On lateral views, the anterior wall of the sac is anterior to the cervical esophagus, below the level of the cricopharyngeal muscle. Esophageal stasis was the most common finding regardless of complaint location. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. A referred earache may occur, especially when nasopharyngeal tumors block the eustachian tube. They are usually unilateral. Although esophagram shows a typical picture of achalasia, this patient had adenocarcinoma of the gastroesophageal junction. The pharyngeal wall consists of overlapping superior middle and inferior constrictors on its posterior aspects and sides. In patients with known pharyngeal cancer, a contrast examination is of value to assist in planning proper work-up and therapy. During swallowing, Zenkers diverticulum appears as a posterior bulging of the lowermost hypopharyngeal wall above an anteriorly protruding pharyngoesophageal segment (cricopharyngeal muscle; Fig. sharing sensitive information, make sure youre on a federal Sato Y, Fukudo S. Gastrointestinal symptoms and disorders in patients with eating disorders. official website and that any information you provide is encrypted 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. Eur J Pediatr. Lateral radiographs may show the air-filled sac anterior to the epiglottic plate, in contrast to a lateral pharyngeal diverticulum, which lies posterior to the epiglottic plate. No overlap of fibers exists between the thyropharyngeal and cricopharyngeal muscles. Achalasia is a progressive disease that requires chronic therapy. The webs protrude to various depths into the esophageal lumen. Pharyngeal Versus Esophageal Stasis: Accuracy of Symptom Localization The 2 best-characterized motility disorders, achalasia and DES, represent only a small percentage of diagnosed motility disorders. Better demonstration of webs is also achieved with the use of large boluses of barium. Am J Gastroenterol. Normal manometry results show normal esophageal body peristalsis with normal lower esophageal sphincter (LES) pressure and relaxation. iowa golf coaches association; recent advances in mechanical engineering ppt; houses for rent in rancho cucamonga'' craigslist; are there seagulls in puerto rico The use of endoscopy and magnetic resonance imaging (MRI) may help exclude malignancy. Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. The lower esophageal sphincter (LES) pressure tracing is at the level of the sleeve (tracing 6). Cricopharyngeal dysfunction: Symptoms, causes, treatment, and more Frontal radiographs in patients with an external laryngocele may show an air-filled sac above and lateral to the ala of the thyroid cartilage. Federal government websites often end in .gov or .mil. MRI is the method of choice for evaluating tumors of the nasopharynx. Radiologists should be as familiar with pharyngeal carcinoma as they are with esophageal carcinoma. About 50% of these patients are asymptomatic and present with a neck mass caused by cervical nodal metastases. Unable to load your collection due to an error, Unable to load your delegates due to an error. Method This study used a prospective analysis of outcomes data from the University of Wisconsin-Madison Voice and Swallow Outcomes database in patients with complaints of bolus stasis who completed the combined videofluoroscopic swallowing study and esophagram to determine the accuracy of bolus stasis localization. Increased incidence of both esophageal squamous cell and adenocarcinoma is observed in patients with long-standing achalasia. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. However, submucosal masses are sometimes missed at endoscopy. Even after therapy, patients continue to have mild symptoms related to aperistaltic esophagus and, thus, will want to still follow careful eating habits. Rohof WO, Salvador R, Annese V, et al. The 5-year survival rate is approximately 40%. endstream
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Aliment Pharmacol Ther. The second branchial cleft cyst may extend between the internal and external carotid arteries at a level superior to their bifurcation. In Laufer I, Levine MS [eds]: Double Contrast Gastrointestinal Radiology, 2nd ed. 16-6 ). What causes VPI? Problem-Solving with Catherine: 5-year-old with Athetoid Cerebral Palsy, Problem-Solving with Catherine: Infant in NICU with HIE. 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. Tertiary contractions are simultaneous, isolated, dysfunctional contractions. The muscle is oriented in 2 perpendicular opposing layers: an inner circular layer and an outer longitudinal layer, known collectively as the muscularis propria. Squamous cell carcinoma usually develops several years after the diagnosis of achalasia. Eckardt AJ, Eckardt VF. 2017 Jun 30. ), An 80-year-old patient with dementia underwent an upper GI examination for epigastric pain. and transmitted securely. For patient education resources, seeHeartburn and GERD CenterandDigestive Disorders Center, as well asAcid Reflux (GERD)andHeartburn. This resembles punctuated equilibrium acting at the level of communities and may occur because the species interact so closely they cannot evolve, instead responding to . This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. The first branchial cleft forms the external auditory meatus. The most common benign lesions are retention cysts of the valleculae or aryepiglottic folds. )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- Scleroderma esophagus is associated with severe and progressive acid reflux symptoms and complications. Pyriform stasis What pharyngeal stage disorder is a result of reduced anterior laryngeal motion, cricopharyngeal dysfunction, and inadequate upper esophageal sphincter opening? for stability and/or r/t tethered oral tissues, r/t mild mandibular hypoplasia). Can dysphagia be cured by surgery? Any ideas are greatly appreciated! [Full Text]. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. A small plaquelike or ulcerative lesion can easily be missed on barium or endoscopic studies but can be detected on MRI or CT studies. Webs appear radiographically as 1- to 2-mm wide, shelflike filling defects along the anterior wall of the hypopharynx or cervical esophagus ( Fig. A dynamic examination reveals a higher percentage of webs than spot images alone. "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 . HHS Vulnerability Disclosure, Help Problem-Solving with Catherine: Adenoid Hypertrophy and Pediatric Dysphagia, Problem-Solving: New infant referral but limited experience, Problem-Solving with Catherine: 3-month-old with TEF and Vocal Cord Paralysis, Lifelong Learners Join Catherine in Houston, State-of-the-Art NICU Practice: Catherine Shaker and Suzanne Thoyre. The tubular esophagus is a muscular organ, approximately 25 cm in length, and has specialized sphincters at proximal and distal ends. 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. Squamous cell carcinomas represent 90% of malignant lesions involving the oropharynx and hypopharynx. No nasopharyngeal regurgitation that I recall. The relationship between the mouth of the Zenkers diverticulum and prominent cricopharyngeus is demonstrated. The pathophysiology of the primary esophageal motility disorders is poorly defined, with the exception of achalasia. With severe lymphoid hyperplasia of the base of the tongue, the nodules may extend into the valleculae, along the lingual surface of the epiglottis, or even into the upper hypopharynx. V4IQ){lP E Curr Gastroenterol Rep. 2015 Dec. 18(1):1. 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 cases were divided into two groups based on whether the . The physiologic process of achalasia is correlated most directly to the loss of the inhibitory nerves at the sphincter, resulting in failure of the LES to completely relax and causing relative obstruction. I like to start with the whys to guide intervention options. Pharyngeal inflammation and ulceration may be seen in patients with Behets syndrome, Stevens-Johnson syndrome, Reiters syndrome, epidermolysis bullosa, or bullous pemphigoid. Advanced achalasia can lead to malnutrition, dehydration, and aspiration. HU6?Q In contrast, lateral pharyngeal diverticula are persistent protrusions of pharyngeal mucosa, usually through the thyrohyoid membrane or, rarely, through the tonsillar fossa. Esophageal motility disorders are not uncommon in gastroenterology. what is pharyngeal stasis - kvkraigad.org The neck of the Zenkers diverticulum can be very broad during swallowing. Radiographically, a small (3-20mm in diameter), round to ovoid, smooth-surfaced outpouching is seen just below the level of the cricopharyngeal muscle ( Fig. Only rarely do these tumors extend through the laryngeal ventricles into the true vocal cords. Thorac Surg Clin. Elliott TR, Wu PI, Fuentealba S, et al. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. Greatly increased prevalence of esophageal dysmotility observed in persons with spinal cord injury. PVA was injected under fluoroscopic monitoring until significant stasis of the artery was noted. FEESST pharyngeal stasis - YouTube Associated complications, including strictures, Barrett esophagus, and adenocarcinoma of the esophagus, are the concern. Primary esophageal motility disorders are idiopathic in nature, but postviral, infectious, environmental, and genetic factors have been hypothesized. Depending on the rate and extent of disease progression, therapy might include endoscopic and surgical interventions. Carlson DA, Ravi K, Kahrilas PJ, et al. On lateral radiographs, the base of the tongue may seem to protrude posteriorly. The pouches are usually bilateral. External and internal laryngoceles do not fill with barium on pharyngograms. Branchial ridges (arches) lie between the branchial clefts. what is pharyngeal stasis - 4tomono.store Influence of Thermal and Gustatory Stimulus in the Initiation of the Pharyngeal Swallow and Bolus Location Instroke. Laryngoceles are seen in patients with increased intralaryngeal pressure, such as glass blowers and wind instrument players. Timing of events during deglutition after chemoradiation therapy for oropharyngeal carcinoma. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. a slitlike depression in the lateral membranous (nonmuscular) pharyngeal wall extending posterior to the opening of the pharyngotympanic (auditory) tube. The webs are seen as isolated findings in 3% to 8% of patients undergoing upper GI barium studies. Patients with external or mixed laryngoceles may have a compressible lateral neck mass. Therapeutic procedures and operations are associated with a small but significant risk of mortality and morbidity. They should be well informed about its lifelong nature. Symptoms attributed to lymphoid hyperplasia of the lingual tonsil include throat discomfort, a globus sensation, and dysphagia. Peristalsis is a sequential, coordinated contraction wave that travels the entire length of the esophagus, propelling intraluminal contents distally to the stomach. 16-19 ). Nodules of tumor may spread to the palatine tonsil, valleculae, or pharyngoepiglottic fold. The risk typically starts increasing after approximately 10 years of having the disease process. E93q">G8}wEkeW8 Reproducibility of axial force and manometric recordings in the oesophagus during wet and dry swallows. Spastic esophageal motility disorders are associated with symptomatic discomfort but do not lead to the severity of dysphagia observed in patients with achalasia. Note the "bird-beak" appearance of the lower esophageal sphincter (LES), with a dilated, barium-filled esophagus proximal to it. Inflammatory disorders of the pharynx or gastroesophageal reflux can alter pharyngeal elevation, epiglottic tilt, or closure of the vocal cords and laryngeal vestibule. Early on in my assessment (maybe ~35 weeks) I couldnt elicit a tongue-lateralizing reflex, havent checked since. Some webs are present in the valleculae or lower piriform sinus. Esophagram of a 65-year-old man with rapid-onset dysphagia over 1 year. Radiographic description of this phenomenon has been called presbyesophagus. 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. Manometry demonstrates diffuse esophageal spasm with simultaneous contractions of the esophagus observed throughout the tracing. All the etiologies that I mentioned, in isolation or in combination, could play a part in the diffuse pharyngeal stasis/residue observed, which is worrisome for bolus mis-direction during the course of a true feeding. However, barium studies may reveal enlargement of the aryepiglottic fold with a smooth overlying mucosa. The dysmorphic features stand out as worrisome, and often craniofacial and cardiac variants like an ASD can co-occur. Pharyngeal definition, of, relating to, or situated near the pharynx. All signs seem to be pointing to a neurological basis for his dysphagia and Im just wondering if there are any last hail marys to try before we start to plan for home on NG, OP feeding therapy, etc. In the United States, no strong association of cervical esophageal webs, iron deficiency anemia, and pharyngoesophageal carcinoma has been found. A recent study (22) showed that the quantification of the oral or pharyngeal stasis (defined as a residue in the oral cavity, in the pharynx during swallowing) in the videofluoroscopic assessment is limited to a subjective character. Recent ECHO showed a moderate ASD. In immunosuppressed patients with acute dysphagia, barium studies are directed toward the esophagus to demonstrate the presence, site, and type of esophagitis. An official website of the United States government. Aryepiglottic fold nodules or mass lesions may cause dysphonia or respiratory symptoms such as stridor. However, the postcricoid defect is probably related to redundancy of the mucosal and submucosal tissue in this area. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. Cochrane Database Syst Rev. The typical picture of achalasia. Physiologic characteristics of achalasia are additionally useful in assisting with establishing the diagnosis through chemical challenge testing. Head rotation as an effective compensatory technique for dysphagia pharyngeal: [adjective] relating to or located or produced in the region of the pharynx. [QxMD MEDLINE Link]. Inflammation-induced dysmotility may result in laryngeal penetration and stasis. 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. This association was termed Plummer-Vinson syndrome or Paterson-Kelly syndrome. 2017 Feb 1. 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. 2010 Feb. 22(2):142-9, e46-7. Farmer's Empowerment through knowledge management. Esophageal Motility Disorders: Background, Etiopathophysiology Although acute epiglottitis usually affects children between 3 and 6 years of age, it occasionally causes severe stridor and sore throat in adults. As a result, pending further data, they might consider a G-Tube with a Nissen (to optimize airway protection and more safely buy him time for response to therapy and evolution to guide the differential), instead of home NG, which would have its own attendant sequelae. Food or stomach acid backing up into the throat. Life expectancy is not affected, and weight loss is rare. 2013 Apr. The secondary peristaltic wave is induced by esophageal distension from the retained bolus, refluxed material, or swallowed air. Neurological disorders aff Esophageal stasis was the most common finding regardless of complaint location. The value of pharyngeal scintigraphy in predicting - PubMed The quiet cry may suggest retracted tongue (? Esophageal dysmotility develops as the smooth muscle of the esophagus is replaced by scar tissue, gradually leading to progressive loss of peristalsis and a weakening of LES. ,885 5*9`aXq[V#F2,\CSfCE{Wg?4C+U; XS{3)3:t,F,[(gn9qEaM^&Tydqt|8e^p
3F. The pharyngeal outpouchings are of endodermal origin and are termed branchial pouches. Barium studies are used primarily to evaluate the symptoms of nasal regurgitation and voice changes caused by soft palate insufficiency and to rule out a synchronous esophageal tumor. They are also known as Killian-Jamieson pouches or Killian-Jamieson diverticula . what is pharyngeal stasis - ellinciyilmete.com grade 1 pharyngeal anastomotic leak - National Library of Medicine Inability to swallow. Possible complications, therapeutic options, expected outcomes, and dietary modifications should be explained. The lateral pharyngeal wall may protrude beyond the normal expected contour of the pharynx in areas unsupported by muscle layers. These tumors infiltrate deeply into the intrinsic and extrinsic muscles of the tongue. Ulcerative lesions may deeply penetrate the tongue and valleculae and invade the pre-epiglottic space ( Fig. With achalasia, the risk of squamous cell carcinoma of the esophagus is higher than that of the general population. Future research should focus on identifying symptom profiles that could lead to targeted swallowing evaluations based on patient history and complaint. This site needs JavaScript to work properly. A combination of internal and external laryngocele is termed a mixed laryngocele. 16-3 ). 144(4):718-25; quiz e13-4. Abdullah Fayyad, MD, MBBS is a member of the following medical societies: American Gastroenterological AssociationDisclosure: Nothing to disclose. Pathologically, a unilocular cyst is lined by keratinizing, stratified, squamous epithelium and is filled with desquamated keratinaceous debris. [2]. Mucosal irregularity may be seen as abnormal barium collections resulting from surface ulceration or as a lobulated, finely nodular, or granular surface texture. Accessibility On frontal radiographs obtained in patients with lymphoid hyperplasia, multiple smooth, round, or ovoid nodules are symmetrically distributed over the surface of the base of the tongue ( Fig. 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). c)IG}$EolC9f/6y8xr|}uBQ^hJ\|J}01`c55#
Epub 2021 Feb 20. Hospitalization for achalasia in the United States 1997-2006. 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. 16-7 ) and do not empty as quickly after swallowing. The coordination of these simultaneously contracting muscle layers produces the motility pattern known as peristalsis. Hypertrophy of the lingual tonsil frequently occurs after puberty, as a compensatory response after tonsillectomy, or as a nonspecific response to allergies or repeated infection. In Europe, the incidence of achalasia is similar to that of the United States. In DES, muscular hypertrophy or hyperplasia has been described in the distal two thirds of the esophagus. 6l9mU%RFHK1!e#Q,BET#T&U+{s]]Y. Clinical and manometric course of nonspecific esophageal motility disorders. The site is secure. J Am Coll Surg. Purpose The purpose of this article was to determine whether patients who complain of bolus stasis are accurate at localizing bolus stasis as measured by a videofluoroscopic swallowing study with an esophagram. The measurements of premature pharyngeal entry, pharyngeal transit time, and postswallow pharyngeal stasis by scintigraphy were correlated with those of VFS. If you log out, you will be required to enter your username and password the next time you visit. Between 1% and 15% of patients with head and neck squamous cell carcinoma subsequently develop squamous cell carcinoma of the esophagus. [QxMD MEDLINE Link].
Unauthorized use of these marks is strictly prohibited. Esophageal motility disorders, excluding achalasia, lack population-based studies. Killians dehiscence has been variably described as arising between the thyropharyngeal and cricopharyngeal muscles or between the oblique and horizontal fibers of the cricopharyngeal muscle. This delayed spill may result in dysphagia or a choking sensation because of overflow aspiration. Response to amyl nitrate, with disappearance of the spasm on esophagram. 1995 Jul;98(7):1154-63. doi: 10.3950/jibiinkoka.98.1154. J39.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Radiographic findings in pharyngeal carcinoma. 2013 Jun. National Library of Medicine Gravesen FH, Gregersen H, Arendt-Nielsen L, Drewes AM. The Killian-Jamieson space is a triangular area of weakness in the cervical esophagus just below the cricopharyngeal muscle. Share cases and questions with Physicians on Medscape consult. The thyropharyngeal muscle arises from the lateral ala of the thyroid cartilage; it courses laterally and posteriorly to merge with its counterpart from the opposite side in a raphe in the posterior pharyngeal wall. Some radiographic and manometric studies have suggested that spasm with elevated pressure of the upper esophageal sphincter or incoordination and abnormal relaxation of the upper esophageal sphincter (achalasia) are contributing factors. Crit Rev Diagn Imaging 28:133179, 1988. Zenkers diverticulum (posterior hypopharyngeal diverticulum) is an acquired mucosal herniation through an area of anatomic weakness in the region of the cricopharyngeal muscle (Killians dehiscence). This is an example of pseudoachalasia, which reinforces the absolute need for esophagogastroduodenoscopy (EGD) in patients with radiologic diagnosis of achalasia. The primary role is to clear the esophagus of retained food or any gastroesophageal refluxate. These webs are thought to be normal variants in the valleculae and piriform sinuses. He also has a high palate and often is nasally congested. I am surprised there was not retrograde flow into the nasopharynx (what some describe as nasopharyngeal regurgitation), given the diffuse residue. Regardless of its underlying histologic characteristics, a benign pharyngeal tumor usually appears radiographically as a smooth, round, sharply circumscribed mass en face and as a hemispheric line with abrupt angulation in profile (see Figs. Ineffective esophageal motility (IEM): the old-new frontier in esophagology. The relationship between gastroesophageal reflux disease and Zenkers diverticulum is also controversial. You are being redirected to
2011 Nov. 21(4):465-75. Gastroenterology. On lateral views, the pouches are seen as oval ring shadows (occasionally with an air-contrast level) below the hyoid bone at the level of the valleculae, just behind the epiglottic plate, along the anterior hypopharyngeal wall. Patients with lateral pharyngeal pouches usually have no symptoms. Synonym (s): recessus pharyngeus [TA], recessus infundibuliformis, Rosenmller fossa, Rosenmller recess. 22(2):226-30. 16-5 ). Squamous cell carcinomas that affect the epiglottis, aryepiglottic folds, mucosa overlying the arytenoid cartilages, false vocal cords, and laryngeal ventricles are defined as supraglottic carcinomas. %%EOF
list of sundown towns in new england; jeff mudgett wikipedia. The response to amyl nitrate (a smooth muscle relaxant), with partial relaxation of the lower esophageal sphincter (LES), allows some barium to pass through it into the stomach. Herbella FA, Colleoni R, Bot L, Vicentine FP, Patti MG. High-resolution manometry findings in patients after sclerotherapy for esophageal varices. The degree of ganglion cell loss parallels the disease duration such that, at 10 years, ganglion cells are likely completely absent. Rarely, branchial cleft cysts may communicate with the pharynx (branchial cleft fistulas), filling with barium during pharyngography. With severe luminal narrowing, dysphagia may result, especially in patients with circumferential cervical esophageal webs. Squamous cell carcinomas of the base of the tongue are poorly differentiated lesions that often present as advanced lesions with nodal metastases. Signs and symptoms associated with dysphagia can include: Pain while swallowing. The LES pressure tracing is at the level of the sleeve (tracing 6). Radiographically, the diverticula are persistent, barium-filled sacs of various sizes connected to a bulging lateral hypopharyngeal wall by a narrow neck ( Fig. Incomplete opening and early closure of the cricopharyngeal muscle, and early closure of the upper cervical esophagus, have been associated with gastroesophageal reflux disease. 12:CD005046. Approximately 50% of patients complain of hearing loss because of eustachian tube involvement. Patients with complaints of bolus stasis in the throat (i.e., pharynx and cervical esophagus) were less accurate at localizing bolus stasis than patients with complaints in the thoracic esophagus ( p < .001). Some pharyngeal and cervical esophageal webs are associated with diseases that cause inflammation and scarring, such as epidermolysis bullosa or benign mucous membrane pemphigoid. Neck radiographs may show smooth enlargement of the epiglottis and aryepiglottic folds. After swallowing, barium in the diverticulum is regurgitated into the hypopharynx. Int J Mol Sci. ASHA / What is a swallowing disorder? Patients with second branchial cleft cysts usually present between the ages of 10 and 40 years with a painless or fluctuant mass in the upper neck along the upper third of the anterior border of the sternocleidomastoid muscle. Racial and environmental differences in the incidence of achalasia and other esophageal motility disorders might be present; however, because of the low incidence of disease and underdiagnosis in developing countries, these differences have not been demonstrated.