what is pharyngeal stasis

They are usually unilateral. (From Levine MS, Rubesin SE: Radio-logic investigation of dysphagia. HHS Vulnerability Disclosure, Help government site. Int J Mol Sci. 2015 Oct. 8(5):255-63. [QxMD MEDLINE Link]. Medscape Education, Challenges in Gastroesophageal Reflux Disease Assessment and Management, encoded search term (Esophageal Motility Disorders) and Esophageal Motility Disorders, Gastroesophageal Reflux Disease (GERD) Imaging, Fast Five Quiz: Gastroesophageal Reflux Disease Management, Fast Five Quiz: Gastroesophageal Reflux Disease (GERD), Fast Five Quiz: Gastroesophageal Reflux Disease Practice Essentials, PPI Use in Type 2 Diabetes Links With Cardiovascular Events, Transgender People in Rural America Struggle to Find Doctors Willing or Able to Provide Care. Retention cysts and granular cell tumors are the most common benign tumors of the base of the tongue ( Fig. HU6?Q 16-6 ). 2009 Aug 28. This lymphoid tissue causes the normal surface of the base of the tongue to be divided into small nodules of varying size. Barium studies allow detection of more than 95% of structural lesions below the pharyngoesophageal fold. 30(3):1-5. 2015 Aug;37(8):1193-9. doi: 10.1002/hed.23735. Webs are thin mucosal folds usually located along the anterior wall of the lower hypopharynx and proximal cervical esophagus. 2ZX3G$>L7tBTAUl x:v=> Lh %`=msXaR{ArBAo 16-4 ). The LES pressure tracing is at the level of the sleeve (tracing 6). MeSH 2009 Aug. 54(8):1680-5. Sato Y, Fukudo S. Gastrointestinal symptoms and disorders in patients with eating disorders. Barium may also be trapped above early closure of the upper cervical esophagus. In contrast, saccular cysts of the aryepiglottic folds arise from the mucus-secreting glands of the appendix of the laryngeal ventricle and are filled with mucoid secretions. Retention cysts of the aryepiglottic folds are lined by squamous epithelium and filled with desquamated squamous debris ( Fig. [QxMD MEDLINE Link]. Abstract: Ankyloglossia, or tongue tie, and its impact on the oral phase of feeding has been studied and debated for decades. UES opened for a portion of the bolus to pass through, pharyngeal stripping was not great. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Has there been a neuro consult? endstream endobj 227 0 obj <>stream Ronnie Fass, MD, FACP, FACG Chief of Gastroenterology, Head of Neuroenteric Clinical Research Group, Southern Arizona Veterans Affairs Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine This unsupported part of the thyrohyoid membrane is perforated by the superior laryngeal artery and vein and the internal laryngeal branch of the superior laryngeal nerve. If symptoms progress, then the workup should be repeated because DES can progress to achalasia. Anteriorly, there is the larynx, epiglottis, and posterior part of the tongue. However, barium studies may reveal enlargement of the aryepiglottic fold with a smooth overlying mucosa. 144(4):718-25; quiz e13-4. The radiologist carefully searches for spread to the nasal cavity, sinuses, and cranial base, especially for cranial nerve involvement. The 2023 edition of ICD-10-CM J39.2 became effective on October 1, 2022. Radiographic findings in pharyngeal carcinoma. Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist. The https:// ensures that you are connecting to the If saccular dilation of the appendix is confined by the thyroid cartilage, it is termed an internal laryngocele. This characteristic likely explains why the botulinum toxin (acetylcholine release inhibitor) may have therapeutic benefit in patients with achalasia. Because such a strong association exists between head and neck squamous cell carcinoma and esophageal carcinoma, a major goal of a preoperative radiologic study is to rule out a synchronous primary esophageal cancer. This infant has pharyngeal stasis post swallow on the swallow study. Neurogastroenterol Motil. 16-14 ). These webs are thought to be normal variants in the valleculae and piriform sinuses. Tertiary contractions are simultaneous, isolated, dysfunctional contractions. This barium, trapped between downwardly progressing pharyngeal contraction and the cricopharyngeal muscle, is termed a pseudo-Zenkers diverticulum ( Fig. Transient or persistent protrusions of the anterolateral cervical esophagus into the Killian-Jamieson space are termed lateral cervical esophageal pouches or diverticula, respectively. Response to amyl nitrate, with disappearance of the spasm on esophagram. Therapeutic procedures and operations are associated with a small but significant risk of mortality and morbidity. I am surprised there was not retrograde flow into the nasopharynx (what some describe as nasopharyngeal regurgitation), given the diffuse residue. coordinated stasis The idea, proposed in 1992 by Gordon Baird, that certain groups of species remain unaltered for tens of millions of years, then experience an episode of rapid extinction and the formation of new species. In the 4-week-old embryo, paired grooves of ectodermal origin, termed branchial clefts, appear on both sides of the neck region. Catherine Shaker 2023 Seminars: Reinforce Your Intellectual Curiosity! ASHA / Pharyngeal Phase Bolus. Epub 2021 Feb 20. Achalasia manometry picture Note the nonrelaxing lower esophageal sphincter (LES) and the absence of esophageal body peristalsis. If you log out, you will be required to enter your username and password the next time you visit. In Europe, the incidence of achalasia is similar to that of the United States. In the peristaltic esophageal body, achalasia is characterized by a loss of intrinsic acetylcholine-containing nerves. An ulcerated lesion appears as an irregular barium collection disrupting the expected contour of the base of the tongue. Pharyngeal airway changes in Class III patients treated with double jaw orthognathic surgery-maxillary advancement and mandibular setback. 16-16 ). Cochrane Database Syst Rev. However, other manometric studies have shown the following: (1) there is normal coordination between pharyngeal contraction and relaxation of the upper esophageal sphincter; (2) the upper esophageal sphincter relaxes completely during swallowing (i.e., there is no achalasia); and (3) the resting pressure of the upper esophageal sphincter is low (i.e., there is no spasm). This is the American ICD-10-CM version of J39.2 - other international versions of ICD-10 J39.2 may differ. J39.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Ectopic thyroid tissue and thyroglossal duct cysts may occur at the tongue base but are rare. Radiographically, a small (3-20mm in diameter), round to ovoid, smooth-surfaced outpouching is seen just below the level of the cricopharyngeal muscle ( Fig. Diffuse residue, hard to quantify as it varied throughout the study, but definitely not a littleenough that poses a risk for aspiration post-swallow/as feeding continues. Dysphagia. Lingual tonsil lymphoid hyperplasia can be coarsely nodular, asymmetrically distributed, or masslike. Abdullah Fayyad, MD, MBBS Gastroenterology Staff, Private Practice, Digestive and Liver Disease Consultants When decreased base of tongue movement, impaired pharyngeal pressure generation, and presence of pharyngeal residue are noted during a VFSS, a neurologic etiology can be suspected. Diagnostic pitfalls and how to avoid them. Better demonstration of webs is also achieved with the use of large boluses of barium. Manometry may reveal elevated LES pressure greater than 40 mm Hg in more than 60% of patients; however, hypertensive LES is not universal or required for the manometric diagnosis. Motility is preserved at the proximal striated muscle portion of the esophagus. for: Medscape. 16-16 and 16-17 ). Laryngeal involvement in neurofibromatosis (von Recklinghausens disease) is rare but usually involves the region of the arytenoid cartilage and aryepiglottic folds. Rohof WO, Salvador R, Annese V, et al. )dC(SOL*W vRlYE1Zt[@m.)S*=V!/XZ;,3`{9WW(Kr[tfJ[XR[N{\Q*}iRf8w!fM}CS7x.03cO]Mux: T*xo~g|[IlyQV[G_W6W(=ihk- 8600 Rockville Pike In addition to alcohol and smoking abuse, poor ventilation, nasal balms, ingested carcinogens, and upper respiratory viruses such as the Epstein-Barr virus have been implicated as causative factors. Medical team is very supportive of therapy. Praveen K Roy, MD, MSc Clinical Assistant Professor of Medicine, University of New Mexico School of Medicine "When the results of the oropharyngeal exam and the esophagram were combined, esophageal stasis in isolation was the most common finding at all complaint locations, with the exception of patients who complained of stasis in the cervical and thoracic esophagus where the most common finding was no stasis." "Pharyngeal stasis in isolation . new hanover high school football roster; st mary's glacier camping colorado; espn 2025 basketball rankings; is february 11 2022 a federal holiday; janae from sweetie pies: new baby; lahat may hangganan quotes; 2015 Oct. 28(7):699-704. 223 0 obj <> endobj See the images below. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. Is there any particular intervention improving pharyngeal clearance with the swallow. Herbella FA, Colleoni R, Bot L, Vicentine FP, Patti MG. High-resolution manometry findings in patients after sclerotherapy for esophageal varices. The exception is the . Timing of events during deglutition after chemoradiation therapy for oropharyngeal carcinoma. 0 The muscle is oriented in 2 perpendicular opposing layers: an inner circular layer and an outer longitudinal layer, known collectively as the muscularis propria. No nasopharyngeal regurgitation that I recall. The lower esophageal sphincter (LES) is composed entirely of smooth muscle and maintains a steady baseline tone to prevent gastric reflux into the esophagus. World J Gastroenterol. 16-19 ). 2015 Dec. 174(12):1629-37. Some webs show inflammatory changes. Dis Esophagus. This region is bounded superiorly by the greater cornu of the hyoid bone, anteriorly by the thyrohyoid muscle, posteriorly by the superior cornu of the thyroid cartilage and stylopharyngeal muscle, and inferiorly by the ala of the thyroid cartilage. You are being redirected to We present a 21-month-old patient with significant pharyngeal phase dysphagia which was most saliently characterized by impaired base of tongue movement, poor pressure generation, and diffuse residue resulting in aspiration. Esophageal dysmotility may be caused by: An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus. [QxMD MEDLINE Link]. Scarring may cause distortion of the pharyngeal contours. [1] As with any other chronic illness, prevalence exceeds incidence significantly. Muller M, Eckardt AJ, Gopel B, Eckardt VF. Esophagram of a 65-year-old man with rapid-onset dysphagia over 1 year. Catherine Shaker Seminars: Formula One Style in Austin! Carlson DA, Ravi K, Kahrilas PJ, et al. The radiologist may be the first physician to suggest a diagnosis of pharyngeal carcinoma ( Fig. ), An 80-year-old patient with dementia underwent an upper GI examination for epigastric pain. Clinical and manometric course of nonspecific esophageal motility disorders. In immunosuppressed patients with acute dysphagia, barium studies are directed toward the esophagus to demonstrate the presence, site, and type of esophagitis. Enter your email address to subscribe to this blog and receive notifications of new posts by email. fX"cr4Fe"?zp8k$i?NrMqjnvVu^5TUfVrGMZWI/];^gAC]Hq$6)\~|ounXx2 f(E^4ikb Qh/#GH+;&*~7ka<2( \ The esophagus functions solely to deliver food from the mouth to the stomach where the process of digestion can begin. The proximal esophagus is predominantly striated muscle, while the distal esophagus and the remainder of the GI tract contain smooth muscle. The pharynx is the site of common illnesses, including sore throat and tonsillitis. 2021 Dec;36(6):1063-1071. doi: 10.1007/s00455-020-10239-3. If high-amplitude (>60 mm Hg) simultaneous contractions occur, the entity is categorized as vigorous achalasia, which may represent an early stage of classic achalasia. Only rarely do these tumors extend through the laryngeal ventricles into the true vocal cords. [QxMD MEDLINE Link]. Esophageal motility disorders discussed in this article include the following: Spastic esophageal motility disorders, including diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive LES, Nonspecific esophageal motility disorder (inefficient esophageal motility disorder), Secondary esophageal motility disorders related to scleroderma, diabetes mellitus, alcohol consumption, psychiatric disorders, and presbyesophagus. Tumors of various histologic types tend to occur at specific locations in the pharynx. Occasionally, a deeply infiltrating, primarily submucosal lesion may be manifested by subtle asymmetric enlargement of the tongue base. Most patients with cervical esophageal webs are asymptomatic. Wondering about work of breathing, swallow-breathe interface with both pacifier dips and/or clinical observation of PO feeding. connect4education register; don't be a felix cdcr video; westfield knox redevelopment 2020 The upper esophageal sphincter (UES) is comprised of several striated muscles, creating a tonically closed valve and preventing air from entering into the gastrointestinal tract. The pathogenesis of Zenkers diverticulum is as controversial as the muscular anatomy. At the LES, the loss of inhibitory nerves is demonstrated by loss of nitric oxide synthase and vasoactive intestinal peptide (VIP) immunohistochemistry staining. 1989 Mar;85(4):243-5, 250, 260. doi: 10.1080/00325481.1989.11700632. When large, the cysts may extend posteriorly to the sternocleidomastoid muscle, displacing the carotid sheath. The secondary peristaltic wave is induced by esophageal distension from the retained bolus, refluxed material, or swallowed air. 57(3):683-9. Branchial pouch sinuses or fistulas are tracts that extend from the pharynx and end blindly in the soft tissues of the neck (sinus) or extend to the skin (fistulas). Surgeon. The most common branchial vestige is a cyst arising from the second branchial cleft. These studies are especially valuable in areas of the pharynx that are difficult to evaluate by endoscopy (e.g., lower base of the tongue, valleculae, lower hypopharynx, pharyngoesophageal segment). Lateral pharyngeal pouches are extremely common, and the frequency of their occurrence increases with age. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. of dysfunction of deglutition (DOSS), the presence of food stasis (Eisenhuber scale), laryngeal penetration and laryngotracheal aspiration (PAS) and oral and pharyngeal transit time were evaluated . what is pharyngeal stasislack of education leads to violence what is pharyngeal stasis. Gravesen FH, Gregersen H, Arendt-Nielsen L, Drewes AM. The LES relaxes during swallows and stays opened until the peristaltic wave travels through the LES, then contracts and redevelops resting basal tone. official website and that any information you provide is encrypted Epub 2021 Feb 5. The complications of Zenkers diverticulum include bronchitis, bronchiectasis, lung abscess, diverticulitis, ulceration, fistula formation, and carcinoma. Diagnosis of esophageal motility disorders: esophageal pressure topography vs. conventional line tracing. Eckardt AJ, Eckardt VF. The relationship between the mouth of the Zenkers diverticulum and prominent cricopharyngeus is demonstrated. [QxMD MEDLINE Link]. Among the VFSSs, those showing pharyngeal stasis by mechanical obstruction due to cervical osteophytes were selected for inclusion in this study. [QxMD MEDLINE Link]. Function Anatomy Conditions and Disorders Care Frequently Asked Questions Overview What is the pharynx? [QxMD MEDLINE Link]. PMC 16-12 ). After swallowing, barium in the diverticulum is regurgitated into the hypopharynx. Lateral view of the pharynx shows well-circumscribed plaques (. J Neurogastroenterol Motil. Barium studies are contraindicated because they may exacerbate edema, triggering an episode of acute respiratory arrest. Ronnie Fass, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Neurogastroenterology and Motility Society, American Society for Gastrointestinal Endoscopy, Israeli Medical AssociationDisclosure: Received grant/research funds from Takeda Pharmaceuticals for conducting research; Received consulting fee from Takeda Pharmaceuticals for consulting; Received honoraria from Takeda Pharmaceuticals for speaking and teaching; Received consulting fee from Vecta for consulting; Received consulting fee from XenoPort for consulting; Received honoraria from Eisai for speaking and teaching; Received grant/research funds from Wyeth Pharmaceuticals for conducting research; Received grant/research funds f. Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine. An intraluminal mass may be manifested radiographically by obliteration of the normal luminal contour, extra barium-coated lines protruding into the expected pharyngeal air column, a focal area of increased radiopacity, or a filling defect in the barium pool. The 5-year survival rate varies from 76% for patients with localized tumors to 10% to 20% for patients with cervical lymph node metastases. Unable to load your collection due to an error, Unable to load your delegates due to an error. Neurological disorders affecting oral, pharyngeal . The LES relaxes during swallows. [2]. Small or predominantly submucosal lesions may be hidden in the valleculae or the recess between the tongue and tonsil (glossotonsillar recess). Muscle wall thickening has been described in patients who are asymptomatic and, conversely, has been absent in some patients with typical symptoms and manometric findings. Radiographic description of this phenomenon has been called presbyesophagus. The peristaltic contraction wave travels at a speed of 2 cm/s and correlates with manometry-recorded contractions. The pharynx, usually called the throat, is part of the respiratory system and digestive system. Furthermore, the examination can detect coexisting structural lesions (e.g., prominent cricopharyngeal muscle, Zenkers diverticulum, web, stricture) that may be difficult to circumvent safely at endoscopy. being unable to chew food properly. Such patients usually demonstrate normal findings on pharyngograms or evidence of nonspecific lymphoid hyperplasia of the palatine or lingual tonsils. The coordination of these simultaneously contracting muscle layers produces the motility pattern known as peristalsis. Abdel Jalil AA, Castell DO. 16-11 ). Current clinical approach to achalasia. The site is secure. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. Patients with benign tumors of the base of the tongue may be asymptomatic or may complain of throat irritation or dysphagia. The term comes from the oropharynx, the location in the back of the throat, and dysphagia, which means disordered swallowing. Clipboard, Search History, and several other advanced features are temporarily unavailable. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Choking or coughing may be caused by laryngeal penetration during swallowing or aspiration of barium trapped in ulcerated tumors. A barium examination can also be used to rule out a second primary lesion in the esophagus. The most common benign lesions are retention cysts of the valleculae or aryepiglottic folds. However, no studies to date have shown convincing evidence that surveillance is worthwhile. Advanced achalasia can lead to malnutrition, dehydration, and aspiration. The risk typically starts increasing after approximately 10 years of having the disease process. Deciphering Oral Stasis: Managing the Challenging Combination of Dementia and Dysphagia - Part I Presenter: Michelle Tristani, M.S., CCC-SLP Moderated by: Amy Natho, M.S., CCC-SLP, CEU Administrator, SpeechPathology.com 1 . Lateral view shows a smooth-surfaced hemispheric mass (, A smooth-surfaced, well-circumscribed mass (, (From Rubesin SE, Glick SN: The tailored double-contrast pharyngogram. Frontal radiographs in patients with an external laryngocele may show an air-filled sac above and lateral to the ala of the thyroid cartilage. Significant acid reflux might lead to disabling symptoms, caused by reflux or its complications. A small plaquelike or ulcerative lesion can easily be missed on barium or endoscopic studies but can be detected on MRI or CT studies. Initial results of diagnostic endoscopy may be negative. Gastroenterology. The pouches are usually bilateral. Most patients are asymptomatic and in the fifth to sixth decade of life. 16-1 ). Webs may extend laterally, and a few extend circumferentially. Plain radiographic diagnosis of acute epiglottitis is important (even in adults) because manipulation of the tongue or pharynx may exacerbate edema and respiratory distress. Tumors of the epiglottis and aryepiglottic folds may also result in dysphagia, coughing, or choking because of laryngeal penetration. Velopharyngeal insufficiency (VPI) is when the soft palate does not close tightly against the back of the throat, leading to air coming out the nose (characterized by hypernasality and/or nasal air emission) during speech. MRI is the method of choice for evaluating tumors of the nasopharynx. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison. A laryngocele is a protrusion of ciliated pseudostratified columnar epithelium and loose areolar connective tissue arising from saccular dilation of the appendix of the laryngeal ventricle. The inferior constrictor muscle is composed of the thyropharyngeal and cricopharyngeal muscles. Pharyngeal definition, of, relating to, or situated near the pharynx. Gatto AR, Cola PC, da Silva RG, Ribeiro PW, Spadotto AA, Henry MAAC. None of the clinical or physiologic behaviors can be attributed strictly to being born preterm, though preterm birth would increase risk for co-morbidities. Please enable it to take advantage of the complete set of features! Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience. We explored four different methods, namely, the visuoperceptual The National Library of Medicine (NLM), on the NIH campus in Bethesda, Maryland, is the world's largest biomedical library and the developer of electronic information services that delivers data to millions of scientists, health professionals and members of the public around the globe, every day. and transmitted securely. A dynamic examination reveals a higher percentage of webs than spot images alone. [3] It is also seen in patientsfollowing eradication of esophageal varices by endoscopic sclerotherapy, in association with an increased number of endoscopic sessions but not with manometric parameters. No documented abnormalities exist regarding the distribution of myenteric neurons in patients diagnosed with spastic motility disorders of the esophageal body, but diffuse fragmentation of vagal filaments, increased endoneural collagen, and mitochondrial fragmentation are described. Efficient transport by the esophagus requires a coordinated, sequential motility pattern that propels food from above and clears acid and bile reflux from below. There appears to be a functional imbalance between excitatory and inhibitory postganglionic pathways, disrupting the coordinated components of peristalsis. Federal government websites often end in .gov or .mil. Some tumors may be detected during barium studies performed for other reasons. Associated complications, including strictures, Barrett esophagus, and adenocarcinoma of the esophagus, are the concern. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison. Philadelphia, WB Saunders, 1992. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Growth Disorders: 7 Cases of a Developing Problem, Trending Clinical Topic: Intermittent Fasting. With the partial ganglion cell loss in patients with achalasia, edrophonium (acetylcholine esterase inhibitor) increases LES pressure while atropine (muscarinic antagonist) decreases LES pressure. Likely at risk for bolus mis-direction from below (refluxate), d/t what sounds like proximal hypotonia that could make timely effective response to retrograde flow from the esophageal body unreliable. 12:CD005046. However, any asymmetrically distributed coarse nodularity or mass must be viewed with suspicion. The .gov means its official. There are no criteria based on size for differentiating nodularity of the base of the tongue because of normal lingual tonsils from that resulting from reactive lymphoid hyperplasia. There are no skeletal structures in the fourth pharyngeal arch. Spastic esophageal motility disorders are associated with symptomatic discomfort but do not lead to the severity of dysphagia observed in patients with achalasia. Please confirm that you would like to log out of Medscape. Webs may be confused radiographically with redundant mucosa in the anterior wall of the pharyngoesophageal segment at the level of the cricoid cartilage. Anatomically, the circular muscle layer at the LES is thickened, but, microscopically, individual muscle cells are grossly normal. Diverticula appear on frontal views as saccular protrusions that have narrow necks (see Fig. Webs also should not be confused with a prominent cricopharyngeal muscle, which appears as a round, broad-based protrusion from the posterior pharyngeal wall at the level of the pharyngoesophageal segment. Many of these fistulas are present at birth and communicate with the skin. Chest pain is, in fact, a more common complaint that may precipitate emergency room visits and cardiologic evaluations. If infected, the wall of the branchial cleft cyst becomes thickened and may enhance with the administration of intravenous contrast medium. Webs in the distal esophagus have been associated with gastroesophageal reflux disease. Hoarseness. Lateral spot image of the pharynx shows obliteration of the contour of the lower soft palate, which is replaced by a lobulated mass (, (From Rubesin SE, Rabischong P, Bilaniuk LT, etal: Contrast examination of the soft palate with cross-sectional correlation.

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