Original article
Pharyngeal Dysphagia: What the Radiologist Needs to Know

https://doi.org/10.1067/j.cpradiol.2007.08.009Get rights and content

Dysphagia is defined as difficulty in swallowing. Oropharyngeal dysphagia is defined as difficulty in moving the bolus from the mouth to the esophagus. The best initial evaluation of suspected oropharyngeal dysphagia is a barium study which can evaluate motility of the oropharynx and hypopharynx and provide double-contrast views that may identify structural or mucosal abnormalities. Pharyngeal diverticula, Zenker's and Killian–Jamieson diverticula, and pharyngeal pouches are readily identified on these studies. Zenker's diverticula are the commonest diverticulum implicated in pharyngeal dysphagia and typically occur in the setting of cricopharyngeal dysfunction. The radiologist must not only diagnose these diverticula but also understand the normal postoperative appearance after diverticulotomy, often confusing for the uninitiated imager. Cervical webs are a common finding in pharyngeal dysphagia and should not be mistaken for a normal postcricoid defect. Other potentially challenging diagnostic issues include correct identification of lingual hyperplasia, which mimics lymphoma, and detection of squamous carcinoma, which is more mass-like but sometimes difficult to see among the complex anatomic lines of the pharynx. All of the above abnormalities are easily differentiated from the retention cyst, the most common “mass” in the pharynx. Pathology extrinsic to the pharynx, such as tumor and cervical osteophytes, can result in secondary symptoms from mass effect. This article discusses the various radiographic findings in normal and abnormal states of the pharynx, an anatomically and functionally complicated segment of the gastrointestinal tract.

Section snippets

Anatomy

The pharynx extends from the nasal cavity to the upper esophageal sphincter, the cricopharyngeus.1, 2 It is divided into three regions: nasopharynx, oropharynx, and hypopharynx (FIG 1, FIG 2). It is formed of inner circular and outer longitudinal layers of striated muscle.

The lingual tonsil is located at the base of the tongue and extends to the vallecula. It can undergo hyperplasia (Fig 3),4 which can be difficult to differentiate from tumor such as lymphoma (Fig 4). Lymphoma of the lingual

Pharyngeal Pouches and Diverticula

Lateral pharyngeal pouches (FIG 5, FIG 6) are transient protrusions of pharyngeal mucosa through areas of weakness of the lateral pharyngeal wall, most common in the region of the tonsillar fossa or the thyrohyoid membrane, where the superior laryngeal artery and vein perforate the membrane. Pouches are more common in the elderly, are typically bilateral, and in almost all cases are asymptomatic. Pharyngeal diverticula (Fig 7)persist and are most common in wind instrument players, glass

Zenker's Diverticula

Zenker's diverticulum is a pulsion diverticulum that arises in the hypopharynx just proximal to the cricopharyngeus. It is most common in older men. Although it protrudes from an intrinsic area of anatomic weakness (Fig 8), it is thought to be secondary to cricopharyngeal dysfunction (Fig 9)6, 7, 8, 9 and resultant elevated pharyngeal pressure. The diverticulum originates in the hypopharynx but extends inferiorly (Fig 10), trapping food and liquid within the sac. The distended sac may compress

Surgical Treatment of Zenker's Diverticula

Treatment of Zenker's diverticulum may be done by traditional open surgical or endoscopic techniques including the following10, 11:

  • Diverticulum invagination

  • Diverticulopexy

  • Diverticulectomy

  • Endoscopic diverticulotomy

  • Cautery

  • CO2 laser

  • Stapler

Since Zenker's diverticulum is thought to arise at least in part as a complication of abnormal relaxation of the cricopharyngeus, cricopharyngeal myotomy has had a long standing history in the treatment of Zenker's diverticula and is usually performed in

Other Diverticula

Killian–Jamieson diverticula arise from the proximal anterolateral cervical esophagus (Fig 17), also in a location of anatomic weakness. They are smaller, less common, less likely to cause symptoms, and less likely to be associated with secondary aspiration or gastroesophageal reflux disease than Zenker's diverticula.18

Webs

Webs are thin mucosal folds most frequently located along the anterior wall of the lower hypopharynx and proximal cervical esophagus. Webs appear as 1 to 2 mm in width shelf-like filling defects (FIG 18, FIG 19). Occasionally, webs are circumferential. Cervical webs have been linked to conditions such as gastroesophageal reflux disease, epidermolysis bullosa dystrophica, or benign mucus membrane pemphigoid.19 Some evidence supports an association between cervical esophageal webs and iron

Benign Tumors

Although not neoplastic, retention cysts are the most common benign mass lesions in the pharynx (Fig 21).20 They are small, round or ovoid, well-circumscribed, smooth-surfaced submucosal masses, best seen on frontal views of the pharynx. They are typically located in the valleculae or along the aryepiglottic folds. These cysts are thought to result from dilation of mucus glands in the lamina propria or deeper layers due to retained secretions and chronic inflammation. Usually asymptomatic,

Malignant Tumors

Squamous cell carcinoma is by far the most common malignant tumor of the pharynx. Tongue base squamous cell carcinomas may extend into the valleculae, pharyngoepiglottic fold, or palatine tonsil and may penetrate deep into the tissue of the tongue. Fluoroscopically, ulcerative tumors are seen as irregular contrast collections extending anteriorly, disrupting the normal smooth contour of the tongue base. Polypoid tumors project posteriorly and laterally into the oropharynx and are best

Extrinsic Compression

Dysphagia can sometimes result from extrinsic compression from space-occupying lesions within the pharynx or neck. Bulky lymphadenopathy and vertebral osteophytes24 are common etiologies. Less common sources are benign tumors like lipomas or rare malignant soft-tissue tumors such as sarcomas.

Large syndesmophyte/osteophyte complexes in diffuse idiopathic skeletal hyperostosis can cause pharyngeal dysphagia (“DISHphagia”) (Fig 24).25 There are several mechanisms of dysphagia caused by osteophytes.

Conclusion

The pharynx is an anatomically and functionally complicated segment of the gastrointestinal tract. The radiologist must be familiar with the normal, abnormal, as well as postoperative, radiographic findings of the pharynx.

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