(B) Left posterior oblique view of the pharynx demonstrates amputation of the epiglottic tip (black arrow) and nodularity of the mucosa (white arrows).
Source: Reproduced from Rubesin [31], with permission.
Figure 6.29 Polypoid squamous cell carcinoma of the right piriform sinus. (A) Frontal view of the pharynx demonstrates loss of the normal contour of the right piriform sinus and a barium‐etched mass (arrows) protruding into the lumen. The valleculae and epiglottic tip are spared. (B) Lateral view of the pharynx demonstrates a large, lobulated barium‐etched mass (arrows). The epiglottic tip (e) and laryngeal vestibule (arrowhead) are spared.
Source: Reproduced from Rubesin and Glick [23], with permission.
Figure 6.30 Plaque‐like squamous cell carcinoma of the posterolateral pharyngeal wall. (A) Steep oblique view of the pharynx demonstrates focal mucosal nodularity and plaque‐like elevation (arrows) of the posterior pharyngeal wall. (B) Lateral view of the pharynx demonstrates mucosal nodularity (arrows) en face.
Figure 6.31 Ulcerated squamous cell carcinoma of the pharyngoesophageal segment. Lateral view of the pharynx shows a barium‐filled ulcer (large arrow) at the pharyngoesophageal segment. The posterior pharyngeal wall is destroyed by tumor (small arrows) centered at the pharyngoesophageal segment but extending vertically into the distal hypopharynx and proximal cervical esophagus.
Even so, other investigators have shown that double‐contrast esophagography can be a useful imaging test for Barrett’s esophagus in patients with reflux symptoms when these individuals are classified as being either at high, moderate, or low risk for Barrett’s esophagus based on specific radiologic criteria [85]. Patients who are classified at high risk for Barrett’s esophagus because of a mid‐esophageal stricture or ulcer or a reticular pattern are almost always found to have this condition, so endoscopy and biopsy should be performed for a definitive diagnosis. A larger group of patients are at moderate risk for Barrett’s esophagus because of esophagitis or peptic strictures in the distal esophagus, so the decision for endoscopy should be based on the severity of symptoms, age, and overall health of the patient. However, most patients are at low risk for Barrett’s esophagus because of the absence of esophagitis or strictures, and the risk of Barrett’s esophagus is so small in this group that these individuals can be treated empirically for their reflux symptoms without need for endoscopy. Thus, double‐contrast esophagography can be used to separate patients into various risk groups for Barrett’s esophagus to determine the relative need for endoscopy and biopsy in these patients.
Figure 6.32 Lymphoma of the palatine tonsil. Lateral view of the pharynx after instillation of intranasal barium shows a large, smooth mass (thick arrows) filling the lateral hypopharynx. A barium‐coated ring shadow (thin arrow) represents a central ulcer. The posterior pharyngeal wall is thickened (double arrow) and has a nodular surface. The epiglottic tip (e) is identified.
Source: Reproduced from Levine MS, Rubesin SE. Radiologic investigation of dysphagia. AJR Am J Roentgenol1990; 154:1157–1163, with permission.
Figure 6.33 Lymphoma of the base of the tongue. Lateral view of the pharynx shows that the base of the tongue is enlarged (thick arrows) and protruding posteriorly. The valleculae are obliterated (thin arrow).
Source: Reproduced from Rubesin and Laufer [57], with permission.
Figure 6.34 Diffuse radiation changes. (A) Frontal view of the pharynx shows that epiglottis (large arrow) is enlarged and has a smooth bulbous contour. The valleculae are flattened (left valleculae identified with a small arrow). The aryepiglottic folds are markedly but smoothly enlarged (right aryepiglottic fold identified by double arrow). The mucosa overlying the muscular processes of the arytenoids is elevated (white arrowhead identifies mucosa overlying muscular process of the left arytenoid cartilage). (B) Lateral view of the pharynx demonstrates a bulbous epiglottic tip (black arrow), elevated aryepiglottic folds (thin arrows), elevated mucosa overlying the muscular processes of the arytenoid cartilages (open arrow), and slit‐like valleculae (arrowhead). Barium fills the laryngeal vestibule (L).
Source: Reproduced from Rubesin [31], with permission.
Infectious esophagitis
Candida esophagitis
Candida albicans is the most common cause of infectious esophagitis. It usually occurs as an opportunistic infection in immunocompromised patients, but Candida esophagitis may also result from local esophageal stasis caused by severe esophageal motility disorders such as achalasia and scleroderma [86]. In some patients with these motility disorders, a “foamy” esophagus may develop with innumerable tiny bubbles layering out in the barium column; this phenomenon presumably results from esophageal infection by the yeast form of the organism [87]. Single‐contrast barium studies have limited value in detecting Candida esophagitis because of the superficial nature of the disease. In contrast, double‐contrast barium studies have a sensitivity of about 90% in diagnosing Candida esophagitis in relation to endoscopy [88, 89], primarily because of the ability to demonstrate mucosal plaques with this technique.
Candida esophagitis is usually manifested on double‐contrast studies by discrete plaque‐like lesions corresponding to the white plaques seen on endoscopy [88]. The plaques may appear as linear or irregular filling defects that are often oriented longitudinally in relation to the long axis of the esophagus and are separated by segments of normal intervening mucosa