Symptomatic lower esophageal muscular ring: response to botox

Esophageal A-ring is associated with the severity of gastroesophageal reflux

BACKGROUND

The esophageal A-ring (EAR) is an anatomic finding appreciated on videofluoroscopic esophagram (VFE) at the junction of the tubular esophagus and esophageal vestibule. EARs are appreciated on a small subset (5%) of VFEs. We hypothesize that EARs represent a compensatory mechanism to protect against gastroesophageal reflux (GER).

OBJECTIVE

To evaluate the association between EAR and GER.

STUDY DESIGN

Case control study.

METHODS

All persons having undergone ambulatory pH testing with an EAR identified on VFE between November 1, 2014 and June 30, 2014 were identified. All cases were matched to controls by age, gender, and the presence/absence of hiatal hernia. Subjective dysphagia severity was assessed with the EAT10 and the presence of erosive esophagitis and intestinal metaplasia on esophagoscopy was abstracted.

RESULTS

The mean (±SD) age of the entire cohort (N = 20) was 63 (±7.7) years. 60% was female. The mean composite DeMeester pH score for persons with and without an EAR was 48.9 (±39.6) and 15.4 (±12.3), respectively (P = .033). The mean total % time of pH < 4 for persons with and without an EAR was 26.4 (±21.9) and 7.7 (±6.8), respectively (P = .034). The prevalence of erosive esophagitis among persons with and without an EAR was 70% and 10%, respectively (P = .019).

CONCLUSION

There is a significant association between the presence of esophageal A-rings on esophagography and the severity of acid reflux on endoscopy and ambulatory pH testing. The data suggest that the presence of an esophageal A-ring may be either a compensatory mechanism to protect against gastroesophageal reflux and/or an inflammatory consequence of peptic esophagitis.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:951-954, 2020.

In-office transnasal esophagoscope-guided botulinum toxin injection of the lower esophageal sphincter

PURPOSE OF REVIEW

Thin caliber transnasal esophagoscopes allow for a rapidly expanding array of office-based esophageal procedures, including botulinum toxin injections, in unsedated patients.

RECENT FINDINGS

While botulinum toxin has been used in the esophagus and lower esophageal sphincter for many years, there is no current description of performing this procedure in an unsedated patient using transnasal esophagoscopy. Indications include achalasia, hypertensive lower esophageal sphincter, distal esophageal spasm, nutcracker esophagus and obstructing muscular rings. There is a paucity of data in the literature pertaining to spastic esophageal motility disorders and muscular rings. Randomized controlled trials of achalasia treatments suggest that botulinum toxin injections should be reserved for patients who are poor surgical candidates and/or have failed pneumatic dilation.

SUMMARY

In-office transnasal esophagoscopy-guided lower esophageal sphincter botulinum toxin injection has not been described in the literature. Indications include esophageal spasm, muscular rings and achalasia, with recent data suggesting that botulinum toxin should not be an initial therapy for most patients with achalasia.