Crit Rev Diagn Imaging 28:133179, 1988. A videofluoroscopic swallow study (VFSS) allows for visualization of the oral, pharyngeal, and esophageal phases of the swallow. Catherine Shaker Swallowing and Feeding Seminars, Research Corner: Infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Persistence of branchial pouches or clefts results in the formation of sinus tracts or cysts. Manometry demonstrates diffuse esophageal spasm with simultaneous contractions of the esophagus observed throughout the tracing. [2]. Postgrad Med. 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). This lymphoid tissue causes the normal surface of the base of the tongue to be divided into small nodules of varying size. Only rarely do these tumors extend through the laryngeal ventricles into the true vocal cords. True soft tissue tumors of the aryepiglottic folds, such as lipomas, neurofibromas, hamartomas, granular cell tumors, and oncocytomas, are rare. Federal government websites often end in .gov or .mil. gopuff warehouse address; barts health nhs trust canary wharf; 16-3 ). The inferior constrictor muscle is composed of the thyropharyngeal and cricopharyngeal muscles. A referred earache may occur, especially when nasopharyngeal tumors block the eustachian tube. 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). Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. A true Zenkers diverticulum may be confused with barium trapped above a cricopharyngeal muscle that has closed before the pharyngeal contraction wave has passed. Is there any particular intervention improving pharyngeal clearance with the swallow. There appears to be a functional imbalance between excitatory and inhibitory postganglionic pathways, disrupting the coordinated components of peristalsis. The dysmorphic features stand out as worrisome, and often craniofacial and cardiac variants like an ASD can co-occur. The proximal esophagus is predominantly striated muscle, while the distal esophagus and the remainder of the GI tract contain smooth muscle. [QxMD MEDLINE Link]. Ineffective esophageal motility (IEM): the old-new frontier in esophagology. Achalasia manometry picture Note the nonrelaxing lower esophageal sphincter (LES) and the absence of esophageal body peristalsis. Four outpouchings from the pharynx grow to meet the branchial clefts. Eric A Gaumnitz, MD is a member of the following medical societies: American Gastroenterological Association, American Neurogastroenterology and Motility Society, American Society for Gastrointestinal EndoscopyDisclosure: Nothing to disclose. Small or predominantly submucosal lesions may be hidden in the valleculae or the recess between the tongue and tonsil (glossotonsillar recess). The pouches are usually bilateral. [QxMD MEDLINE Link]. In the United States, no strong association of cervical esophageal webs, iron deficiency anemia, and pharyngoesophageal carcinoma has been found. However, double-contrast examination of the pharynx may demonstrate the plaques of Candida pharyngitis or the ulcers of herpes pharyngitis, particularly in patients with AIDS ( Fig. 16-13 ). ,885 5*9`aXq[V#F2,\CSfCE{Wg?4C+U; XS{3)3:t,F,[(gn9qEaM^&Tydqt|8e^p 3F. Dysphagia. AJR 154:11571163, 1990. Muller M, Eckardt AJ, Gopel B, Eckardt VF. being unable to chew food properly. Achalasia affects both sexes in equal numbers. E93q">G8}wEkeW8 o Can protude into pharynx and cause pharyngeal stasis. [QxMD MEDLINE Link]. The cases were divided into two groups based on whether the . High-resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities. used kompact kamp mini mate for sale. Incomplete opening and early closure of the cricopharyngeal muscle, and early closure of the upper cervical esophagus, have been associated with gastroesophageal reflux disease. Peristalsis is a sequential, coordinated contraction wave that travels the entire length of the esophagus, propelling intraluminal contents distally to the stomach. Effect of orthognathic surgery on pharyngeal airway space: a cephalometric evaluation using dolphin imaging software/Avaliacao cefalometrica do espaco aereo faringeo apos cirurgia ortognatica por meio do . Increased incidence of both esophageal squamous cell and adenocarcinoma is observed in patients with long-standing achalasia. 16-11 ). Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist. 223 0 obj <> endobj This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. ENT did not find any structural issues, but his cry is described as quiet by nurses. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). For patient education resources, seeHeartburn and GERD CenterandDigestive Disorders Center, as well asAcid Reflux (GERD)andHeartburn. Pyriform stasis What pharyngeal stage disorder is a result of reduced anterior laryngeal motion, cricopharyngeal dysfunction, and inadequate upper esophageal sphincter opening? The primary role is to clear the esophagus of retained food or any gastroesophageal refluxate. 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. 16-14 ). Lingual tonsil lymphoid hyperplasia can be coarsely nodular, asymmetrically distributed, or masslike. 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 cyst at the base of the tongue. 16-4 ). This is the American ICD-10-CM version of J39.2 - other international versions of ICD-10 J39.2 may differ. 16-10 ). The webs are seen as isolated findings in 3% to 8% of patients undergoing upper GI barium studies. 16-1 ). Clinical and manometric course of nonspecific esophageal motility disorders. [High-resolution manometry of pharyngeal swallowing dynamics]. Asymmetrical distensibility is seen as flattening of the pharyngeal contour caused by fixation of structures by infiltrating tumor or by an extrinsic mass impinging on the pharynx. The clinical presentation of a motility disorder is varied, but, classically, dysphagia and chest pain are reported. Epub 2021 Feb 5. Some webs show inflammatory changes. 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. Achalasia commonly presents in the fifth decade but rarely may develop in children as well as in elderly persons. 6l9mU%RFHK1!e#Q,BET#T&U+{s]]Y. However, barium studies may reveal enlargement of the aryepiglottic fold with a smooth overlying mucosa. [QxMD MEDLINE Link]. 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. Patients with benign tumors of the base of the tongue may be asymptomatic or may complain of throat irritation or dysphagia. The barium examination can also show areas behind bulky tumors that are difficult to visualize by endoscopic examination. Cricopharyngeal dysfunction is most common in older adults. Radulovic M, Schilero GJ, Yen C, et al. Results Dysphagia evaluation was completed in 301 patients with complaints of bolus stasis. Before 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. Future research should focus on identifying symptom profiles that could lead to targeted swallowing evaluations based on patient history and complaint. The pharynx is the site of common illnesses, including sore throat and tonsillitis. Patients with impaired base of tongue movement and impaired pressure generation resulting in pharyngeal residue in the setting of a normal neurologic workup could possibly present with a posterior tongue tie which should be examined and included in the differential diagnosis. Physiologic characteristics of achalasia are additionally useful in assisting with establishing the diagnosis through chemical challenge testing. Barium studies are contraindicated because they may exacerbate edema, triggering an episode of acute respiratory arrest. Webs in the distal esophagus have been associated with gastroesophageal reflux disease. Thorac Surg Clin. Nonperistaltic isolated contractions or low-amplitude simultaneous contractions of the esophageal body may be observed. 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. If you log out, you will be required to enter your username and password the next time you visit. Rohof WO, Salvador R, Annese V, et al. The fourth and sixth pharyngeal arches cartilages merge to give rise to the laryngeal cartilages. Circumferential webs appear as ringlike shelves in the cervical esophagus. Although esophagram shows a typical picture of achalasia, this patient had adenocarcinoma of the gastroesophageal junction. c)IG}$EolC9f/6y8xr|}uBQ^hJ\|J}01`c55# The lower esophageal sphincter (LES) is composed entirely of smooth muscle and maintains a steady baseline tone to prevent gastric reflux into the esophagus. Exophytic lesions are more common ( Fig. Reproducibility of axial force and manometric recordings in the oesophagus during wet and dry swallows. 15(32):3969-75. for stability and/or r/t tethered oral tissues, r/t mild mandibular hypoplasia). Complications of botulinum toxin injections for treatment of esophageal motility disorders. Note the "bird-beak" appearance of the lower esophageal sphincter (LES), with a dilated, barium-filled esophagus proximal to it. 16-19 ). list of sundown towns in new england; jeff mudgett wikipedia. [QxMD MEDLINE Link]. 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. The symptoms of pharyngeal carcinoma are nonspecific and usually of short duration (<4 months). A barium examination can also be used to rule out a second primary lesion in the esophagus. Obliteration of the contour indicates that the lateral and inferior piriform sinus has been replaced by a soft tissue mass (. Some pharyngeal and cervical esophageal webs are associated with diseases that cause inflammation and scarring, such as epidermolysis bullosa or benign mucous membrane pemphigoid. Nasal regurgitation was observed during the initial double-contrast swallow. J Neurogastroenterol Motil. Esophageal dysmotility may be caused by: An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus. Gravesen FH, Gregersen H, Arendt-Nielsen L, Drewes AM. Praveen K Roy, MD, MSc is a member of the following medical societies: Alaska State Medical Association, American Gastroenterological AssociationDisclosure: Nothing to disclose. However, the postcricoid defect is probably related to redundancy of the mucosal and submucosal tissue in this area. Esophageal stasis was the most common finding regardless of complaint location. Squamous cell carcinomas of the base of the tongue are poorly differentiated lesions that often present as advanced lesions with nodal metastases. Abdel Jalil AA, Castell DO. This website also contains material copyrighted by 3rd parties. Achalasia is a progressive disease that requires chronic therapy. The relationship between the mouth of the Zenkers diverticulum and prominent cricopharyngeus is demonstrated. The lingual tonsil is an aggregate of 30 to 100 follicles along the pharyngeal surface of the tongue, extending from the circumvallate papillae to the root of the epiglottis. Sato Y, Fukudo S. Gastrointestinal symptoms and disorders in patients with eating disorders. 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. Several older northern European series showed an association of cervical esophageal webs, iron deficiency anemia, and pharyngeal or esophageal carcinoma. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. In the 4-week-old embryo, paired grooves of ectodermal origin, termed branchial clefts, appear on both sides of the neck region. Patients with small lesions are often asymptomatic but present with enlarged cervical nodes. "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 . 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. Measurement of Pharyngeal Residue From Lateral View Videofluoroscopic Images Catriona M. Steele,a,b Melanie Peladeau-Pigeon,a Ahmed Nagy,a,c,d and Ashley A. Waitoa Purpose: The field lacks consensus about preferred metrics for capturing pharyngeal residue on videofluoroscopy. If the dilation extends above the thyroid cartilage and through the thyrohyoid membrane, the sac is termed external laryngocele. 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. Neurological disorders affecting oral, pharyngeal . Well-differentiated tumors are usually exophytic and easily seen on barium studies ( Fig. Hoarseness occurs primarily in patients with laryngeal carcinoma, supraglottic carcinoma, or carcinoma of the medial piriform sinus infiltrating the arytenoid cartilage or cricoarytenoid joint. Ectopic thyroid tissue and thyroglossal duct cysts may occur at the tongue base but are rare. [Temporal and spatial pattern analysis of pharyngeal swallowing in patients with abnormal sensation in the throat]. Tumors of the epiglottis and aryepiglottic folds may also result in dysphagia, coughing, or choking because of laryngeal penetration. Radiographically, an exophytic lesion appears as a polypoid mass projecting into the oropharyngeal air space. An esophagram demonstrating the corkscrew esophagus picture observed in a patient with manometry confirmed findings of diffuse esophageal spasm (DES). What we know so far suggests a poor prognosis for being a full PO feeder at time of d/c from the NICU and the etiology(ies) is/are unlikely to resolve in the short term, given multiple complex co-morbidities, as yet not fully determined. Nasopharyngeal squamous cell carcinoma occurs at a relatively young age, with 20% of patients being younger than 30 years. Recent ECHO showed a moderate ASD. The radiographic findings of pharyngeal cancer include an intraluminal mass, mucosal irregularity, and impairment or loss of normal mobility or distensibility ( Fig. These tumors may spread laterally to the pharyngoepiglottic folds and lateral pharyngeal walls. 2ZX3G$>L7tBTAUl x:v=> Lh %`=msXaR{ArBAo The use of endoscopy and magnetic resonance imaging (MRI) may help exclude malignancy. The fourth pharyngeal arch forms the laryngeal cartilages, muscles of the soft palate and pharynx, part of the subclavian artery and the arch of the aorta. Eur J Pediatr. 30(3):1-5. The upper anterolateral pharyngeal wall is poorly supported in the region of the posterior and superior portions of the thyrohyoid membrane. A zone of lymphoid tissue surrounds the epithelium. Whether gastroesophageal reflux predisposes patients with a large Killian dehiscence to the formation of Zenkers diverticulum is unknown. This infant has pharyngeal stasis post swallow on the swallow study. The coordination of these simultaneously contracting muscle layers produces the motility pattern known as peristalsis. The cricopharyngeal muscle constitutes the lower portion of the inferior constrictor muscle, arising from the lateral cricoid cartilage to encircle the lowermost hypopharynx. ), Partially obstructing cervical esophageal web. Abdullah Fayyad, MD, MBBS is a member of the following medical societies: American Gastroenterological AssociationDisclosure: Nothing to disclose. Esophageal motility disorders, excluding achalasia, lack population-based studies. Unauthorized use of these marks is strictly prohibited. A frontal view shows loss of the normal contour of the left piriform sinus. Inflammatory disorders of the pharynx or gastroesophageal reflux can alter pharyngeal elevation, epiglottic tilt, or closure of the vocal cords and laryngeal vestibule. 2010 Feb. 22(2):142-9, e46-7. hb```f``r Retention cysts of the aryepiglottic folds are lined by squamous epithelium and filled with desquamated squamous debris ( Fig. Has there been a neuro consult? Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison. They are usually unilateral. The motor learning from the pacifier dips would keep him learning but minimize risk. 12:CD005046. Most of these patients have recurrent aphthous stomatitis and oropharyngeal ulceration. Gatto AR, Cola PC, da Silva RG, Ribeiro PW, Spadotto AA, Henry MAAC. Hospitalization for achalasia in the United States 1997-2006. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis in the throat. 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. ASHA / What is a swallowing disorder? Poorly differentiated tumors are frequently of the ulcerative infiltrative type and may be obscured on barium studies by the underlying nodular lymphoid tissue of the palatine tonsil. The pharyngeal wall consists of overlapping superior middle and inferior constrictors on its posterior aspects and sides. Diagnostic pitfalls and how to avoid them. We put him on an oral rest for now. Primary peristalsis is the peristaltic wave triggered by the swallowing center. 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. Killian-Jamieson diverticula can be bilateral or unilateral. Partial obstruction is suggested by a jet phenomenon or by dilation of the esophagus or pharynx proximal to the web (see Fig. Radiographic findings in pharyngeal carcinoma. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Nonepithelial tumors arising from the supporting tissues of the pharynx are rare. This area of weakness occurs in one third of patients. The muscle is oriented in 2 perpendicular opposing layers: an inner circular layer and an outer longitudinal layer, known collectively as the muscularis propria. On double-contrast frontal views in which a modified Valsalva maneuver is performed, the pouches are seen as hemispheric, barium-coated protrusions above the notch in the lateral pharyngeal wall. 2015 Aug;37(8):1193-9. doi: 10.1002/hed.23735. Radiographically, a small (3-20mm in diameter), round to ovoid, smooth-surfaced outpouching is seen just below the level of the cricopharyngeal muscle ( Fig. 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. Low peristaltic amplitudes normally occur at the transition zone between the striated and smooth muscle portions; however, the peristalsis is uninterrupted. Most patients with Killian-Jamieson diverticula are asymptomatic, but some may complain of dysphagia or regurgitation. 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. 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. You are being redirected to However, no studies to date have shown convincing evidence that surveillance is worthwhile. Elliott TR, Wu PI, Fuentealba S, et al. The .gov means its official. Radiographically, the diverticula are persistent, barium-filled sacs of various sizes connected to a bulging lateral hypopharyngeal wall by a narrow neck ( Fig. Patients should be counseled about their disease. Transient or persistent protrusions of the anterolateral cervical esophagus into the Killian-Jamieson space are termed lateral cervical esophageal pouches or diverticula, respectively. These tracts are lined by ciliated columnar epithelium. 0 No nasopharyngeal regurgitation that I recall. 2011 Nov. 21(4):465-75. This delayed spill may result in dysphagia or a choking sensation because of overflow aspiration. Considerable variation is found in the arrangement of the muscle bundles of the thyropharyngeal and cricopharyngeal muscles. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTc0NzgzLW92ZXJ2aWV3. Dis Esophagus. Greatly increased prevalence of esophageal dysmotility observed in persons with spinal cord injury. Pathologically, a unilocular cyst is lined by keratinizing, stratified, squamous epithelium and is filled with desquamated keratinaceous debris. A dynamic examination reveals a higher percentage of webs than spot images alone. Food coming back up (regurgitation) Frequent heartburn. In scleroderma, the primary defect in this systemic process is related to smooth muscle atrophy and fibrosis. 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. This association was termed Plummer-Vinson syndrome or Paterson-Kelly syndrome. Some patients with Zenkers diverticulum are asymptomatic. Diagnosis of esophageal motility disorders: esophageal pressure topography vs. conventional line tracing. Plain radiographic diagnosis of acute epiglottitis is important (even in adults) because manipulation of the tongue or pharynx may exacerbate edema and respiratory distress. Pharyngeal inflammation and ulceration may be seen in patients with Behets syndrome, Stevens-Johnson syndrome, Reiters syndrome, epidermolysis bullosa, or bullous pemphigoid. 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. Scleroderma esophagus is associated with severe and progressive acid reflux symptoms and complications. what is pharyngeal stasislack of education leads to violence what is pharyngeal stasis. The quiet cry may suggest retracted tongue (? These tumors infiltrate deeply into the intrinsic and extrinsic muscles of the tongue. Genetics consult? OT consult? National Library of Medicine bringing food back up, sometimes through the nose. Webs are thin mucosal folds usually located along the anterior wall of the lower hypopharynx and proximal cervical esophagus. They include sore throat, dysphagia, and odynophagia. [1] As with any other chronic illness, prevalence exceeds incidence significantly. endstream endobj 224 0 obj <> endobj 225 0 obj <> endobj 226 0 obj <>stream HU6?Q [QxMD MEDLINE Link]. 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. Cervical nodal metastases are seen in one third to one half of patients. 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. Rarely, branchial cleft cysts may communicate with the pharynx (branchial cleft fistulas), filling with barium during pharyngography. Among the anomalies seen in SCI patients weretype II achalasia (12%), type III achalasia (4%), esophagogastric junction outflow obstruction (20%), hypercontractile esophagus (4%), and peristaltic abnormalities (weak peristalsis with small or large defects or frequent failed peristalsis) (48%). Achalasia is associated with significant and progressive symptomatic discomfort. sharing sensitive information, make sure youre on a federal Praveen K Roy, MD, MSc Clinical Assistant Professor of Medicine, University of New Mexico School of Medicine PMC This space is bounded superiorly by the inferior margin of the cricopharyngeal muscle, anteriorly by the inferior margin of the cricoid cartilage, and inferomedially by the suspensory ligament of the esophagus originating from the posterior wall of the cricoid cartilage, just before the tendon forms the longitudinal muscle of the esophagus. (From Levine MS, Rubesin SE: Radio-logic investigation of dysphagia. 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. Variable amounts of inflammatory cells have been described within the myenteric plexus along with the disappearing nerves. In one autopsy series, 16% of patients had incidental cervical esophageal webs.