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384 A. Ba-Ssalamah et al.
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Fig. 18 Hydro-MDCT of the oesophagus in axial (a, b), and
coronal (c) reformations in a patient with a small Zenker’s
diverticulum, lateroposterior to the upper oesophagus filled
Fig. 19 Hydro-MDCT of the oesophagus in axial (a), coronal
(b), and sagittal (c) reformations shows a large paraesophageal
hernia with so-called ‘‘upside down stomach,’’ which is an
with air (a, arrow), and a duplication cyst, which appears as a
smoothly marginated homogeneous mass with water-equivalent
attenuation in the lower oesophagus (b, c, arrows)
extreme form in which all of the stomach has herniated into the
thoracic cavity and no portions of the stomach can be detected
below the diaphragm (arrows and arrowheads)
6.3 Duplication Cyst
Duplication cysts of the oesophagus are rare congenital anomalies that may be noted incidentally on
conventional chest radiographs as an indeterminate
mediastinal mass and require further investigation by
CT (Kuhlman et al. 1985).
6.3.1 CT Findings
Duplication cysts are smoothly marginated, homogeneous masses with water-equivalent attenuation that
most commonly occur in the lower oesophagus
(60 %). They are intimately related to the oesophagus
but rarely communicate with it. The cyst may have a
paraoesophageal or intramural location (Fig. 18).
6.4 Hiatal Hernia
Oesophageal hiatal hernias comprise two types: sliding
axial hernia and paraoesophageal hernia (Eren and
Ciris 2005). Sliding hiatal hernia is a displacement of
the upper stomach with the cardioesophageal junction
upward into the posterior mediastinum. In the paraoesophageal type, all or part of the stomach herniates
into the thorax with an undisplaced gastrooesophageal
Cross-Sectional Imaging of the Oesophagus 385
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Fig. 20 Hydro-MDCT of the oesophagus in coronal reforma-
tion shows a small axial herniation of the stomach that has
resulting in a small retrocardiac mass, and the cardia is
junction. Haemorrhage, incarceration, obstruction, and
strangulation of the stomach and intestine are the most
common complications.
6.4.1 CT Findings
Axial herniation of the stomach results in a large retrocardiac mass and the cardia is displaced into the
thoracic cavity. With CT, the demonstration of gastric
folds is frequent and pathognomonic. A good distension of the stomach and oesophagus is very helpful
in the differential diagnosis. A paraoesophageal hernia is associated with fixation of the gastric cardia and
portions of the stomach herniated alongside the
oesophagus. ‘‘Upside down stomach’’ is an extreme
form of hernia, in which all of the stomach has herniated into the thoracic cavity and no portions of the
stomach can be detected below the diaphragm
(Fig. 19).
displaced into the thoracic cavity (arrowheads). The gastroesophageal junction and distal oesophagus show marked wall
thickening due to reflux oesophagitis (arrow)
patients and can lead to treatment interruptions, which
in turn adversely affects survival.
6.5.1 CT Findings
The inflamed oesophageal mucosa shows uniform,
circumferential wall thickening that usually involves
a relatively long oesophageal segment. Inflammatory
and neoplastic wall changes cannot be reliably distinguished based on CT morphology. Short segments
of ulcerative wall thickening are more suggestive of a
malignant lesion, while longer segments are more
consistent with an inflammatory process. The most
common CT findings are a thickened oesophageal
wall and a target sign. Although endoscopy is a more
sensitive modality for detecting this condition, the CT
finding of a relatively long segment of circumferential
oesophageal wall thickening, with or without a target
sign, should suggest the diagnosis of oesophagitis in
the proper clinical setting (Fig. 20).
6.5 Oesophagitis
Inflammation of the oesophagus is not an indication
for CT. Oesophagitis may be noted incidentally during the course of a CT staging examination or followup (Berkovich et al. 2000). High-grade oesophagitis
manifests in 33–41 % of patients with malignancies,
who are treated with concurrent chemo-radiotherapy.
Painful oesophagitis decreases the nutritional status of
6.6 Oesophageal Varices
Varices of the oesophagus are mainly caused by
portal hypertension. In this case gastric varices communicate with the oesophageal and perioesophageal
veins, which are drained via the azygos/hemiazygos
venous system to the superior vena cava (Balthazar
et al. 1987).
386 A. Ba-Ssalamah et al.
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Fig. 21 Hydro-MDCT of the oesophagus in the axial refor-
mation (venous phase) views in a patient with oesophageal
varices, which appear as brightly enhancing dot-like structures
within the oesophageal wall (arrows)
6.6.1 CT Findings
Oesophageal varices are best visualised in the portal
venous phase or in the delayed phase after administration of contrast material. Oesophageal varices
present as intraluminal (intramural, submucous)
tubular, often dot-like structures that show marked
pooling of intravenous contrast medium (Fig. 21).
Paraoesophageal varices are often larger and have a
more serpiginous structure. CT criteria for oesophageal varices are defined more specifically as nodular
Fig. 22 Hydro-MDCT of the oesophagus in the coronal view
in a patient with paraoesophageal varices, which appear as
brightly enhancing tortuous veins adjacent to the oesophageal
wall (arrow)
or tubular enhancing lesions within the oesophageal
wall that contact the intraluminal surface, thus distinguishing oesophageal from paraoesophageal varices. While oesophageal varices can be appreciated
easily by endoscopy, paraoesophageal varices are
only seen on CT or endoscopic sonography (Fig. 22).
a congenital aortic diverticulum (Kommerell’s
diverticulum), (Fig. 24) in this case dysphagia is more
likely due to compression of the oesophagus (Keum
et al. 2006). CT angiography has already replaced
invasive DSA in the evaluation of thoracic vascular
anomalies and has become the diagnostic procedure
of first choice.
6.7 Dysphagia Lusoria and Aortic
Disease
Aberrations in the course of the aortic arch or supraaortic branches can displace or compress the
proximal oesophagus, leading to dysphagia. The most
frequent cause is an anomalous right subclavian artery
that arises from the descending aorta as a fourth
supraaortic branch and passes behind the oesophagus
that rarely cause dysphagia (dysphagia lusoria)
(Fig. 23). Other causes are a duplicated aortic arch or
an aortic aneurysm. In cases of an anomalous right
subclavian artery its aortic origin may be wide due to
6.7.1 CT Findings
Contrast-enhanced MDCT allows the diagnosis of the
variants of the aortic arch very easily. The aberrant
right subclavian artery, or dysphagia lusoria, demonstrates a typical pattern on contrast-enhanced MDCT
and is more easily diagnosed using multiplanar
reconstructions. It arises more posteriorly than normal, and runs behind the oesophagus (Fig. 23). An
aortic diverticulum appears as a circumscribed
asymmetric aneurysm like protrusion from wide
funnel-shaped origin of the subclavian artery in the
distal aortic arch (Fig. 24).
Cross-Sectional Imaging of the Oesophagus 387
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Fig. 23 Hydro-MDCT of the oesophagus in axial (a), and
coronal (b) reformations shows an abberrant right subclavian
artery (arrowhead) that courses more posteriorly to the
Fig. 24 Hydro-MDCT of the
oesophagus in axial (a) and
sagittal (b) reformations
shows a right-sided aortic
arch with retro-oesopahgeal
left subclavian artery (lusoria
type) arising from an aortic
diverticulum of Kommerell
(arrowhead), which must not
confused with an aneurysm of
the origin of the subclavian
artery. The oesophagus is
compressed (arrow)
7 Clinical Value of Multi-Detector CT
Hydro-MDCT especially in combination with FDGPET is particularly useful in the evaluation and initial
staging of patients with oesophageal carcinoma as well
as for treatment planning and assessing tumour
response to therapy. At present, CT or FDG-PET/CT
plays a major role as a triage tool to aid in choosing the
appropriate treatment for patients with oesophageal
cancer. FDG-PET/CT may help distinguish between
surgical candidates with limited disease and possible
curative surgery or patients who need preoperative
chemoradiation for downstaging, and patients who
need only palliative therapy in advanced cases with
compressed oesophagus (arrow in a), indicative of dysphagia
lusoria. Note the non-compressed oesophagus distally (arrow b)
distant metastases. Thus,the pre-surgical assessmentof
patients with oesophageal cancer with surgical exploration prior to the decision about further therapeutic
procedures can beavoided. If CT orPET/CT depending
on availability shows definitive advanced disease with
extended tumour spread, pre-surgical chemotherapy is
used to downstage the tumour. After completion of
chemotherapy, restaging of the tumour will be performed. Ifthere is apositive response to chemotherapy,
curative surgical therapy will be attempted. Therefore,
preoperative staging of oesophageal cancer appears to
be, byfar, themost important indication for FDG-PET/
CT of the oesophagus. In addition, multi-detector CT
plays an important role in the evaluation of postoperative complications and detection oftumour recurrence
388 A. Ba-Ssalamah et al.
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following oesophagectomy. MDCT can determine the
presence, location, and severity of oesophageal perforations. Furthermore, Hydro-MDCT is an evolving
method for the assessment of other intra- and extraluminal processes of the oesophageal wall.
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Radiat Oncol Biol Phys 81(5):e759–e765
Endoscopy of the Pharynx and Esophagus
https://t.me/med1917
Doris-Maria Denk-Linnert and Rainer Scho¨fl
Contents
1 Introduction.............................................................. 391
2 Endoscopy of the Pharynx and Larynx................ 392
2.1 Indirect Rigid Endoscopy of the Hypopharynx
and Larynx................................................................. 392
2.2 Flexible (Video-)Endoscopy of the Pharynx
and Larynx................................................................. 393
2.3 Examples of Typical Findings .................................. 393
2.4 Flexible Endoscopic Evaluation of Swallowing
(with Sensory Testing) .............................................. 394
2.5 Direct Endoscopy of the Pharynx and Larynx......... 397
3 Endoscopy of the Esophagus .................................. 398
3.1 Symptoms of Esophageal Diseases........................... 399
3.2 Rigid Esophagoscopy (Rigid
Hypopharyngoesophagoscopy).................................. 400
3.3 Flexible Esophagoscopy ............................................ 400
3.4 Rigid Versus Flexible Esophagoscopy ..................... 405
3.5 Recent Developments and Future Prospects ............ 406
4 Role of Endoscopy in the Diagnostic Work-up
of Dysphagic Patients .............................................. 406
5 Conclusion ................................................................ 406
References.......................................................................... 406
D.-M. Denk-Linnert (&)
Department of Otorhinolaryngology,
Section of Phoniatrics, Vienna Medical School,
Medical University of Vienna, Währinger Gürtel 18–20,
1090 Vienna, Austria
e-mail: doris-maria.denk-linnert@meduniwien.ac.at
R. Schöfl
4th Department of Internal Medicine, Hospital of the
Elisabethinen, Fadingerstraße 1, 4020 Linz, Austria
Abstract
Endoscopy ofthe pharynxand esophagus contributesto
the diagnostic work-up of the patients with pharyngeal
and esophageal disorders. Dysphagia is one ofthe main
symptoms. In many cases, endoscopy has emerged as
‘‘first-line’’ examination. In addition to the endoscopic
visualization ofthe(aero)-digestive tract,biopsies allow
histological diagnosis, and therapeutic manipulations
can be performed. However, radiography, especially
videofluoroscopy, remains indispensable. A main focus
of diagnostic interest is the differential diagnosis
between structural diseases and functional disorders.
In order to meet the diagnostic and therapeutic
requirements an interdisciplinaryapproachisnecessary.
Among others, otorhinolaryngologists, gastroenterologists, radiologists and surgeons cooperate in the patient
management.
1 Introduction
The pharynx and esophagus belong to the upper digestive
tract; their morphology and function enable normal
swallowing. Dysphagia is one of the main symptoms in
patients with pharyngeal and esophageal disorders. Diagnostics need to consider the entire swallowing sequence
from the oral cavity to the stomach. However, there is a
close relationship between diseases of the pharynx, larynx
and esophagus: gastrointestinal disorders, e.g., reflux disease, may show extraesophageal manifestations in the
pharynx and larynx, and in case of tumors in the upper
aerodigestive tract or esophagus, additional simultaneous
tumors necessitating early diagnosis may appear.
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_634,
Springer-Verlag Berlin Heidelberg 2012
391
392 D.-M. Denk-Linnert and R. Scho¨fl
https://t.me/med1917
For diagnosticevaluation, endoscopyhas emerged as
the ‘‘first-line’’ examination. Technical progress has
improvedthequalityofendoscopicimagingandenabled
clinically routine video documentation. In addition to
the endoscopic visualization of the aerodigestive tract,
biopsies, recentlyassistedby moleculardiagnosticssuch
as PCR (polymerase chain reaction), allow histological
diagnosis. A wide variety of therapeutic manipulations,
such as ballon dilatation,mucosal resections orstenting,
can be performed. Together with radiology, endoscopy
has become indispensable in the management of diseases of the pharynx and esophagus. A main focus of
diagnostic interest is the differential diagnosis between
structural diseases and functional disorders. For therapeutic decision-making, it is of utmost importance to
prove or exclude malignancy and aspiration.
Patients with pharyngeal and esophageal diseases will
often cross specialty lines. About 80 % of patients with
esophageal disorders present first to an otolaryngologist
because they suffer from head and neck symptoms, such
as dysphagia, cough or globus sensation. Whereas otolaryngology dealswith laryngo-pharyngealdisorders, the
management of esophageal diseases falls more appropriately within therealmof gastroenterology (whichdeals
with the whole intestine), aswell as thoracicsurgery. This
interdisciplinary approach is discussed in this chapter.
Endoscopy and radiology are not the only instrumental methods in the diagnostic armamentarium. In
addition, depending on the patient’s symptoms and
endoscopic or radiologicfindings,further examinations
may be needed for conclusive analysis of the pharynx
and esophagus. For example, manometry, manofluorography, (impedance/) pH-metry, scintigraphy for
quantification ofthe pharyngo-esophageal transport, or
electromyography provide valuable information.
It is the aim of this chapter to describe the endoscopic examinationof the upper aerodigestive tract and
examples of typical findings, and in it, advantages and
limitations of endoscopy are demonstrated. Moreover,
the role of endoscopy within the diagnostic work-up of
dysphagic patientsand future aspectswill be discussed.
2 Endoscopy of the Pharynx
and Larynx
A critical area for deglutition without aspiration is
crossing of the airway and digestive tract, which is
localized in the hypopharynx. Apart from their role in
Fig. 1 Rigid telescope and flexible rhinolaryngoscope
deglutition, pharyngeal structures are part of the vocal
tract, which is responsible for articulation and resonance. Therefore, the pharynx and larynx, as part of
the upper aerodigestive tract, have to be evaluated in
context by the otolaryngologist. With the mirror
examination, the ability to adequately visualize the
pharynx and larynx may be limited. Therefore,
endoscopy has become a clinical routine.
Candidates for endoscopy of the pharynx and larynx are patients presenting with symptoms of respiratory and swallowing diseases, such as dysphagia,
aspiration, regurgitation, odynophagia and dysphonia
(hoarseness). Before endoscopy is carried out, a history is taken and a mirror examination of ears, nose,
mouth, pharynx and larynx is performed.
The indirect endoscopy of the pharynx and larynx
shows their inner surfaces via optical instruments,
either transorally, with rigid endoscopes (telescopes),
or transnasally, with flexible endoscopes. Video
documentation should be obtained whenever possible.
2.1 Indirect Rigid Endoscopy
of the Hypopharynx and Larynx
Rigid 70 and 90 telescopes (Fig. 1) are used to evaluate
the hypopharynx and larynx indirectly. They provide a
magnifiedviewin high resolution,allowvideotaping for
documentation, and can be used in association with
stroboscopy to evaluate vocal fold vibrations. In addition, indirect rigid endoscopy enables the performance
of office-based laryngeal surgical procedures under
topical anesthesia (such as biopsies and indirect phonosurgery for voice improvement in selected cases).
Endoscopy of the Pharynx and Esophagus 393
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For endoscopy, the patient sits in an upright position,
with his tongue protruding, and the examiner gently
inserts the objective end of the telescope posteriorly over
the base of the tongue until the hypopharynx and larynx
are seen. The unphysiological patient condition with the
tongue protruded allows only the examination of ‘‘hi’’phonation, but not the direct observation of articulation
and swallowing. In cases of gag reflex, local anesthesia
can facilitate the examination. The observer examines
morphology (e.g., signs of inflammation, tumor) and
function (respiratory and phonatory vocal fold mobility,
pooling/aspiration of saliva).
2.2 Flexible (Video-)Endoscopy
of the Pharynx and Larynx
Transnasal flexible nasopharyngolaryngoscopy is a
common procedure among otorhinolaryngologists
for assessing nasal, velopharyngeal and laryngeal
pathology. Moreover, it is used for the evaluation of
oropharyngeal swallowing and as a treatment tool in
biofeedback therapy of voice and swallowing disorders.
The flexible rhinolaryngoscope consists of an
objective lens at the distal end of the insertion portion
of the endoscope. The diameter of the insertion tube
of the scope is kept as small as possible (3–4 mm).
A xenon or halogen light source is used. With a chip
camera, the image is viewed on a monitor and
recorded on a digital recorder.
The videoendoscopic technique is a clinical standard for esophagogastroscopes. Recently, technical
progress has made video-rhinolaryngoscopes with a
small diameter (about 3.2 mm outer diameter) possible for transnasal insertion (Kawaida et al. 2002). The
image transfer is not performed via the fibers, but
with a chip camera at the tip of the endoscope. This
technique provides better optical resolution and digital signal modulation.
The flexible nasopharyngolaryngoscope is inserted
through the nasal passage; a topical anesthesia (e.g.
anesthetic and decongestant spray) can be applied
beforehand. The examination begins with the visualization of the nasal fossa, the epipharynx and velum,
and velopharyngeal competence and closure are tested. Then the endoscope is passed down to just above
the epiglottis, where the larynx and hypopharynx can
be seen (panoramic view). The base of the tongue,
position and morphology of the epiglottis,
configuration of the posterior pharyngeal wall, vallecular spaces, piriform sinuses, arytenoids and vocal
folds are investigated. After that, the scope is moved
further down to just above the vocal folds for detailed
inspection (larynx view). Signs of inflammation,
mucosal abnormalities, mass lesions and vocal fold
mobility can easily be observed. If local anesthesia
was administered to reduce the cough reflex, the
glottic level can possibly be passed for inspection of
the subglottic region and trachea.
Flexible endoscopy is also appropriate for patients
who cannot be examined by mirror or rigid endoscopy
because of a strong gag reflex, and for patients who
are not able to cooperate, e.g., pediatric or emergency
patients. The main advantage is that the flexible
endoscope can be left in position during phonation,
articulation and swallowing, therefore it is used for
evaluation of functions. As a limitation, it has to be
pointed out that the image quality of flexible endoscopy does not reach that of rigid endoscopy. Whenever videostroboscopy is performed, the method of
choice is rigid endoscopy.
Our experience with more than 5,000 endoscopies
shows that flexible endoscopy is a procedure without
major complications. However, vasovagal reaction,
laryngospasm or epistaxis are described in the literature. Therefore, all emergency measurements for
managing such complications must be available.
2.3 Examples of Typical Findings
Normal Hypopharynx and Larynx. The base of the
tongue, posterior pharyngeal wall, piriform sinus and
supraglottis are covered by intact epithelium; the vocal
folds present in a white color due to the non-keratinizing squamous epithelium. Both vocal folds move
symmetrically between the respiration and phonation
positions. No pooling of saliva or food is seen.
Hypopharynx Carcinoma. Foreign tissue and perhaps ulceration is seen in the hypopharynx (posterior
pharyngeal wall, piriform sinus or postcricoid region).
Due to tumor infiltration, vocal fold motility may be
disturbed. Figure 2 shows an exophytic tumor mass in
the left piriform sinus, reaching the postcricoid wall.
Due to tumor infiltration, the left vocal fold is paralyzed. The patient’s symptoms included dysphonia,
dyspnea and long-lasting, slowly progressing
dysphagia.
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