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ImagI ng of the Pharynx and t he esoP hagus
REFERENCES
1. Langmore SE. Endoscopic evaluation and treatment of swallowing disorders. Thieme Medical
Publishers; 2001.
2. Aviv JE, Takoudes TG, Ma G, Close LG. Ofce-based esophagoscopy: a preliminary report.
Otolaryngol Head Neck Surg. 2001;125(2):170–175.
3. Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in oto-
laryngology. Curr Opin Otolaryngol Head Neck Surg. 2002;10(6):437–442.
4. Belafsky PC, Postma GN, Daniels SK, Koufman JA. Swallowing and the aging adult. Dysphagia.
2003;18(4):2 84 –291.
5. Langmore SE, Schatz K, Olson N. Endoscopic and videouoroscopic evaluations of swallow-
ing and aspiration. Ann Otol Rhinol Laryngol. 1991;100(8):678–681.
6. Martin-Harris B, Brodsky MB, Michel Y, et al. MBS measurement tool for swallow impair-
ment—MBSImp: establishing a standard. Dysphagia. 2008;23(4):392–405.
7. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale.
Dysphagia. 1996;11(2):93–98.
8. Bastian RW. Videoendoscopic evaluation of patients with dysphagia: an adjunct to the modi-
ed barium swallow. Otolaryngol Head Neck Surg. 1991;104(3):339–350.
9. Miles A, Moore S, McFarlane M, et al. The impact of clinical training on the accuracy of endo-
scopic assessment of swallowing. Int J Speech Lang Pathol. 2014;16(6):570–578.
10. ASHA. Practice portal: Adult dysphagia. American Speech-Language-Hearing Association.
https://www .asha .org /Practice -Portal /Clinical -Topics /Adult -Dysphagia/.
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5 Typical Fluoroscopic Results
5.1 PHARYNGEAL AND ESOPHAGEAL TOPOGRAPHIC ANATOMY
Prior to considering the radiologic anatomy, it is necessary to analyze the topographic anatomy of
these structures (Fig ure 5.1) [1]. The patient’s habitus affects the length of the upper alimentary tract.
The gastroesophageal junction and the incisor teeth are 40 cm apart on average. The esophagus is
typically 24 cm long, while the mouth cavity and hypopharynx are about 16 cm long. The esophagus
and hypopharynx are attened anteriorly against the thoracic and cervical spines. The retropharyngeal fat and paravertebral gaps provide posterior cushioning for the hypopharynx, separating
it from the cervical spine and the adjacent muscles. While the hypopharynx rests anteriorly on
the suspensory ligament and cricoarytenoid muscle of the cricoid lamina, the carotid sheaths are
located laterally next to its walls. The thyroid gland partially surrounds the sphincter zone of the
cervical esophagus and may extend posteriorly, dividing it from the carotid sheaths. The thyroid
gland partially encloses the superior portion of the cervical esophagus laterally, while the remainder is loosely linked anteriorly to the trachea’s posterior wall. Laterally, between the trachea and the
esophageal wall, lie the recurrent laryngeal nerves. The vagal nerves and esophageal lymph glands
are strongly attached to the esophagus below the tracheal bifurcation. Around the level of the fth
thoracic vertebra, the thoracic esophagus extends to the tracheal bifurcation after lying posterior to
the trachea. Here, the left major bronchus passes anteriorly above the esophagus. To pass through
the esophageal gap at the level of the rst lumbar vertebra, the thoracic esophagus enters from the
thoracic inlet, which is somewhat to the left of the thoracic spine. It then swings slightly to the right
at around the seventh thoracic vertebra. The aortic arch crosses posteriorly and inferiorly alongside
Figure 5.1 Anatomy of the esophagus.
DOI: 10.1201/9781003508113-5
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ImagI ng of the Pharynx and t he esoP hagus
the esophagus at the fourth thoracic vertebra, creating a left-sided depression. Just posterior to the
esophagus at the T-S level, the descending aorta swings to the right after following the left side of
the esophagus. The esophagus and the pericardial sac that surrounds the left atrium of the heart
are in contact below the level of the left main bronchus. The parietal pleura and subclavian veins
are next to the esophagus above T4. With the exception of the area where the azygous vein crosses
(around T4), the right parietal pleura is located lateral to the esophagus on the right side. Until it
passes through the esophageal hiatus of the diaphragm on the left side, the esophagus turns laterally inferior to the seventh dorsal vertebra and comes into contact with the left parietal pleura once
more. In the thoracic cavity, the esophagus is attened anteroposteriorly and has a resting width of
around 2 cm. On the underside of the left lobe of the liver, which sits above it anteriorly, the abdominal segment of the esophagus creates a groove.
5.2 PHARYNGEAL AND ESOPHAGEAL RADIOGRAPHIC ANATOMY
Due to the relative ease of direct inspection, radiographic examinations of the oral cavity are rarely
performed [2]. Nonetheless, it is the appropriate location to start uoroscopic observations because
it is a component of the upper gastrointestinal tract (Figure 5.2). The tongue is in direct contact with
the hard palate while the mouth is closed and at rest. The front part of the tongue drops to provide
space for the thick barium bolus as the mouth is opened to absorb it (Figure 5.3). The bolus is then
collected in a V-shaped groove at the center of the tongue. When the jaw and mouth are closed and
the tongue pushes the bolus against the hard palate, the mandibular teeth are braced against the
maxillary teeth to start the swallowing action. The bolus is propelled into the hypopharynx by this
stripping action. After being properly prepared by salivation and placing the bolus in the tongue’s
central groove, a portion of a big, thick barium bolus is retained in the lateral buccal region and
ingested by repetitive tongue activity. Drinking barium through a straw or glass causes the uid
to pool at the front of the mouth while the tongue is lowered a signicant distance. Periodically,
propulsion persists without any jaw or tooth bracing. The next consideration is the radiologic evaluation of the cervical esophagus, orohypopharynx, and oral cavity as shown on lateral and anteroposterior lms of this area prior to, during, and following a barium swallow. In this regard, the
Figure 5.2 Bolus in the mouth.
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tyP ICa l fluorosCoPIC results
Figure 5.3 Bolus on the tongue.
oral cavity and the lateral routine lm of the neck can be separated into many zones for in-depth
examination: the oral cavity extends from the uvula or soft palate to the lips. Stretching from the
base of the skull to the lowest tip of the uvula, the nasopharynx is located behind the soft palate.
The oropharynx reaches the hyoid bone from behind the uvula and soft palate. The hypopharynx
reaches the pharyngoesophageal junction from the level of the hyoid bone. One to two centimeters
below the pharyngoesophageal junction is the sphincter zone. Stretching from the sphincter zone
to the thoracic inlet is the cervical esophagus.
5.2.1 Oral Cavity
The size and position of the tongue, the amount of air in the oral cavity, the size and thickness of the
soft palate and uvula, the presence or absence of teeth, dental plates, or xed dentures, the shape
and contour of the oral cavity, including the mandible and maxillae, and the presence or absence
of malocclusion are all taken into account on the plain lateral lm of the neck. A portion of the roof
of the palate is delineated by a barium bolus that is lodged anteriorly after the intake of opaque
material but before it is swallowed with the mouth shut. An inferior “ragged” look results from the
tongue being attened and the barium obscuring the oor. The bolus lls the whole oral cavity at
the start of the barium swallow and starts to overow into the valleculae. The palate’s whole roof
is well dened (Figure 5.4). As it starts its stripping activity, the bolus is now mostly located in the
tongue’s central groove, which is depressed aside from its anterior region. A coating of barium
forms on the dorsal surface of the tongue and the roof of the mouth as soon as the bolus is swallowed with the mouth shut. At the base of the tongue, where it is highly exaggerated all the way
down to the vallecula, this barium coating is most noticeable. Because teeth, xed bridges, dental
llings, and the cervical spine are overlaid, the anteroposterior lm of the neck, taken before barium
consumption and with the mouth closed, is typically not helpful for this, but we perform it in our
clinical routine. The vestibules ll with air during the Valsalva maneuver, and, occasionally, aberrant soft tissue densities can be seen. When the mouth is open, the inner part of the oral cavity and
the tongue with its central groove can be clearly seen. Nevertheless, this anteroposterior view is
often used to verify the existence of a specic lesion that has already been discovered or, especially
in a modied barium swallow impairment prole setting and after barium, to assess the symmetry
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ImagI ng of the Pharynx and t he esoP hagus
Figure 5.4 Palate roof.
of the swallow. The identication of salivary calculi is another application for this projection. A
barium bolus is seen to lie between the tongue’s dorsal surface and the palate’s roof in the anteroposterior projection (Figure 5.5). Additionally, barium lls the inner oral cavity’s lateral recesses
(Figure 5.6). Some barium may also be seen in the oropharynx and lateral ventricles upon swallowing. Following swallowing, a residual layer of barium surrounds the posterior molar recesses, the
lateral ventricles, and the dorsum of the tongue; the dorsalsurface of the tongue and oropharynx is
highlighted by a thin layer of leftover barium (Figure 5.7). Sometimes, the bolus is seen as a straight
column as it descends into the oropharynx (Figure 5.8). During and after a barium swallow, oblique
lms of the oropharyngeal region are also highly helpful in identifying anomalies.
5.2.2 Nasal Cavity
With the mouth shut, the nasopharynx is often delineated by air on a simple lateral lm of the neck
(Figure 5.2). The nasopharynx is a recess that extends into the oropharynx and hypopharynx from
the base of the skull, behind the uvula and soft palate. Sometimes a calcied stylohyoid ligament
would split it in two. Except for a tiny section just posterior to the uvula at the point of contact
between the soft palate and the posterior pharyngeal wall, the nasopharynx is typically not opacied after barium intake, particularly at the height of the swallowing action. This functional point
can result in a pseudodiverticulum or a shadow that resembles a beak (Fig ure 5.9). Barium regurgitation into the nasopharynx is an aberrant nding that suggests inadequate muscular coordination.
The nasal cavity and cervical spine’s superimposed shadows make it difcult to see the oropharynx
and nasopharynx in the anteroposterior view of the mouth.
5.2.3 Oropharynx
A simple lateral lm of the neck provides the greatest denition of the oropharynx (Figure 5.2). It
is best to take lms while at rest and when the dry swallow is at its peak [3]. The air column in this
region typically provides a clear outline of the posterior pharyngeal wall, the base of the tongue,
the valleculae, and the tip of the epiglottis. The degree of movement can be measured at the height
of the swallowing process. It is also possible to identify abnormal soft tissue masses. Delineating
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tyP ICa l fluorosCoPIC results
Figure 5.5 Anteroposterior projection.
Figure 5.6 Barium lls mouth lateral recesses.
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ImagI ng of the Pharynx and t he esoP hagus
Figure 5.7 Residual barium after swallow.
Figure 5.8 Barium column through oropharynx.
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tyP ICa l fluorosCoPIC results
Figure 5.9 Beak-like radio transparency of the nasopharynx.
the surrounding soft tissues can be accomplished with the help of a lm made during the Valsalva
maneuver, which overdistends the oropharynx with air. Lateral lms exposed at the height of a
swallow following barium consumption may also show aberrant masses. The inverted epiglottis,
which is folded across the glottis introitus, may now be seen outlined inside the barium column
due to the opacication of the valleculae (Figure 5.10). The rear surface of the tongue, the valleculae,
and the posterior pharyngeal wall will be well dened by any remaining barium after the bolus has
been swallowed (Fig u re 5.11). The mandible’s superimposed shadow largely obscures the oropharynx in anteroposterior plain lms. A solid, attened column of barium represents the oropharynx
during a barium swallow as it descends to reach the posterior wall of the hypopharynx (Figure 5.12).
This region is coated with residual barium following bolus passage; however, the degree of tonicity
of the thyrohyoid ligaments, the thickness and length of the patient’s neck, the angle of projection,
and the amount of residual barium retained in the valleculae all affect how visible the oropharyngeal structures are.
5.2.4 Hypopharynx
There are upper and lower parts of the hypopharynx on the lateral plain neck lm (Figure 5.2) [4].
The air-lled top part reaches into the open larynx and trachea and is continuous with the oropharynx. Anteriorly, the valleculae, epiglottis, and laryngeal introitus are typically clearly dened. The
pharyngeal and oropharyngeal walls are connected posteriorly. Because the larynx presses against
the cervical spine, the inferior part of the hypopharynx is airless. A thickened postcricoid soft tissue
density is often how it is seen. Even in the absence of cricoid cartilage calcication, the lower pole of
the cartilage extends posteriorly into the subglottic region, creating a soft tissue impression inside
the air column. The cervical spine, laryngeal cartilages, and hyoid bone are typically so heavily
overlaid in an anteroposterior plain lm that the hypopharynx is not clearly dened. The lateral
position during bolus ingestion causes the hypopharynx to inate superiorly and narrow inferiorly
where it enters the gaping sphincter, resembling an irregular funnel at the height of swallowing.
With the exception of the lowest cricopharyngeal impression (Figure 5.13), which must be distinguished from an advancing peristaltic primary wave often seen at a higher level, the posterior wall
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ImagI ng of the Pharynx and t he esoP hagus
Figure 5.10 Epiglottis.
Figure 5.11 Barium residue on the valleculae.
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tyP ICa l fluorosCoPIC results
Figure 5.12 Barium through hypopharynx.
Figure 5.13 Cricopharyngeal impression.
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