pharynx is irradiated when patients undergo radiation therapy for squamous cell carcinoma of the larynx or pharynx, lymphoma of the pharynx or cervical lymph nodes, or metastases to the neck. Historically, the pharynx was included in the radiation portal in patients who also underwent radiation therapy for thyrotoxicosis and tuberculous lymphadenitis. Chronic radiation injury to the pharynx is characterized by vascular damage with mucosal atrophy and fibrosis of muscle and submucosal tissue. Edema caused by lymphatic and venous obstruction is most marked in the epiglottis and mucosa overlying the muscular processes of the arytenoid cartilages. Osteomyelitis and chondronecrosis are more severe complications.
Figure 6.22 Lymphoid hyperplasia of the palatine tonsils and tongue base. (A) Frontal view of the pharynx demonstrates that the left and right palatine tonsils (arrows) protrude deeply into the oropharynx. Ovoid nodules carpet the base of the tongue. (B) Lateral view of the pharynx during phonation reveals a mass in the tonsillar fossae (white arrows) and nodules at the tongue base (black arrows).
Source: Reproduced from Rubesin [31], with permission.
Radiation edema and fibrosis is manifested on barium studies by smooth, bulbous enlargement of the epiglottis, smooth thickening of the aryepiglottic folds, and elevation of the mucosa overlying the muscular processes of the arytenoid cartilages [31, 40, 65] (Figure 6.34). Other findings include flattening of the valleculae and atrophy of the soft palate if this structure is included in the radiation portal [3]. Radiation fibrosis leads to diminished or absent epiglottic tilt and poor closure of the laryngeal vestibule with subsequent laryngeal penetration [66]. Constrictor muscle paresis may result in poor clearance from the hypopharynx with stasis and overflow aspiration. Nodularity or focal ulceration of the mucosal surface should suggest the possibility of persistent or recurrent tumor [65].
Esophagus
Technique
Barium studies of the esophagus are usually performed as biphasic examinations that include both upright double‐contrast views with a high‐density barium suspension and prone single‐contrast views with a low‐density barium suspension [67]. The patient first ingests an effervescent agent and then rapidly gulps the high‐density barium in the upright, left posterior oblique (LPO) position in order to obtain double‐contrast views of the esophagus. The esophagus normally has a smooth, featureless appearance en face and a thin white etching where it is seen in profile (Figure 6.35A). Occasionally, collapsed or partially collapsed views may show the normal longitudinal folds as thin, straight, delicate structures no more than 1–2 mm in width (Figure 6.35B). The patient is then placed in a recumbent, right‐side down position for double‐contrast views of the gastric cardia and fundus. The cardia can often be recognized by the presence of three or four stellate folds that radiate to a central point at the gastroesophageal junction (GEJ), also known as the cardiac rosette [68] (Figure 6.35C). In some patients with tumor involving the cardia, these lesions may be manifested by distortion, effacement, or obliteration of this rosette.
Figure 6.23 Lymphoid hyperplasia of the tongue base. Barium fills the grooves between smooth ovoid nodules symmetrically distributed on the vertical surface of the tongue.
After the double‐contrast phase of the examination is completed, the patient is placed in the prone, right anterior oblique (RAO) position and takes discrete swallows of a low‐density barium suspension in order to evaluate esophageal motility. Esophageal dysmotility is considered to be present when abnormal peristalsis is detected on two or more of five separate swallows [69]. The patient then rapidly gulps the low‐density barium suspension to optimally distend the esophagus (particularly the distal esophagus) in order to rule out rings or strictures that could be missed on the double‐contrast phase of the examination. Finally, the patient is turned from a supine to a right lateral position to assess for spontaneous gastroesophageal reflux or for reflux induced by a Valsalva maneuver or water‐siphon test.
Gastroesophageal reflux disease
The purpose of barium studies in patients with reflux symptoms is not simply to document the presence of a hiatal hernia or gastroesophageal reflux, but rather to detect the morphologic sequelae of reflux, including reflex esophagitis, peptic strictures, Barrett’s esophagus, and esophageal adenocarcinoma. These conditions are therefore considered separately in subsequent sections.
Reflux esophagitis
Reflux esophagitis is by far the most common inflammatory disease involving the esophagus. This condition is characterized on single‐contrast esophagrams by thickened folds, marginal ulceration, and decreased distensibility, but such findings are detected only in patients with advanced disease. In contrast, double‐contrast esophagrams have a sensitivity approaching 90% for the diagnosis of reflux esophagitis because of the ability to detect superficial ulcers or other findings that cannot be visualized on single‐contrast studies [70, 71]. Thus, double‐contrast esophagography is the radiologic technique of choice for patients with suspected GERD.
Early reflux esophagitis may be manifested on double‐contrast studies by a finely nodular or granular appearance of the mucosa with poorly defined radiolucencies that fade peripherally as a result of mucosal edema and inflammation [72, 73] (Figure 6.36). In almost all cases, this nodularity or granularity extends proximally from the GEJ as a continuous area of disease. With more advanced disease, barium studies may reveal shallow ulcers and erosions in the distal esophagus. The ulcers may have a punctate, linear, or stellate configuration, and are frequently associated with surrounding halos of edematous mucosa, radiating folds, or sacculation of the adjacent esophageal wall [73] (Figure 6.37A). Other patients may have a solitary ulcer at or near the GEJ, often on the posterior wall of the distal esophagus [74] (Figure 6.37B). It has been postulated that the location of these ulcers is related to prolonged exposure to refluxed acid that pools posteriorly when patients sleep in the supine position [74]. Other patients may have widespread ulceration involving the distal third or even half of the thoracic esophagus. In such cases, however, the ulceration almost always extends distally to the region of the GEJ. Thus, the presence of ulcers that are confined to the upper or mid esophagus should suggest another cause for the patient’s disease.
Figure 6.24 Cervical esophageal web. (A) Frontal and (B) lateral views demonstrate a thin radiolucent band (white arrows) encircling the cervical esophagus. A jet of barium (black arrow) spurting through the opening in the web indicates that there is partial