Table Of ContentRadiologic
Examination of
the Orohypopharynx
and Esophagus
Costantino Zaino
Thomas C. Beneventano
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THE BARIUM SWALLOW
WITH 450 ILLUSTRATIONS
[I
SPRINGER-VERLAG
New York Heidelberg Berlin
Dr. Costantino Zaino Dr. Thomas C. Beneventano
Associate Research Fellow Department of Radiology
Department of Diagnostic Radiology Montefiore Hospital and Medical Center
Montefiore Hospital and Medical Center 111 East 210 Street
Bronx, New York 10467
Send correspondence to:
Dr. Costantino Zaino
18 Warren Avenue
Tuckahoe, New York 10707
Library of Congress Cataloging in Publication Data
Zaino, Costantino.
Radiologic examination of the orohypopharynx and esophagus.
Bibliography: p.
I ncl udes index.
1. Esophagus-Radiography. 2. Pharynx-Radiography. I. Beneventano,
Thomas c., joint author. II. Title
RC815.7.Z34 616.3'2'07572 77-21426
All rights reserved.
No part of this book may be translated or reproduced in any form without
written permission from Springer-Verlag.
© 1977 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1977
9 8 7 6 5 4 3 2 1
ISBN-13: 978-1-4612-6346-3 e-ISBN-13: 978-1-4612-6344-9
DOl: 10.1 007/978-1-4612-6344-9
Designer: Natasha Sylvester
Dedicated to our wives
Vole Zaino
Marilyn l. Beneventano
FOREWORD
The esophagus, ostensibly a simple tubular structure whose
functional role often is minimized and even ignored, is, in re
ality, a highly complex viscus. The problems associated with
disorders of the esophagus are not only related to the usual en
tities which may be anticipated in any portion of the gastroin
testinal tract, but include in a major fashion the functional
mechanisms indigenous to the pharyngoesophageal and eso
phagogastric junctions.
A number of disorders, representative of the classical cate
gories of disease, affect the esophagus. These include the
various congenital and developmental abnormalities, of which
some are complex. Trauma to the esophagus is not un
common, and infective and inflammatory lesions of this struc
ture are encountered relatively frequently. The different types
of neoplasms of the esophagus are relatively few in number,
but are commonly observed-the most serious, from the point
of view of survival, being carcinoma. The collagen disorders,
particularly scleroderma and dermatomyositis, affect the eso
phagus all too often. A miscellaneous group includes such en
tities as achalasia and varices, occurring in varying degrees of
frequency. Functional abnormalities of the oropharynx, hypo
pharynx and esophagus, particularly relating to swallowing
and the frequently encountered instances of spasm of the
pharyngoesophageal and the esophagogastric junctions, consti
tute an important and common source of difficulty in the pa
tient population at large. In this regard, anatomic, radiologic,
and physiologic studies of these structures have provided
through the years vital data which has proved of considerable
VII
...
VIII • FOREWORD
help to the clinician who deals with the functional and organic
disorders commonly encountered. Fundamental problems in
this area, however, still remain to be resolved.
The two authors of this monograph bring to the work di
verse but complementing backgrounds, which have interfaced
most effectively in its preparation. Dr. Costantino Zaino has
been the co-author of two previous monographs on the eso
phagus, dealing principally with the complex problems atten
dant on the pharyngoesophageal and esophagogastric junc
tions. His gross anatomic and detailed histologic studies have
been correlated with specific radiologic findings, providing im
portant contributions to these two areas. Thus, Dr. Zaino
brings to this monograph a professional lifetime of effort on the
subject.
Dr. Thomas C. Beneventano is one of the country's aca
demic leaders in the radiology of gastrointestinal disorders. As
head of the section of gastrointestinal radiology at the Albert
Einstein College of Medicine (Montefiore Hospital and Medi
cal Center), his clinical, investigative, teaching and organiza
tional activities have established him in the front ranks of the
individuals in his special field.
Thus, the combined efforts of a long-time student of dis
orders of the esophagus and a recognized authority in the radiol
ogy of the gastrointestinal tract have culminated in this work.
This monograph should serve as a forum of information not
only for radiologists, but also for gastroenterologists (and other
internists), pathologists, surgeons and even anatomists.
And finally, it is hoped that the monograph will represent an
important effort contributing to a better understanding of the
physiologic mechanisms and related anatomic and radiologic
features of this interesting segment of the gastrointestinal
tract. The applications of such studies may indeed lead in tum
to a better appreciation of the causes of various organic dis
orders, which affect the esophagus and other related structures.
HAROLD G. JACOBSON, M.D.
PREFACE
The barium swallow is the simplest, commonest, and most in
formative roentgenologic procedure in the examination of the
orohypopharynx and esophagus. Since the advent of the image
intensifier tube, fluoroscopy has become far more effective and
less dangerous to the patient and radiologist and the frequent
use of cinefluoroscopy and cineradiography has become pos
sible.
In 1896, Cannon and Meltzer (55) first used bismuth subni
trate as an opaque medium in the examination of the digestive
tract and again used it in the first public demonstration of a
fluoroscopic examination. Years later, barium sulfate was sub
stituted for the bismuth and has been used since with excellent
results.
The orohypopharynx has been a neglected portion of the
upper gastrointestinal tract in diagnostic roentgenology be
cause of the rapid transit time of the opacifying bolus. Hence a
detailed routine study of this area has been almost impossible.
With the common use of cine and tapes, which permits a lei
surely and slowed-down frame-by-frame study, a new dimen
sion has been added, allowing the roentgenologic recognition
of numerous functional disturbances as well as early structural
changes.
In this monograph the authors will present a review of the
normal roentgenologic anatomy and will consider functional
and organic disorders of the orohypopharynx and esophagus.
Certain aspects concerning functional mechanisms and dis
orders of the oral cavity and fundus of the stomach will also be
presented. The purpose and current timing for such a review
has been prompted by the following:
IX
x • PREFACE
1. recent anatomico-roentgen studies by the authors affording
a new concept of the underlying anatomy of the upper and
lower sphincters of the esophagus
2. the attempted radiologic correlation by the authors with
abnormal intraluminal pressure studies, indicating a num
ber of disorders of the esophagus and particularly its struc
tures
3. the need for a closer and clearer correlation of the dynamics
and the static images of this region as conveyed by cinera
diography and tapes
4. the neglected emphasis of roentgen findings in the oral cav
ity and the pharynx
5. the reporting of a number of pathologic entities not included
in previous texts on the esophagus
6. a preliminary detailed listing of roentgen findings aiding
in the eventual computation of the roentgen diagnosis of
lesions of the digestive tract.
Most lesions and disorders of this region, with roentgeno
logic manifestations, from infancy to old age, will be reviewed
and only the minimal essential embryology, gross anatomy,
pathophysiology, and clinical aspects will be included. The
normal roentgenologic anatomy will be given in detail and the
emphasis will be primarily on roentgenologic diagnosis.
The authors would like to thank the following physicians who ACKNOWLEDGMENTS
provided case material: Doctors Robert Appelman, P. 1. Cle
metson, Sam Glasser, Alfons Hillel, Neil Messinger, Rubem
Pochaczevsky, Henry Pritzker, Irwin Schlossberg, Seymour
Sprayregen, Karkarla Subbarao, and Guy W. Van Sickle.
We would also like to acknowledge the help of Mrs.
Cleophus Anderson and Miss Louise Ferri, who spent many
hours typing the manuscript; George N. Tanis, R.B.P., and
Charles J. Fox, who prepared the photographic reproductions;
Satumino Velez, for technical assistance; and Sandra 1.
Nehlsen, PhD., who prepared the medical illustrations.
We are especially grateful to Dr. Harold G. Jacobson for re
viewing and editing this manuscript. His invaluable assistance
is most deeply appreciated.
CONTENTS
CHAPTER TECHNIQUE
~
General Remarks
Contrast Media 2
Variation in Technique Because of Age 6
Types of Examinations 9
Fluoroscopic and Filming Technique 10
Special Examinations 12
Special Maneuvers and Positions 20
Special Tests 23
Special Studies 24
CHAPTER NORMAL ANATOMICOROENTGEN STUDIES
AND CORRELATIONS 29
~
Gross Anatomy 29
Mediastinum and Diaphragm 36
Radiologic Anatomy 38
Checklist of Observations During and Following a
Barium Swallow 69
XI
