Pharyngeal Dysphagia: What the Radiologist Needs to Know

Normal pharyngeal anatomy. Frontal (A), and lateral (B), views reveal vallecula (asterisks), piriform sinuses (arrows), and epiglottis (curved arrow). Note the reticular appearance at the base on the tongue (small arrow); this represents the lingual tonsil.

Normal MR anatomy. Sagittal MR reveals the three anatomic regions of the pharynx: nasopharynx, oropharynx, and hypopharynx. The nasopharynx is separated from the oropharynx by the soft palate (arrow). The oropharynx is separated from the hypopharynx at the level of the hyoid (curved arrow). The cricopharyngeus, upper esophageal sphincter, is located at the C5-6 vertebral body level and separates the hypopharynx from the cervical esophagus. Vallecula (white asterisk), epiglottis (white arrow), and laryngeal vestibule (V) are easily identified.

Lingual hyperplasia. (A) Frontal view reveals increased nodularity (asterisk) of the lingual tonsil, extending into the vallecular space (arrow). (B) Note the nodularity is symmetric, uniform, and does not have mass effect, suggesting that it represents hyperplasia and not a mass. True (t) and false (f) vocal chords delineate the intervening laryngeal ventricle (small arrow).

Lingual lymphoma. Frontal (A), and lateral (B), radiographs reveal increased nodularity of the lingual tonsil. However, unlike hyperplasia, this nodularity is larger, less uniform, and has well-defined, mass-like borders (arrows).

Pharyngeal pouch. Frontal radiograph reveals bilateral, small pharyngeal pouches (arrows). Pouches are transient, present only with increased pharyngeal pressure, such as during Valsalva, phonation, or swallowing. They are almost always asymptomatic.

Asymmetric pharyngeal pouches. Frontal spot image reveals small left pharyngeal pouch (arrow) and even smaller right protrusion (small arrow).

Pharyngeal diverticulum. Frontal radiograph reveals unilateral, persistent pharyngeal diverticulum (arrow) with air–fluid level. These are typically seen in patients with abnormally increased pharyngeal pressure.

Killian's dehiscence. Killian's dehiscence (triangle of Killian) located between the inferior pharyngeal constrictors and the cricopharyngeus. It is an area of anatomic weakness in the hypopharynx, serving as the origin of Zenker's diverticula. (Reprinted from van Overbeek,⁶ with permission from Annals.)

Cricopharyngeal bar. Lateral radiograph reveals failure of relaxation of the cricopharyngeus (asterisk). Although this patient has not developed a Zenker's diverticulum, ballooning at Killian's dehiscence is seen posteriorly (arrow).

Large Zenker's diverticulum. Oblique view reveals large Zenker's diverticulum, extending inferiorly and compressing the cervical esophagus.

Zenker's diverticulum with aspiration. Lateral view reveals moderate size Zenker's diverticulum (asterisk) with flap-like cricopharyngeus (arrows). This is also referred to as the “party” wall, separating the diverticulum from the cervical esophagus. Note aspirated barium (curved arrow) extending along the anterior trachea.

Perforated Zenker's diverticulum. Lateral radiograph reveals extravasated contrast and gas extending along prevertebral space (arrows) in this patient who had bronchoscopy with perforation of Zenker's diverticulum.

Diverticulopexy. Lateral radiograph reveals suspension of the Zenker's diverticulum superiorly (arrow). This improves diverticular emptying and relieves extrinsic cervical esophageal compression, reducing aspiration risk and dysphagia, respectively.

Endoscopic stapling diverticulotomy. (A) Drawing of a large Zenker's diverticulum demonstrates dysfunctional cricopharyngeus, creating a flap-like party wall between the diverticulum and cervical esophagus. (B) Lateral spot image reveals similar configuration of diverticulum and flap-like cricopharyngeus. (C) Endoscopic stapling device straddles the party wall, with one limb in the esophagus and the other in the diverticulum, simultaneously making an incision in the party wall with three rows of staples along each cut edge (arrows, D). Note, it is recommended that this procedure not be performed for diverticula less than 3 cm, because of purchase needed by the endoscopic device for an adequate cut and staple line. (Color version of figure is available online.)

Endoscopic CO₂ laser diverticulotomy. Endoscopic images reveal party wall before (asterisk) and after (arrows) endoscopic laser division (A and B, respectively). (Reprinted from Takes et al,¹³ with permission from John Wiley & Sons, Inc.) (Color version of figure is available online.)

Endoscopic diverticulotomy. (A) Patient before endoscopic diverticulotomy. (B) After diverticulotomy, diverticulum is slightly smaller, but still retains an air–fluid level. Patient's symptoms dramatically improved, although aspiration persists (arrows).

Killian–Jamieson diverticulum. Frontal, A, and lateral, B, radiographs reveal diverticulum (arrow) extending from the anterolateral cervical esophagus. Killian–Jamieson diverticula originate below the cricopharyngeus, unlike the Zenker's diverticula, which originate in the hypopharynx above the cricopharyngeus.

Hypopharyngeal web. Lateral radiograph reveals a focal ring-like stricture (curved arrow) in the hypopharynx, at the level of the cricopharyngeus. Note mild proximal ballooning and jet effect (small arrows), suggesting significant narrowing. Also, there is laryngeal penetration (curved arrow).

Cervical web. Focal ring-like web in the cervical esophagus (arrows) is located caudle to the cricopharyngeus (asterisk).

Postcricoid defect (arrow). Lobular filling defect along the anterior wall of the hypopharynx should not be confused with a web. This filling defect changes with peristalsis, and there is no proximal ballooning or jet effect to suggest significant stenosis.

Retention cyst. Similar well-defined round filling defect is seen in the left vallecula. Retention cysts are almost always asymptomatic.

Fibrovascular polyp. (A) Esophagram reveals lobular filling defect in the mid and distal thoracic esophagus (long arrow). Note the long stalk, which extends from the hypopharynx, where most fibrovascular polyps originate (short arrows). (B) Intraoperative specimen reveals elongated fibrovascular polyp. (Color version of figure is available online.)

Squamous cell carcinoma. (A) Frontal radiograph reveals lobular filling defect in the left vallecula (arrow) with obliteration of the left piriform sinus. (B) Lateral radiograph reveals mass obliterating the entire left piriform sinus (arrows). (C) Cross-sectional imaging reveals mass (asterisk) in left piriform sinus displacing the hypopharynx to the right.

DISHphagia. (A) Frontal image from a barium swallow reveals extrinsic compression along the right hypopharynx (arrow). (B) Lateral view reveals a large anterior syndesmophyte complex in this patient with diffuse idiopathic skeletal hyperostosis (asterisks). (C) Sagittal reconstructed CT images revealing anterior displacement of the hypopharynx and cervical esophagus by the large bony protuberances. Postsurgical image after syndesmophytes surgically resected reveals decreased displacement of the hypopharynx on the frontal (arrow), (D) and lateral (E) views.