olin. RadioL (1979) 30, 485-488
gseudotumours of the Oropharynx due to Muscular Contraction p. K. ASAMOAH*
X-raY Department, Fazakerley Hospital, Liverpool Normal filling defects in the barium-Idled oropharynx are described. These pseudotumours result from the contraction, elevation and backward pulling of the soft palate assisted by the rounded ridge (of Passavant) in the pharyngeal wall produced by contraction of the palatopharyngeal sphincter, and the action of the palatopharyngei during swallowing. Other anatomical explanations for these filling defects are mentioned. The importance of recognising the changing pattern of these defects as being normal, and their differentiation from space occupying lesions in the oropharynx is emphasised.
Although the pharynx is easily examined by direct visualisation, radiology still plays a role in the investigation of lesions of the pharynx. The methods of examination are plain radiographs (at rest, phonating 'Ee' and 'Aa'), high kilovoltage techniques, xerography, tomography, zonography, positive contrast pharyngograms and barium swallow recording the information in a variety of ways. Due to the speed of swallowing the radiologist is often frustrated in his attempts to record on film his fluoroscopic observations of the pharynx. Little attention is usually paid to the pharynx during barium examination of the upper alimentary tract. The demonstration of unusual filling defects in the oropharynx of two patients who complained of food sticking in their throat prompted this study of the pharynx by barium swallow. An appearance which can mimic disease in the oropharynx is reported together with an explanation of the anatomical basis of these pseudotumours.
ANATOMY The pharynx is a musculomembranous channel between the mouth and oesophagus, nose and larynx. Anatomically it is divided into the nasal, oral and laryngeal parts. The nasopharynx lies behind the nose and above the soft palate. A collection of lymphoid tissue, the pharyngeal tonsil or adenoid, lies in the mucous membrane of its roof and posterior wall. This is well developed in children and is sometimes seen as a Idling defect in the air-fried nasopharynx. The laryngopharynx extends from the epiglottis to tile *Present address: Department of Radiology, Warrington General Hospital, Lovely Lane, Warrington, WA5 1QG.
cricoid cartilage where it is continuous with the oesophagus. The nasopharynx and laryngopharynx are extensions of the nose and larynx respectively and are static structures. The oropharynx extends from the soft palate to the epiglottis and communicates with the mouth through the oropharyngeal isthmus and the nasopharynx via the pharyngeal isthmus. It has three walls - the soft palate above and behind, the back of the posterior third of the tongue anteriorly, and the pharyngeal wall posteriorly and laterally. These walls contain muscles and move actively in a coordinated manner. The soft palate is a movable fold suspended from the posterior border of the hard palate_ It is seen as a filling defect separating the nasal and oral parts of the pharynx. The lateral walls present the palatoglossal and palatopharyngeal arches and the palatine tonsils which may be seen as filling defects in the air-filled oropharynx. The pharyngeal muscles consist of the superior, middle and inferior constrictors and three muscles which descend from the styloid process (stylopharyngeus), from the cartilaginous torus of the auditory tube (salpingopharyngeus) and from the soft palate (palatopharyngeus). In addition a constant band of muscle fibres, the palatopharyngeal sphincter, arises from the palatine aponeurosis and sweeps backwards to blend with the internal surface of the superior constrictor near its upper border (Fig. 1). MATERIAL AND METHOD Thirty-five consecutive patients, 15 males and 20 females aged between 18 and 71 years (mean 40_0 years), were referred for barium studies of the upper alimentary tract because of dysphagia and/or upper alimentary tract symptoms_ Fluoroscopic and postero-anterior spot radiographs of the pharynx
CLINICAL RADIOLOGY
486
Medialpterygoid plate
Tensor Levator(cut) I /'i ~" I .... trictorattached~ to,amo,ua
Lev2PhiSc2gr
' ,/',
'] .t W
~
Lo;t;h~r;tnr;on od palatinus
I
I':'
palate
~ ~ / ' , 1~'
7 SOf:palate Medialstrandof pharyngo-palatinus
Fig. 1 - The muscles of the left half of the soft palate and adjoining part of the pharyngeal wall. (J. Whillis, Journal of Anatomy and Physiology, reproduced by kind permission of the publishers.) were taken during the swallowing of barium. Cine film and video tape recording were employed in five and 10 o f the patients respectively. These were studied and the presence, number and extent o f Idling defects in the barium-fdled oropharynx were noted. RADIOGRAPHIC FINDINGS Posterolateral filling defects were seen in the barium-filled oropharynx in all of the patients but were extremely prominent in 15, seven males and eight females aged between 20 and 71 years (mean 40.6 years). Fig. 2 shows oropharyngeal filling defect or pseudotumour in a lateral fluoroscopic spot radiograph during swallowing. The soft palate is elevated and pulled backwards to close the pharyngeal istlamus. The second component of the filling defect (arrow) is very prominent and irregular and mimics a turnout. Direct examination of the pharynx by an ENT surgeon revealed no abnormality. Fig. 3a illustrates the pharynx at rest with barium coating the oral and laryngeal parts. The air in the nasal and oral parts is continuous. Fig. 3b shows the barium in the mouth has been swallowed and the appearances are very similar to those in Fig. 2. Fig. 3c is a postero-anterior view. The fdling defects are in the lateral sides of the oropharynx. Fig. 4 shows a prominent oropharyngeal filling defect in a patient without
Fig. 2 - Pharyngogram in a 20-year-old woman complaining of food sticking in her pharynx. The soft palate is elevated. The posterior component of the oropharyngeal filling defect (arrow) is prominent and irregular with appearance mimicking a tumour, and accentuated by adjacent air bubbles.
dysphagia or pharyngeal symptoms. Figs 5a and 5b illustrate the increasing prominence of the lower component o f the filling defect during swallowing, and further progression of barium down the pharynx. DISCUSSION The presence of filling defects due to the adenoids and the palatine tonsils in the air-filled nasopharynx and oropharynx respectively is well appreciated. Filling defects which change shape in the bariumfilled oropharynx are not well documented. Gustav Passavant described a rounded ridge on the pharyngeal wall in 1869. Whillis (1930) described the anatomy of the palatopharyngeal sphincter which is at the same level as the ridge of Passavant as observed in the living subject. This muscle produces a rounded ridge on the pharyngeal wall when the palate is elevated during swallowing or phonating 'Ee'. There is considerable disagreement over details of deglutition, which involves a highly complex neuromuscular integration. However, the first stage of swallowing is voluntary and involves the tensing and elevation of the soft palate, and the closure and firm approximation o f the soft palate to the posterior pharyngeal wall by
PSEUDOTUMOURS OF THE OROPHARYNX DUE TO MUSCULAR CONTRACTION
Fig. 3a
487
Fig. 3b Fig. 3a - Lateral pharyngogram at rest. Barium is held in the mouth and the soft palate (SP) is relaxed. The nasopharyngeal air is continuous with that in the oropharynx. NP, nasopharynx; T, tongue; PS, post-pharyngeal soft tissues. Fig. 3b - Same patient. Pharyngogram obtained during swallowing. The oropharynx shows the appearances of a pseudotumour similar to those in Fig. 2.
Fig. 3c Same patient. Postero-anterior view showing lateral oropharyngeal filling defects.
contraction of the palatopharyngeal sphincter and the upper fibres of the superior constrictor. These actions close the pharyngeal isthmus and prevent the contents of the oropharynx from passing upwards. Complex muscle actions (including the middle constrictor) prevent the bolus from entering the larynx. The palatopharyngei shorten the pharynx and pull it upwards and thus convert the posterior pharyngeal wall into an inclined plane directed downwards and backwards, The third stage is effected by the inferior constrictor which compresses the bolus into the oesophagus (Warwick and Williams, 1973). It is suggested that the oropharyngeal pseudotumours result from contraction of the soft palate assisted by contraction o f the palatopharyngeal sphincter and the action of t h e palatopharyngei. The anterior component of the filling defect is usually smooth and there is general agreement that it is due to the soft palate. The lower or posterior component, however, is thought to be due to the
488
CLINICAL RADIOLOGY ration that the defects change shape and size durinswallowing would suggest an appearance due t~o contractile structures like the soft palate, the P~la, topharyngeal sphincter and the palatopharyngei, and perhaps the tonsils (in younger patients) contribute to these defects. The lower component sometira~s appears particularly irregular and simulates the appearance of a turnout on radiographs, and seems to be due to the presence of swallowed air adjacent to the muscular prominence. Papillomas, fibromas, lipomas, rnyomas and ex~. phytic turnouts o f the tonsillar areas, the pharyngeal wall and soft palate m a y be mimicked by these normal filling defects. The latter can be observed to change shape and size during swallowing and dis. appear at rest. Acknowledgements.
I am grateful to Professor G.
Whitehouse for his encouragement, advice and assistance, Dr
M. Goldman for his encouragement, Professor Eric Samuel, CBE, and Dr G. M. Ardran for their comments on some of the radiographs, Mr D. Adkins for preparing the illustrations and Mrs J. Williams for secretarial assistance. Fig. 4 - Prominent oropharyngeal filling defect in a 20-yearold man without pharyngeal symptoms or dysphagia.
REFERENCES
palatine tonsil or the Eustachian cushion (E. Samuel, personal communication) or the soft palate, the palatopharyngeus and sometimes the palatine tonsils (G. N. Ardran, personal communication). The obser-
Warwick, R. & Williams, P. L. (1973). Gray's Anatomy, 35th edn, pp. 1249-1250. Longman Group Ltd. Whfllis, J. (1930). A note on the muscles of the palate and the superior constrictor. Journal of Anatomy and Physiology, 65, 92 95.
Fig. 5a --- Small oropharyngeal smooth filling defect without adjacent air bubbles,
Fig. 5b - Same patient. There has been further progression of barium in the pharynx and the pseudotumodr has increased in size.
gseudotumours of the Oropharynx due to Muscular Contraction p. K. ASAMOAH*
X-raY Department, Fazakerley Hospital, Liverpool Normal filling defects in the barium-Idled oropharynx are described. These pseudotumours result from the contraction, elevation and backward pulling of the soft palate assisted by the rounded ridge (of Passavant) in the pharyngeal wall produced by contraction of the palatopharyngeal sphincter, and the action of the palatopharyngei during swallowing. Other anatomical explanations for these filling defects are mentioned. The importance of recognising the changing pattern of these defects as being normal, and their differentiation from space occupying lesions in the oropharynx is emphasised.
Although the pharynx is easily examined by direct visualisation, radiology still plays a role in the investigation of lesions of the pharynx. The methods of examination are plain radiographs (at rest, phonating 'Ee' and 'Aa'), high kilovoltage techniques, xerography, tomography, zonography, positive contrast pharyngograms and barium swallow recording the information in a variety of ways. Due to the speed of swallowing the radiologist is often frustrated in his attempts to record on film his fluoroscopic observations of the pharynx. Little attention is usually paid to the pharynx during barium examination of the upper alimentary tract. The demonstration of unusual filling defects in the oropharynx of two patients who complained of food sticking in their throat prompted this study of the pharynx by barium swallow. An appearance which can mimic disease in the oropharynx is reported together with an explanation of the anatomical basis of these pseudotumours.
ANATOMY The pharynx is a musculomembranous channel between the mouth and oesophagus, nose and larynx. Anatomically it is divided into the nasal, oral and laryngeal parts. The nasopharynx lies behind the nose and above the soft palate. A collection of lymphoid tissue, the pharyngeal tonsil or adenoid, lies in the mucous membrane of its roof and posterior wall. This is well developed in children and is sometimes seen as a Idling defect in the air-fried nasopharynx. The laryngopharynx extends from the epiglottis to tile *Present address: Department of Radiology, Warrington General Hospital, Lovely Lane, Warrington, WA5 1QG.
cricoid cartilage where it is continuous with the oesophagus. The nasopharynx and laryngopharynx are extensions of the nose and larynx respectively and are static structures. The oropharynx extends from the soft palate to the epiglottis and communicates with the mouth through the oropharyngeal isthmus and the nasopharynx via the pharyngeal isthmus. It has three walls - the soft palate above and behind, the back of the posterior third of the tongue anteriorly, and the pharyngeal wall posteriorly and laterally. These walls contain muscles and move actively in a coordinated manner. The soft palate is a movable fold suspended from the posterior border of the hard palate_ It is seen as a filling defect separating the nasal and oral parts of the pharynx. The lateral walls present the palatoglossal and palatopharyngeal arches and the palatine tonsils which may be seen as filling defects in the air-filled oropharynx. The pharyngeal muscles consist of the superior, middle and inferior constrictors and three muscles which descend from the styloid process (stylopharyngeus), from the cartilaginous torus of the auditory tube (salpingopharyngeus) and from the soft palate (palatopharyngeus). In addition a constant band of muscle fibres, the palatopharyngeal sphincter, arises from the palatine aponeurosis and sweeps backwards to blend with the internal surface of the superior constrictor near its upper border (Fig. 1). MATERIAL AND METHOD Thirty-five consecutive patients, 15 males and 20 females aged between 18 and 71 years (mean 40_0 years), were referred for barium studies of the upper alimentary tract because of dysphagia and/or upper alimentary tract symptoms_ Fluoroscopic and postero-anterior spot radiographs of the pharynx
CLINICAL RADIOLOGY
486
Medialpterygoid plate
Tensor Levator(cut) I /'i ~" I .... trictorattached~ to,amo,ua
Lev2PhiSc2gr
' ,/',
'] .t W
~
Lo;t;h~r;tnr;on od palatinus
I
I':'
palate
~ ~ / ' , 1~'
7 SOf:palate Medialstrandof pharyngo-palatinus
Fig. 1 - The muscles of the left half of the soft palate and adjoining part of the pharyngeal wall. (J. Whillis, Journal of Anatomy and Physiology, reproduced by kind permission of the publishers.) were taken during the swallowing of barium. Cine film and video tape recording were employed in five and 10 o f the patients respectively. These were studied and the presence, number and extent o f Idling defects in the barium-fdled oropharynx were noted. RADIOGRAPHIC FINDINGS Posterolateral filling defects were seen in the barium-filled oropharynx in all of the patients but were extremely prominent in 15, seven males and eight females aged between 20 and 71 years (mean 40.6 years). Fig. 2 shows oropharyngeal filling defect or pseudotumour in a lateral fluoroscopic spot radiograph during swallowing. The soft palate is elevated and pulled backwards to close the pharyngeal istlamus. The second component of the filling defect (arrow) is very prominent and irregular and mimics a turnout. Direct examination of the pharynx by an ENT surgeon revealed no abnormality. Fig. 3a illustrates the pharynx at rest with barium coating the oral and laryngeal parts. The air in the nasal and oral parts is continuous. Fig. 3b shows the barium in the mouth has been swallowed and the appearances are very similar to those in Fig. 2. Fig. 3c is a postero-anterior view. The fdling defects are in the lateral sides of the oropharynx. Fig. 4 shows a prominent oropharyngeal filling defect in a patient without
Fig. 2 - Pharyngogram in a 20-year-old woman complaining of food sticking in her pharynx. The soft palate is elevated. The posterior component of the oropharyngeal filling defect (arrow) is prominent and irregular with appearance mimicking a tumour, and accentuated by adjacent air bubbles.
dysphagia or pharyngeal symptoms. Figs 5a and 5b illustrate the increasing prominence of the lower component o f the filling defect during swallowing, and further progression of barium down the pharynx. DISCUSSION The presence of filling defects due to the adenoids and the palatine tonsils in the air-filled nasopharynx and oropharynx respectively is well appreciated. Filling defects which change shape in the bariumfilled oropharynx are not well documented. Gustav Passavant described a rounded ridge on the pharyngeal wall in 1869. Whillis (1930) described the anatomy of the palatopharyngeal sphincter which is at the same level as the ridge of Passavant as observed in the living subject. This muscle produces a rounded ridge on the pharyngeal wall when the palate is elevated during swallowing or phonating 'Ee'. There is considerable disagreement over details of deglutition, which involves a highly complex neuromuscular integration. However, the first stage of swallowing is voluntary and involves the tensing and elevation of the soft palate, and the closure and firm approximation o f the soft palate to the posterior pharyngeal wall by
PSEUDOTUMOURS OF THE OROPHARYNX DUE TO MUSCULAR CONTRACTION
Fig. 3a
487
Fig. 3b Fig. 3a - Lateral pharyngogram at rest. Barium is held in the mouth and the soft palate (SP) is relaxed. The nasopharyngeal air is continuous with that in the oropharynx. NP, nasopharynx; T, tongue; PS, post-pharyngeal soft tissues. Fig. 3b - Same patient. Pharyngogram obtained during swallowing. The oropharynx shows the appearances of a pseudotumour similar to those in Fig. 2.
Fig. 3c Same patient. Postero-anterior view showing lateral oropharyngeal filling defects.
contraction of the palatopharyngeal sphincter and the upper fibres of the superior constrictor. These actions close the pharyngeal isthmus and prevent the contents of the oropharynx from passing upwards. Complex muscle actions (including the middle constrictor) prevent the bolus from entering the larynx. The palatopharyngei shorten the pharynx and pull it upwards and thus convert the posterior pharyngeal wall into an inclined plane directed downwards and backwards, The third stage is effected by the inferior constrictor which compresses the bolus into the oesophagus (Warwick and Williams, 1973). It is suggested that the oropharyngeal pseudotumours result from contraction of the soft palate assisted by contraction o f the palatopharyngeal sphincter and the action of t h e palatopharyngei. The anterior component of the filling defect is usually smooth and there is general agreement that it is due to the soft palate. The lower or posterior component, however, is thought to be due to the
488
CLINICAL RADIOLOGY ration that the defects change shape and size durinswallowing would suggest an appearance due t~o contractile structures like the soft palate, the P~la, topharyngeal sphincter and the palatopharyngei, and perhaps the tonsils (in younger patients) contribute to these defects. The lower component sometira~s appears particularly irregular and simulates the appearance of a turnout on radiographs, and seems to be due to the presence of swallowed air adjacent to the muscular prominence. Papillomas, fibromas, lipomas, rnyomas and ex~. phytic turnouts o f the tonsillar areas, the pharyngeal wall and soft palate m a y be mimicked by these normal filling defects. The latter can be observed to change shape and size during swallowing and dis. appear at rest. Acknowledgements.
I am grateful to Professor G.
Whitehouse for his encouragement, advice and assistance, Dr
M. Goldman for his encouragement, Professor Eric Samuel, CBE, and Dr G. M. Ardran for their comments on some of the radiographs, Mr D. Adkins for preparing the illustrations and Mrs J. Williams for secretarial assistance. Fig. 4 - Prominent oropharyngeal filling defect in a 20-yearold man without pharyngeal symptoms or dysphagia.
REFERENCES
palatine tonsil or the Eustachian cushion (E. Samuel, personal communication) or the soft palate, the palatopharyngeus and sometimes the palatine tonsils (G. N. Ardran, personal communication). The obser-
Warwick, R. & Williams, P. L. (1973). Gray's Anatomy, 35th edn, pp. 1249-1250. Longman Group Ltd. Whfllis, J. (1930). A note on the muscles of the palate and the superior constrictor. Journal of Anatomy and Physiology, 65, 92 95.
Fig. 5a --- Small oropharyngeal smooth filling defect without adjacent air bubbles,
Fig. 5b - Same patient. There has been further progression of barium in the pharynx and the pseudotumodr has increased in size.
