distention and duration of opening at the pharyngoesophageal segment, also known as the upper esophageal sphincter (UES), during bolus passage and maximum
distention of PES through closure. Adequate PES opening is critical for bolus clearance into the
esophagus. Impaired opening can cause residue in the pyriform sinuses and backow into the
pharynx, increasing aspiration risk (Fig ure 9.14a–e).
Figure 9.14 Component 14: Pharyngoesophageal Segment Opening. 0 = Complete distension,
complete duration, no obstruction of ow. Straight edges throughout the segment with no appreciable narrowing from the pharynx to the proximal esophagus. PES remains distended long enough
for the entire bolus to pass through the esophageal inlet. 1 = Partial distension, partial duration,
partial obstruction of ow. A score of (1) can be represented in several ways: (1) Narrowing of the
PES at the esophageal inlet while maintaining opening long enough for most of the bolus to pass. (2)
Adequate distension of the PES but with early collapse allowing most of the bolus to pass. (3) Both
narrowing and early collapse of the PES resulting in partial obstruction. 2 = Minimal distension,
minimal duration, marked obstruction to ow. A score of (2) can appear as follows: (1) Signicant
narrowing of the PES resulting in resistance to bolus passage. (2) Rapid collapse of the PES allowing only a minimal portion of the bolus to pass. (3) Both signicant narrowing and rapid collapse
of the PES resulting in marked obstruction. 3 = No distension with total obstruction to ow. The
PES does not open, and there is no bolus clearance. Generally results in the need for the patient to
expectorate. Escape into the laryngeal vestibule or nasal cavity is common.
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ImagI ng of the Pharynx and t he esoP hagus
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0: Complete distention and appropriate duration.
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1: Partial distention and/or shortened duration.
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2: Minimal distention with marked obstruction.
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3: No opening of the PES.
9.6.15 Tongue Base Retraction
This component evaluates the posterior movement of the tongue base toward the posterior pharyngeal wall during the pharyngeal phase of swallowing.
Adequate tongue base retraction is necessary to generate pharyngeal pressure and ensure efcient bolus propulsion. Inadequate retraction leads to vallecular residue and incomplete bolus clearance. Here we study the posterior retraction of the tongue resulting in approximation of the tongue
base (TB) with the anteriorly displacing pharyngeal wall (PW) and especially the presence and
degree of bolus or air between the TB and PW, during maximal retraction of the tongue and maximum posterior movement (Figu re 9.15a –f).
Figure 9.15 Component 15: Tongue Base Retraction. 0 = No contrast between TB and PW in the
lateral viewing plane; it resembles a “merging” of the tongue base and pharyngeal wall. 1 = Trace
column of contrast or air between TB and PW. Represented by only a trace column of contrast or air
between the TB and PW. 2 = Narrow column of contrast or air between TB and PW. Resembles an
amount of air or contrast similar to “collection” (Components 5 and 16). 3 = Wide column of air or
contrast between TB and PW. 4 = No visible posterior motion of TB. Despite initiating a swallow, the
patient below demonstrates no appreciable posterior motion of the TB.
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Figure 9.15 Continued.
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0: Complete contact between tongue base and posterior pharyngeal wall.
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1: Trace column of contrast or air between structures.
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2: Narrow column of contrast or air.
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3: Wide column of contrast or air.
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4: No visible posterior movement of the tongue base.
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ImagI ng of the Pharynx and t he esoP hagus
9.6.16 Pharyngeal Residue
Here we study contrast material remaining in the pharynx after completion of the rst swallow, or
following the last swallow of the sequential swallowing task (Fig ure 9.16a–f).
Figure 9.16 Component 16: Pharyngeal Residue. 0 = Complete pharyngeal clearance. 1 = Trace
residue within or on pharyngeal structures. Trace, or lining, of residue within or on any of the pharyngeal structures. 2 = Residue collection within or on pharyngeal structures, an amount sufcient
to extract or “scoop” from the pharynx. 3 = Majority of contrast within or on pharyngeal structures;
> half of the bolus remains in the pharynx, relative to the bolus size. 4 = Minimal to no pharyngeal
clearance.
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0: Complete clearance.
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1: Trace retention.
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2: Collection of residue within or on pharyngeal structures.
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3: Majority of contrast within or on pharyngeal structures.
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4: Minimal to no pharyngeal clearance.
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9.6.17 Esophageal Clearance
This component observes the bolus as it moves through the esophagus while the patient is in an
upright seated position. Impaired esophageal motility or obstruction may result in bolus retention
or retrograde ow. Identication is critical for appropriate referral (Figure 9.17a–f).
Figure 9.17 Component 17: Esophageal Clearance. 0 = Complete clearance, esophageal coating,
after a primary or secondary wave of contraction. There may be esophageal coating resembling a
trace outline of the lining of the esophagus. 1 = Esophageal retention. Esophageal retention after
a primary or secondary wave of contraction. May resemble a ”collection” of contrast material anywhere along the full length of the esophagus. 2 = Esophageal retention with retrograde ow below
the PES. 3 = Esophageal retention with retrograde ow through the PES. 4 = Minimal to no esophageal clearance.
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0: Complete clearance.
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1: Residue remaining.
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2: Retrograde ow below PES.
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3: Retrograde ow through PES.
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4: Minimal to no esophageal clearance.
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