The significance of webs in the hypopharynx and upper esophagus.

Abstract

The true incidence of webs in the hypopharynx and upper esophagus is not known, as many are probably not detected by the routine radiological examination of the upper gastrointestinal tract. This is particularly true if the patient has no symptoms referable to deglutition. Since the introduction of cineradiologic technics in the Columbia-Presbyterian Medical Center five years ago for the routine examination of the upper gastrointestinal tract, the detection of webs has increased sharply. During the ten-year period, 1950–1960, only 9 patients with webs were discovered, while during the past five years, 44 additional examples of this lesion were detected, 15 during the immediate past year. This fact prompted a review of 53 cases with radiographically demonstrable webs in the pharynx or upper esophagus that have been seen during the past fifteen years, in order to assess the clinical significance of the finding (Table I). Clinical Material The ratio of whites and Negroes was 30 to 23 and of males to females 22 to 31. Most of the webs occurred in the cervical esophagus near the cricopharyngeus (Fig. 1), although 4 were in the hypopharynx (Fig. 2) and 3 in the upper thoracic esophagus (Fig. 3). The absence of a definite anatomic landmark for the pharyngoesophageal junction makes precise localization of some webs difficult except when a cricopharyngeal impression is present. Some webs occur at or just below the cricopharyngeus and, because this is properly a part of the pharynx, they could be regarded as pharyngeal (Fig. 4). Multiple webs, present in 3 patients (Figs. 5 and 9), may involve either the esophagus, the hypopharynx, or both. Radiographic Aspects In our opinion, the use of cineradiography is responsible for the increase in number of cases of esophageal webs diagnosed during the past five years. Many are visible for only a fraction of a second when the pharynx or esophagus is maximally distended, and are perhaps demonstrated on only one or two frames at camera speeds of 8 to 10 frames per second. Webs are also overlooked because the hypopharynx and cervical esophagus are not carefully studied, especially when there are no symptoms referable to this area. While we begin the routine cineradiographic examination in the mesopharynx with camera speeds of 8 frames per second, a careful study ideally requires camera speeds of 24 to 30 frames per second because of the extraordinary rapidity of deglutition. The typical web appears radiographically as a filling defect arising at right angles from the anterior wall of the cervical esophagus, usually at or just below the cricopharyngeus. Its thickness is uniform and rarely exceeds 2 mm. Immediately beneath the web, in some cases, it is possible to recognize a short segment of esophagus in which distensibility is limited. The lower limit of this segment may be separated from the normal esophagus by a second web (Fig. 5).