Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy

Radiographic Findings after Cricopharyngeal Myotomy

Single film examinations (iodine and/or barium) were reviewed in 28 patients who had undergone surgery on the cricopharyngeal muscle due to Zenker diverticula (24 patients), cricopharyngeal muscle incoordination (3 patients) and pharyngoesophageal web (one patient). All patients had had a myotomy which included the cricopharyngeal muscle and up to 3 cm of the cervical esophagus. Lateral and anterior deviation of the pharynx and cervical esophagus occurred regularly. A pharyngocutaneous fistula developed in 2 patients which healed within 3 weeks. In 5 patients there was a posterior leak of contrast medium during the first postoperative week which healed within 2 weeks. Six of these seven patients with a fistula or a leak had had either a diverticulum removed or sustained an accidental mucosal perforation. No patient had recurrence of diverticula, although, 9 patients developed a cricopharyngeal muscle impression. Iodine and barium examinations are important for monitoring early and late postoperative changes after cricopharyngeus myotomy.

The Upper Esophageal Sphincter Area

The localization of the upper esophageal sphincter is partly controversial. The aim of the present study was to elucidate whether or not the sphincter area could be allocated within an area inferior to and separate from the cricopharyngeal muscle. Cineradiography of the pharyngo-esophageal segment in 252 dysphagial patients disclosed a posterior impression in 55 (22%). There were no signs of a circular impression or other indications of a sphincter localized inferior to the circopharyngeus as revealed on these cinefilms. Macro- and microscopic examination of 16 autopsy specimens revealed the level of the upper esophageal sphincter to be localized within the cricopharyngeal muscle. There was no indication of any sphincter inferior to the crico-pharyngeus in the cervical esophagus.

[Treatment of upper esophageal sphincter achalasia as a little-known chapter of surgery]

It is presented the results of survey and treatment of 32 patients with upper esophageal sphincter achalasia. In 29 of them achalasia was consequence of stroke in brain stem (Zakharchenko-Wallenberg syndrome). 28 patients were operated using P. Chodoch method in 7 cases and author's technique of myotomy with pharyngoesophageal junction plasty in 21 patients. Plastic myotomy gives excellent and good results in 81% of observations due to preservation of innervation of muscles providing function of epiglottis and pharyngeal constrictors. Severe condition of patients and elderly age are indication for P. Chodoch myotomy.

Indications and outcomes of endoscopic CO2 laser cricopharyngeal myotomy

OBJECTIVES/HYPOTHESIS

To describe indications, management, and outcomes of endoscopic CO2 laser cricopharyngeal myotomy (CPM).

STUDY DESIGN

Case series with chart review.

METHODS

All patients treated with endoscopic CO2 laser CPM over a 6-year period were identified. A retrospective chart review was performed for surgical indication, history and physical examinations, and swallow evaluations. Swallowing outcomes were assessed using the Functional Outcome Swallowing Scale (FOSS); findings were compared across groups.

RESULTS

Eighty-seven patients underwent endoscopic CO2 laser CPM during the study period for cricopharyngeal dysfunction. Indications included Zenker's diverticulum (ZD) (39), DiGeorge syndrome (two), stroke (five), nerve injury (two), radiation for head and neck cancer (15), idiopathic (16), hyperfunctional tracheoesophageal speech (five) and dysphagia from cricopharyngeus stricture after laryngectomy (three). Mean, median, and mode time to feeding postoperatively were 1.4, 1, and 0 days respectively. Mean, median, and mode hospital stays were 1.8, 1, and 1 day respectively. Overall, FOSS scores improved from 2.6 to 1.6 (P < .001). Improvement was greatest for patients with ZD (2.4 to 1.0) and cricopharyngeal dysfunction from nerve injury (3.3 to 1.8) and least for those with prior radiation (3.9 to 3.2). All patients undergoing CPM for poor tracheoesophageal speech regained speech postoperatively. No patients developed mediastinitis, abscess, or fistula.

CONCLUSIONS

Endoscopic CO2 laser CPM is a safe treatment for cricopharyngeal dysfunction of various causes, though swallowing outcomes may vary depending on the surgical indication. Early feeding postoperatively after CPM is safe and facilitates early hospital discharge.

LEVEL OF EVIDENCE

4.

Flexible endoscopic and surgical management of Zenker's diverticulum

Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle. The etiology of Zenker's diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenker's diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.

Pharyngeal Stasis of Secretions in Patients with Zenker Diverticulum

Objective. To determine whether patients with Zenker diverticulum are more likely to have stasis of secretions in the left piriform sinus, on in-office endoscopy, than patients with nonspecific dysphagia.

Study Design. A case–control study.

Setting. A subspecialty swallowing clinic.

Subjects and Methods. All patients with radiographically confirmed Zenker diverticulum who were evaluated over a 5-year period were selected. A control group with dysphagia due to radiographically confirmed esophageal dysmotility, prominent cricopharyngeal bar, or stricture was identified. Two blinded laryngologists reviewed the recorded laryngopharyngoscopies.

Results. Thirty-four patients with Zenker diverticulum were identified; 11 were excluded because of previous surgery or other neurological conditions. Twelve (52.17%) of the remaining 23 Zenker diverticulum patients and 2 of the 73 (2.74%) control patients had greater pooling in the left versus right piriform sinus (2-tailed t test, P < .0001). The sensitivity of this physical examination finding in identifying patients with Zenker diverticulum was 52.17% (95% confidence interval, 31.08%-72.58%) and specificity was 97.26% (95% confidence interval, 89.56-99.52%). Patients with Zenker diverticulum less than 4 cm in size had increased pooling in the left versus right piriform compared with larger diverticulums. After surgical intervention, there was a statistically significant decrease in the asymmetrical pooling (2-tailed t test, P = .0067).

Conclusion. Increased pooling in the left compared with the right piriform, on in-office endoscopy, is predictive of the presence of a Zenker diverticulum. This information can sharpen clinical acumen in evaluating patients with dysphagia. In turn, it will help the clinician counsel the patient regarding diagnosis and radiographic imaging.

Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: report of a case

Primary cricopharyngeal dysfunction (PCD) is a rare idiopathic disorder of the upper esophageal sphincter (UES), characterized by oropharyngeal dysphagia, frequent aspiration, and narrowing at the level of the UES. Cricopharyngeal myotomy (CPM) has been used to treat oropharyngeal dysphagia of different causes including anatomic, neuromuscular, iatrogenic, inflammatory, neoplastic, and idiopathic; however, the indications for CPM and predictors of its outcome are not clearly defined. We report a case of PCD with hypertonic UES caused by a structural abnormality localized in the cricopharyngeus muscle, visualized as a cricopharyngeal bar, which we treated successfully by CPM, achieving long-term relief.

Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation

OBJECTIVES

Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation.

METHODS

HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus.

RESULTS

UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function.

CONCLUSIONS

Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.

[Suspension diverticulopexy for Zenker's diverticulum]

INTRODUCTION

Zenker's diverticulum is an unusual condition. Its treatment requires surgery but there is no consensus regarding the various operative techniques. Through an open cervical approach, the diverticulum can be either resected or suspended with or without a concurrent myotomy of the cricopharyngeus muscle. An innovative option is endoscopic trans-oral stapled esophago-diverticulostomy.

PATIENTS

and method: We retrospectively reviewed a consecutive series of 36 patients operated on between 1988 and 2006. Median age was 77.5 years and M/F sex ratio was 1.4. Through an open neck approach, diverticulectomy without cricopharyngeal myotomy was performed in 7 patients, diverticulectomy with myotomy in 11, and diverticulopexy with myotomy in 18.

RESULTS

Morbidity rate was 13.8%. One fistula and one recurrence occurred in both diverticulectomy groups with and without myotomy. There was no morbidity after suspension diverticulopexy which also allowed earlier oral feeding (1 vs. 6 days) and shortened hospitalization (6 vs. 13.5 days).

CONCLUSION

Diverticulopexy with cricopharyngeus myotomy is an effective, reliable, and reproducible technique for the correction of Zenker's diverticula smaller than 5 cm. Diverticulectomy should be reserved for larger diverticula. Technical improvements of transoral stapled diverticulostomy are still required before it can be promoted as an alternative therapy.

Monitoring of pharyngeal and upper esophageal sphincter activity with an arterial dilation balloon catheter

In patients with dysphagia and radiologic signs of dysfunction of the upper esophageal sphincter (UES), manometry is helpful in giving a better understanding of muscular activity during swallowing. Traditional manometric methods include use of perfusion catheters or solid-state intraluminal strain gauges. The rapid and asymmetric pressure variations in the UES and difficulties compensating for the pharyngolaryngeal elevation during swallowing limit the value of these methods. We used an arterial balloon dilation catheter as a probe in manometric recording of the UES in 28 healthy volunteers. Simultaneous perfusion manometry of the pharynx with the same catheter was performed to assess the coordination of the muscular activity in the esophageal entrance during swallowing. The catheter was well tolerated by all subjects. We found an average resting pressure in the UES of 31.0 mmHg, and the average maximum pressure during contraction was 89.0 mmHg. The average duration of the swallowing act was 3.9 s. All subjects displayed a complete UES relaxation and a normal coordination of propagated pressure in the hypopharynx and UES. The results were highly reproducible and the interindividual range was low. Arterial dilation catheters are safe and have suitable physical properties for pressure monitoring in the UES.

Long-term results of endosurgical and open surgical approach for Zenker diverticulum

AIM: To assess the effectiveness of minimally invasive versus traditional open surgical approach in the treatment of Zenker diverticulum.

METHODS: Between 1976 and 2006, 297 patients underwent transoral stapling (n = 181) or stapled diverticulectomy and cricopharyngeal myotomy (n = 116). Subjective and objective evaluations of the outcome of the two procedures were made at 1 and 6 mo after operation, and then every year. Long-term follow-up data were available for a subgroup of patients at a minimum of 5 and 10 years.

RESULTS: The operative time and hospital stay were markedly reduced in patients undergoing the endosurgical approach. Overall, 92% of patients undergoing the endosurgical approach and 94% of those undergoing the open approach were symptom-free or were significantly improved after a median follow-up of 27 and 48 mo, respectively. At a minimum follow-up of 5 and 10 years, most patients were asymptomatic after both procedures, except for those individuals undergoing an endosurgical procedure for a small diverticulum (< 3 cm).

CONCLUSION: Both operations relieve the outflow obstruction at the pharyngoesophageal junction, indicating that cricopharyngeal myotomy has an important therapeutic role in this disease independent of the resection of the pouch and of the surgical approach. Diverticula smaller than 3 cm represent a formal contraindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter.

Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction

OBJECTIVE

To evaluate the therapeutic effectiveness of botulinum toxin type A (BTX-A) in poststroke patients with cricopharyngeal muscle dysfunction.

DESIGN

Before-after trial.

SETTING

University hospital.

PARTICIPANTS

Eight poststroke patients.

INTERVENTION

BTX-A injection into the cricopharyngeal muscle under endoscope guidance for poststroke cricopharyngeal muscle dysfunction.

MAIN OUTCOME MEASURES

Clinical symptom score, disability rating scale for swallowing impairment, videofluoroscopic swallowing study, and upper esophageal sphincter (UES) manometry.

RESULTS

Clinical symptom score, disability rating scale for swallowing impairment, residue in piriform sinus, and UES pressure were all significantly improved at 2 weeks after BTX-A injection compared with evaluations before injection (P<.05). The effects on the clinical symptom score and disability rating scale for swallowing impairment continued to be significantly improved to 12 weeks after injection (P<.05). However, the residue in piriform sinus and the UES pressure at 12 weeks postinjection were reduced compared with before-injection evaluations; these results were not significant. The pharyngeal transit time was not changed after injection. There were no side effects observed in the patients studied.

CONCLUSIONS

The results of the present study suggest that BTX-A injection may be an effective and safe treatment in patients with poststroke cricopharyngeal muscle dysfunction.

Dysphagia in aging

Dysphagia is a common problem in older patients and is becoming a larger health care problem as the populations of the United States and other developed countries rapidly age. Changes in physiology with aging are seen in the upper esophageal sphincter and pharyngeal region in both symptomatic and asymptomatic older individuals. Age related changes in the esophageal body and lower esophageal sphincter are more difficult to identify, while esophageal sensation certainly is blunted with age. Stroke, Parkinson's disease, amyotrophic lateral sclerosis, Zenker's diverticula, and several other motility and structural disorders may cause oropharyngeal dysphagia in an older patient. Esophageal dysphagia can also be caused by both disorders of motility (achalasia, diffuse esophageal spasm, scleroderma and others) and structure (malignancy, strictures, rings, external compression, and others). Many of these disorders have an increased prevalence in older patients and should be sought with an appropriate diagnostic evaluation in older patients. The treatment of dysphagia in older patients is similar to that in younger patients, but more invasive therapies such as surgery may not be possible in some older patients making less aggressive medical and endoscopic therapy more attractive.

Evolution of surgical treatment for pharyngeal pouch

BACKGROUND

The development of endoscopic techniques, particularly endoscopic stapling, has led to a re-evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed.

METHODS

An electronic literature search was undertaken on the pathophysiology, history and surgery of pharyngeal pouch (Zenker's diverticulum). These last two terms were used to the search the Cochrane, Medline and Embase databases (from 1966 to date) and the bibliographies of extracted articles.

RESULTS AND CONCLUSION

With recognition of the central role of the cricopharyngeus muscle in the pathogenesis of pouch formation, the emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy. Minimally invasive techniques have become established since the advent of endoscopic stapling devices. Although randomized controlled data are lacking, the endoscopic approach appears to offer advantages in terms of a shorter duration of anaesthesia, more rapid resumption of oral intake, shorter hospital stay and quicker recovery. It is associated with excellent success rates and minimal morbidity.

Dysphagia: evaluation and treatment

The evaluation of dysphagia begins with a careful history, which usually points to the underlying cause in up to 80% of cases. The goals of the history are to distinguish oropharyngeal causes from esophageal causes of dysphagia and to distinguish mechanical from motor disorders of the esophagus in those patients with esophageal dysphagia. Evaluation typically begins with a videofluoroscopic examination in patients with oropharyngeal dysphagia and begins with a routine barium swallow or upper GI endoscopy in patients with esophageal dysphagia. Esophageal manometry may be an adjunct to the evaluation of patients with esophageal dysphagia, particularly to confirm specific motor disorders, such as achalasia. The management of functional causes of dysphagia is supportive and empiric given the lack of well-controlled treatment studies in this heterogenous group of patients.

Cricopharyngeal myotomy in the treatment of Zenker's diverticulum

BACKGROUND

Transection of the cricopharyngeus muscle supposedly is of crucial therapeutic importance, because of its hypothesized pathogenic role in Zenker's diverticulum (ZD). This retrospective, nonrandomized study evaluates the outcomes of surgical therapy, with reference to cricopharyngeal myotomy (CM).

STUDY DESIGN

Seventy-nine patients underwent diverticulectomy from 1985 to 1999. Group A (n = 47; men:women, 29:18; mean age +/- SD: 69 +/- 12 [range 35 to 87] years) underwent CM because of clearly discernible hypertrophic transverse fibers. In group B (n = 32; men:women, 22:10; mean age +/- SD 68 +/- 13 [range 36 to 95] years), without such transverse fibers, no CM was carried out. Dysphagia, regurgitation, and diverticular radiomorphology were classified according to ordinal scales. Diverticular volumes were calculated from barium swallows. Postoperative symptoms and outcomes were evaluated by questionnaires sent to the patients.

RESULTS

The two groups did not differ significantly in severity of preoperative dysphagia and regurgitation, radiomorphology, or median diverticular volume. Both groups experienced postoperative alleviation of symptoms (p < 0.001), persisting slightly in 11 of 47 (23%) group A and 4 of 32 (13%) group B patients (p > 0.05). Of these, seven group A (64%) patients and three group B patients (75%) had additional upper gastrointestinal tract (GIT) diseases. Recurrent diverticula occurred in one patient and postoperative complications in five patients per group (p > 0.05). Diverticular volume and upper GIT comorbidities, but not CM, were significant risk factors for persistent symptoms in the multivariate analysis.

CONCLUSIONS

CM has no significant influence on postoperative results, if carried out depending on the anatomic state and configuration of the cricopharyngeus muscle. This is suggested by the favorable outcomes of patients, with persistent symptoms being caused by factors other than CM.

Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction

OBJECTIVES

To investigate the efficacy of botulinum toxin A (BTA)-induced chemodenervation of the upper esophageal sphincter (UES) in patients with dysphagia and UES dysfunction.

STUDY DESIGN

Prospective clinical trial in 10 selected patients with pure UES dysfunction.

METHODS

In each patient 30 units of BTA were injected into the UES under brief general anesthesia. Videofluoroscopic swallowing study (VSS) was done and a clinical symptom score was determined before and after treatment.

RESULTS

On VSS relative opening of the UES improved in all patients (mean +/- SD: 47 +/- 14% before versus 71 +/- 24% after treatment; P < .01). Hypopharyngeal retention or laryngeal penetration of barium was significantly reduced in four of seven patients. Clinical symptom scores improved in all patients. One patient was free of symptoms, mild dysphagia persisted in six patients, and moderate dysphagia persisted in three patients.

CONCLUSIONS

Our results support the use of BTA in selected patients with pure UES dysfunction. Its efficacy is limited by the possibility of a persistent structural stenosis of the UES and the risk of BTA diffusion into the larynx or hypopharynx.

Cricopharyngeal myotomy does not increase the risk of esophagopharyngeal acid regurgitation

OBJECTIVE

It is not known whether cricopharyngeal myotomy predisposes to esophagopharyngeal regurgitation. Using ambulatory, dual pharyngeal, and esophageal pH monitoring before and after cricopharyngeal myotomy, our aim was to determine the effect, if any, of myotomy on the frequency of esophagopharyngeal acid regurgitation.

METHODS

We studied prospectively 18 patients who underwent cricopharyngeal myotomy for pharyngeal dysphagia (10 Zenker's, eight neurogenic dysphagia), of whom 17 agreed to undergo dual pH monitoring preoperatively, and 10 who agreed to both pre- and postoperative monitoring.

RESULTS

Symptoms of gastroesophageal reflux disease were present in 30%. Cricopharyngeal myotomy significantly reduced basal upper esophageal sphincter pressure by 49%, from 37+/-5 mm Hg to 19+/-3 mm Hg (p = 0.007). Esophagopharyngeal regurgitation was a rare event and the frequency of it did not differ between patients and healthy controls. Preoperatively, three regurgitation events in two patients did not differ from the postoperative frequency of a total of two events in the same two patients.

CONCLUSIONS

Increased esophageal acid exposure is common and esophagopharyngeal regurgitation is rare in unselected patients undergoing cricopharyngeal myotomy for pharyngeal dysphagia. Myotomy does not increase the frequency of esophagopharyngeal acid regurgitation in such patients.

The treatment of Zenker's diverticula: a review

A historical review reveals that the treatment of Zenker's diverticula has paralleled its presumed pathophysiology. With the development of technical facilities to better evaluate the pharyngoesophageal region, incomplete relaxation of the upper esophageal sphincter (UES) seems to represent the key element in the development of high pharyngeal pressures with a subsequent outpouching responsible for the diverticulum formation. Many studies have justified myotomy as an essential component in the treatment of pharyngoesophageal diverticula because it represents an efficient therapy with little morbidity. A diverticulopexy should be added for pouches between 1 and 4 cm and a diverticulectomy should be performed for sacs greater than 5 cm to expect the best relief of symptoms. Other treatment modalities have recently been used such as the endoscopic division of the common wall between the cervical esophagus and the diverticulum with either electrocautery (Dohlman's procedure), a laser, or a stapling device. This method is gaining popularity because it achieves a good clinical outcome, especially in high-risk patients. However, more studies are needed to confirm its long-term effectiveness.

Pharyngeal swallowing disorders: selection for and outcome after myotomy

OBJECTIVE

To develop selection criteria based on the mechanical properties of pharyngoesophageal swallowing that indicate when patients with pharyngeal dysphagia will benefit from a myotomy.

SUMMARY BACKGROUND DATA

The pathophysiology of pharyngoesophageal swallowing disorders is complex. The disorder is of interest to several medical specialists (gastroenterologists, otorhinolaryngologists, general and thoracic surgeons), which contributes to confusion about the entity. The management is compounded because it is most frequently seen in the elderly, is often associated with generalized neuromuscular disease, and occurs with a high prevalence of concomitant disease. The selection of patients for myotomy is difficult and of major importance to the quality of life of the affected patients.

METHOD

One hundred seven patients without a Zenker diverticulum but with pharyngeal dysphagia underwent a detailed manometric assessment of the upper esophageal sphincter (UES). Cricopharyngeal opening was identified by the presence of a subatmospheric pressure drop before bolus arrival. Impaired pharyngoesophageal segment compliance resulting in a resistance to pharyngoesophageal flow was determined by measuring the intrabolus pressure generated by a 5-ml liquid bolus.

RESULTS

Thirty-one of 107 patients underwent a myotomy (29%). Both impaired sphincter opening and increased intrabolus pressure predicted a good outcome.

CONCLUSION

Myotomy is beneficial in patients with pharyngeal swallowing disorders and manometric evidence of defective sphincter opening and increased intrabolus pressure.

Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia

BACKGROUND

Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months).

RESULTS

Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40).

CONCLUSIONS

Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.

Sleeve recording of upper esophageal sphincter resting pressures during cricopharyngeal myotomy

OBJECTIVE

The manometric effects of a 6-cm cricopharyngeal myotomy are recorded while the operation is being performed from cervical esophagus to the cricopharyngeus and then to the hypopharynx.

SUMMARY BACKGROUND DATA

Cricopharyngeal myotomy is used in the treatment of oropharyngeal dysphagia of different causes. The operation decreases the resting pressure in the upper esophageal sphincter (UES). The components responsible for this decrease have not been clarified.

METHODS

Fourteen patients with oropharyngeal dysphagia underwent a sleeve recording of the UES resting pressures under general anesthesia before and after sequential myotomy of the pharyngoesophageal junction. Patients were assessed in the awake state before and after the whole myotomy.

RESULTS

Upper esophageal pressures remain unchanged after division of 2 cm of the cervical esophageal muscle. Section of 2 cm of the cricopharyngeal area results in a significant decrease of the sphincter resting pressure (p < 0.01). The division of 2 cm of hypopharyngeal muscle results in a further significant reduction of the resting pressure (p < 0.005).

CONCLUSIONS

Extension of the cricopharyngeal myotomy over hypopharyngeal musculature produces a more significant decrease of UES resting pressure.

Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum

BACKGROUND/AIMS

To evaluate the role of upper oesophageal sphincter (UOS) compliance in dysphagia, the functional consequences of surgery were evaluated in eight patients with pharyngeal diverticula. The study examined the hypotheses that hypopharyngeal intrabolus pressure is an indicator of UOS compliance and that UOS opening and intrabolus pressure are normalised by surgery.

METHODS

In eight patients and nine healthy controls, we measured the timing of swallow events, UOS relaxation, maximal UOS dimensions, intrabolus pressure, and trans-sphincteric bolus flow rates by simultaneous videoradiography and pharyngeal manometry.

RESULTS

Bolus flow rates were not changed by surgery. Surgery significantly increased UOS opening (p = 0.0001) and reduced hypopharyngeal intrabolus pressure (p = 0.0001). The slope of the relation between sphincter area and intrabolus pressure was steeper in patients than controls and was normalised by surgery. Surgery had minor effects on basal UOS tone and timing of swallow events.

CONCLUSIONS

Upper oesophageal sphincter compliance is poor in Zenker's diverticulum and is normalised by surgery. Hypopharyngeal intrabolus pressure, which correlates with resistance to trans-sphincteric bolus flow, is a useful indicator of UOS compliance. Intrabolus pressure may be a predictor of outcome after myotomy in pharyngeal dysphagia. Cricopharyngeal myotomy is a mandatory component of surgery for Zenker's diverticulum.

Myology of the pharyngoesophageal segment: gross anatomic and histologic characteristics

Although numerous studies have been performed on the function and dysfunction of the pharyngoesophageal segment, few studies have investigated features of the musculature in this area. Thus, the purpose of this study was to systematically exam. ine the structure (gross anatomy and histology) in this area and to relate these findings to the functions of the pharyngoesophageal segment. Twenty-one autopsy and surgery patients underwent careful measurement and observation of 1. the vertical (cephalad-caudad) height of the cricopharyngeus muscle (CP); 2. the presence or absence of Kilfian's dehiscence; and 3. the separation or blending of the CP with the upper esophageal circular muscles. Of the 21 subjects, muscle specimens were removed from 8 (4 autopsy, 4 surgical) to include a muscle strip from the upper esophageal circular muscles, CP, and inferior pharyngeal constrictor and submitted to a battery of histological and histochemical tests. Gross anatomic measurements of the vertical height of the CP were substantially longer than those reported elsewhere. Killian's dehiscence was shown to be present in fewer than one third of the specimens. Histology of these muscles also showed significant differences from the muscles discussed in other published reports, particularly when fresh and autopsy material were compared. These specialized muscles, therefore, require further detailed study.

Analysis of intrabolus forces in patients with Zenker's diverticulum

This report presents 10 patients with Zenker's diverticulum who were evaluated with simultaneous solid-state manometry and fluoroscopy. With this method, intrabolus forces are determined. Each patient had abnormal intrabolus forces regardless of the size of the diverticulum and cricopharyngeal muscle dysfunction. In the literature, there has been conflicting manometry results when studying Zenker's diverticulum. The use of analysis of intrabolus forces increases the sensitivity of manometric evaluation. This study establishes pressure abnormality in the pharyngoesophageal segment of patients with Zenker's diverticulum. The pathogenesis of Zenker's is presented based on these findings.

Transmucosal cricopharyngeal myotomy with the potassium-titanyl-phosphate laser in the treatment of cricopharyngeal dysmotility

Cricopharyngeal dysfunction is a relatively uncommon disorder that is widely misunderstood. Cricopharyngeal dysmotility is thought to represent abnormal function of the upper esophageal or cricopharyngeal sphincter. The cause of this dysfunction is related to uncoordinated pharyngeal swallowing, achalasia, or a combination of these factors. Unfortunately, standard diagnostic tests have not consistently demonstrated a failure of the cricopharyngeal sphincter to malfunction; therefore, cricopharyngeal myotomy has been suggested as a diagnostic and therapeutic tool in the treatment of dysmotility. Our report focuses on the current trends in the diagnosis and treatment of cricopharyngeal dysfunction. We also present a case report of a transmucosal cricopharyngeal myotomy performed with the potassium-titanyl-phosphate (KTP) laser. The KTP laser was found to be relatively safe and effective and did not demonstrate significant morbidity. Our conclusion was that a transmucosal cricopharyngeal myotomy with the KTP laser may represent a viable alternative for patients with cricopharyngeal dysmotility.

Esophageal disease in the elderly patient

Disorders of the esophagus in elderly patients are usually associated with the classic symptoms of dysphagia, regurgitation, chest pain, and heartburn. Pulmonary complaints as a result of undiagnosed esophageal disease are common in this age group. Diagnosis is often delayed because symptoms are attributed to underlying cardiac and pulmonary disease. Elderly patients are more susceptible to the complications of aspiration and malnutrition that often accompany inadequately treated esophageal disease; therefore, prompt and aggressive treatment is indicated. Criteria for surgical intervention in esophageal disease do not change with age. Properly selected elderly patients tolerate esophageal surgery well. Age alone should not constitute a contraindication to surgery of the esophagus.

Muscle pathology in idiopathic cricopharyngeal dysphagia. Enzyme histochemical and electron microscopic findings

The structural changes in the cricopharyngeal muscle (CM) were examined ultrastructurally and by enzyme histochemistry in five patients suffering from idiopathic cricopharyngeal dysphagia (ICD). Diagnosis was established by fiberoptic esophagoscopy, esophageal manometry and cineradiography. Cricopharyngeal myotomy was performed with marked improvement in all patients. Intraoperatively, a biopsy was taken from the CM. Additionally, all patients underwent neurological examination for possible generalized muscle disease, and a biopsy was taken from a limb muscle. CM from nine cadavers without known history of dysphagia served as control. The control samples disclosed structural changes which were considered to be pathological in other skeletal muscles, and required that the criteria for CM pathology we modified accordingly. In three patients changes in CM histology suggested specific pathogenesis: one patient had evidence for a generalized myositis but was only symptomatic for dysphagia. Another patient had muscle fiber atrophy and slight inflammation in her CM, possibly due to alcohol abuse. The third patient had loss of CM fibers with replacement by connective tissue enough to cause functional disturbances. In two patients no cause for dysphagia was found in either immunohistochemistry or electron microscopic studies. These results demonstrate the special structural features of the CM and indicate that ICD can have multiple etiologies.

Diverticuloplasty for severe mucosal injury after cricopharyngeal myotomy

Cricopharyngeal myotomy with either diverticulopexy or diverticulectomy is the recommended therapy for Zenker's diverticulum. Mucosal injury during myotomy is rare and usually can be managed by direct mucosal closure. A technique is described to repair a serious mucosal defect that may occur during cricopharyngeal myotomy.

Effects of drugs and electrical field stimulation on isolated muscle strips from rabbit pharyngoesophageal segment

Muscle activity of isolated muscle strips from the middle pharyngeal constrictor, the inferior pharyngeal constrictor, the cricopharyngeal muscle, and the cervical esophagus of the rabbit was studied in organ baths in response to drugs and electrical field stimulation. These muscles of the pharyngoesophageal segment seem to lack an autonomic adrenergic and cholinergic innervation, as determined by responses to specific drugs. The nerve-evoked contractile responses of the two lower muscles of the segment were almost completely abolished by the curarelike drug gallamine, suggesting a somatic cholinergic nerve supply. However, in the two upper muscles, the major part of the response was resistant to gallamine, which suggests involvement of non-adrenergic, nonmuscarinic, nonnicotinic receptors in the transmission of nerve impulses in these muscles. These results suggest a differential innervation of the upper and lower pharyngeal muscles.

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Cricopharyngeal myotomy in the treatment of dysphagia

Cricopharyngeal myotomy was performed on 60 patients suffering from cervical oesophageal dysphagia. Of 37 that had a Zenker diverticulum the diverticulum was excised in 24. All patients were free of symptoms on post-operative follow-up at 2-10 years. In 10 patients with a cervical oesophageal web or postcricoid stenosis, the ability to eat normal food was restored. In 7 of 9 patients with neuromuscular diseases affecting swallowing and 2 of 4 patients with cricopharyngeal achalasia, food intake improved after myotomy. Apart from 4 transient palsies of the left recurrent nerve and 2 patients with aspiration pneumonia, no serious complications occurred. Cricopharyngeal myotomy can be a safe and effective method to improve the swallowing and quality of life of patients suffering from cervical oesophageal dysphagia of varied aetiology.

Surgical therapy of Zenker's diverticulum: low risk and high efficiency

Surgery for the treatment of Zenker's diverticulum was performed at our institution in a total of 43 patients over 6 1/2 years. Cervical myotomy with diverticulectomy was performed in 32 of the patients and myotomy alone in 11. Mortality totaled 0%, with a reversible lesion of the recurrent nerve occurring in 7%. In 60% of the cases investigated preoperatively (N = 40), motility disorders of the upper esophageal sphincter (UES) could be demonstrated using manometry as well as with cineradiography in 92% of the patients. Follow-up studies in 39 of the cases 25 months (mean) postprocedure indicated 82% of the patients to be symptom-free, with the remaining 18% demonstrating a marked improvement. Postoperative manometry as well as cineradiography carried out in 12 patients revealed the presence of UES motility dyscoordination in 8% and 25%, respectively. There were, however, no signs of recurrence of the diverticulum. The high number of patients in our study group demonstrating motility disorders of the UES emphasizes the need for cervical myotomy as part of the surgical therapy for Zenker's diverticulum.

Inclusion body myositis associated with progressive dysphagia: treatment with cricopharyngeal myotomy

A 68-year-old man known to have inclusion body myositis underwent a cricopharyngeal myotomy in an attempt to improve his progressive dysphagia. Morphological studies from tissues obtained during this procedure showed the diagnostic features typical of this chronic inflammatory myopathy. To our knowledge this is the first pathological demonstration of inclusion body myositis involving the pharyngeal skeletal musculature.

The hypopharyngeal diverticulum. A simultaneous cineradiographic and manometric examination

The upper esophageal sphincter (UES) was studied in 10 patients with symptomatic hypopharyngeal diverticulum during rest and at deglutition using simultaneous cineradiography and manometry by means of triple pressure microtransducers. In all 10, cineradiographic examinations were performed. Occurrence of double pressure peaks was examined in 8/10. In 7/10, the length and resting pressure of the UES could be determined. In 5/10, the UES pressure could be recorded when the bolus was in the pharynx and in 6/10 when it reached the UES. The pressure below the neck of the diverticulum at the time when the bolus reached the diverticular entrance, was of the same magnitude or exceeded the resting pressure of the UES in 4 patients and was approximately 0 kPa in 2 patients. In 3 patients the UES contraction was elicited as soon as the bolus entered the pharynx and remained so till it had passed the UES. In 3 patients the contrast bolus was seen to pass simultaneously into the diverticulum and into the esophagus, even though the sphincter was contracted. It is plausible that the pharyngeal wall gives way when a bolus is forced against the contracted UES by the high peristaltic pressure forming a pulsion diverticulum as postulated already by Zenker in 1878. Double pressure peaks were registered in the UES at rest in 6 patients indicating a split between the muscle bundles in the sphincter.

Effect of cricopharyngeal myotomy on pharyngoesophageal function: pre- and postoperative cineradiographic findings

The pre- and postoperative cineradiographic findings in 14 dysphagic patients who underwent cricopharyngeal myotomy were compared. The reason for the operation was Zenker's diverticulum (7 patients), lack of cricopharyngeal coordination (5 patients), or a cervical esophageal web (2 patients). After the operation the function of the epiglottis, laryngeal vestibule, and pharyngeal constrictors was unaltered (11 patients) or improved (3 patients), although 4 cases showed residual impression due to the cricopharyngeal muscle. Postoperatively, 9 patients developed defective peristalsis and 10 had impaired tonicity of the cervical esophagus. It is concluded that myotomy alters the motor function of the pharyngoesophageal segment considerably. Moreover, certain functions of the pharynx proper are changed by this procedure.

Dimension of the pharyngo-esophageal segment in dysfunction of the cricopharyngeal muscle

Defective relaxation of the cricopharyngeal muscle (cricopharyngeal dysfunction) is radiographically demonstrated as a posterior impression into the pharyngo-esophageal segment of the gullet in patients with dysphagia. It has been assumed that this impression implies a mechanical obstacle to the swallowed bolus. Therefore, the width of the pharyngo-esophageal segment was measured in three groups of individuals; 139 non-dysphagic volunteers, 25 dysphagic patients with a normal relaxation of the cricopharyngeus and 25 dysphagic patients with cricopharyngeal dysfunction. Compared with the other two groups of patients studied the patients with cricopharyngeal dysfunction were found to have a slightly wider gullet above and below the cricopharyngeal muscle. However, at the level of the cricopharyngeal muscle they had an equal sized or slightly narrower lumen than the patients in the two control groups. The results obtained suggest that the posterior impression due to cricopharyngeal dysfunction does not cause a substantial mechanical obstacle to swallowing in the majority of patients.

Pharyngeal diverticula

A series of 73 hypopharyngeal (Zenker's) diverticula is reported and the choice of treatment and technique of excision are discussed. The problems of excision include operation on an infected site with limited access but few patients are unfit for the procedure. Preoperatively the sac should be packed and the oesophagus stented. The side of approach is unimportant as the condition is essentially midline. Cricopharyngeal myotomy appears to reduce the recurrence rate, possibly by improving coordination of pharyngeal contraction and upper oesophageal relaxation. The use of electrocoagulation is not recommended as 20% of patients require repeated general anaesthesia and the procedure fails in 13%. For all but the smallest pouches, excision is the treatment of choice.

The width of the pharyngo-esophageal junction area

In order to elucidate the pharyngo-esophageal segment in normal and abnormal conditions the width of the pharyngo-esophageal junction area on three different levels: hypopharynx, infracricoid segment of the cervical esophagus (ICCO) and cervical esophagus was measured in 150 non-dysphagial volunteers and in 252 dysphagial patients examined with cineradiography during barium swallowing. The result indicates that a narrow ICCO in absolute figures reflects the size of the swallowed bolus and is not a predictor of pharyngeal abnormality, per se. However, when the width of the ICCO in a.p. projection is less than 3/4 of the width in lateral projection this can indicate a narrow ICCO and should lead to endoscopy for further evaluation.

The upper esophageal sphincter during normal deglutition. A simultaneous cineradiographic and manometric investigation

The upper esophageal sphincter was studied during deglutition in 7 healthy subjects using simultaneous cineradiography and manometry. The pressure measuring device consisted of 3 sensors distally placed, and separated by 10 mm. They recorded pressure obliquely to the right at an angle of 15 to 45 degrees anteriorly. During the swallowing sequence a pressure sensor initially placed in the high pressure zone of the sphincter easily slid out of position due to asynchronous movements of the sphincter and the pressure measuring device. These movements can result in erroneous interpretation of pressure recordings. Continuous radiologic monitoring during the entire swallowing sequence thus seems to be mandatory. Immediately before the bolus entered the upper esophageal sphincter, the sphincter relaxed and low or even negative pressures were registered. When the bolus had passed onwards the sphincter contracted gradually, to resume its pre-swallow pressure.