Pharynx and Esophagus Flashcards
studies dedicated to evaluation of swallowing disorders and suspected lesions of the pharynx and esophagus
Barium pharyngography, barium swallow, barium esophagography
Upper GI series, also called barium meal is an extended barium examination of the alimentary tract from the pharynx and esophagus down to the level of
ligament of Treitz
what should be done to distend and collapse the pharynx and optimize visualization of mucosal detail in Barium pharyngography
lateral and AP views of the pharynx are recorded with the patient phonating “eee” and “aaahh”
positioning of patient in esophagogram
upright position and in prone right anterior oblique positioning
pharynx extend from ____ to ____
nasal cavity to larynx
3 pharyngeal compartments
oropharynx, nasopharynx, hypopharynx
nasopharynx extends from ___ to ____
skull base to the soft palate
function of the nasopharynx
entirely respiratory
oropharynx extend from ___ to ____
posterior to the oral cavity and extends from the soft palate to hyoid bone
hypopharynx extend from ___ to ____
extends from hyoid bone to cricopharyngeus muscle
forms the anterior boundary of the oropharynx
base of the tongue
separates the larynx from the oropharynx and hypopharynx
epiglottis and aryepiglottic folds
two symmetrical pouches formed in the recess between the base of the tongue and epiglottis
valleculae
valleculae is divided by the ___ medially and bounded by ____ laterally
median glossoepiglottic fold and lateral glossoepiglottic fold
deep, symmetrical, lateral recesses formed by the protrusion of the larynx into the hypopharynx
piriform sinuses
extent of the esophagus
from the cricopharyngeus muscle at the level of C5-6 to the GEJ
muscle layers of the esophagus
outer longitudinal muscle layer and inner circular muscle layer lined by stratified squamous epithelium
esophagus lacks ____, which allows for rapid spread of tumor into adjacent tissues
serosal layer
segment of esophagus that is predominantly striated muscle
proximal 1/3
segment of esophagus that is predominantly smooth muscle
distal 2/3, below the level of the aortic arch
normal instrinsic impression on the esophagus are made by the
aortic arch, left main bronchus, left atrium
multiple regular, transverse folds, 1 mm thick, result from contraction of the longitudinal fibers in the muscularis mucosa. this pattern is called
feline esophagus
feline esophagus in humans is an early sign
dysmotility or esophagitis
Abnormal distention of the esophagus measures
more than 10 mm in the upper esophagus and more than 20 mm in lower esophagus
air fluid levels in the esophagus are normal or abnormal?
always abnormal
normal thickness of the wall of esophagus in CT and MR
2 to 4 mm
anatomy of the esophagogastric region is complex. The length of the esophagus is ___ and its termination is ___
length is tubular, termination is saccular
the saccular termination of the esophagus is called the
esophageal vestibule
the tubulovestibular junction of the esophagus is formed by a symmetrical muscular ring called
A ring
asymmetrical mucosal ring or notch that occurs at the junction of esophageal squamous epithelium with gastric columnar
B ring
B ring is also marked by this line which is a thin ragged line of demarcation seen on double-contrast views of lower esophagus
Z line
Radiographic markers of GEJ
B ring and Z line
It is a 2-4 cm long high pressure zone located in the esophageal vestibule. It is a physiologic rather than an anatomic structure
lower esophageal sphincter
angled opening in the diaphragm, formed by the edges of the diaphragmatic crura. On CT and MR, the crura appear as often prominent, teardrop-shaped structures of muscle density
esophageal hiatus
With normal breathing, the proximal vestibule and A ring lie in the
thorax
with normal breathing, the mid-vestibule is in the ____, the distal vestibule and B ring are in the _____
the mid-vestibule is in the esophageal hiatus, the distal vestibule and B ring are in the abdomen
with swallowing, the vestibule and B ring are seen in
vestibule opens and moves upward and the B ring may be seen 1 cm above the diaphragm
normal process of swallowing can be divided into
oral, pharyngeal and esophageal ohases
stage of swallowing that involves mastication, formation of bolus, and voluntary transport of the bolus from the oral cavity into the pharynx
oral stage
movement of larynx, laryngeal vestibule, epiglottis and aryepiglottic folds during swallowing
larynx elevates, laryngeal vestibule closes, epiglottis and aryepiglottic folds close over the opening into the larynx and deflect the bolus thru the lateral piriform recesses
functional upper esophageal sphincter is formed by
cricopharyngeus and other pharyngeal muscles
composed of a rapid wave of inhibition that opens the sphincters, followed by a slow wave of contraction that moves the bolus
primary peristalsis
appears as a stripping wave that traverses the entire esophagus from top to bottom
primary peristalsis
secondary peristalsis is initiated by the
distention of esophageal lumen
peristaltic wave that starts in the mid-esophagus and spreads simultaneously up and down the esophagus to clear reflux or any part of a bolus left behind
secondary peristalsis
nonproductive contractions associated with motility disorders. Irregular contractions follow one another at close intervals from the top to bottom of the esophagus
tertiary waves
contractions that cause a corkscrew or beaded appearance of the esophageal barium column
tertiary waves
defined as awareness of swallowing difficulty during the passage of solids or liquids from mouth to stomach
dysphagia
food “sticking in the throat” and painful swallowing is called
odynophagia
defined as entry of barium into the laryngeal vestibule without passage below the vocal cords
laryngeal penetration
aspiration is evident when the ingested bolus passes thru
vocal cords into the proximal trachea
this is attributable to failure of complete relaxation of the UES, commonly resulting in dysphagia and aspiration
cricopharyngeal achalasia
shelf-like impression on barium column at the pharyngoesophageal junction at the level of C5-6
cricopharyngeal bar
cricopharyngeus muscle is normally ____ between swallows and ____ during swallowing
normally closed between swallows, relaxes for passage of bolus during swallowing
when this is present during swallowing, it indicates dysfunction and incomplete opening
cricopharyngeal bar
narrowing of the esophageal lumen greater than how many percent is generally accepted as definite cause of dysphagia
50%
cricopharyngeal dysfunction is commonly associated with what conditions
GERD, Zenker diverticulum, neuromuscular disorders of the pharynx
disease of unknown etiology characterized by absence of peristalsis in the body of esophagus, marked increase in the resting pressure of LES, failure of LES to relax with swallowing
Achalasia
deficiency of ganglion cells in the myenteric plexus (Auerbach plexus) throughout the esophagus
achalasia
clinical presentation of this condition is insidious, usually at age 30 to 50 years, with dysphagia, regurgitation, foul breath and aspiration
achalasia
tertiary waves in achalasia are common in what stage of disease
early stage
tx of achalasia
balloon dilation or Heller myotomy
diseases that may mimic esophageal achalasia include
chagas disease, carcinoma of GEJ, peptic strictures
caused by destruction of ganglion cells of the esophagus due to a neurotoxin released by protozoa, Trypanosoma cruzi, endemic to South america, especially eastern Brazil. radiographic appearance is identical to achalasia. associated abnormalities include cardiomyopathy, megaduodenum, megaureter and megacolon
Chagas disease
this condition may mimic achalasia, but tends to involve a longer (> 3.5 cm) segment of the distal esophagus, is rigid, and tends to show more irregular tapering of the distal esophagus and mass effect
Carcinoma of GEJ
syndrome of unknown cause, characterized by multiple tertiary esophageal contractions, thickened esophageal wall, and intermittent dysphagia and chest . primary peristalsis is usually present, but the contractions are infrequent
Diffuse esophageal spasm
in this condition, LES is frequently dysfunctional and the condition commonly improves with injection of Clostridium botulinum toxin at the GEJ or with endoscopic balloon dilation of the LES
diffuse esophageal spasm
characterized on barium studies by intermittently absent of weakened primary esophageal peristalsis with simultaneous, nonperistaltic contractions that compartmentalize the esophagus, producing a classic corkscrew appearance. CT reveals circumferential thickening (5 to 15 mm) of the wall of the distal 5 cm of esophagus in 20% of patients
diffuse esophageal spasm
common cause of abnormalities of the oral, pharyngeal or esophageal phases of swallowing
neuromuscular dysfunction
most common cause of neurologic dysfunction causing swallowing problem include
cerebrovascular disease and stroke
systemic disorder of unknown case characterized by progressive atrophy of smooth muscle and progressive fibrosis of affected tissues. the esophagus is affected 75 to 80% of patients. presents with weak to absent peristalsis in the distal 2/3 of esophagus, delayed esophageal emptying, stiff dilated esophagus that does not collapse with emptying, wide-gaping LES with free gastroesophageal reflex
scleroderma
esophagitis frequently results in
abnormal esophageal motility and visualization of tertiary esophageal contractions
occurs as a result of incompetence of the LES. the resting pressure of LES is abnormally decreased and fails to increase with raised intra-abdominal pressure
GERD
complications of GERD
reflux esophagitis, stricture, development of Barrett esophagus and esophageal dysmotility
a finding of importance in treating GERD surgically
shortening of esophagus
provocative maneuvers to demonstrate GERD
Valsalva, leg raising and cough
most sensitive means of diagnosing GERD
monitoring of esophageal pH for 24 hours in an ambulatory patient
management of GERD
medically with agents that inhibit gastric acid production or surgically with fundoplication
normal esophageal hiatus should not exceed ___ mm
15 mm
protrusion of any portion of the stomach into the thorax. considered synonymous with GERD, however most patients with this condition do not have GERD or evidence of esophagitis. It delays the clearance of reflux and promotes development of RE
hiatus hernia
Most common hiatus hernia
sliding hiatal hernia
presence of retrocardiac mass with air-fluid level suggests
sliding hiatal hernia
crucial factors in producing symptoms of and causing complications in sliding hiatal hernia
function of LES and presence of pathologic GERD
most common type of paraesophageal hernia
mixed or compound hiatal hernia
type of hiatal hernia in which the GEJ remains in normal location, while a portion of the stomach herniates above the diaphragm
paraesophageal hernia
type of paraesophageal hernia wherein the GEJ is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated
Mixed or compound type
paraesophageal hernias, especially when large, with most of the stomach in the thorax, are at risk for
volvulus, obstruction, and ischemia
protrusions of pharyngeal mucosa through areas of weakness of the lateral pharyngeal wall
lateral pharyngeal diverticula
most common region of lateral pharyngeal diverticula
region of tonsillar fossa, thyrohyoid membrane
mostly seen in wind instrument players; reflect increased intrapharyngeal pressusre
lateral pharyngeal diverticula
complication of lateral pharyngeal diverticula
laryngeal penetration and aspiration
Zenker diverticulum arises from
hypopharynx, just proximal to UES
location of Zenker diverticulum
posterior midline at the cleavage plane known as Kilian dehiscence
structure between the circular and oblique fibers of the cricopharyngeus muscle
Kilian dehiscence
this diverticulum has a small neck, that is higher than the sac
Zenker diverticulum
Zenker diverticulum is rarely found in what age
under age 40
diverticulum that originate on the lateral wall of proximal cervical esophagus in a gap just below the cricopharyngeus and lateral to the longitudinal tendon of the esophagus
Kilian-Jamieson diverticula
these diverticulum are less common and considerably smaller than Zenker diverticulum and appear on pharyngoesophagography as persistent left-sided or, less frequently, bilateral outpouchings from the proximal cervical esophagus below the cricopharyngeus
Kilian-Jamieson diverticula
mid esophageal diverticula types
pulsion and traction
diverticula occur as a result of distorted esophageal peristalsis
pulsion
diverticula that occur because of fibrous inflammatory reactions of adjacent lymph nodes and contail all esophageal layers
traction diverticula
most of these diverticulas have large mouths, empty well and are usually asymptomatic
mid esophageal diverticula
diverticula that occur just above the LES, usually on the right side. usually found in patients with esophageal motility disorder. it has small neck, higher than sac, in which they may trap food and liquids and cause symptoms
epiphrenic diverticula
small outpouchings of esophagus that usually occurs as a sequela of severe esophagitis
sacculation
how to differentiate sacculations from ulcerations
smooth contour of sacculations
dilated excretory ducts of deep mucus glands of esophagus. they appear as flask-shaped barium collections that extend from the lumen or as lines and flecks of barium outside the esophageal wall. tends to occur in clusters and in association with strictures
intramural pseudodiverticula
intramural tracking that bridges is seen in
intramural pseudodiverticula
radiographic signs of esophagitis
thickened esophageal folds (>3mm), limited esophageal distensibility (asymmetric flattening), abnormal motility, mucosal plaques and nodules, erosions and ulcerations, localized strictures and intramural pseudodiverticulosis (barium filling of dilated 1 to 3 mm submucosal glands)
hallmark finding of esophagitis
ulcers
small esophageal ulcers are found in
RE, herpes, acute radiation, drug-induced esophagitis, benign mucus membrane pemphigoid
larger esophageal ulcers are found in
CMV, HIV, Barrett esophagus and carcinoma
small esophageal ulcers measures
<1 cm
large esophageal ulcers measure
> 1cm
result of esophageal mucosal injury by exposure to gastroduodenal secretions
reflux esophagitis
findings of RE are always prominent in the
distal esophagus and GEJ
early change of RE
mucosal edema; granular or nodular pattern of esophagus
most common cause of esophageal ulcerations
RE
key in differentiating RE ulcers from those of herpes or drug induced esophagitis
prominence of the ulcerations in the distal rather than proximal or mid-esophagus
complications of RE include
ulceration, bleeding, stricture, Barrett esophagus
acquired condition of progressive columnar metaplasia of the distal esophagus caused by chronic gastroesophageal reflux. columnar rather than squamous epithelium line the esophagus
Barrett esophagus
it is a premalignant condition of the esophagus, with a 30 to 40 times increased risk of developing adenocarcinoma
Barrett esophagus
characteristic radiographic appearance of Barrett esophagus
high (mid-esophageal) stricture or deep ulcer in a patient with GERD
reticular mucosal pattern of esophageal mucosa, resembling areae gastricae of stomach is also suggestive of
Barrett esophagus
infectious esophagitis is found most commonly in patients with
compromised immune system, those who use steroids for a long time, cytotoxic drugs and AIDS
most common cause of infectious esophagitis
Candida albicans
prominent symptom of infectious esophagitis
odynophagia
most characteristic radiographic finding of infectious esophagitis
plaque-like lesions demonstrated by air-contrast esophagrams
fulminant diseases of infectious esophagitis produces _____ with a pattern of tiny bubbles at the top of the barium column
foamy esophagus
begins as discrete vesicles that rupture to form discrete mucosal ulcers. ulcers may be linear, punctate or ring-like and have a characteristic radiolucent halo
Herpes simplex esophagitis
most characteristic of herpes
discrete ulcers on a background of normal mucosa involving the mid-esophagus
cause of fulminant esophagitis in patient with AIDS
CMV
esophagitis that characteristically manifests as one or more large, flat, mucosal ulcers
CMV
HIV esophagitis causes
giant ulcers and severe odynophagia
least common portion of the GI tract to be involved by TB
esophagus
manifestation of esopgeal TB
ulceration, stricture, sinus tract, abscess formation
result of intake of oral medications that produce a focal inflammation in areas of contact with mucosa
Drug-induced esophagitis
drugs that cause drug-induced esophagitis
tetracyline, doxycycline, quinine, aspirin, indomethacin, ascorbic acid, potassium chloride, theophylline
radiographic appearance of drug-induced esophagitis
identical to herpes esophagitis, with discrete ulcers separated by normal mucosa in mid-esophagus
healing in drug-induced esophagitis happens within ____ days of discontinuing the offending medication
7 to 10 days
drug induced esophagitis appearance
feline esophagus
agents that produce deep (full thickness) coagulation necrosis
alkaline agents/ liquid lye
radiation esophagitis produces
long smooth stricture
chemotherapeutic drug that greatly accentuate esophageal inflammation
doxorubicin hydrochloride (adriamycin)
defined as any persistent narrowing of the esophagus
strictures
most common cause of esophageal strictures
fibrosis induced by inflammation and neoplasm
True or false: radiographic findings are not reliable in differentiating benign from malignant strictures
true
causes of distal esophageal strictures
Barrett esophagus, mediastinal radiation, caustic ingestion and skin diseases such as pemphigoid, erythema multiforme, epidermolysis bullosa dystrophica
benign esophageal strictures usually present as
smoothly tapering concentric narrowing
malignant esophageal strictures are characteristically
abrupt, asymmetric, eccentric narrowings with irregular, nodular mucosa, tapered margins
why does malignant esophageal strictures have tapered margins
because of ease of submucosal spread of tumor
most common cause of esophageal stricture
RE
small smooth sacculations and fixed transverse folds that cause scarring of
RE
most RE stricture size are
1- 3 cm
pathologic fixed ring-like stricture at the level of B ring , caused by RE
Schatzki ring
typical Schatzki ring are of what size
2 to 4 mm in length
long term nasogastric intubation may cause
long segment stricture
Barrett esophagus tend to be high in the mid esophagus and may be smooth and tapered or ring-like narrowings. the high position is because of
tendency for strictures to occur at the squamocolumnar junction, which has been displaced to a position well above GEJ
corrosive strictures appears
long and symmetrical
this type of esophagitis may occur in patients who have undergone partial or total gastrectomy
alkaline reflux esophagitis
reflux of bile or pancreatic secretions into the esophagus results in
development of severe alkaline reflux esophagitis and distal esophageal strictures
this surgical procedure helps prevent reflux of bile and pancreatic secretion into the esophagus
Roux-en-Y reconstruction
this should be suspected when barium examination performed in patients who have undergone partial or total gastrectomy or gastrojejunostomy reveals a long stricture in the distal esophagus
Alkaline reflux stricture
increasingly common diagnosis made most often in young men with a history of allergies
eosinophilic esophagitis
presents with long-standing history of dysphagia and food impaction. Barium studies demonstrate smooth, long-segment narrowing of the esophagus or a series of ring-like strictures called “ringed esophagus”
eosinophilic esophagitis
treatment of eosinophilic esophagitis
steroids
doses of ___ Gy to esophagus causes radiation strictures
50 to 60 Gy
strictures from radiation therapy happens after how many months
3-6 months after radiotherapy
radiation induced esophageal strictures appears
smooth and tapered and usually in the upper or mid-esophagus
characteristic esophagram finding of malignant stricture
prominent or nodular shoulders
they are thin (1-2 mm) delicate membranes that sweep partially accross the esophageal lumen
Webs
pharyngeal webs most commonly arise from the
anterior wall of hypopharynx
esophageal webs may occur anywhere, but they are most common in the
cervical esophagus just distal to the cricopharyngeus impression
causes of extrinsic compression in the esophagus
lung carcinoma, lymphoma, metastasis to mediastinal nodes, tuberculosis, histoplasmosis
thick esophageal folds are commonly present in
RE
appear as serpiginous filling defects that change in size with changes in intrathoracic pressure and that collapse with esophageal peristalsis and distention
varices
esophageal varices are best demonstrated with what imaging
UGI with mucosal relief views
refers to portosystemic collateral veins that enlarge because of portal hypertension
uphill varices
uphill varices are formed by
coronary vein collaterals connect with gastroesophageal varices that drain into the IVC via azygos system
formed as a result of obstruction of SVC with drainage from the azygos system through esophageal varices to portal vein
downhill varices
these are thick, tortuous, longitudinal folds that resemble varices but are rigid and persistent
varicoid carcinoma
appears as intraluminal mass in the pharynx seen as filling defect, abnormal luminal contour, or focal increased density, mucosal irregularity owing to ulceration or mucosal elevations and asymmetrical distensibility due to infiltrating tumor or extrinsic nodal mass
pharyngeal carcinoma
most pharyngeal carcinoma are
Squamous cell CA
pharyngeal carcinomas usually arise from
base of tongue, palatine tonsil, posterior pharyngeal wall, piriform sinus
benign lesions that typically involve the valleculae and should not be mistake for pharyngeal neoplasm. appear as smooth, well-defined round or oval filling defects best appreciated on frontal views. they arise from dilation of mucus glands caused by chronic inflammation
pharyngeal retention cysts
true or false: pharyngeal retention cysts are never malignant
true
lymphoma of pharynx usually manifest as
large, bulky tumor of lingual or palatine tonsils
most common cell type of esophageal carcinoma related to increasing incidence of GERD
adenocarcinoma
arises from malignant transformation of columnar epithelium of Barrett esophagus in the lower third of esophagus
esophageal adenocarcinoma
arises from stratified squamous epithelium that lines the entire esophagus
squamous cell carcinoma
imaging features of two cell types of esophageal carcinoma are indistinguishable, except that adenocarcinoma is almost always
distal, usually invades the GEJ and is much more likely to invade the stomach
esophageal tumors assume four basic imaging patterns, namely
annular constricting lesion, polypoid pattern, infiltrative, ulcerated mass
this pattern of esophageal tumor appears as an irregular ulcerated stricture, which is most common
annular constricting lesion
pattern of esophageal tumor that causes an intraluminal filling defect
polypoid pattern
pattern of esophageal tumor that grows predominantly in the submucosa and may simulate a benign stricture
infiltrative pattern
least common pattern of esophageal tumor
ulcerative
esophageal tumors spreads quickly due to
direct invasion into adjacent tissues because of lack of serosal covering on esophagus
lymphatic spread of esophageal tumor
neck, mediastinum, below diaphragm
hematogeneous spread of esophageal tumor
lung, liver and adrenal gland
esophageal malignancy findings
irregular thickening of the esophageal wall (> 5mm), eccentric narowing of lumen, dilation of esophagus above the area of narrowing, invasion of periesophageal tissues and metastases to mediastinal lymph nodes and liver
diagnosis of esophageal malignancy are through
endoscopy and biopsy
most common benign neoplasm of the esophagus, accounting for 50% if all benign esophageal neoplasms
leiomyoma
true or false: GISTs are common in the rest of the GI tract and rare in the esophagus
true
esophageal tumor that is firm, well encapsulated, and arises in the wall
leiomyoma
most commonly affected age group in esophageal leiomyoma
25 to 35 years old
true or false: most cases of esophageal leiomyoma has no symptoms
true
strongly indicative of leiomyoma
calcifications
rare cause of esophageal filling defect that are benign, composed of fatty and fibrous tissue with accompanying blood vessels. appears as large elongated intraluminal masses in the upper esophagus
fibrovascular polyps
congenital abnormalities in the esophagus that are usually incidental findings presenting without symptoms. 60% of which occurs in the lower esophagus. CT shows a well-defined cystic mass
esophageal duplication cysts
differential diagnosis for esophageal duplication cysts include
bronchogenic and neuroenteric cyst
extrinsic lesions to the esophagus that may simulate an esophageal mass or filling defect. causes include
mediastinal adenopathy, lung carcinoma, vascular structures
arises from the aorta distal to the left subclavian artery. to reach its destination, it must cross the mediastinum behind the esophagus. it causes a characteristic upward-slanting linear filling defect on the posterior aspect of esophagus
aberrant right subclavian artery
life-threatening event requiring prompt diagnosis and treatment in which more than half of the cases are related to esophageal instrumentation
esophageal perforation
chest radiograph findings in esophageal perforation
widened mediastinum, pleural effusion, pneumohydrothorax
contrast studies for esophageal perforation
contrast studies should be performed initially with low-osmolar water soluble agents and if negative, followed by repeating the study with barium
key finding in esophageal perforation
focal or diffuse extravasation of contrast outside the esophagus
blunt trauma may tear the esophagus by what mechanism
increase in intraesophageal pressure
refers to rupture of the esophageal wall as a result of forceful vomiting
Boerhaave syndrome
the tear in Boerhaave syndrome is usually in the
left posterior wall near the left crus of diaphragm
tears that involves only the mucosa and not the full thickness of the esophagus. tears are usually caused by violent retching and copious hematemesis
Mallory-Weiss tear
Mallory-Weiss tear appears ____
longitudinally oriented barium collection, 1 to 4 cm in length in the distal esophagus
impacted foreign bodies in the esophagus may be removed by
use of Foley balloon catheter or wire basket or by gaseous distention with gas-producing crystals
