Between 1% and 15% of patients with head and neck squamous cell carcinoma subsequently develop squamous cell carcinoma of the esophagus. A lateral pharyngeal diverticulum is a protrusion of nonkeratinizing squamous mucosa originating in the pharynx. A second branchial cleft cyst is found at the level of the hyoid bone, deep to the sternocleidomastoid muscle. Considerable variation is found in the arrangement of the muscle bundles of the thyropharyngeal and cricopharyngeal muscles. Radiologists should be as familiar with pharyngeal carcinoma as they are with esophageal carcinoma. They include sore throat, dysphagia, and odynophagia. Eur J Pediatr. Initial results of diagnostic endoscopy may be negative. The most common branchial vestige is a cyst arising from the second branchial cleft. 37(12):1210-9. 2015 Aug;37(8):1193-9. doi: 10.1002/hed.23735. 2009 Aug. 21(8):796-806. The lower esophageal sphincter (LES) is composed entirely of smooth muscle and maintains a steady baseline tone to prevent gastric reflux into the esophagus. Frontal view of the pharynx obtained as the bolus is passing through the lower pharynx and pharyngoesophageal segment. Inflammatory disorders of the pharynx or gastroesophageal reflux can alter pharyngeal elevation, epiglottic tilt, or closure of the vocal cords and laryngeal vestibule. Branchial pouch sinuses or fistulas are tracts that extend from the pharynx and end blindly in the soft tissues of the neck (sinus) or extend to the skin (fistulas). The pharynx is the site of common illnesses, including sore throat and tonsillitis. [QxMD MEDLINE Link]. 2015 Oct. 28(7):699-704. FOIA Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison. The clinical presentation of a motility disorder is varied, but, classically, dysphagia and chest pain are reported. Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist. V4IQ){lP E Eric A Gaumnitz, MD Professor of Medicine, Division of Gastroenterology, University of Wisconsin School of Medicine; Program Director, Gastroenterology and Hepatology Fellowship, University of Wisconsin School of Medicine and Public Health; Director, Motility Unit, University of Wisconsin Hospitals Response to amyl nitrate, with disappearance of the spasm on esophagram. The lateral pharyngeal wall may protrude beyond the normal expected contour of the pharynx in areas unsupported by muscle layers. Medscape Education, Challenges in Gastroesophageal Reflux Disease Assessment and Management, encoded search term (Esophageal Motility Disorders) and Esophageal Motility Disorders, Gastroesophageal Reflux Disease (GERD) Imaging, Fast Five Quiz: Gastroesophageal Reflux Disease Management, Fast Five Quiz: Gastroesophageal Reflux Disease (GERD), Fast Five Quiz: Gastroesophageal Reflux Disease Practice Essentials, PPI Use in Type 2 Diabetes Links With Cardiovascular Events, Transgender People in Rural America Struggle to Find Doctors Willing or Able to Provide Care. Patients with small lesions are often asymptomatic but present with enlarged cervical nodes. Peristalsis is a sequential, coordinated contraction wave that travels the entire length of the esophagus, propelling intraluminal contents distally to the stomach. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. The loss of nerves along the esophageal body causes aperistalsis, leading to stasis of ingested food and subsequent dilation of the esophagus. Neurogastroenterol Motil. [QxMD MEDLINE Link]. With severe luminal narrowing, dysphagia may result, especially in patients with circumferential cervical esophageal webs. Exophytic lesions are more common ( Fig. Abdullah Fayyad, MD, MBBS is a member of the following medical societies: American Gastroenterological AssociationDisclosure: Nothing to disclose. 2010 Feb. 22(2):142-9, e46-7. Squamous cell carcinomas represent 90% of malignant lesions involving the oropharynx and hypopharynx. Significant acid reflux might lead to disabling symptoms, caused by reflux or its complications. Herbella FA, Colleoni R, Bot L, Vicentine FP, Patti MG. High-resolution manometry findings in patients after sclerotherapy for esophageal varices. At the time of diagnosis, the esophagus usually is dilated, and the tumor is advanced. Killians dehiscence has been variably described as arising between the thyropharyngeal and cricopharyngeal muscles or between the oblique and horizontal fibers of the cricopharyngeal muscle. There appears to be a functional imbalance between excitatory and inhibitory postganglionic pathways, disrupting the coordinated components of peristalsis. However, no studies to date have shown convincing evidence that surveillance is worthwhile. J Stroke Cerebrovasc Dis. Pyriform stasis What pharyngeal stage disorder is a result of reduced anterior laryngeal motion, cricopharyngeal dysfunction, and inadequate upper esophageal sphincter opening? 16-14 ). When advanced, this condition can lead to such severe dysphagia that malnutrition, weight loss, and dehydration can develop. The junction of the ala of the thyroid cartilage and thyrohyoid membrane is seen on frontal views as a notch in the lateral pharyngeal wall. Pharyngeal inflammation and ulceration may be seen in patients with Behets syndrome, Stevens-Johnson syndrome, Reiters syndrome, epidermolysis bullosa, or bullous pemphigoid. Achalasia is a progressive disease that requires chronic therapy. Has there been a neuro consult? Lateral Pharyngeal Pouches and Diverticula, Branchial Cleft Cysts, Branchial Cleft Fistulas, and Branchial Pouch Sinuses, Lateral Cervical Esophageal Pouches and Diverticula, Lymphoid Hyperplasia of the Lingual and Palatine Tonsils, Surgery for Tongue and Oropharyngeal Cancers, Surgery for Zenkers Diverticulum and Pharyngeal Pouches. Elliott TR, Wu PI, Fuentealba S, et al. The benign nature of these lesions should be confirmed by endoscopic examination. The relationship of contraction and food bolus is more complex because of intrabolus pressures from above (contraction from above) and the resistance from below (outflow resistance). Dysphagia. AJR 154:11571163, 1990. Chest pain is, in fact, a more common complaint that may precipitate emergency room visits and cardiologic evaluations. The symptoms of pharyngeal carcinoma are nonspecific and usually of short duration (<4 months). With severe ulceration, amputation of the uvula and tip of the epiglottis may be observed radiographically. All the etiologies that I mentioned, in isolation or in combination, could play a part in the diffuse pharyngeal stasis/residue observed, which is worrisome for bolus mis-direction during the course of a true feeding. endstream endobj 227 0 obj <>stream Thanks for such a detailed history to help to consider possibilities. In contrast, the neck of Zenkers diverticulum is on the posterior hypopharyngeal wall, and the sac extends inferiorly behind the cervical esophagus. Retention cysts of the aryepiglottic folds are lined by squamous epithelium and filled with desquamated squamous debris ( Fig. %PDF-1.6 % Inflammation-induced dysmotility may result in laryngeal penetration and stasis. The radiologist may be the first physician to suggest a diagnosis of pharyngeal carcinoma ( Fig. The fourth and sixth pharyngeal arches cartilages merge to give rise to the laryngeal cartilages. [High-resolution manometry of pharyngeal swallowing dynamics]. However, in the setting of a normal MRI with normal motor development, other etiologies need to be explored. j=e,e)_E)g4Hv[IO^SiwLev`h-`` F b6 fAtXA k``eD*wd:PW0+ bQp2082a>7 :JF' {v on@d o=g 'AExrIcJ k [QxMD MEDLINE Link]. Is there any particular intervention improving pharyngeal clearance with the swallow. Many nasopharyngeal squamous cell cancers are undifferentiated tumors, and many have a reactive lymphoid stroma. Extrinsic nerves may also be affected, characterized by Wallerian degeneration of the axoplasm and myelin sheaths within the vagus nerve and dorsal motor nucleus. [QxMD MEDLINE Link]. Genetics consult? The inferior constrictor muscle is composed of the thyropharyngeal and cricopharyngeal muscles. Diverticula appear on frontal views as saccular protrusions that have narrow necks (see Fig. In contrast, lateral pharyngeal diverticula are persistent protrusions of pharyngeal mucosa, usually through the thyrohyoid membrane or, rarely, through the tonsillar fossa. Life expectancy is not affected, and weight loss is rare. Most patients with Killian-Jamieson diverticula are asymptomatic, but some may complain of dysphagia or regurgitation. Sato Y, Fukudo S. Gastrointestinal symptoms and disorders in patients with eating disorders. Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ. Barium may also be trapped above early closure of the upper cervical esophagus. The second branchial cleft forms the middle ear, eustachian tube, and floor of the tonsillar fossa. Achalasia commonly presents in the fifth decade but rarely may develop in children as well as in elderly persons. Complications of botulinum toxin injections for treatment of esophageal motility disorders. bringing food back up, sometimes through the nose. Early on in my assessment (maybe ~35 weeks) I couldnt elicit a tongue-lateralizing reflex, havent checked since. All signs seem to be pointing to a neurological basis for his dysphagia and Im just wondering if there are any last hail marys to try before we start to plan for home on NG, OP feeding therapy, etc. Nutcracker esophagus is the most common motility disorder (>40% of all motility disorders diagnosed), but it is the most controversial in significance. The 5-year survival rate varies from 76% for patients with localized tumors to 10% to 20% for patients with cervical lymph node metastases. Retention cyst at the base of the tongue. [QxMD MEDLINE Link]. Recent ECHO showed a moderate ASD. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Structural Abnormalities of the Pharynx, Miscellaneous Abnormalities of the Stomach and Duodenum, Pharynx: Normal Anatomy and Examination Techniques. Nasal regurgitation was observed during the initial double-contrast swallow. The https:// ensures that you are connecting to the With severe lymphoid hyperplasia of the base of the tongue, the nodules may extend into the valleculae, along the lingual surface of the epiglottis, or even into the upper hypopharynx. Four outpouchings from the pharynx grow to meet the branchial clefts. Cross-sectional imaging studies are the examinations of choice for showing spread of tumor into the submucosa, intrinsic muscles, tissues extrinsic to the pharynx, and regional lymph nodes. ), An 80-year-old patient with dementia underwent an upper GI examination for epigastric pain. Influence of Thermal and Gustatory Stimulus in the Initiation of the Pharyngeal Swallow and Bolus Location Instroke. 2012 Mar. Epub 2014 Jul 7. Patients with pharyngeal symptoms or a palpable neck mass may undergo pharyngoesophagography as the initial diagnostic examination. Carcinoma arises in less than 1% of patients with Zenkers diverticulum, but it is usually fatal. The relationship between gastroesophageal reflux disease and Zenkers diverticulum is also controversial. The use of endoscopy and magnetic resonance imaging (MRI) may help exclude malignancy. Please enable it to take advantage of the complete set of features! In the United States, no strong association of cervical esophageal webs, iron deficiency anemia, and pharyngoesophageal carcinoma has been found. Posterior tongue tie, base of tongue movement, and pharyngeal dysphagia: what is the connection?. RadioGraphics 8:641665, 1988.). In contrast, saccular cysts of the aryepiglottic folds arise from the mucus-secreting glands of the appendix of the laryngeal ventricle and are filled with mucoid secretions. Diagnosis of esophageal motility disorders: esophageal pressure topography vs. conventional line tracing. With achalasia, the risk of squamous cell carcinoma of the esophagus is higher than that of the general population. Scleroderma is a systemic disease with a progressive nature. Head Neck. Sinus tracts that end blindly are occasionally seen in adults. Squamous cell carcinoma usually develops several years after the diagnosis of achalasia. Physiologic characteristics of achalasia are additionally useful in assisting with establishing the diagnosis through chemical challenge testing. Persistence of branchial pouches or clefts results in the formation of sinus tracts or cysts. Primary peristalsis is the peristaltic wave triggered by the swallowing center. Poorly differentiated tumors are frequently of the ulcerative infiltrative type and may be obscured on barium studies by the underlying nodular lymphoid tissue of the palatine tonsil. Severe ulceration with subsequent scarring may also be caused by lye ingestion ( Fig. Webs in the distal esophagus have been associated with gastroesophageal reflux disease. )dC(SOL*W vRlYE1Zt[@m.)S*=V!/XZ;,3`{9WW(Kr[tfJ[XR[N{\Q*}iRf8w!fM}CS7x.03cO]Mux: T*xo~g|[IlyQV[G_W6W(=ihk- Neurological disorders aff The risk factors, age of presentation, and histologic type are more varied than those of the typical squamous cell carcinoma of the oropharynx and hypopharynx. 16-2 ). [QxMD MEDLINE Link]. Problem-Solving with Catherine: Adenoid Hypertrophy and Pediatric Dysphagia, Problem-Solving: New infant referral but limited experience, Problem-Solving with Catherine: 3-month-old with TEF and Vocal Cord Paralysis, Lifelong Learners Join Catherine in Houston, State-of-the-Art NICU Practice: Catherine Shaker and Suzanne Thoyre. Racial differences in the incidence of achalasia and other esophageal motility disorders have not been established. Any change in the character of dysphagia or bloody discharge in a patient known to have Zenkers diverticulum should suggest a complication. [QxMD MEDLINE Link]. Esophageal dysmotility develops as the smooth muscle of the esophagus is replaced by scar tissue, gradually leading to progressive loss of peristalsis and a weakening of LES. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. 233 0 obj <>/Filter/FlateDecode/ID[<9925DAB172E4C04EAA11C856BA143EA3>]/Index[223 23]/Info 222 0 R/Length 65/Prev 694135/Root 224 0 R/Size 246/Type/XRef/W[1 2 1]>>stream Abdullah Fayyad, MD, MBBS Gastroenterology Staff, Private Practice, Digestive and Liver Disease Consultants The site is secure. 2014. If saccular dilation of the appendix is confined by the thyroid cartilage, it is termed an internal laryngocele.

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