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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1015_Библиотеки_им_академика_М_И_Перельмана
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204 P. Pokieser and M. Scharitzer
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Fig. 6 Fifth standard position. This image shows the middle
and lower esophagus in the erect left posterior oblique position.
It is useful to repeat this scene in the right posterior oblique
position to obtain two different projections of the esophageal
phase. Gravity enforces the passage of contrast material in the
erect position. With a single act of swallowing, the passage
through the lower esophageal sphincter is shown (arrows). The
patient is asked to swallow just once, to hinder repeated
superimpositions of peristaltic waves. Practical advice: about
3 s after the pharyngeal phase in the first or second standard
position, you develop the fifth standard position by following
the bolus. This can be done when no abnormal findings were
visible during the pharyngeal phase; then stop the movement of
the central beam, when the esophagogastric junction is visible
Fig. 7 Sixth standardposition.Theesophageal passage in prone
position allows the peristaltic wave of the esophagus to be
visualized. Repeated in the supine position, the esophageal
transport is visualised ina different way. Hernias, rings andother
findings are often seen in one position only—prone or supine. The
cranially V-shaped peristaltic wave (arrow) is followed downwards fromthetop.As advised forthefifth standard position, you
may follow the peristaltic wave with the central beam. The
central beam should not be moved, during visualization of the
dynamic movements of the esophagogastric junction
the patient has referred her problem, questions should
focus on the presence of the symptoms or syndromes
discussed in more detail in the following sections.
2.1 Dysphagia
Eating and drinking have to be executed without pulmonary compromise and shouldbeforpersonaland social
pleasure, nutrition and hydration. Any subjective feeling
of disturbance is called dysphagia (Buchholz 1996).
In oropharyngeal dysphagia, the patient has difficulty swallowing. Isolated oral dysphagia is
The Clinical and Radiological Approach to Dysphagia 205
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Fig. 8 This graph demonstrates the seven functional units of
swallowing. Within 1 s, six of the units complete the pharyngeal stage of swallowing; then the esophagus bridges the long
Fig. 9 a The oral phase is started by the intake of a beverage
or the ingestion of food into the oral cavity. The lips close and
seal the oral cavity anteriorly. To form the bolus, the substance
is first loaded on the dorsum of the tongue. This process is
under voluntary control. In this process, the tongue and soft
uncommon and based on neurogenic disorders or
diminished salivary flow. Also, some drugs (anticholinergics, antihistaminics, antidepressants, antihy-
distance through the mediastinum to the stomach. A complete
barium swallow of about 15 ml should reach the stomach
within 10 s
palate together seal off the posterior part of the oral cavity
(arrows). b When the involuntary act of deglutition is started,
the tongue performs a wave-like movement and presses the
manipulated bolus along the hard palate backwards into the
pharynx. c Only the barium coating remains in the oral cavity
pertensives, and diuretics) affect salivary flow, and
neuroleptic drugs may slow or disrupt the oral phase
of swallowing.
206 P. Pokieser and M. Scharitzer
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Fig. 10 a This75-year-old womanwith cerebralischemiacannot
control the bolusintheoralcavity.b The oraltransit is achieved by
tilting the head backwards. This causes some blurring and the
spatialresolutionisreduced.Onlyminimalamounts ofmaterialare
Fig. 11 a An 81-year-old woman suffers from Parkinson’s
disease. She has already aspirated material from previous
swallows. Pooling in the valleculae is present. b The tongue
fails to reach the hard palate and cannot propel the whole bolus
Pharyngealdysphagiaisoften describedbythepatient
as asensation ofdifficultpassage ofthe bolus through the
region of the suprasternal notch, most frequently caused
by neuromuscular disorders causing weakness and/or
incoordination of the striated muscles used for swallowing (Buchholz 1987). Less frequently, structural
narrowings, such as neoplasms, postoperative defects,
Zenker’s diverticula, or mucosal webs, are found.
In esophageal dysphagia, thematerial seems to stick
along the swallowing tract; the patient may localize the
site anywhere from the suprasternal notch to the epigastrium. Usually the patient cannot differentiate
between the proximal or distal site of an esophageal
lesion (Edwards 1974). For example, a Schatzki ring at
the level of the esophagogastric junction or achalasia
often produce symptoms above the suprasternal notch.
Intermittent esophageal dysphagia for solid food is
transported. Aspiration occurs (arrow). c Contrast material has
pooled in the lower oral cavity beneath the anterior parts of the
tongue. Minor aspiration after the swallow (postdeglutitive) has
occurred, and there is pooling in the valleculae (arrow)
into the oropharynx. Dorsal excursion of the tongue appears to
be limited (arrow). c Barium mixed with mucus remains stuck
to the hard palate and the tongue. Retentions in the valleculae
have increased
typical for lower esophageal rings or strictures with a
remaining lumen of less than 2 cm. Rapid progress of
solid food dysphagia within 3 months is often found in
esophageal carcinoma. If there is no sign or proof of
aspiration, esophageal dysphagia for fluids only indicates esophageal motor disorders. Depending on the
severity of the motility disturbance, the latter can produce solid food dysphagia as well. Regurgitation of
previously ingested food can arise during a meal from
any cause or location; late regurgitation of undigested
food is typical of a Zenker’s diverticulum or achalasia.
Complaints of sour and/or bitter material with heartburn is pathognomonic for gastroesophageal reflux
(GER). Furthermore, gastroesophageal reflux disease
(GERD) is the most common cause of ‘‘non- cardiac
chest pain.’’ After exclusion of a cardiac cause, the
esophagus has to be evaluated. A 3-week therapy with
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specific history. If patients with chest pain do not
show any evidence of cardiac disease, the term ‘‘noncardiac chest pain’’ is often diagnosed.
2.2 Aspiration
Aspiration is defined as the entry of liquid or food into
the airways below the level of theglottis. Choking and/
or coughing immediately following a swallow, as well
as recurrent pneumonia, is suspect of aspiration. Silent
aspiration may occur if the cough reflex is absent or
diminished. Persons who aspirate are at increased risk
for serious respiratory sequelae, including airway
obstruction and aspiration pneumonia. The quantity,
Fig. 12 In this 69-year old patient with cerebral ischemia, the
dorsal closureof the oralcavity is disturbedand contrast medium
prematurely passes into the pharynx—so-called ‘‘leaking’’
proton pump inhibitors can be an effective diagnostic
and therapeutic approach. Odynophagia means painful
swallowing; the pain is described as ‘‘sharp,’’ usually
indicating ulcerative mucosal lesions of the pharynx or
esophagus, whereas a dull or squeezing pain is associated with esophageal spasm.
the depth of aspiration (trachea or distal airways), and
the physical properties of the aspirate influence the
effectsofaspiration (Palmer etal.2000). Aspiration can
occur anterograde, during or immediately after swallowing, or as retrograde aspiration of gastric or
esophageal contents. The radiologist must be aware of
patients at risk of aspiration. The tailored VF study
avoids severe aspiration during the examination (Jones
and Donner 1988).
3 Multidisciplinary Evaluation
2.1.1 Globus Sensation
Globus is a common problem, found in about 5 % of
general otolaryngologic patients. A ‘‘lump in the
throat,’’ the sensation of a foreign body, sore throat,
frequent throat clearing and fullness, are typical
complaints of these patients. Symptoms tend to occur
intermittently. Often the symptom improves during
eating, while a combination with dysphagia is frequently found. In 75 % of 150 patients with globus as
the only symptom, VF could depict pathological
functional and/or morphologic findings; evidence of
an esophageal motor disorder was present in 47 % of
them (Schober et al. 1995). A high incidence of
esophageal motility disorders in this setting was
detected by manometry in 87 % (Moser et al. 1991).
Globus sensation seems to be a symptom of laryngopharyngeal irritation, not specific to GERD, but in
which GERD plays a role (Woo et al. 1996). There
remains an open discussion about the pathogenesis
of globus. However, the term ‘‘globus hystericus’’
should be avoided, and pharyngeal and/or esophageal
pathologies should be ruled out according to the
The radiologist should be familiar with the specific
techniques of different medical fields when investigating patients with swallowing problems. There is a
considerable overlap in using different clinical tests
by different clinical fields, with variations from
country to country. We try to clarify the clinical
interaction more than the borders between clinical
specialties.
function and physical mobility, as well as his/her
nutritional and hydration status.
the respiratory function related to aspiration or conditions in which aspiration might cause severe problems. The cardiovascular system has to be assessed
for possible sources of emboli to the brain; impairment of the musculoskeletal system can affect normal
mobility; and the swallowing mechanism can be
affected by different systemic diseases, such as
scleroderma or muscular diseases.
of Swallowing Disorders
General patient status includes mental and social
Examination of the chest can reveal problems with
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Fig. 13 a Before the act of swallowing, the soft palate, in
conjunction with the tongue, seals off the oral cavity dorsally
(arrow). b During the pharyngeal phase, the soft palate is raised
to a right angle and tightens the oropharynx together with the
posterior wall of the pharynx (arrow). The latter is called
Passavant’s cushion at this level, where the pharyngeal wall
Fig. 14 In this 55-year-old patient with myasthenia, elevation
of the soft palate is disturbed. A gap of air remains between the
posterior wall of the pharynx and the soft palate (arrow) when
the patient utters the ‘‘k’’ sound
converges to the soft palate. Thus, food particles are prevented
from entering the nasopharynx. One can test the elevation of
the soft palate towards the posterior wall of the pharynx by
having the patient utter words beginning with a ‘‘k’’, such as
‘‘Kathy’’. c After the act of swallowing, the soft palate returns
to its original position
Fig. 15 This 53-year-old woman who had undergone surgery
for a carcinoma of the right tonsil has a defect in the dorsal soft
palate, that causes regurgitation. During swallowing, spillage of
contrast material into the nasopharynx can be observed (arrow).
Contrast material haspenetratedintothelarynx. The soft palate is
shortened and deformed postoperatively. Aspiration has occurred
The status of otolaryngologists and speech/language pathologists includes a full head and neck
examination. The neck should be evaluated for masses, especially for adenopathies, enlarged thyroid, and
scars that indicate surgery on structures involved in
swallowing. An inspection should be performed of the
oral cavity, cranial nerve function, palate, pharynx
and larynx, with indirect laryngoscopy or by fiberoptics to assess for tumors, mucosal integrity, vocal
cord motion, pooling of secretions into the vallecula
or the piriform sinus, as well as sensation and voice
(Sonies et al. 1987). Stridor is a sign of upper airway
obstruction and may be audible only on auscultation
over the trachea; the sounds of swallowing motility
and the palpation of the elevation of the hyoid and
larynx are part of the dynamic clinical investigation.
Fiberoptic endoscopic evaluation of swallowing
(FEES) is a well-established diagnostic test and
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Fig. 16 a The epiglottis is usually seen even without contrast
medium, in the lateral view of the pharynx (arrow). b The
epiglottis should tilt below the horizontal plane. The complete
tilt can be seen as a small longitudinal structure at the end of the
bolus passage (arrow). c Even healthy individuals with a good
Fig. 17 a, and, b Incomplete epiglottic tilt (arrow). c This is combined with retention in the valleculae and piriform sinuses
(arrows)
swallowing function occasionally reveal asymmetrical tilting of
the epiglottis. In frontal views, one side tilts more deeply than
the other (arrows). Unilateral muscular weakness can cause the
same finding but is often combined with abnormal radiological
findings or other clinical signs of swallowing impairment
Fig. 18 a The hyoid bone and the air column in the lateral
projection. The hyoid is visible as a bony structure, while the
larynx is represented by an air column (arrows). b To protect
the respiratory tract, the hyoid and larynx move cranially and
ventrally at the beginning of the involuntary act of swallowing
(arrow). The elevation of the larynx is visible fluoroscopically.
It has to be emphasized that the pharyngeal muscles are
elevating simultaneously, almost invisible for VF. c The
opening of the larynx is tightly closed during the movement
of the larynx, and the air column of the trachea is visible up to
the horizontal end at the level of the vocal cord (arrow). During
elevation, the hyoid and larynx come closer to each other. The
upward movement of the larynx can be measured as an
approximation. It varies widely and individually and with the
volume of the bolus. If the elevation is less than 1 cm it can be
described as abnormal. The height of a cervical vertebral body
represents another approximation to estimate the minimum of
laryngeal elevation
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Fig. 19 a In this 45-year-old man who underwent resection of a
tumor of the pharynx, retentions of contrast material in the
hypopharynx from previous swallows are present. b The larynx
Fig. 20 a A 65-year-old man after a mild stroke. The opening
of the larynx closes too late or in an incomplete manner. In this
case, contrast medium enters the subepiglottic space (arrow). It
may penetrate deeper into the supra-glottic space (arrowhead).
enables assessment of nasal, velopharyngeal, and
laryngeal pathology of morphologic and functional
changes as well. The flexible, light-weight instruments are inserted through the nose. Video documentation can be integrated. FEES is complementary
to VF and the application and interpretation of results
is the interdisciplinary task of otolaryngologists,
speech/language pathologists and radiologists. FEES
does not show the entire motion of essential foodway
structures and the bolus during swallowing, but can
identify aspiration and pharyngeal retentions. Firstly,
results of FEES and VF are ‘‘diagnostic studies.’’
Secondly, they allow the clinician to design an
appropriate diet and compensatory maneuvers
designed to improve pharyngeal clearance and reduce
aspiration. This use of VF and FEES is called ‘‘therapeutic studies’’ it includes investigations that test the
effectiveness of therapy.
rises veryslightly,less than 1 cm andnot even 50 % ofthe height
of a cervical vertebral body (arrow). c After the swallow, some
drops of contrast material have entered the larynx
b When this relatively mild disorder of closure is present, most
of the material that enters is pressed back into the pharynx from
the larynx (arrow). c Postdeglutitively, only the subepiglottic
space is marked (arrow)
FEES is also used by neurologists. However, the
neurologic examination is a crucial part of the
multidisciplinary approach to dysphagic patients.
Cerebrovascular disease, Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis, poliomyelitis, myasthenia gravis and dementia are examples
of the wide spectrum of neurological disorders that
may involve deglutition.
Invasive treatment of the upper esophageal
sphincter (UES) is performed by otolaryngologists
as well as general surgeons, and is frequently used
as therapy for Zenker’s diverticulum. Different
surgical strategies are under continuous discussion.
Myotomy of the UES with or without resection of
the diverticulum itself, and myotomy with laser or
with an endoscopic approach are applied to restore
an adequate opening of the pharyngoesophageal
segment.
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Fig. 21 a This 62-year-old man who had a stroke clearly
aspirates before the involuntary act of swallowing, as the
swallowing act begins too late and contrast medium has entered
the larynx long before the initiation of swallowing (arrow).
Fig. 22 a Frontalview of a64-year-old man withfracture of the
skull base andcerebralhemorrhageshowspremature leakage and
pooling of contrast material in the right piriform sinus (arrow).
b Bariumenters the larynxand the tracheabefore the involuntary
Gastroenterologists and surgeons are specialists in the
diagnosis and treatment of esophageal disease. Endoscopy reveals even subtle mucosal details and can take
biopsies for pathologic diagnosis. But endoscopy may
overlook subtle rings or stenoses, that can be passed by
the endoscope, but will hinder larger boluses of solid
food. Furthermore, endoscopy cannot display the topographic relation of stenoses to the important anatomic
b Mild aspiration of some drops of water-soluble contrast
medium is visible (arrow). There is an incomplete epiglottic tilt
and retentions in the valleculae (arrowhead)
swallow (arrows). cIntradeglutitivepharyngealpropulsioninthe
frontal projection when the patient tries to clear the retentions
with repeated swallows (arrows). Less than 10 % of the bolus
was aspirated before the involuntary swallow (arrowhead)
landmarks in all cases and often cannot be forwarded
distal to a narrow stenosis. VF is helpful in such instances, providing excellent topographic overviews, testing
for subtle stenoses with solid bolus, and examining the
esophagus distal to stenoses. Benign and malignant
macromorphological changes of the esophageal tube are
detected byendoscopy andVF (Scharitzer etal. 2002).In
esophageal motility disorders, VF can detect a delayed
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Fig. 23 a This 77-year-old woman after laser resection of a
laryngeal carcinoma, presents with a competent seal of the oral
cavity dorsally before swallowing. b The postoperative defect
causes insufficient closure of the larynx and more than 10 % of
Fig. 24 a A 55-year-old man after a stroke, in frontal
projection. Pharyngeal retentions in the valleculae and piriform
sinuses are present. There is an intense coating of the
pharyngeal walls. Aspiration from previous swallows is present
(arrows). b Reduced movements of the lateral pharyngeal walls
the swallowed contrast medium is aspirated during the
pharyngeal phase. c The aspirated contrast medium has reached
the bronchial tree. Thus, after the swallow, only small amounts
are visible in the trachea
cannot propel the whole volume of 15 ml through the
pharyngeal tube. c After swallowing, aspiration occurs (arrow),
caused by retentions in the piriform sinuses. The retentions
have caused an overflow at the laryngeal entrance, which has
opened and moved caudally in the resting phase
Fig. 25 a First, a slight grade I aspiration. This means that a
few drops of contrast medium are aspirated. b Second, a
moderate intradeglutitive aspiration, grade II. As far as can be
seen, no more than 10 % of the bolus has been aspirated.
c Third, a massive grade III aspiration with an aspirated volume
of far more than 10 % of the ingested bolus
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Fig. 26 a The right time point at which the pharyngeal
contraction begins is very important for a physiological
swallowing act. If the contrast medium has passed the angle
of the jaw or has reached the valleculae, the involuntary act of
swallowing should begin (arrow). b In the lateral view, the
onset of pharyngeal wave of contraction can be seen as an
indentation (arrow), that descends rapidly during the propulsion
of the bolus. c After the passage, there should only be a coat of
contrast medium in the valleculae and the sinus (arrow), but no
residues with fluid levels
Fig. 27 a In the frontal view, the pharyngeal walls are
delineated lateral convex without retentions in the piriform
sinuses (arrows). b The lateral pharyngeal walls should move
rapidly towards medial, with a symmetrical movement
(arrows). c In the late intradeglutitive phase, the bolus is
squeezed out of the pharynx (arrows)
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