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Contributors
https://t.me/med1917
Kasim Abul-Kasim Faculty of Medicine, Diagnostic Centre for Imaging and
Functional Medicine, Ska˚ne University Hospital, Malmo¨, Sweden; Lund
University, Malmo¨, Sweden
Karin Aksglæde Division for Gastrointestinal Motility Disorders, Department
of Radiology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C,
Denmark, e-mail: kariaksg@rm.dk
Jacqui Allen Department of Otolaryngology, North Shore Hospital, Takapuna,
Auckland, New Zealand, e-mail: jeallen@voiceandswallow.co.nz; Jacqueline.
Allen@waitematadhb.govt.nz
Samuel Hannes Baldinger University Polyclinic for Endocrinology, Diabetes
and Clinical Nutrition, University Clinic for General Medicine, University
Hospital, Bern, Switzerland
Filippo Barbiera Unita`Operativa di Radiologia ‘‘Domenico Noto’’, Azienda
Ospedali Civili Riuniti ‘‘Giovanni Paolo II’’, 92019, Sciacca, Italy
Ahmed Ba-Ssalamah Department of Radiology, Medical University of Vienna,
Vienna, Austria, e-mail: ahmed.ba-ssalamah@meduniwien.ac.at
Peter C. Belafsky Center for Voice and Swallowing, University of California,
Davis, Sacramento, CA, 95817, USA, Unita`Operativa di Radiologia ‘‘Domenico Noto’’, Azienda Ospedali Civili Riuniti ‘‘Giovanni Paolo II’’, 92019 Sciacca,
Italy
Jane E. Benson Russell H. Morgan Department of Radiology and Radiological
Science, The Johns Hopkins University School of Medicine, 600 North Wolfe
Street, Baltimore, MD 21205, USA, e-mail: jbenson@jhmi.edu
Katarina Bodén Department of Diagnostic Radiology, Karolinska University
Hospital and Karolinska Institute, Stockholm, Sweden
Edmundo Brito-de la Fuente Innovation and Development Centre Clinical
Nutrition and Pharmaceuticals, Science Production and Technology, Fresenius
Kabi Deutschland GmbH, 61440, Oberursel, Germany, e-mail: edmundo.
brito@fresenius-kabi.com
Margareta Bülow Neurological Department and Diagnostic Centre of Imaging and Functional Medicine, Ska˚ne University Hospital, 205 02 Malmo¨,
Sweden, e-mail: margareta.bulow@med.lu.se
xv
xvi Contributors
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S. Burton Abteilung Neurologie, m&i-Fachklinik Bad Heilbrunn, Wo¨rnerweg
30, 83670 Bad Heilbrunn, Germany
Silvia Carrión Unidad de Exploraciones Funcionales Digestivas, Hospital de
Mataro´, Universitat Auto`noma de Barcelona, Barcelona, Spain, Centro de
Investigacio´n Biome´dica en red de Enfermedades Hepa´ticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, Spain
Massimo Castagnola Istituto di Biochimica e Biochimica Clinica, Facolta`di
Medicina, Universita`Cattolica and Istituto per la Chimica del Riconoscimento
Molecolare, CNR, Rome 00168, Italy
Michael Y. Chen Department of Radiology, Medical Center Boulevard, Wake
Forest University School of Medicine, Winston-Salem, NC 27157, USA
Pere Clavé Centro de Investigaeio´n Biome´dica, Universitat Auto`noma de
Barcelona, Hospital de Mataro´, Barcelona, Spain
Jason D. Conway Department of Gastroenterology, Medical Center Boulevard, Wake Forest University School of Medicine, Winston Salem, NC 27157,
USA, e-mail: jconway@wakeh ealth.edu
Doris-Maria Denk-Linnert Section of Phoniatrics, Department of Otorhinolaryngology, Vienna Medical School, Medical University of Vienna, Wa¨hringer
Gu¨rtel 18-20, 1090 Vienna, Austria, e-mail: doris-maria.denk-linnert@
meduniwien.ac.at
Edith Eisenhuber Krankenhaus Goettlicher Heiland, Dornbacher Strasse
20-28, 1170, Vienna, Austria
Olle Ekberg Department of Clinical Sciences/Medical Radiology, Shane
University Hospital, Lund University, 205 02 Malmo¨, Sweden; Diagnostic
Centre of Imaging and Functional Medicine, Ska˚ne University Hospital, 205 02
Malmo¨, Sweden; Department of Diagnostic Radiology, Malmo¨University
Hospital, 205 02 Malmo¨, Sweden, e-mail: olle.ekberg@med.lu.se
Jörgen Ekström Department of Pharmacology, Institute of Neuroscience and
Physiology, Sahlgrenska Academy at the University of Gothenburg, Box 431,
SE-405 30, Go¨teborg, Sweden, e-mail: jorgen.ekstrom@pharm.gu.se
Lars I. Eriksson Department of Anaesthesiology and Intensive Care Medicine,
Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
Daniele Farneti Voice and Swallowing Center, ‘‘Infermi’’ Hospital, Rimini,
Italy, e-mail: lele_doc@libero.it
Pascale Fichaux Bourin Unite´de la Voix et de la De´glutition, Department of
Ear‘ Nose and Throat, CHU de Toulouse, Hoˆ pital Larrey, 31059 Toulouse
Cedex 9, France, e-mail: fichaux-bourin.p@chu-toulouse.fr
Barbara J. Fueger Department of Radiology, Medical University of Vienna,
Vienna, Austria
Contributors xvii
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Peter Funch-Jensen Division for Gastrointestinal Motility Disorders, Department of Radiology, Aarhus Universit y Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark, Aleris-Hamlet Hospital, and Clinical Institute, Aarhus
University, Aarhus C, Denmark
Críspulo Gallegos Departamento de Ingenierı´a Quı´mica, Universidad de
Huelva, 21071 Huelva, Spain
Shaheen Hamdy Department of Inflammation Sciences, Sa lford Royal NHS
Foundation Trust, University of Manchester, Manchester, M6 8HD, UK;
Department of GI Sciences (Clinical Sciences Building), Salford Royal NHS
Foundation Trust, Inflammation Sciences Research Group, University of
Manchester, Manchester, M6 8HD, UK, e-mail: e-mail: shaheen.hamdy@
manchester.ac.uk
Christian Hannig Institut fu¨rRo¨ntgendiagnostik des Klinikums rechts der Isar,
Technische Universita¨tMu¨nchen, Ismaningerstrasse 22, 82756, Munich,
Germany
Anna I. Hårdemark Cedborg Department of Anaesthesiology and Intensive
Care Medicine, Karolinska University Hospital and Karolinska Institute,
Stockholm, Sweden
Hanne Witt Hedström Department of Neuroradiology, Karolinska University
Hospital and Karolinska Institute, Stockholm, Sweden
Bengt Jeppsson Department of Surgery, University Hospital of Skane-Malmo¨,
Institute of Clinical Sciences, Lund University, Malmo¨, Sweden
Nina Khosravani Department of Pharmacology, Institute of Neuroscience and
Physiology, Sahlgrenska Academy at the University of Gothenburg, Box 431,
SE-405 30, Go¨teborg, Sweden
Martijn P. Kos ENT Department, Waterland Hospital, Purmerend, The
Netherlands
Christiane Kulinna-Cosentini Department of Radiology, Medical University of
Vienna, Wa¨hringer Gu¨rtel 18-20, 1090, Vienna, Austria
Richard Kuylenstierna Department of Otorhinolaryngology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
A. Laverty Abteilung Neurologie, m&i-Fachklinik Bad Heilbrunn, Wo¨rnerweg
30, 83670 Bad Heilbrunn, Germany
Alessandro Laviano Department of Clinical Medicine, Sapienza University,
Rome, Italy
Johannes Lenglinger Motility Laboratory, Department of Surgery, Medical
University of Vienna, Vienna, Austria,e-mail: johannes.lenglinger@meduniwien.
ac.at
Marc S. Levine Department of Radiology, Hospital of the University of
Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA, e-mail: marc.
levine@uphs.upenn.edu
xviii Contributors
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M. Macleod Abteilung Neurologie, m&i-Fachklinik Bad Heilbrunn, Wo¨rner-
weg 30, 83670 Bad Heilbrunn, Germany, e-mail: marjorymacleod1950@
yahoo.co.uk
Hans F. Mahieu ENT Department, Meander Medical Center, Amersfoort,
The Netherlands, e-mail: hf.mahieu@meandermc.nl
Thomas Mandl Department of Rheumatology, Ska˚ne University Hospital, 205
02 Malmo¨, Sweden
Bonnie Martin-Harris MUSC Evelyn Trammell Institute for Voice and Swallowing Disorders, Otolaryngology Head and Neck Surgery, Medical University
of South Carolina, Charleston, SC, USA
Irene Messana Dipartimento di Scienze Applicate ai Biosistemi, Universita`di
Cagliari, Cittadella Universitaria Monserrato, 09042 Cagliari, Monserrato,
Italy
Emilia Michou Department of Inflammation Sciences, Salford Royal NHS
Foundation Trust, University of Manchester, Manchester M6 8HD, UK
Satish Mistry Department of Inflammation Sciences, Salford Royal NHS
Foundation Trust, University of Manchester, Manchester M6 8HD, UK
Francesco Mozzanica Department of Biomedical and Clinical Sciences
‘‘L. Sacco’’, University of Milan, Via GB Grassi, 74 20157 Milan, Italy
Göran Nylander Diagnostic Centre of Imaging and Functional Medicine,
Ska˚ne University Hospital, 205 02 Malmo¨, Sweden
Rolf Olsson Diagnostic Centre of Imaging and Functional Medicine, Ska˚ne
University Hospital, 205 02 Malmo¨, Sweden, e-mail: rolf.olsson@med.lu.se
David J. Ott Department of Radiology, Medical Center Boulevard, Wake
Forest University School of Medicine, Winston-Salem, NC 27157, USA
Peter Pokieser Department of Radiology, University of Vienna, Wa¨hringer
Gu¨rtel 18-20, 1090 Vienna, Austria, e-mail: peter.pokieser@meduniwien.ac.at
Mario Prosiegel Abteilung Neurologie, m&i-Fachklinik Bad Heilbrunn,
Wo¨rnerweg 30, 83670 Bad Heilbrunn, Germany, e-mail: mario.prosiegel@
fachklinik-bad-heilbrunn.de
Michèle Puech Unite´de la Voix et de la De´glutition, Department of Ear‘ Nose
and Throat, CHU de Toulouse, Hoˆ pital Larrey, 31059 Toulouse Cedex 9,
France
Stephen E. Rubesin Department of Radiology, University of Pennsylvania
School of Medicine, MRI Building 1-08, University of Pennsylvania Medical
Center, 3400 Spruce St., Philadelphia, PA 19104-4283, USA, e-mail: Stephen.
Rubesin@uphs.upenn.edu
Martina Scharitzer Department of Radiology, University of Vienna, Wa¨hringer
Gu¨rtel 18-20, 1090 Vienna, Austria
Contributors xix
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Wolfgang Schima Department of Radiology, Krankenhaus Goettlicher
Heiland, Dornbacher Strasse 20-28, 1170 Vienna, Austria, e-mail: wolfgang.
schima@khgh.at; wolfgang.schima@meduniwien.ac.at
Antonio Schindler Department of Biomedical and Clinical Sciences ‘‘L. Sacco’’,
University of Milan, Via GB Grassi, 74 20157, Milan, Italy, e-mail: antonio.
schindler@unimi.it
Rainer Schöfl 4th Department of Internal Medicine, Hospital of the Elisabethinen, Fadingerstraße 1, 4020 Linz, Austria
Renée Speyer Mozartstraat 47, 6521 GB, Nijmegen, The Netherlands, e-mail:
r.speyer@online.nl
Zeno Stanga University Polyclinic for Endocrinology, Diabetes and Clinical
Nutrition, University Clinic for General Medicine, University Hospital, Bern,
Switzerland, e-mail: zeno.stanga@insel.ch
Christina Stene Department of Surgery, A¨ngelholm Hospital, Institute of
Clinical Sciences, Lund University, Malmo¨, Sweden, e-mail: christina.stene@
med.lu.se
Eva Sundman Department of Anaesthesiology and Intensive Care Medicine,
Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
Per Thommesen Division for Gastrointestinal Motility Disorders, Department
of Radiology, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C,
Denmark
Dipesh H. Vasant Department of Inflammation Sciences, Salford Royal NHS
Foundation Trust, University of Manchester, Manchester M6 8HD, UK
Eric Verin Service de Physiologie, Hoˆ pital Charles Nicolle, CHU de Rouen,
Rouen, France,
Arastoo Vossough Department of Radiology, Hospital of the University of
Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
Virginie Woisard Unite´de la Voix et de la De´glutition, Department of Ear‘
Nose and Throat, CHU de Toulouse, Hoˆ pital Larrey, 31059 Toulouse Cedex
9, France
Anita Wuttge-Hannig Gemeinschaftspraxis fu¨r Radiologie, Strahlentherapie
und Nuklearmedizin, Dres. Wuttge-Hannig-Rosskopf-Schepp-Sindelar, Karlsplatz 3-5, 80335 Munich, Germany, e-mail: Olle.Ekberg@med.lu.se
Part I
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Anatomy and Physiology
Anatomy and Physiology
https://t.me/med1917
Olle Ekberg and Go¨ran Nylander
Contents
1 Introduction.............................................................. 3
2 Anatomy of the Pharynx and Larynx................... 4
2.1 Cartilages of the Larynx and Pharynx......................... 4
2.2 Muscles ...................................................................... 4
2.3 The Larynx ................................................................ 8
2.4 The Mucosal Surface................................................. 12
3 Anatomy of the Esophagus..................................... 12
4 Neuroanatomy and Physiology of Swallowing..... 14
References.......................................................................... 18
O. Ekberg (&) G. Nylander
Diagnostic Centre of Imaging and Functional Medicine,
Skåne University Hospital, 205 02 Malmö, Sweden
e-mail: olle.ekberg@med.lu.se
Abstract
The oral cavity, pharynx and esophagus constitute
three anatomically and functionally integrated
areas that are involved in swallowing. They are
made up of muscular tubes surrounded by cartilages and bones. Swallowing in controlled by the
brain stem in the central nervous system where the
swallowing centre is located.
1 Introduction
The swallowing apparatus is made up of three
anatomically and functionally separated, but integrated, areas, namely, the oral cavity, the pharynx, and
the esophagus. These are tubular structures with
muscular walls, in certain areas containing bone
and cartilage. Each compartment functions independently, but for a successful swallowing process a
finely tuned coordination between the compartments
is necessary. Each compartment acts as a hydrodynamic pump. Between these pumps are interconnected
valves.
To interpret the findings of the radiological
examination, detailed knowledge of anatomy and
physiology in this area is mandatory. In this context it
is also important to understand that the larynx, both
anatomically and physiologically, is an integrated part
of the pharynx during swallowing. The nomenclature
used in this chapter corresponds to anglicized Latin
commonly in use (Williams et al. 1989). The
description below refers to the adult individual. Those
interested in newborns and infants are referred to
works by Bosma (1973, 1976).
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2011_369,
Ó Springer-Verlag Berlin Heidelberg 2012
3
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are connected, not only with the median and lateral
thyrohyoid ligaments but also by the thyrohyoid
membrane (Fig. 4). There is a lateral opening in the
thyrohyoid membrane through which the laryngeal
artery, vein, and nerve pass. There is also a small cartilage in the posterior and lateral part of the thyrohyoid
ligament. This is called the triticeal cartilage.
Thecricoidcartilagehastheshapeofasignetring and
is made up of a thin anterior part called the arcus of the
cricoid cartilage and a posterior thicker portion called
the lamina of the cricoid cartilage (Fig. 5). On its lateral
marginthecricoidcartilagehasan articulatefacet for the
inferior cornu of the thyroid cartilages. The lamina
Fig. 1 The mandible seen posteriorly
2 Anatomy of the Pharynx
and Larynx
2.1 Cartilages of the Larynx and Pharynx
Several of the important swallowing muscles insert on
the inside of the mandible (Fig. 1). On the inside and
medial surface of the mandible there is a centimetersized crest called the mylohyoid line, where the
mylohyoid muscle inserts. Anteriorly in the midline on
the posterior surface of the mandible there are a couple
of eminences (mental spines) on which the geniohyoid
and genioglossus muscles insert. These muscles then
also insert within the tongue and on the hyoid bone,
respectively. The hyoid bone is made up of a body and
four horns, two on eachside (Fig. 2). Theupper two are
called the lesser cornu of the hyoid bone, and the lower
ones are called the greater cornu of the hyoid bone.
From the lesser cornu there is a ligament that connects
the cornu withthe styloid processof the skullbase. This
ligament is called the stylohyoid ligament.
The thyroid cartilage is made up of two quadrilateral laminae, their anterior borders fused inferiorly
and with a convexity superiorly and anteriorly. It also
has a notch in the midline and superiorly. Posteriorly
the cartilage has four horns (cornu). Two of these
have a superior direction (superior cornu of the
thyroid cartilage) and two have an inferior direction
(inferior cornu of the thyroid cartilage; Fig. 3).
The superior cornu is connected via the thyrohyoid
ligament with the greater cornu of the hyoid bone. The
inferior cornu articulate directly against the cricoid
cartilage. The hyoid bone and the thyroid cartilage
continues superiorly and dorsally in an eminence that
ends with an articulate facet. Against this surface the
arytenoid cartilages articulate. Two inferior horns of the
thyroid cartilage articulate as described above against
the cricoid cartilage. The thyroid and cricoid cartilages
arealsoconnectedviathecricothyroidligament(Fig. 6).
Inferiorly to the cricoid cartilage is the trachea.
The core of the epiglottis is made up of cartilage.
This thin foliate lamella has the form of a racket with
a plate and a shaft. The shaft (petiolus) has a ligament
(thyroepiglottic ligament) that connects it to the
posterior surface of the thyroid cartilage (Fink and
Demarest 1978; Fig. 7a).
The anterior surface of the epiglottis has a fanshaped ligament connecting it to the hyoid bone
(Fig. 7b). This ligament is an extension of the median
glossoepiglottic ligament.
The arytenoid cartilages are shaped like small
pyramids and are located at the posterior and superior
corners of the cricoid cartilage. On top of this pyramid is another small cartilage, namely, the corniculate
cartilage (Fig. 8).
Thereby there is a wall of cartilages, ligaments,
and membranes extending from the hyoid bone and
inferiorly. It reaches all the way to the anterior surface
of the trachea. In the following the relation of the
musculature and mucous membrane to these stabilizing structures will be described.
2.2 Muscles
The floor of the mouth is made up of several muscles,
the positions of which are given in Figs. 9 and 10.The
caudal extreme of the floor of the mouth is made up of
the geniohyoid muscle and the mylohyoid muscle. The
Anatomy and Physiology 5
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Fig. 2 The hyoid bone seen
superiorly and from the left
(a) and anteriorly (b)
Fig. 3 The thyroid cartilage
seen anteriorly (a), anteriorly
and from the left (b), and
from the left (c)
latter inserts on the mylohyoid line on the mandible. It
extends to the hyoid bone, where it inserts (Fig. 9). It is
madeupofa broadmusculardiaphragmthatcoversmost
of the floor of the mouth. Covering this muscle is the
geniohyoid muscle extending from the mental spines in
the midline of the mandible to the body of the hyoid
bone. The stylohyoid muscles extend from the styloid
process to the lesser cornu on both sides (Fig. 10).
Inferiorlyarethethyrohyoidmuscle,thehyoid bone,and
the thyroid cartilage (Fig. 9). Inferior to the hyoid bone
are the sternohyoid muscles and the omohyoid muscles.
2.2.1 Muscles of the Tongue
The genioglossus muscle is the largest muscle of the
tongue and it extends from the mental spines on
the mandible. This fan-shaped muscle widens as it
extends backwards into the tongue. The superior
fibers run to the tip of the tongue, and the middle
fibers run to the dorsum of the tongue and a few of
the inferior fibers extend to the hyoid bone, where the
muscle inserts on the body of the hyoid bone
(Fig. 11a). The hyoglossus muscle extends from the
body and greater cornu of the hyoid bone and extends
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levator veli palatini muscle extends from the inferior
and lateral surface of the temporal bone close to the
foramen of the internal carotid artery as well as from
the inferior aspect of the tubal cartilage (of the
auditory tube). The muscle then extends inferiorly,
medially, and anteriorly and inserts on the midportion
of the aponeurosis of the soft palate (Fig. 13). The
tensor veli palatini muscle extends from the skull base
and from the pterygoid processes of the sphenoid
bone and extends first inferiorly and then turns at a
right angle medially over the hamulus of the pterygoid process to spread horizontally in the aponeurosis
of the soft palate (Fig. 14).
The palatopharyngeal muscle is the most prominent muscle in the soft palate and constitutes the arch.
Fig. 4 Hyoid bone and thyroid cartilage seen anteriorly and
from the left. Light hatching the thyrohyoid membrane, dark
hatching the lateral and median thyrohyoid ligaments. There is
a hole in the membrane for the passage of vessels and nerves
It extends from the inferior body of the tubal cartilage, pterygoid processes, and aponeurosis of the soft
palate. This is the posterior extreme of the soft palate.
The muscle then extends further inferiorly and
posteriorly and forms part of the posterior wall of
from there superiorly into the lateral portions of the
tongue (Fig. 11b). The styloglossus muscle extends
the pharynx. It also reaches the posterior surface of
the thyroid cartilage (Fig. 15).
from the styloid processes of the skull base and the
stylomandibular ligaments. It then extends into
the lateral part of the tongue all the way to the tip of
the tongue (Fig. 11c).
These three muscles join within the tongue and the
muscle bundles fuse (Fig. 11d).
There are also a couple of external tongue muscles
that connect the tongue with the skull base, the
mandible, and the hyoid bone. Other tongue muscles
are separated from these structures and are located
solely within the tongue. They can be divided into
four muscles: (1) the longitudinal superficial muscle,
(2) the longitudinal deep muscle, (3) the transverse
lingual muscles, and (4) the vertical lingual muscles.
A small portion of the transverse lingual muscles runs
up into the soft palate, where it is called the glossopalatine muscle (Fig. 12). Another small portion of
this muscle is called the glossopharyngeal muscle and
extends into the pharyngeal wall musculature
(Fig. 12). In this way the musculature of the tongue
inserts on the skull base, mandible, hyoid bone, soft
palate, and lateral pharyngeal wall.
2.2.3 Muscles of the Pharynx
All muscles in the oral cavity, larynx, and pharynx
are striated. Of the two arches that surround the
tonsils, the medial arch is made up of the previously described palatopharyngeal muscle and the
lateral arch is made up of the glossopalatine muscle
(Fig. 16).
The walls of the pharynx are made up of a fibrous
fascia connected to the mucosa on the inside and to
the musculature on the outside of the wall. Superiorly
towards the skull base there is no proper muscular
layer. The only layers here are the mucosa and fascia,
called the fibrous layer of the pharynx. This has a
width of about 2 cm. Further inferiorly are the constrictor musculatures (Fig. 17). The main part of the
wall of the pharynx is made up of constrictor muscles
and elevators. The elevators are located on the inside,
which is unique in the gastrointestinal tract. The
muscles surrounding the oropharyngeal junction area
are schematically shown in Fig. 18.
The pharyngeal constrictors are made up of
three portions. The superior pharyngeal constrictor
2.2.2 Muscles of the Soft Palate
The soft palate has an important function during
swallowing. It is made up of a fibrous aponeurosis on
which a couple of swallowing muscles insert. The
extends from above with four portions, namely, from
the pterygoid process of the sphenoid bone, from
the pterygomandibular raphe, from the mylohyoid
line on the mandible, and also from the transverse
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