Primary esophageal motility disorders are idiopathic in nature, but postviral, infectious, environmental, and genetic factors have been hypothesized. Four outpouchings from the pharynx grow to meet the branchial clefts. Timing of events during deglutition after chemoradiation therapy for oropharyngeal carcinoma. National Library of Medicine RadioGraphics 8:641665, 1988.). Approximately 50% of patients develop cervical nodal metastases. 2021 Apr;30(4):105349. doi: 10.1016/j.jstrokecerebrovasdis.2020.105349. Patients with benign tumors of the base of the tongue may be asymptomatic or may complain of throat irritation or dysphagia. 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. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. A combination of internal and external laryngocele is termed a mixed laryngocele. 7(2):101-13. Barium studies of the pharynx are usually of limited value in patients with acute sore throat caused by viral, bacterial, or fungal infection. Eric A Gaumnitz, MD Professor of Medicine, Division of Gastroenterology, University of Wisconsin School of Medicine; Program Director, Gastroenterology and Hepatology Fellowship, University of Wisconsin School of Medicine and Public Health; Director, Motility Unit, University of Wisconsin Hospitals These protrusions are commonly found in those who have increased intrapharyngeal pressure (e.g., wind instrument players, glass blowers, people with severe sneezing episodes). The pharynx is the site of common illnesses, including sore throat and tonsillitis. The complications of Zenkers diverticulum include bronchitis, bronchiectasis, lung abscess, diverticulitis, ulceration, fistula formation, and carcinoma. Tertiary contractions are simultaneous, isolated, dysfunctional contractions. Philadelphia, WB Saunders, 1992. Elliott TR, Wu PI, Fuentealba S, et al. 233 0 obj <>/Filter/FlateDecode/ID[<9925DAB172E4C04EAA11C856BA143EA3>]/Index[223 23]/Info 222 0 R/Length 65/Prev 694135/Root 224 0 R/Size 246/Type/XRef/W[1 2 1]>>stream pharyngeal: [adjective] relating to or located or produced in the region of the pharynx. Aryepiglottic fold nodules or mass lesions may cause dysphonia or respiratory symptoms such as stridor. Esophageal motility disorders are not uncommon in gastroenterology. He also gets very constipated. Symptoms attributed to lymphoid hyperplasia of the lingual tonsil include throat discomfort, a globus sensation, and dysphagia. [2]. Synonym (s): recessus pharyngeus [TA], recessus infundibuliformis, Rosenmller fossa, Rosenmller recess. The degree of ganglion cell loss parallels the disease duration such that, at 10 years, ganglion cells are likely completely absent. Brooks, L., Landry, A., Deshpande, A., Marchica, C., Cooley, A., & Raol, N. (2020). 16-7 ). These vallecular and piriform sinus webs are composed of mucosa, lamina propria, and underlying blood vessels. 245 0 obj <>stream Epub 2021 Feb 5. Radiographically, the diverticula are persistent, barium-filled sacs of various sizes connected to a bulging lateral hypopharyngeal wall by a narrow neck ( Fig. Image courtesy of Andrew Taylor, MD, Professor, Abdominal Imaging, Department of Radiology, University of Wisconsin Medical School, Madison. 1989 Mar;85(4):243-5, 250, 260. doi: 10.1080/00325481.1989.11700632. When small, the cysts are anterior to the sternocleidomastoid muscle. Among the VFSSs, those showing pharyngeal stasis by mechanical obstruction due to cervical osteophytes were selected for inclusion in this study. Other signs and symptoms include nasal obstruction, epistaxis, pain, headache, and damage to the fifth cranial nerve. If it is not neurologic, could it be anatomic? 16-11 ). However, the impact of posterior tongue ties on the pharyngeal phase of swallowing is not well documented in the literature. The MBS studies are often visually rated by the speech pathologist to determine the bolus transit time through the various phases of swallowing, location and cause of the stasis, compensatory maneuvers useful for partially or completely eliminating the stasis, timing of the swallow reflex, coordination of the structures involved in the swallow reflex, amount of aspiration/penetration, causes . The diverticula are lined by nonkeratinizing squamous epithelium surrounded by loose areolar connective tissue, with many vascular spaces. Praveen K Roy, MD, MSc is a member of the following medical societies: Alaska State Medical Association, American Gastroenterological AssociationDisclosure: Nothing to disclose. 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. Dis Esophagus. The secondary peristaltic wave is induced by esophageal distension from the retained bolus, refluxed material, or swallowed air. 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%). Pharyngeal phase problems include -having a hard time starting a swallow -getting food or liquid into your airway, called aspiration -having some food or liquid stay in your throat after you've swallowed, called residue. divina peruvian pepper jam; haverhill high school yearbooks; bluey stuffed animal disney store; introduction to environmental engineering and science 3rd edition ebook Any change in the character of dysphagia or bloody discharge in a patient known to have Zenkers diverticulum should suggest a complication. In DES, muscular hypertrophy or hyperplasia has been described in the distal two thirds of the esophagus. The peristaltic contraction wave travels at a speed of 2 cm/s and correlates with manometry-recorded contractions. The underlying cause of all the primary motility disorders remains elusive. 16-18 ). (From Levine MS, Rubesin SE: Radio-logic investigation of dysphagia. The secondary motility disorders, such as scleroderma esophagus or esophageal motility disorder of diabetes, are better understood from the standpoint of the preexisting underlying disorders. Outcomes of treatment for achalasia depend on manometric subtype. Esophageal dysmotility may be caused by: An ulcer, stricture, irritation, infection, inflammation, or cancer in the esophagus. In 80% of patients, the cause of a patient's dysphagia can be suggested from the history, including dysmotility of the esophagus. Killian-Jamieson diverticula can be bilateral or unilateral. Most patients with Killian-Jamieson diverticula are asymptomatic, but some may complain of dysphagia or regurgitation. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. They are also known as Killian-Jamieson pouches or Killian-Jamieson diverticula . An esophagram demonstrating the corkscrew esophagus picture observed in a patient with manometry confirmed findings of diffuse esophageal spasm (DES). Ulcerative lesions may deeply penetrate the tongue and valleculae and invade the pre-epiglottic space ( Fig. 208(6):1035-44. 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. Nonepithelial tumors arising from the supporting tissues of the pharynx are rare. Branchial pouch sinuses arise from the tonsillar fossa (second pouch), upper anterolateral piriform fossa (third pouch), or lower anterolateral piriform sinus (fourth pouch; Fig. He also has a high palate and often is nasally congested. 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). The radiographic findings of pharyngeal cancer include an intraluminal mass, mucosal irregularity, and impairment or loss of normal mobility or distensibility ( Fig. 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 . Early on in my assessment (maybe ~35 weeks) I couldnt elicit a tongue-lateralizing reflex, havent checked since. Lateral pharyngeal pouches are extremely common, and the frequency of their occurrence increases with age. Only rarely do these tumors extend through the laryngeal ventricles into the true vocal cords. Esophageal stasis was the most common finding regardless of complaint location. These pouches and diverticula are relatively common and may be confused radiographically with Zenkers diverticulum. Is there any particular intervention improving pharyngeal clearance with the swallow. 99>X5W0k|KkzvD7\Q{*{[Vs* @Lid{ EM>;"t1wDZ. Most of these tumors are keratinizing squamous cell carcinomas. In contrast, the neck of Zenkers diverticulum is on the posterior hypopharyngeal wall, and the sac extends inferiorly behind the cervical esophagus. The most common branchial vestige is a cyst arising from the second branchial cleft. Careers. Frontal radiographs in patients with an external laryngocele may show an air-filled sac above and lateral to the ala of the thyroid cartilage. If you log out, you will be required to enter your username and password the next time you visit. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Structural Abnormalities of the Pharynx, Miscellaneous Abnormalities of the Stomach and Duodenum, Pharynx: Normal Anatomy and Examination Techniques. This characteristic likely explains why the botulinum toxin (acetylcholine release inhibitor) may have therapeutic benefit in patients with achalasia. Depending on the rate and extent of disease progression, therapy might include endoscopic and surgical interventions. The pathogenesis of Zenkers diverticulum is as controversial as the muscular anatomy. Neurological disorders affecting oral, pharyngeal . Recent ECHO showed a moderate ASD. 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 Problem-Solving with Catherine: 5-year-old with Athetoid Cerebral Palsy, Problem-Solving with Catherine: Infant in NICU with HIE. On frontal views during swallowing, pouches appear as transient, hemispheric, contrast-filled protrusions from the lateral hypopharyngeal wall, below the hyoid bone and above the calcified edge of the thyroid cartilage ( Fig. Ive talked with team and parents both about aspiration risk and oral feeding aversion. Complications of botulinum toxin injections for treatment of esophageal motility disorders. Would you like email updates of new search results? 2013 Jun. Familial clustering is observed, but a genetic relationship is not established. [QxMD MEDLINE Link]. In Europe, the incidence of achalasia is similar to that of the United States. Esophageal motility disorders are less common than mechanical and inflammatory diseases affecting the esophagus, such as reflux esophagitis, peptic strictures, and mucosal rings. 2017 Feb 1. The pharynx, usually called the throat, is part of the respiratory system and digestive system. The LES pressure tracing is at the level of the sleeve (tracing 6). Gravesen FH, Gregersen H, Arendt-Nielsen L, Drewes AM. The tubular esophagus is a muscular organ, approximately 25 cm in length, and has specialized sphincters at proximal and distal ends. hTmo6+bpNQ@av@A9G^I;Rr$;Y\#0"&Z2-t2& #WBq#@ @+$>EWuO72Ou-Zs*[P Jd|!6kSKWEsw]J]WfDvNj _i8n[&7gsct Patients with pharyngeal symptoms or a palpable neck mass may undergo pharyngoesophagography as the initial diagnostic examination. 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. 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. "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 . In the 4-week-old embryo, paired grooves of ectodermal origin, termed branchial clefts, appear on both sides of the neck region. Thorac Surg Clin. At the LES, the loss of inhibitory nerves is demonstrated by loss of nitric oxide synthase and vasoactive intestinal peptide (VIP) immunohistochemistry staining. Muller M, Eckardt AJ, Gopel B, Eckardt VF. If symptoms progress, then the workup should be repeated because DES can progress to achalasia. Patients with external or mixed laryngoceles may have a compressible lateral neck mass. 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). ), An 80-year-old patient with dementia underwent an upper GI examination for epigastric pain. Cochrane Database Syst Rev. Conclusion Patients are poor at localizing bolus stasis, and esophageal stasis is common in patients who complain of pharyngeal stasis. bringing food back up, sometimes through the nose. Any ideas are greatly appreciated! [QxMD MEDLINE Link]. Transient or persistent protrusions of the anterolateral cervical esophagus into the Killian-Jamieson space are termed lateral cervical esophageal pouches or diverticula, respectively. If saccular dilation of the appendix is confined by the thyroid cartilage, it is termed an internal laryngocele. ), Partially obstructing cervical esophageal web. 110(7):967-77; quiz 978. The barium examination can also show areas behind bulky tumors that are difficult to visualize by endoscopic examination. They should be well informed about its lifelong nature. In scleroderma, the primary defect in this systemic process is related to smooth muscle atrophy and fibrosis. 16-4 ). Nutcracker esophagus is the most common motility disorder (>40% of all motility disorders diagnosed), but it is the most controversial in significance. 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. An official website of the United States government. endstream endobj 227 0 obj <>stream 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 . Patients with lateral pharyngeal pouches usually have no symptoms. Lymphoid hyperplasia of the palatine tonsils. Anteriorly, there is the larynx, epiglottis, and posterior part of the tongue. Inability to swallow. 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. Diverticula appear on frontal views as saccular protrusions that have narrow necks (see Fig. Inflammatory disorders of the pharynx or gastroesophageal reflux can alter pharyngeal elevation, epiglottic tilt, or closure of the vocal cords and laryngeal vestibule. [QxMD MEDLINE Link]. Rommel N, Omari TI, Selleslagh M, et al. Enter your email address to subscribe to this blog and receive notifications of new posts by email. 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. 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. The lower esophageal sphincter (LES) is composed entirely of smooth muscle and maintains a steady baseline tone to prevent gastric reflux into the esophagus. The inferior constrictor muscle is composed of the thyropharyngeal and cricopharyngeal muscles. Accessibility Carcinoma arises in less than 1% of patients with Zenkers diverticulum, but it is usually fatal. The proximal esophagus is predominantly striated muscle, while the distal esophagus and the remainder of the GI tract contain smooth muscle. 16-10 ). endstream endobj startxref Disclaimer. Patients should be counseled about their disease. HHS Vulnerability Disclosure, Help 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. Some diseases with diffuse mucous membrane ulceration affect the pharynx. [QxMD MEDLINE Link]. The incidence of achalasia is 1-3 case per 100,000 population per year. The exception is the . This controversial finding causes difficulty in attributing symptoms or manometric abnormalities to muscle structure changes. 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. endstream endobj 224 0 obj <> endobj 225 0 obj <> endobj 226 0 obj <>stream No overlap of fibers exists between the thyropharyngeal and cricopharyngeal muscles. Nodules of tumor may spread to the palatine tonsil, valleculae, or pharyngoepiglottic fold. When large, the cysts may extend posteriorly to the sternocleidomastoid muscle, displacing the carotid sheath. 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. 16-19 ). The incidence of esophageal dysmotility appears to increased in patients with spinal cord injury (SCI). Small or predominantly submucosal lesions may be hidden in the valleculae or the recess between the tongue and tonsil (glossotonsillar recess). Cross-sectional imaging studies are the examinations of choice for showing spread of tumor into the submucosa, intrinsic muscles, tissues extrinsic to the pharynx, and regional lymph nodes. True soft tissue tumors of the aryepiglottic folds, such as lipomas, neurofibromas, hamartomas, granular cell tumors, and oncocytomas, are rare. Most patients with cervical esophageal webs are asymptomatic. See more. Peristalsis is a sequential, coordinated contraction wave that travels the entire length of the esophagus, propelling intraluminal contents distally to the stomach. The 5-year survival rate is approximately 40%. 6l9mU%RFHK1!e#Q,BET#T&U+{s]]Y. persistent drooling of saliva. 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. 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. Ineffective esophageal motility (IEM): the old-new frontier in esophagology. for: Medscape. Lateral view shows a smooth-surfaced hemispheric mass (, A smooth-surfaced, well-circumscribed mass (, (From Rubesin SE, Glick SN: The tailored double-contrast pharyngogram. He was eventually diagnosed with a posterior tongue tie and underwent a frenulectomy. The 2023 edition of ICD-10-CM J39.2 became effective on October 1, 2022. Uncoordinated or abnormal muscles in the mouth, throat or esophagus. 2015 Dec. 174(12):1629-37. Reassurance is important in patients with spastic motility disorders, especially in the setting of noncardiac chest pain. Nasopharyngeal squamous cell carcinoma occurs at a relatively young age, with 20% of patients being younger than 30 years. 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. Catherine Shaker Swallowing and Feeding Seminars, Research Corner: Infant and maternal factors associated with attainment of full oral feeding (FOF) in premature infants. gopuff warehouse address; barts health nhs trust canary wharf; Barium may also be trapped above early closure of the upper cervical esophagus. Dysphagia. The pharyngeal outpouchings are of endodermal origin and are termed branchial pouches. 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. ASHA / What is a swallowing disorder? An ulcerated lesion appears as an irregular barium collection disrupting the expected contour of the base of the tongue. Results via subsequent VFSS revealed significant improvement in base of tongue movement, pharyngeal pressure generation, and pharyngeal constriction, resulting in efficient movement of the bolus through the pharynx into the esophagus, no nasopharyngeal regurgitation, no aspiration, and near resolution of his pharyngeal dysphagia. coughing or choking when eating or drinking. Hoarseness occurs primarily in patients with laryngeal carcinoma, supraglottic carcinoma, or carcinoma of the medial piriform sinus infiltrating the arytenoid cartilage or cricoarytenoid joint. Normal manometry results show normal esophageal body peristalsis with normal lower esophageal sphincter (LES) pressure and relaxation. Neck radiographs may show smooth enlargement of the epiglottis and aryepiglottic folds. Laryngoceles are seen in patients with increased intralaryngeal pressure, such as glass blowers and wind instrument players. Postgrad Med. On lateral views, the anterior wall of the sac is anterior to the cervical esophagus, below the level of the cricopharyngeal muscle. Occasionally, a deeply infiltrating, primarily submucosal lesion may be manifested by subtle asymmetric enlargement of the tongue base. Results Dysphagia evaluation was completed in 301 patients with complaints of bolus stasis. Incomplete opening and early closure of the cricopharyngeal muscle, and early closure of the upper cervical esophagus, have been associated with gastroesophageal reflux disease. Before Lateral view of the pharynx shows well-circumscribed plaques (. o Can protude into pharynx and cause pharyngeal stasis. Rohof WO, Salvador R, Annese V, et al. However, no studies to date have shown convincing evidence that surveillance is worthwhile. 16-17 ). Physiologic characteristics of achalasia are additionally useful in assisting with establishing the diagnosis through chemical challenge testing. This work supports a comprehensive evaluation of both the pharynx and the esophagus for patients with complaints of bolus stasis . Lymph node metastases are seen ipsilaterally or contralaterally in more than 70% of patients. Diagnostic Accuracy of an Esophageal Screening Protocol Interpreted by the Speech-Language Pathologist. Diagnostic pitfalls and how to avoid them. Webs may be confused radiographically with redundant mucosa in the anterior wall of the pharyngoesophageal segment at the level of the cricoid cartilage. 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. Share cases and questions with Physicians on Medscape consult. There appears to be a functional imbalance between excitatory and inhibitory postganglionic pathways, disrupting the coordinated components of peristalsis. With achalasia, the risk of squamous cell carcinoma of the esophagus is higher than that of the general population. In Laufer I, Levine MS [eds]: Double Contrast Gastrointestinal Radiology, 2nd ed. [QxMD MEDLINE Link]. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. A lateral pharyngeal diverticulum is a protrusion of nonkeratinizing squamous mucosa originating in the pharynx. Most patients are asymptomatic and in the fifth to sixth decade of life. The LES relaxes during swallows and stays opened until the peristaltic wave travels through the LES, then contracts and redevelops resting basal tone. The third and fourth branchial pouches form the piriform sinuses. 16-15 ). 16-16 ). Nasal regurgitation was observed during the initial double-contrast swallow. When advanced, this condition can lead to such severe dysphagia that malnutrition, weight loss, and dehydration can develop. Unauthorized use of these marks is strictly prohibited. The relationship between the mouth of the Zenkers diverticulum and prominent cricopharyngeus is demonstrated. Thanks for such a detailed history to help to consider possibilities. 2016 Apr 30. Efficient transport by the esophagus requires a coordinated, sequential motility pattern that propels food from above and clears acid and bile reflux from below. Squamous cell carcinomas of the head and neck (e.g., tongue, pharynx, larynx) constitute 5% of all cancers in the United States, whereas esophageal carcinomas constitute only 1% of all cancers. The esophagus functions solely to deliver food from the mouth to the stomach where the process of digestion can begin. 16-8 ). Such patients usually demonstrate normal findings on pharyngograms or evidence of nonspecific lymphoid hyperplasia of the palatine or lingual tonsils. They are usually unilateral. Rarely, branchial cleft cysts may communicate with the pharynx (branchial cleft fistulas), filling with barium during pharyngography. Scleroderma esophagus is associated with severe and progressive acid reflux symptoms and complications. A barium examination can also be used to rule out a second primary lesion in the esophagus. 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. [QxMD MEDLINE Link]. Catherine Shaker 2023 Seminars: Reinforce Your Intellectual Curiosity! 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. Farmer's Empowerment through knowledge management. Disorders of esophageal motility are referred to as primary or secondary esophageal motility disorders and categorized according to their abnormal manometric patterns. The lower esophageal sphincter (LES) pressure tracing is at the level of the sleeve (tracing 6). None of the clinical or physiologic behaviors can be attributed strictly to being born preterm, though preterm birth would increase risk for co-morbidities.
Dallas National Golf Club General Manager,
John Morgan Kualoa Ranch Net Worth,
Articles W