Original articlePharyngeal Dysphagia: What the Radiologist Needs to Know
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.
References (29)
- et al.
The treatment of Zenker's diverticula: A review
Semin Thorac Cardiovasc Surg
(1999) - et al.
Endoscopic stapling diverticulotomy: An audit of difficulties, outcome, and patient satisfaction
Otolaryngol Head Neck Surg
(2006) - et al.
The radiological appearances after the endoscopic cricopharyngeal myotomy: Dohlman's procedure
Clin Radiol
(1997) - et al.
Large pedunculated polyps originating in the esophagus and hypopharynx
Ann Thorac Surg
(2006) - et al.
Examination of the patient with dysphagia
Radiology
(1988) - et al.
Radiologic investigation of dysphagia
AJR
(1990) - et al.
Lines of the pharynx
Radiographics
(1987) - et al.
Lymphoid hyperplasia at the base of the tongueSpectrum of a benign entity
Radiology
(1982) - et al.
Non-Hodgkin's lymphoma of the gastrointestinal tract: Radiographic findings
AJR
(1997) Pathogenesis and methods of treatment of Zenker's diverticulum
Ann Otol Rhinol Laryngol
(2003)
Morphology of the cricopharyngeal muscle in Zenker and control specimens
Acta Otol Rhinol Laryngol
Pharyngeal pouch (Zenker's diverticulum)
Postgrad Med J
Zenker's diverticulum—A historical review and trends in therapy
Acta Otolaryngol
Evolution of surgical treatment for pharyngeal pouch
Br J Surg
Cited by (21)
Imaging in Otolaryngology
2018, Imaging in OtolaryngologyImaging in Gastroenterology
2018, Imaging in GastroenterologyDiagnostic Imaging: Head and Neck
2017, Diagnostic Imaging: Head and NeckOpen approaches to cricopharyngeal hypertonicity and hypopharyngeal diverticulum
2016, Operative Techniques in Otolaryngology - Head and Neck SurgeryCitation Excerpt :After a thorough history and physical examination, most commonly the workup of a patient complaining of dysphagia, regurgitation of undigested food, or aspiration is a radiographic evaluation. Grant et al1 states that the best initial test is a barium study that allows for the evaluation of oropharyngeal and hypopharyngeal motility and which can identify structural or mucosal abnormalities. A modified barium swallow is a diagnostic modality in which a patient eats various consistencies of food treated with barium under fluoroscopic evaluation.
Diagnostic Imaging: Gastrointestinal
2015, Diagnostic Imaging: GastrointestinalZenker's Diverticulum
2014, Clinical Gastroenterology and HepatologyCitation Excerpt :There is no clear evidence of causation by these additional lesions, but it is important to note that additional causes of dysphagia might be present in patients with ZD. The radiologic features of ZD are well known.24 Esophagography is necessary to confirm the diagnosis of ZD (Figure 2A and B); however, dynamic continuous fluoroscopy is preferred (Supplementary Video 1) because static images may be insufficient in patients with small diverticulum.