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This paper explains the differential diagnosis of neurological dysphagia. Special groups of diseases are described that can only be assessed by dynamic recording modalities like videofluoroscopy and high-speed cineradiography. The need for dynamic recording results from the physiological data of deglutition. The act of deglutition lasts only 0.7 s, but requires the well-coordinated action of 5 cranial nerves and 26 muscle groups. For a systematic analysis of the underlying neurological disease a precise description of possible pathological single observations from the oral cavity to the cardia is offered to the radiologist. Important hints concerning possible "pitfalls" due to non-neurologically caused pharyngoesophageal motility disturbances are given. Although dynamic recording does not always allow the precise diagnosis of the underlying neurological disease, it enables us to classify the motor disturbances and leads to distinct "groups of disease." Thus, dynamic recording of deglutition is of crucial importance for further conservative or functional surgical treatment of the dysphagic patient.

The estimated number of the incidence of undiagnosed chronic aspiration pneumonia after cerebral or cerebrovascular injury seems very high. According to American statistics, at least 6% of these patients die from aspiration pneumonia within the first year. The high temporal resolution of cineradiography with frame rates of the complex process of pharyngeal swallowing lasting 0.7 s. The method enables us to differentiate between so-called pre-, intra- and postdeglutitive aspiration, which means aspiration before, during and after the triggering of the swallowing reflex. Together with an established score for the severeness of the aspiration, the method supplies important data for setting up a functional surgical and/or conservative program for rehabilitation and for follow-up-studies.

Videocinematography is a valuable tool in the diagnostic workup and planning of functional surgery in cleft patients. The high resolution and depiction of the finest mucosal structures in motion allow objective and dynamic assessment of the individual velopharyngeal function. A total of 170 cleft patients were examined by videocinematography, and the results were compared to nasoendoscopy and to the clinical examination. The marked superiority of this radiological technique with regard to clearness of depiction and ease of use is shown. It can therefore be recommended without reservation for the pre- and postoperative assessment of cleft patients.

The use of high-frequency video cineradiography makes possible an objective and dynamic rendering of the individual velopharyngeal closer pattern. The high resolution and the depiction of the finest mucosal structures while in motion achieved by this technique opens up the possibility of exact and objective 3-dimensional evaluation of the velopharyngeal gap. Following secondary velopharyngoplasty on 80 cleft palate patients, the velopharyngeal closure was studied by means of high-frequency video cineradiography and this rendering was then compared to results obtained by nasoendoscopy and to the clinical findings. It became definitely apparent that the radiological technique is markedly superior in relation to clearness of depiction and ease of use, especially in young children. This imaging technique can be recommended without reservation for pre- and postoperative control of speech-improving procedures.

In order to prevent aspiration following loss of function of the UOS a new sphincter may develop. This usually arises from the oblique part of the cricopharyngeus muscle and the caudal part of the thyropharyngeus muscle and it is functionally independent of the UOS. We examined 40 patients by cinematography: these included 30 patients with a Zenker's diverticulum, 8 patients following myotomy of the UOS and 2 patients with tumour infiltration of the UOS. The new sphincter could be demonstrated in 70% of patients with Zenker's diverticulum: its function depended on the size and localisation of the diverticulum. Following myotomy of the UOS the new sphincter is usually only just perceptible. In one case there was, however, marked dyskinesia, requiring further myotomy.

Two impressions can be seen on the ventral aspect of the hypopharynx and upper oesophagus; on static images it is difficult to differentiate these from small tumours. In order to evaluate this region more accurately, we have examined 150 patients by means of rapid rate cinematography. In 52.6% we found a constant irregular or convex impression formed by the cricoid; in the other cases this was not seen or was quite minimal. In 93% a sub-cricoid impression could be demonstrated which was due to lax mucosa. Characteristically, this showed a variable appearance during the passage of a bolus. Only the cricoid impression was associated with dysphagia.

In the diagnostic work-up of the benign dysphagia modern radiology must not only describe morphologic alterations but also has to keep in mind the great importance of motility disorders. Dysfunction of the esophagus can be assessed by fluoroscopy alone. The superior method to analyze the motility disorders of the oropharyngeal and pharyngo-esophageal transport is high-speed cineradiography at a frame-rate of 50 frames/sec on 35-mm film because of the very fast and complex patterns of motion during oropharyngeal deglutition, which occurs within only 0.5 to 0.7 sec. The upper esophageal sphincter turned out to play a very important role in many motility disorders of the pharynx and the esophagus, which often secondarily leads to permanent structural lesions. Examples are given, in which kinds of disorders cineradiography contributes to diagnosis and therapy. In some cases it turned out to be the method of first choice, as for example for aspiration.

This article reviews the sensory and the motor coordination during the oro-pharyngeal and pharyngo-esophageal stage of deglutition including laryngeal dynamics. The performance of swallowing takes less than one second. In this short period the well-coordinated action of five cranial nerves and 26 muscle-groups has to be accomplished. There is a great number of dysfunctions, that can occur during this rapid and complex motility phenomena.

After treatment of laryngeal cancer 35 patients with dysphagia have been examined by high speed cineradiography. When compared to normal swallowing patterns, the following abnormalities were observed: Excursion of the posterior pharyngeal wall during swallowing is twice as intensive as normal. The function of the base of the tongue becomes more important for pharyngeal emptying--a fact that surgeons should take into consideration when planning laryngeal resection. Timing of pharyngeal constriction and function of the upper esophageal sphincter are definitively altered. In view of these changes we think that cineradiography can help to find better methods for functional surgery of the pharynx and the adjacent structures.

The differentiation between stage T3 and stage T4 pharyngeal tumors is of crucial importance for the proper therapeutic approach (surgery, surgery with consecutive radio- or radiochemotherapy, chemotherapy). The clinical relevance of the additional information provided by cineradiography was evaluated in combination with the endoscopic and computed tomographic results. We performed static and dynamic pharyngography with mono- and double-contrast-methods in four planes, including pharyngeal distension (Valsalva's and Müller's maneuver) and phonation. For the dynamic study, high-speed cineradiography (35 mm film, 50 frames/s) was used. Twenty-three patients with histologically proven neoplasms were examined. It was determined that surgery was technically feasible in 4 out of 14 patients who were previously presumed to have inoperable tumors. In 2 cases, an extension of the tumor mass was seen by cineradiography (results proven intraoperatively).

By the X-ray Cineradiografie we are able to examine and to judge the dynamic of the wrist bones by 50 pictures/sec. in comparison to one another and also depending on their ligaments. We did an investigation of 170 patients with painful wrist. With the method we were able to make up a clear diagnosis and to propose the therapy. I.e.: If consecutive shortening of the radius after distal radius fracture resulting ingruency of the wrist joint is relevant, or a scaphoid pseudarthrosis is fixed elastically, or a scaphoic dissociation is effective. The variations were shown in comparison to normal circumstances.

A radiocinematographic procedure of the pharyngeal examination of snorers is presented. By swallowing, by the production of pharyngeal sounds and by the forced inspiration which produces snoring sounds a dysfunction or an obstruction in the upper respiration tract can be located. This method is a useful diagnostic aid in snoring disease which should precede surgical interventions in the pharynx.

We present a rare case of fistulation from the duodenum into the prosthesis site of an aortic Y graft removed 8 months previously owing to infection. We have verified the topographical and anatomical location of the fistulation by fistula filling and CT and MR examination. To our knowledge such a postoperative complication has not been previously documented. In evaluating and comparing our observation we discuss their significance for topographical associations and prognosis and as an indication for surgical intervention.

This review discusses the radiological findings and diagnostic procedures of pharyngeal and esophageal motility disorders. The physiological and gastroenterological aspects of these different pathological entities are described in another article of the same issue. Both articles together are supposed to deliver a review of the most important esophageal motility disorders.

Since December 1984 303 patients have undergone examination in our Multidisciplinary Consultation Service for Swallowing Disorders; 117 of them were suffering from typical globus symptoms. We were able to increase the yield of detection of organic lesions by use of the technique of 35 mm film cineradiography with a rate of 50 frames/s. Frame-by-frame analysis and computer-assisted evaluation showed that 80% of the patients with globus symptoms suffered from one or more underlying organic diseases, which could often be treated later with success. We found an increased incidence of early hypopharyngeal diverticula, webs, and motility disorders of the upper esophageal sphincter often associated with gastro-esophageal reflux or weakness of the pharyngeal wall. Cineradiography proved to be a very important tool in the analysis of the pharyngeal swallow in globus pharyngis.

CT findings and treatment results after CT-monitored surgery of a large perineal cyst are described. This was identified as a Müllerian duct cyst which is considered--according to world literature--to be a great rarity. The high rate of relapses even on instillation of sclerosing solutions, as well as differential diagnosis in relation to other perineal cystic space-occupying growths, are discussed.

6% of all patients suffering from a cerebrovascular injury die from aspiration pneumonia within the first year. The high temporal resolution of high-speed cineradiography (HFK) (50 frames/sec.) allows the recording of the 0.7 sec. process of pharyngeal swallow. Five case-examples are presented (total number of cases: 95) illustrating the possibility of differentiation between three types of aspiration by means of cineradiography. These types are the so-called pre-, intra- and postdeglutitive aspiration, that is aspiration before or after triggering of the swallowing reflex. This differentiation is of great therapeutic importance. The analysis of disturbances of pharyngo-laryngeal motility and the temporal coordination allows setting up individual surgical and/or conservative programme for rehabilitation.

After a synopsis of brain stem structures participating in swallowing, the main neurologic diseases are presented as a part of which swallowing disorders may occur: central and peripheral nervous system, motor end-plates and muscles can be involved. The sequence of clinical examination is described with special reference to findings in mouth, pharynx and larynx as well as to findings in high-frequency cinematography. After description of normal swallowing pre-, intra- and postdeglutitive mechanisms of aspiration are shown. This distinction has proved useful for practical reasons. Finally we give a survey of therapeutic possibilities reported in recent years in literature and developed in our hospital, divided into indirect (facilitation of orofacial and laryngeal voluntary muscles) and direct therapeutic strategies (strategy of compensation during feeding). In connection with this therapeutic possibilities applied during pre-, intra- and postdeglutitive phase, depending on neuromuscular disturbances, are also described.

Since the pharynx and the esophagus are a functional unit, functional radiodiagnosis has to be directed at pharyngo-esophageal interaction. Among our collective of 73 patients suffering from achalasia or diffuse esophageal spasm, we were able to recognize a substantially increased incidence of morphological or functional pharyngeal disorders by means of cineradiography. The functional alterations in particular were often not revealed by conventional fluoroscopy. High-speed cineradiography, with its high temporal and spatial resolution, turned out to be a valuable tool in analysis of the origin of pharyngeal dysphagia. Manometry correlated very well with the radiologic findings in tubular esophagus, but proved unreliable in the detection of alterations of the upper esophageal sphincter region, because of problems inherent in the method. Furthermore, membranous stenosis (webs), lateral or dorsal diverticula, and asymmetry of the pharynx were observed strikingly often.