In patients with chronic sore throats, barium studies are primarily of value for assessing the presence and severity of gastroesophageal reflux.
Acute ulceration and chronic scarring of the pharynx may be caused by a variety of uncommon diseases, including Behçet’s syndrome, bullous pemphigoid, benign mucous membrane pemphigoid, epidermolysis bullosa, erythema multiforme major (Stevens–Johnson syndrome), Reiter’s syndrome, and Crohn’s disease [41]. Lye ingestion may cause marked ulceration with amputation of the epiglottis and severe scarring (Figure 6.21).
Lymphoid hyperplasia
Lymphoid hyperplasia is a nonspecific response to aging, allergies, and repeated infections, involving the palatine tonsils (Figure 6.22) or base of the tongue [42]. Lymphoid hyperplasia of the lingual tonsil may also occur as a compensatory response to prior tonsillectomy. Lymphoid hyperplasia may extend into the valleculae, vallecular surface of the epiglottis, or even the proximal hypopharynx. There are no radiographic criteria for differentiating lymphoid hyperplasia of the tongue base from the normal lingual tonsil. Lymphoid hyperplasia is characterized on barium studies by numerous 3–7 mm smooth‐surfaced, ovoid nodules symmetrically distributed over the vertical surface of the tongue [42, 43] (Figure 6.23). These nodules may protrude posteriorly into the oropharynx and valleculae. When lingual tonsil lymphoid hyperplasia is focal or mass‐like, it can mimic the appearance of tumor at the base of the tongue [42]. Patients with asymmetric nodularity or mass lesions at the tongue base therefore should undergo further investigation to differentiate lymphoid hyperplasia of the lingual tonsil from malignant tumor.
Pharyngeal and cervical esophageal webs
Webs are thin folds composed of mucosa and submucosa arising predominantly from the anterior wall of the pharyngoesophageal segment and proximal cervical esophagus. Cervical esophageal webs are common findings, occurring in 3–8% of patients who undergo upper gastrointestinal barium studies and in 16% of patients at autopsy [44–47]. The pathogenesis of these webs is uncertain. Some webs in the valleculae have been described as normal variants [48]. Other webs result from diseases that cause chronic scarring. Many patients with cervical esophageal webs also have GERD [31, 49].
Webs are thin (1–2 mm in thickness) folds arising from the anterior wall of the pharyngoesophageal segment or proximal cervical esophagus. A web appears on barium studies as a radiolucent bar in the barium pool or as a thin structure etched in white by barium. Some webs extend circumferentially, with a deeper shelf on their anterior surface. Patients with dysphagia usually have circumferential cervical esophageal webs occluding greater than 50% of the luminal diameter (Figure 6.24). Obstruction is implied by dilatation of the cervical esophagus proximal to the web or by a spurt of barium through the web (the so‐called jet phenomenon) [50, 51].
Figure 6.15 Killian–Jamieson diverticula. (A) Frontal view of the pharynx demonstrates a 1.5 cm sac (thick arrow) just below the level of the cricopharyngeus. A tiny sac is also seen on the right (thin arrow). (B) Lateral view of the pharynx shows that the 1.5 cm sac (thick arrow) extends anterior to the expected course of the cervical esophagus (thin arrow). (C) Lateral view of the pharynx during bolus passage demonstrates that the Killian–Jamieson diverticulum (white arrow) lies below the level of an incompletely opening cricopharyngeus (black arrow). The sac arises from the anterolateral wall of the most proximal cervical esophagus.
Source: Reproduced from Rubesin and Levine [36], with permission.
Figure 6.16 Synchronous Zenker’s and Killian–Jamieson diverticula. Oblique view of the pharynx shows a 2.5 cm Zenker’s diverticulum (Z) with its opening (double black arrow) above the cricopharyngeal bar (thick black arrow). The Killian–Jamieson diverticulum (K) arises below the cricopharyngeal bar, and a portion of the diverticulum extends anterior to the cervical esophagus.
Source: Reproduced from Rubesin [31], with permission.
Tumors
Benign tumors and cysts
The most common benign lesions of the base of the tongue are retention cysts [43]. Granular cell tumors as well as ectopic thyroid tissue and thyroglossal duct cysts also occur at the tongue base. The most common benign tumor‐like lesions of the aryepiglottic folds are retention cysts and saccular cysts [43]. Retention cysts are lined by squamous epithelium and are filled with desquamated debris. Saccular cysts are filled with mucus from glands of the appendix of the laryngeal ventricle [40] and are the mucus‐filled variant of internal laryngoceles. True soft tissue tumors are uncommon and include lipomas, neurofibromas, hamartomas, and oncocytomas, usually arising from the aryepiglottic folds or the mucosa overlying the muscular process of the arytenoid cartilages [40]. Benign tumors arising from the mucoserous minor salivary glands are usually found in the soft palate or tongue base. Chondromas usually arise from the posterior lamina of the cricoid cartilage. Regardless of the specific histologic findings, benign pharyngeal tumors often appear on barium studies as smooth‐surfaced hemispheric masses that protrude into the pharyngeal lumen [52] (Figure 6.25).
Squamous cell carcinoma
In the United States, squamous cell carcinoma of the head and neck (tongue, pharynx, larynx) is five times more common than squamous cell carcinoma of the esophagus. More than 20% of patients with squamous cell carcinomas of the head and neck have synchronous or metachronous carcinomas of the oral cavity, pharynx, larynx, esophagus, or lungs [53]. About 90% of malignant tumors in the oropharynx and hypopharynx are non‐keratinizing squamous cell carcinomas. Almost all of these tumors are detected in moderate or heavy abusers of alcohol, tobacco, or both.
The signs, symptoms, prognosis, and treatment of pharyngeal cancer depend on the location of the tumor. Most patients have symptoms of short duration (less than four months), including sore throat, hoarseness, dysphagia, and odynophagia. The overall five‐year survival rate for these patients is 20–40% [52–54].
The radiographic findings of squamous cell carcinoma are those of any mucosal tumor in the gastrointestinal tract [55–58]. The normal contour of the involved structure is disrupted by a protrusion into the lumen or by an ulceration extending outside the expected luminal contour. Intraluminal tumor is manifested as an area of increased radio‐opacity replacing the normally air‐filled lumen or as a radiolucent filling defect in the barium pool [55] (Figure 6.26). The irregular mucosal surface of the tumor is manifested as a granular, nodular, ulcerated, or lobulated surface or as barium‐etched lines in an unexpected configuration or location [57] (Figure 6.26). The mobility or distensibility of the involved structure may be compromised (Figure 6.27).
The palatine tonsil is the most common site of involvement of squamous cell carcinoma of the pharynx. Tonsillar tumors can spread to the posterior pharyngeal wall, soft palate, and base of the tongue. Lymph node metastases are seen in about one‐half of these patients [52, 54]. Squamous cell carcinomas of the tongue base are usually advanced tumors that already have spread deep into