David J. Curtis

Timing in the normal pharyngeal swallow. Prospective selection and evaluation of 16 normal asymptomatic patients.

A review of timing of pharyngeal events with radiography has been made. A prospective selection of normal asymptomatic patients presenting for a gastrointestinal evaluation was made and timing of 55 events in the videorecorded pharyngeal swallow in these patients was performed. Only 16 normal asymptomatic patients as defined for selection were found among 870 patients presenting for gastroesophageal examination. A detailed description of their timing observations is presented. The timing data were used to temporally order events in the pharyngeal swallow. This ordering of events in the pharyngeal swallow and the data upon which it is based are reported here in detail.

Normal erect swallowing. Normal function and incidence of variations.

Of 871 candidates presenting for upper gastrointestinal examinations, 16 met the rigorous criteria established for selecting asymptomatic normal volunteers. Frame-by-frame evaluation of their videorecorded pharyngeal swallow confirmed many observations made previously utilizing cine recording at much higher radiation dosages. In addition, new observations were made: the nasopharynx may not occlude until the bolus is entirely within the pharynx; air mixes with the bolus if the swallow is an open type; the epiglottis always inverts in normal individuals regardless of the type of swallow (open, air filled oro-and hypopharynx into which the swallowed bolus is dropped; closed, airless oropharynx into which the swallowed bolus is pushed by a continuous peristaltic drive of the tongue and palate, thus reconstituting the pharyngeal space); laryngeal descent may aid in stripping the bolus from the pharynx; the vestibule may not completely close during the swallow and the larynx can still be impervious to the bolus; the peristaltic wave does not begin until the bolus has breeched the cricopharyngeus; the cricopharyngeus may be seen frequently in normal individuals, but does not delay the passage of the bolus; asymmetric flow of the bolus around the larynx is common and may not be the result of epiglottic tilt or head positioning.

Lateral pharyngeal outpouchings: A comparison of dysphagic and asymptomatic patients

Videofluoroscopic pharyngeal timings of individuals with dysphagia were compared with timings from individuals without dysphagia to determine if any abnormal pharyngeal movements were associated with dysphagia.Sixteen lateral pharyngeal outpouchings were seen in 50 dysphagic volunteers, whereas 71 were noted in 138 asymptomatic individuals. The outpouchings appeared just after oral delivery of the bolus into the pharynx after onset of the swallow at approximately 500 ms, as compared to the initial appearance during the mid-pharyngeal swallow at 750 ms in asymptomatic individuals (P<0.01). The outpouchings disappeared during mid-pharyngeal swallow in symptomatic volunteers, at approximately 800 ms compared to disappearance during pharyngeal relaxation in asymptomatic volunteers at approximately 1100 ms (P<0.01). No other timing event was delayed nor event duration prolonged when the two groups were compared.This observation of earlier appearance followed by earlier disappearance of lateral pharyngeal outpouchings in dysphagic individuals may be caused by inner longitudinal pharyngeal muscles that are inhibited and then contract earlier than those seen in asymptomatic individuals. Outpouchings appearing later at the onset of pharyngeal contraction were not associated with dysphagia.

Selecting Radiology Resident Candidates

Radiology resident candidate selection has become a burdensome, subjective, and somewhat arbitrary process. Because the luxury of many well-qualified candidates exists, there is an obligation to select them as honestly, equitably, and objectively as possible. Two years were spent in revising and modifying the resident selection process to make it more uniform and more efficacious. An application scoring form was devised to extract uniform pertinent information from the original application form. Candidates could then be ranked according to a numerical score derived from the form. This allowed easy selection of top candidates to be interviewed. A new interviewing scoring form was developed to include desirable characteristics of resident candidate performance. This form was also devised in such a way as to be easily scored and to allow selection of the top 20 to 25 candidates. These candidates were then ranked by participating faculty members while reviewing their application score forms and their interview forms. Positions for the residency training program were offered according to the ranking. The usefulness of both new forms was evaluated and confirmed by correlating form scores with faculty ranking of academic performance of current residents in the training program.

Abnormal solid bolus swallowing in the erect position

The routine use of solid boluses in the radiologic evaluation of the pharyngoesophagus has not been described in the literature. Because esophageal perforations have been reported as a result of delayed passage of caustic medications, this study was performed to determine the prevalence of solid bolus delay in a routine symptomatic radiologic population. Solid bolus erect swallowing was performed using either a 13 mm barium tablet or a 10 mm bagel bread sphere; occasionally, both were used.All individuals referred for an upper gastrointestinal (GI) examination or barium swallow who complained of dysphagia, heartburn, or chest pain were evaluated with a solid bolus. Any individual demonstrating gastroesophageal reflux, hiatal hernia, Schatzkis B ring, or esophageal motility disturbance was given a solid bolus as well.Individuals swallowing a sphere showed four times more frequent proximal pharyngoesophageal delay than tablet swallowers. The tablet arrested initially more frequently at both the aorta and lower esophageal sphincter than did the sphere. However, there was twice the total incidence of arrest of all swallowed spheres compared to tablets at the aorta. Approximately the same total number of spheres arrested at the lower esophageal sphincter as tablets.Any delay that allows a solid bolus to be overtaken in the erect position by the peristaltic contraction wave can be considered abnormal. The delays usually occur at anatomic narrowings. A sphere is more sensitive than a tablet in evaluating solid bolus pharyngoesophageal dysfunction in the erect position.

Calcification and Ossification in the Arytenoid Cartilage: Incidence and Patterns

Calcification or ossification occurs early and commonly in the arytenoid cartilage. It may be difficult to detect, but there are only eight patterns that specifically identify ossification and calcification. Each arytenoid independently ossifies or calcifies. The cervical spine examination can specifically identify the patterns found at autopsy.

Evaluation of radiology resident cognitive performance.

Using radiographs and slides in three formats, we objectively tested the cognitive performance of 16 residents during an 8-month period. One format tested individual residents with radiographs and required only that a list of findings be provided within a week. For the second method, radiographs were projected to a small group of residents and a single diagnosis for each of ten cases was required. The third format required a larger group of competing residents to view projected slides of ten loosely defined but thematically connected cases and develop one diagnosis. Two of the test formats correlated significantly with a Spearmen rank, r = .50 or better (P less than .025) with a ranking based upon total score on the American College of Radiology Inservice Examination. All three test formats had a Spearmen rank r = .50 or better (P less than .05) when compared with pooled ranking performed by the staff radiologists.

Testing as a Teaching Tool

More than four years ago, the authors initiated testing as a means of obtaining data for evaluating residents. The testing process has evolved now and is used for its teaching value and as a means of objective resident self-evaluation. Testing is designed to provide 10 cases an hour, with characteristics allowing a single diagnosis as a unique answer. No history is provided because a common topic and anatomic area provide a context for each examination. Answers are given during the examination after each question, and discussion follows. All answers are written, and answer sheets are collected. Attendance is high. Test scores are routinely lower than in other forms of evaluation. Testing integrates all aspects of radiology training from cognitive through deductive, simulates written consultations, and provides a means of self-evaluation through rapid feedback. Testing is a viable form of teaching that blends self-evaluation with faculty and peer feedback.

Ranking: a year three follow-up in a different institution.

Ranking residents as a means of semiobjective evaluation of their overall performance was described in 1985. The predictive nature of pooled faculty ranking of residents was stressed. Ranking of resident total scores on The American College In-training Examination and American Board of Radiology written examination was noted to be statistically related to the pooled faculty ranking. Similarly, the faculty ranking was predictive of itself in subsequent rankings. A cohesiveness of faculty consensus was present such that small numbers (five minimum) were predictive of larger groups of participating faculty. All reported observations persist in the new institution. Exceptions to expected residency level of training stratification (eg, third-year residents ranking in the midst of first-year residents, second-year residents ranking above many third-year residents) continue to be the most useful observation in counseling residents. Additional information reported includes sensitivity of the ranking to improvement or nonimprovement of probated residents.

Laryngography, the forgotten art

The paper on Normal Laryngeal Valving Patterns reminds one of the forgotten art of laryngography. Laryngography consisted of fluoroscopic spot filming of the larynx in posterior-anterior (PA) and lateral projections during quiet breathing, phonation (similar to the breatheout-hard examination presented here), valsalva, and modified valsalva maneuvers. The objective was to evaluate the larynx for its mobility and symmetry of appearance and function. This study actually answers many questions posed by the laryngographic technique. Why, for instance, was there variability in the same examination even when the directions were given very explicitly? The variability of examinations and within patients being examined should have been expected, but it is refreshing to see it so explicitly demonstrated. The disappointing part of this study is that laryngography was not considered as a source for research material, rather than swallowing-the examinations are almost hand and glove in their similarity. It should not be too difficult to understand why the medial positioning of the vocal cord and arytenoid are the most consistent observations as the musculature is made to perform these functions best, and all other positionings are secondary. There are seven medial opposers and only one abductor in the larynx. Variability in falsefold positioning is easily explained by varying amounts of submucosal fat, musculature thickness, and cricoarytenoideus contraction. Anterior folding of the arytenoid is just a function of the patients conception of how severe an action the description he was given of the