RDSC 233
Unit 8
Radiography of the pharnyx & esophagus
Bontrager pp. 443-445: 458-460: 469-473
Anatomy of the pharnyx & esophagus
Film Critique
Radiographic anatomy
Exposure Factors
Positioning of:
Soft tissue neck
AP and lateral soft tissue neck
RAO, LAO esophagus
Left lateral esophagus
AP, PA esophagus
Radiographic
Pathology
Atlas of Human Anatomy
Second edition (60)
Need to know
Nasopharynx, oropharynx,
laryngopharynx, esophagus
Soft palate, uvula
Buccal cavity
Epiglottis
Piriform fossa (recess)
Atlas of Human Anatomy
Second edition (57)
Need to know
Soft palate, uvula
Epiglottis
Adnoids
Nasopharynx, oropharynx,
laryngopharynx, esophagus
Vocal folds
Esophagus
Atlas of Human Anatomy
Second edition (25x)
Need to know
Mucosa, submucosa,
& muscular layers
Zigzag (Z) line
Diaphragmatic hiatus
Abdominal part of
esophagus
Examinations of the esophagus
Two procedures are done, one for the throat and one for the esophagus
Barium Swallow (Esophagram) or modified barium swallow (MBS). For
both the pharynx and esophagus the exam begins under fluoroscopy, in
the upright position. Filming is typically done using a spot film camera or
digital fluoroscopy.
90 mm cut film
105 mm roll film
Spot film camera films, or photospots
A similar procedure is done after
a person has had a stroke or
other disabling affliction to the
muscles of speech.
Examinations of the pharnyx
With filtration
Without filtration
This is typically done by a speech
pathologist, using barium paste,
and is the one procedure
commonly recorded on video tape.
This procedure is also called a
barium swallow.
Photos from Bontrager
Examinations of the pharnyx and esophagus
Contrast Media
Like the other examinations of the alimentary track, barium sulfate is used
unless there are contraindications to barium.
Both thin and thick barium are used. Thin barium is useful to outline the
esophagus quickly. When administered in the upright position is empties
into the stomach in seconds. It is also used to diagnose reflux when using
the water test, (shallow LPO), compression, or the toe-touch maneuver.
Thick barium (barium paste) is mixed with one part water to 3-4 parts
barium powder. Commercial products are often packaged in a tube.
Thick barium coats and adheres to the mucosa. It may be mixed with cotton
balls, marshmallows, or other foods.
No patient preparation is need for an esophagram, unless it is to be followed
by an UGI
Examinations of the pharnyx and esophagus
Esophagrams begin under fluoroscopy, in the upright position. The patient
holds a cup of barium, with a straw, in the right hand. The radiologist
instructs the patient to patient to drink, and films in the AP, RPO, and LPO
positions.
The patient is often put into an RAO before the table to lowered to
horizontal. The examination continues in the recumbent position.
Overhead films are taken per the radiologist’s routine.
The trick to overhead filming is to fill the esophagus, from the pharynx to
the cardiac orifice of the stomach, and make the exposure before the
esophagus empties. To do this the patient is instructed to take three
large bolus swallows. On the fourth, breathing is suspended and the
exposure is made at the moment the patient swallows. A shallow
trendelenburg position will help keep the esophagus full.
A large diameter straw is needed, and care must be taken that the end
of the straw does not become vacuum sealed to the bottom of the cup.
Radiographic Positioning of the x
Positioning of:
Soft tissue neck
AP and PA of esophagus
RAO and LAO esophagus
Right lateral esophagus
including
Film Critique
Soft tissue neck
Expose
during
inspiration
Positioned the same as an AP & Lateral
C-spine: ½ the mAs.
Done to assess the patency
Nasopharynx
Adnoids
Oropharynx
Hyoid bone
Esophagus
Trachea
of the airway
* masses
* foreign bodies
* enlarged adnoids (kids)
* epiglottitis (kids)
Routine Esophagus Positioning
Preparation
1. Evaluate the order
2. Greet the patient
3. Take History
What is pertinent Hx?
chest pain, heartburn, dysphagia
(difficulty swallowing), odynophagia
(pain on swallowing)
4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.
5. Explain the exam in layman’s terms
6. Questions?
7. Set technique before positioning
Routine AP, PA Positioning
Steps
1. 14” x 17” lengthwise
(7” x 17” are also used)
2. Prone or spine. Head
turned to side to allow
drinking.
3. CR 1” inferior to sternal
angle (Top of film 2”above
shoulders).
Critique criteria
for frontal projections of the
esophagus
Entire esophagus
filled with barium, in
an unrotated frontal
projection.
When there is inadequate filling
of the esophagus, under-penetration,
and/or insufficient density, the
esophagus is difficult to visualize
against the mediastinum.
Good filling, contrast,
and density, demonstrating
a condition called
presbyesophagus
Routine RAO or LAO Positioning
Steps
1. 14” x 17” lengthwise
(7” x 17” are also used)
2. 350-450 RAO position.
(Spine must be as straight
as possible, especially
with tight collimation.)
3. CR to T5-6 (Top of film 2”
above shoulders), several
inches left of the spinous
processes.
Critique criteria
for RAO & LAO esophagus
Like the RAO stomach, which is the single
best projection, the RAO is also best for the
esophagus.
The heart provides a homogeneous background
to contrast it against, and the distal esophagus,
traversing the esophageal hiatus, is laid out in
profile.
The RAO should demonstrate
the entire barium filled esophagus.
The abdominal portion is more important
than the pharyngeal portion, which may
be evaluated by direct inspection.
Critique criteria
for LAO esophagus
The LAO may provide valuable diagnostic
information, but contrasts the esophagus against
the hilar area of the right lung and foreshortens
the abdominal esophagus at the
gastroesophageal junction.
Photo from Bontrager
The RAO & LAO should both
demonstrate the entire barium
filled esophagus.
The abdominal portion is more important
than the pharyngeal portion, which may
be evaluated by direct inspection.
Routine Right lateral Positioning
Steps
1. 14” x 17” lengthwise
(7” x 17” are also used)
2. Right lateral. C-spine
“coextensive” to T-spine.
3. CR to T5-T6 (Top of film
2”above shoulders) in
the midcoronal plane.
4. The arms may be raised
and superimposed (like a
lateral chest position), or
the left shoulder may be
rotated posteriorly for a
“swimmers lateral.”
Swimmers lateral
Humerus
Critique criteria
for lateral esophagus
Entire barium filled esophagus
projected posterior to heart, and
anterior to the T-spine
Soft tissue
of arm
Why does the esophagus extend
so far below the diaphragm,
and yet the cardiac orifice is not
seen?
The caval opening is in the
left hemidiaphragm. The right
hemidiaphragm is typically higher
than the left due to the liver. In this
case the difference between
them is extreme.
Exposure Factors
From the “Rules of Thumb”
Based on: 3 phase, 100 RS film, 12:1 or 16:1 grid, 40” SID
Because the esophagus is in the mediastinum, technique
calculations are the same as for the abdomen.
Because the contrast is barium, the lower kVp range is the same
as for the single contrast UGI or colon: over 100 for penetration.
Because the diameter of the esophagus is small compared to
the stomach or colon, the upper range is 110 kVp.
In summary: Abdomen technique calculations in 100-110 kVp range
Significant Pathologies
of the esophagus
and their
Radiographic Appearances
TE fistula
Foreign body
Diverticulum
Esophageal CA
Presbyesophagus
Treacheoesophageal (TE) fistula
A congenital or ulcerative opening (fistual
tract) between the esophagus and trachea.
Radiographic examinations of fistulas are
fistulagrams, or sinograms (sinus tract).
Barium in the bronchial tree may result from a TE fistula, or
aspiration of barium.
Foreign bodies in esophagus
Radiolucent FBs,
such as chicken
or fish bones, may
require a swallow
of barium to
demonstrate.
Diverticulum
Rotary blades from an electric razor.
One stuck in the proximal esophagus,
and one in the pyloric canal.
Esophageal Cancer
Colon used to
replace the
esophagus after
it was removed
in a cancer
operation.
Note the
haustrations
Presbyesophagus
An old esophagus
Presby, meaning old, is used
to describe the dilatation and
scalloping of the esophagus
that occurs with age.
43. What is the name, and acronym, for a functional study of the
bladder and urethra?
44. What is the term that describes contrast media that has
escaped from (out of) the bladder, due to a leakage or rupture?
45. What medical specialist (i.e. gynocologist, podiatrist, etc.),
inserts the cystoscope in the performance of a retrograde
cystogram?
46. When the male urethra can not be catheterized due to
obstruction or trauma, what is the name of the procedure
used to fill the urethra with contrast?
43. What is the name, and acronym, for a functional study of the
bladder and urethra? voiding cystourethrogram (VCUG)
44. What is the term that describes contrast media that has
escaped from (out of) the bladder, due to a leakage or rupture?
extravasation
45. What medical specialist (i.e. gynocologist, podiatrist, etc.),
inserts the cystoscope in the performance of a retrograde
cystogram? urologist
46. When the male urethra can not be catheterized due to
obstruction or trauma, what is the name of the procedure
used to fill the urethra with contrast? injection urethrogram
47. A barium swallow for examination of the muscles of speech,
usually following a stroke, utilizes a recording medium used
almost solely for this exam. What is that medium?
48. If a good lateral c-spine were done at 10 mAs, what would be
be used for a soft tissue neck?
49. A supine position in which the head is lower than the feet is
called the
position.
50. What oblique position, and degree of obliquity best
demonstrates the barium filled esopagus.
47. A barium swallow for examination of the muscles of speech,
usually following a stroke, utilizes a recording medium used
almost solely for this exam. What is that medium? Video tape
48. If a good lateral c-spine were done at 10 mAs, what would be
be used for a soft tissue neck? 5 mAs
49. A supine position in which the head is lower than the feet is
called the
position. Trendelenburg
50. What oblique position, and degree of obliquity best
demonstrates the barium filled esopagus. 35-45 RAO
The End