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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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256 S. E. Rubesin
https://t.me/med1917
Fig. 4 Lines of the pharynx.
a Spot radiograph showing
vertically oriented striations
(arrows) in the lateral and
posterior surface of the
hypopharynx. These lines reflect
the underlying longitudinal
muscle layer. b Low-power
photomicrograph of the lateral
pharyngeal wall showing close
apposition of the squamous
epithelium (short arrow)tothe
longitudinal muscle layer (long
arrowhead). Only a thin tunica
propria (long straight arrow)
separates the squamous
epithelium from thelongitudinal
muscle layer. The constrictor
muscle layer is identified by a
curved arrow. (Reproducedwith
permission from Rubesin and
Glick 1988,Figs. 5a,6)
Fig. 5 Postcricoid mucosa.
a Spot radiograph of the pharynx
obtained while the bolus was
passing through the
pharyngoesophageal segment
showing undulating mucosa
(arrows) just behind the cricoid
cartilage. b Low-power
photomicrograph obtained at the
level of the cricoid cartilage (thick
arrow) showing a sinuous
squamous epithelium (curved
arrows) corresponding to the
undulating mucosa seen in a.The
submucosa (long arrow)isvery
thick at this level, reflecting the
need for this area to move easily.
Compare the thickness of the
submucosaherewiththethickness
of the tunica propria in Fig. 4b.
The cricoarytenoid muscle
(arrowhead) lies posterior to the
cricoid cartilage. (a Reproduced
with permission from Rubesin
2000a,Fig.47a;b reproduced
with permissionfromRubesinand
Glick 1988,Fig.8)
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Fig. 6 The thyrohyoid
membrane. a Spot radiograph
of the pharynx showing focal
indentation of the contour of
the lateral hypopharyngeal
wall (arrow). This marks the
transition between the
hypopharynx that lies above
the ala of the thyroid cartilage
and the portion of
hypopharynx confined by the
thyroid cartilage.
b Corresponding line drawing
demonstrating the point where
the anterolateral
hypopharyngeal wall becomes
confined by the thyroid
cartilage (arrow). The
thyrohyoid membrane
(t) bridges the space between
the hyoid bone (b) and the
thyroid cartilage (c). Also
note the epiglottic cartilage
(e) and cricoid cartilage (Cr).
(Reproduced with permission
from Rubesin et al. 1987a,
Fig. 10a and b)
external auditory meatus. The second branchial cleft
forms the middle ear, eustachian tube, and floor of the
tonsillar fossa. The third and fourth branchial pouches
form the piriform sinuses. Persistence of either a
branchial cleft or a branchial pouch may result in a
sinus tract or cyst.
The most common branchial vestige is a cyst
arising from the second branchial cleft. Small second
branchial cleft cysts lie anterior to the sternocleidomastoid muscle. Larger cysts may extend below the
sternocleidomastoid muscle between the internal and
external carotid arteries. These cysts only rarely
communicate with the pharynx (Bachman et al.
1968).
Branchial pouch sinusesendblindly in the softtissue
of the neck. Branchial pouch fistulas extend to theskin.
Branchial pouch sinuses and fistulas arise from the
tonsillar fossa (second pouch), the upper anterolateral
wall of thepiriform sinus (thirdpouches), and thelower
anterolateral wall of the piriform sinus (fourth pouches). Although most of these sinuses and pouches are
present at birth, sinus tracts are occasionally detected
for the first time in adults (Fig. 10).
3.3 Zenker’s Diverticulum
Zenker’s diverticulum (posterior pharyngeal diverticulum) is an acquired mucosal herniation through
Killian’s dehiscence, a gap in the region of the cricopharyngeal muscle, found in about one third of
individuals on autopsy (Zaino et al. 1970). There is
considerable variation in the anatomy of the thyropharyngeal muscle and the cricopharyngeal muscle.
Thus, Killian’s dehiscence has been described as
arising either between the thyropharyngeal muscle
and the cricopharyngeal muscle or between the
oblique and transverse fibers of the cricopharyngeal
muscle (Perrot 1962; Zaino et al. 1967, 1970).
The relationship between Zenker’s diverticulum
and the function of the cricopharyngeal muscle is not
known. In some studies, upper esophageal sphincter
(UES) pressure is normal (there is no spasm), the
muscle relaxes completely during swallowing (there
is no achalasia), and there is normal coordination
between pharyngeal contraction and UES relaxation
(Knuff et al. 1982; Frieling et al. 1988). Other
studies have suggested that there is either abnormal
258 S. E. Rubesin
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Fig. 7 Location of lateral pharyngeal pouches. a Line drawing
performed in the lateral view showing the location of the
unsupported portion of the thyrohyoid membrane (arrow):
posterior to the thyrohyoid muscle (m) and membrane, anterior
to the superior cornu of the thyroid cartilage and inserting fibers
of the stylopharyngeal muscle (s), inferior to the hyoid bone (h),
and superiorto the alaof the thyroidcartilage (a). bDissection of
the pharynx viewed from behind showing the unsupported
portion of the thyrohyoid membrane (black arrow) and the
internal branch of the superior laryngeal nerve (black
relaxation of the UES or incoordination of pharyngeal
contraction. It is also not known whether chronic gastroesophageal reflux predisposes to the development of
Zenker’s diverticulum. Clearly,between 65 and95%of
patients with Zenker’s diverticulum have gastroesophageal reflux (Smiley et al. 1970; Delahunty et al.
1971; Rubesin and Levine 2001).
Zenker’s diverticulum is usually first detected in
elderly patients who complain of dysphagia, halitosis,
choking, hoarseness, or regurgitation of undigested
food. Zenker’s diverticulum is not infrequently found
in asymptomatic individuals or patients being studied
for symptoms of gastroesophageal reflux disease.
Change in the character of dysphagia or bloody discharge in a patient with a known Zenker’s
arrowheads). The thyroid cartilage is identified by open arrows.
Also identified are the palatopharyngeal fold (white P) and its
corresponding palatopharyngeal muscle (black P), the uvula (u),
the circumvallate papillae (tiny white arrow), the left pharyngoepiglottic fold(arrowhead), the leftpiriform sinus (one white dot
on the left), the mucosa overlying the cuneiform and corniculate
cartilages (tiny black arrows), the right arytenoid muscle (one
white dot on the right, and the cricoarytenoid muscle (two white
dots on the right). (Reproduced with permission from Rubesin
et al. 1987a, Figs. 8b, 11c)
diverticulum suggests development of a complication
such as ulceration, fistula formation, or carcinoma
(Nanson 1976; Shirazi et al. 1977).
Radiographically, in the frontal view, Zenker’s
diverticulum appears as a barium-filled sac midline
below the tips of the piriform sinuses (Figs. 11, 12).
In the lateral view, Zenker’s diverticulum appears
as a barium-filled sac posterior to a prominent pharyngoesophageal segment and the upper cervical
esophagus (see Fig. 12). During swallowing, Zenker’s
diverticulum appears as a protrusion of the lower
hypopharyngeal wall posterior to the expected luminal contour, the neck of the diverticulum originating
above a ‘‘prominent’’ pharyngoesophageal segment.
The opening of the diverticulum may be very large
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Fig. 8 Lateral pharyngeal pouches. a Spot radiograph obtained
during drinking showing a small right (small whitearrow)andlarger
left (large white arrow) lateral pharyngeal pouch. Note the
relationship with the hyoid bone (h). The epiglottis (small black
arrows) is tiltingasymmetrically. Notethe heightof the right lateral
pharyngeal pouch(doublearrow) whilethepatient drinksthe bolus.
during swallowing, almost 2 cm in height (Fig. 13).
After the swallow has passed, barium regurgitates
back into the hypopharynx, in rare cases, resulting in
overflow aspiration. Any irregularity of the contour of
the diverticulum suggests development of an ulcer or
carcinoma (Wychulis et al. 1969).
Zenker’s diverticulum should not be confused with
a ‘‘pseudo-Zenker’s diverticulum,’’ barium trapped
above a cricopharyngeal bar that has either opened
incompletely or closed early (Fig. 14). Some pseudoZenker’s diverticula are pouches arising at Killian’s
dehiscence. It is not known whether a Zenker’s
diverticulum can develop from a pseudo-Zenker’s
diverticulum. This author believes that many pseudoZenker’s diverticula result from cricopharyngeal
response to gastroesophageal reflux (Brady et al.
1995).
b Spot radiograph obtained just after the swallow in a showing that
the pharynx has descended to its normal resting position. The notch
identifying the superior border of the thyroid cartilage is identified
(white arrow). Note the difference in height of the thyrohyoid
membrane during swallowing (double arrow in a)andatrest
(double arrow in b)
3.4 Killian-Jamieson Pouches
and Diverticula
Killian-Jamieson diverticula protrude through the
Killian-Jamieson space, a gap in the muscle of the proximal cervical esophagus. This gap is bounded superiorly
by the inferior margin of the cricopharyngeal muscle,
anteriorly by the inferior margin of the cricoid cartilage,
and inferomedially by the suspensory ligament of the
esophagus just below its origin on the posterior lamina of
the cricoid cartilage (Killian 1908). These diverticula are
also known as ‘‘proximal lateral cervical esophageal
diverticula’’ or ‘‘lateral diverticula from the pharyngoesophageal junction area’’ (Ekberg and Nylander 1983a).
Patients with Killian-Jamieson diverticula are usually
asymptomatic or have symptoms caused by abnormal
pharyngeal motility (Rubesin and Levine 2001).
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Fig. 9 Lateral pharyngeal diverticulum. a Spot radiograph
obtained with the patient in the frontal position showing a 5-mm
ovoid sac (arrow), partially filled with barium. Note that the
diverticulumprotruding from theleftlateralupper hypopharyngeal
During pharyngography, the opening of the
Killian-Jamieson diverticulum lies just below the
cricopharyngeal muscle (Fig. 15). The opening of
the sac changes size and shape with elevation of the
cervical esophagus during swallowing (see Fig. 15).
The sac of the diverticulum lies lateral to the proximal
cervical esophagus on frontal views and overlaps the
cervical esophagus on lateral views. Killian-Jamieson
diverticula are more frequently unilateral than bilateral and are usually left-sided (Fig. 16) (Rubesin and
Levine 2001). Bilateral diverticula are seen in about
one quarter of patients. Killian-Jamieson diverticula
are smaller than Zenker’s diverticula, averaging about
1.4 cm (Rubesin and Levine 2001). Regurgitation of
barium from the sac into the hypopharynx is
uncommon because regurgitation is prevented by the
cricopharyngeal muscle. Occasionally, KillianJamieson diverticula and a Zenker’s diverticulum are
seen in the same patient (Fig. 17).
Pouches are also frequently detected at the KillianJamieson space. These pouches may be related to
early closure of the upper cervical esophagus, a
finding associated with gastroesophageal reflux. On
the frontal view, pouches appear as shallow, broadbased protrusions of the lateral proximal cervical
esophageal wall; these pouches are effaced during
swallowing (Ekberg and Nylander 1983a).
wall is about at the level of the valleculae (left vallecula identified
with v). b Spot radiograph obtained with the patient in the lateral
position showing that the ovoid diverticulum (arrow) arises from
the anterior portion of the lateral hypopharyngeal wall
Fig. 10 Second branchial pouch sinus. Spot radiograph
obtained with the patient in a steep right posterior oblique
position showing an irregular barium-filled track (arrows)
arising from the region of the right palatine fossa. (Reproduced
with permission from Rubesin and Glick 1988, Fig. 23b)
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Fig. 11 Small Zenker’s
diverticulum. a Spot
radiograph obtained with the
patient in the frontal position
showing a 5-mm ovoid
barium-filled sac (arrow)
midline below the tips of the
piriform sinuses. b Spot
radiograph obtained with the
patient in the lateral position
showing a 4-mm barium-filled
sac (arrow) posterior to the
expected lumen of the
pharyngoesophageal segment.
Note that this tiny
diverticulum persists after
swallowing but does not
extend posterior to the
pharyngoesophageal segment
Fig. 12 Moderately large
Zenker’s diverticulum. a Spot
radiograph obtained with the
patient in the frontal position
showing a 3-cm barium-filled
sac (arrow) midline below the
tips of the piriform sinuses.
b Spot radiograph obtained
with the patient in the lateral
position showing a relatively
flat, but long barium-filled sac
(large arrows) posterior to the
pharyngoesophageal segment
and upper cervical esophagus
(small arrow)
262 S. E. Rubesin
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Fig. 13 Opening of a moderately large Zenker’s diverticulum.
a Spot radiograph obtained with the patient at rest and in the
lateral position showing a 2 cm 9 3 cm sac (large arrow)
posterior to the pharyngoesophageal segment (small arrow) and
upper cervical esophagus. b Spot radiograph obtained just as
the bolus (b) had approached the pharyngoesophageal segment
Fig. 14 Pseudo-Zenker’s
diverticulum. a Spot image
obtained during swallowing
showing no evidence of a
diverticulum at the level of
the cricoid cartilage, as
identified by redundant
postcricoid mucosa (open
arrow). b Spot image
obtained just after the
swallow had passed showing
barium trapped (arrow) above
a cricopharyngeal bar that had
closed early. Seconds later the
pseudo-Zenker’s diverticulum
disappeared when the
collection of barium entered
the cervical esophagus
showing that the opening (double arrow) of the Zenker’s
diverticulum is very high, at least the height of one vertebral
body. Barium entering the laryngeal vestibule was due to
abnormal timing between the oral and pharyngeal phases of
swallowing. (b Reproduced with permission from Rubesin
1991, Fig. 5c)
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Fig. 15 Killian-Jamieson
diverticula. a Spot radiograph
obtained at the end of the
swallow showing a 1.3-cm
diverticulum (thick arrow)
arising from the left lateral
wall just below the level of
the cricopharyngeal muscle.
The neck (double arrow)of
the diverticulum is broad
during swallowing. b Spot
radiograph obtained just after
the bolus had passed showing
a narrower neck (double
arrow) of the diverticulum.
c Spot radiograph obtained
with the patient in the lateral
position showing a 1.3-cm
diverticulum (large arrow)
below the level of the
cricopharyngeal muscle. Part
of the diverticulum lies
anterior to the expected
course of the
pharyngoesophageal segment
and upper cervical esophagus
(small arrow). Barium in the
laryngeal vestibule and
proximal trachea was related
to a pharyngeal motor
disorder. d Spot radiograph
obtained during swallowing
demonstrating that
part of the diverticulum (white
arrow) lies anterior to the
pharyngoesophageal segment.
The presence of a prominent
cricopharyngeal muscle
(black arrow) demonstrates
that the diverticulum lies
below the cricopharyngeal
muscle. (Reproduced with
permission from Rubesin and
Levine 2001, Fig. 1)
4 Inflammatory and Other Lesions
4.1 Lymphoid Hyperplasia
The normal surface of the base of the tongue has a
reticular pattern created by the underlying lingual
tonsil, an aggregate of 30–100 follicles extending
from the circumvallate papillae to the root of the
epiglottis (see Fig. 2) (Gromet et al. 1982). Hypertrophy of the lingual tonsils may occur after
puberty, as a compensatory response to tonsillectomy/
adenoidectomy, or as nonspecific response to allergy
or repeated infection.
Hypertrophy of the lingual tonsils disrupts the
normal reticular surface pattern. There are no radiographic criteria, however, to differentiate nodularity
of the base of the tongue attributed to the normal
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is demonstrated radiographically, carcinoma or lymphoma should be excluded via ENT examination and/
or MRI.
4.2 Acute Pharyngitis
Acute epiglottitis usually affects children between 3
and 6 years of age, but may also be seen in adults
(Harris et al. 1970). Plain film diagnosis is important,
as manipulation of the tongue/pharynx or barium
studies may exacerbate edema and trigger acute
respiratory arrest (Balfe and Heiken 1986). Smooth
enlargement of the epiglottis and aryepiglottic folds
allows plain film diagnosis of severe epiglottitis.
Barium studies are usually not performed in
immunocompetent patients with acute sore throat. In
immunocompromised patients, barium studies are
used to demonstrate the presence, type, and severity
of esophagitis. Thus, in patients with AIDS, a doublecontrast examination may demonstrate the small
ulcers of herpetic pharyngitis or the plaques of
Candida pharyngitis (Fig. 20) (Rubesin and Glick
1988). Acute inflammatory disorders may cause
laryngeal penetration due to abnormal pharyngeal
elevation, epiglottic tilt, or laryngeal closure.
Videopharyngography may be performed, however, on patients with acute odynophagia or dysphagia after trauma or suspected iatrogenic
trauma. A nonionic water-soluble contrast agent is
Fig. 16 Killian-Jamieson diverticulum. Spot radiograph
obtained during swallowing showing a 1.5-cm barium-filled
sac (arrow) arising from the left lateral wall near the
pharyngoesophageal segment. After swallowing the orifice of
the diverticulum was shown to be below the cricopharyngeal
muscle (Reproduced with permission from Rubesin and Levine
2001, Fig. 2)
lingual tonsil from that of lymphoid hyperplasia. On
frontal views in patients with lymphoid hyperplasia,
there are large 5–7 mm, smooth-surfaced nodules
carpeting the vertical surface of the tongue (Figs. 18,
19a). On the lateral view, these nodules protrude
posteriorly (Fig. 19b). With severe lymphoid hyperplasia, nodules may be detected in the valleculae, on
the lingual surface of the epiglottis, and in the upper
hypopharynx. Although lymphoid hyperplasia can
appear coarsely nodular, asymmetrically distributed,
or masslike, if any asymmetric or masslike nodularity
givenfirst,followedbyanionic,water-soluble
contrast agent if no laryngeal penetration is seen
(Fig. 21). When no perforation is demonstrated
with a water-soluble contrast agent, this author
prefers to give high-density barium, as this form
of barium sticks to the mucosal surface and is
easier to detect in the extraluminal soft tissues
than thin barium.
4.3 Chronic Inflammatory Conditions
In patients with acute corrosive ingestion, watersoluble contrast agent studies may be utilized to
exclude perforation of the pharynx, esophagus, or
stomach. Corrosive ingestion can result in amputation
of the uvula and epiglottis and diffuse ulceration.
With healing and scarring, epiglottic and pharyngeal
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Fig. 17 Zenker’s diverticulum and left lateral Killian-Jamie-
son diverticulum arising in same patient. a Spot radiograph
obtained with the patient in the frontal position demonstrating a
3-cm barium-filled Zenker’s diverticulum (Z) positioned
slightly to the left of the midline. Barium in the right piriform
sinus (p) results from reflux of barium from the Zenker’s
diverticulum back into the hypopharynx. A 1.6-cm left lateral,
barium-filled Killian-Jamieson diverticulum (K) lies below and
wall deformity results in pharyngeal dysmotility
(Fig. 22).
Aphthous stomatitis and oropharyngeal ulceration
with subsequent scarring may be seen in Behçet’s
syndrome, bullous pemphigoid, epidermolysis bullosa, Reiter’s syndrome, and Stevens-Johnson syndrome (Bosma et al. 1968; Kabakian and Dahmash
1978). Amputation of the uvula and tip of the epi-
glottis may be detected radiographically (Bosma et al.
1968).
to the left of the Zenker’s diverticulum. b Spot radiograph
obtained with the patient in a steep right posterior oblique
position showing that the Zenker’s diverticulum (Z) extends
posterior to the pharyngoesophageal segment (arrowhead). Part
of the Killian-Jamieson diverticulum (K) lies anterior to the
course of the proximal cervical esophagus. (Reproduced with
permission from Rubesin and Levine 2001, Fig. 3)
4.4 Webs
Webs are thin folds of epithelium and lamina propria
most frequently found on the anterior wall of the
lower hypopharynx and proximal cervical esophagus
(Clements et al. 1974). Pharyngeal and cervical
esophageal webs are seen in 3–8% of patients
undergoing an upper gastrointestinal examination and
in up to 16% of patients on autopsy (Seaman 1967;
Clements et al. 1974; Nosher et al. 1975; Ekberg
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