RDSC 233 Unit 8Radiography of the pharnyx & esophagus Bontrager pp. 443-445: 458-460: 469-473

Positioning of:

Soft tissue neckAP and lateral soft tissue neck RAO, LAO esophagusLeft lateral esophagusAP, PA esophagus

Radiographic anatomy

Film Critique

Radiographic Pathology

Anatomy of the pharnyx & esophagus

Exposure Factors

Atlas of Human Anatomy Second edition (60)

Need to know

Nasopharynx, oropharynx,laryngopharynx, esophagus

Soft palate, uvula

Buccal cavity

Piriform fossa (recess)

Epiglottis

Atlas of Human Anatomy Second edition (57) Need to know

Nasopharynx, oropharynx,laryngopharynx, esophagus

Soft palate, uvula

Adnoids

Vocal folds

Epiglottis

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

Examinations of the pharnyxA similar procedure is done after a person has had a stroke or other disabling affliction to the muscles of speech.

This is typically done by a speechpathologist, using barium paste,and is the one procedure commonly recorded on video tape.

This procedure is also called abarium swallow. Photos from Bontrager

With filtration Without filtration

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 emptiesinto the stomach in seconds. It is also used to diagnose reflux when usingthe 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 cottonballs, marshmallows, or other foods.

No patient preparation is need for an esophagram, unless it is to be followedby an UGI

Examinations of the pharnyx and esophagus

The patient is often put into an RAO before the table to lowered tohorizontal. 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 tothe cardiac orifice of the stomach, and make the exposure before the esophagus empties. To do this the patient is instructed to take threelarge bolus swallows. On the fourth, breathing is suspended and theexposure is made at the moment the patient swallows. A shallowtrendelenburg position will help keep the esophagus full.

A large diameter straw is needed, and care must be taken that the endof the straw does not become vacuum sealed to the bottom of the cup.

Esophagrams begin under fluoroscopy, in the upright position. The patientholds 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 LPOpositions.

Radiographic Positioning of the x

Positioning of:

Soft tissue neckAP and PA of esophagus RAO and LAO esophagusRight lateral esophagus

Film Critique

including

Soft tissue neck Positioned the same as an AP & Lateral C-spine: ½ the mAs.

Trachea

Nasopharynx

Esophagus

Adnoids

Hyoid bone

Expose during inspiration

Oropharynx

Done to assess the patencyof 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?

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

chest pain, heartburn, dysphagia (difficulty swallowing), odynophagia (pain on swallowing)

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 criteriafor frontal projections of the esophagus

Entire esophagus filled with barium, in an unrotated frontal projection.

When there is inadequate fillingof the esophagus, under-penetration,and/or insufficient density, the esophagus is difficult to visualizeagainst the mediastinum.

Good filling, contrast,and density, demonstratinga 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 criteriafor RAO & LAO esophagusLike the RAO stomach, which is the singlebest 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 demonstratethe entire barium filled esophagus.

The abdominal portion is more importantthan the pharyngeal portion, which maybe evaluated by direct inspection.

Critique criteriafor 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.

The RAO & LAO should both demonstrate the entire barium filled esophagus.

The abdominal portion is more importantthan the pharyngeal portion, which maybe evaluated by direct inspection.

Photo from Bontrager

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

Critique criteriafor lateral esophagus

Entire barium filled esophagusprojected posterior to heart, andanterior to the T-spine

Soft tissue of arm

Humerus

Why does the esophagus extendso far below the diaphragm,and yet the cardiac orifice is notseen?

The caval opening is in theleft hemidiaphragm. The right hemidiaphragm is typically higherthan the left due to the liver. In thiscase the difference betweenthem 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 sameas 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

TE fistula

Foreign body

Diverticulum

Significant Pathologiesof the esophagus

and their

Radiographic Appearances

Esophageal CA

Presbyesophagus

Barium in the bronchial tree may result from a TE fistula, or aspiration of barium.

A congenital or ulcerative opening (fistualtract) between the esophagus and trachea.

Radiographic examinations of fistulas arefistulagrams, or sinograms (sinus tract).

Treacheoesophageal (TE) fistula

Foreign bodies in esophagus

Rotary blades from an electric razor.One stuck in the proximal esophagus,and one in the pyloric canal.

Diverticulum

Radiolucent FBs,such as chickenor fish bones, mayrequire a swallowof barium to demonstrate.

Esophageal Cancer

Colon used to replace the esophagus afterit was removedin a canceroperation.

Note the haustrations

Presbyesophagus

An old esophagus

Presby, meaning old, is usedto describe the dilatation and scalloping of the esophagusthat 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