Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction

Cricopharyngeus muscle dysfunction: a poorly defined disorder from diagnosis to treatment

PURPOSE

Cricopharyngeus muscle dysfunction (CPMD) is a common clinical occurrence with very few clear diagnostic criteria and multiple pathways for treatment. Incidence of CPMD is not known, but some data suggest around 25% of people with dysphagia experience some degree of CPMD, which negatively impacts swallowing safety and efficiency. Workup and treatment of CPMD can require multidisciplinary collaboration across laryngologists, speech-language pathologists with training in dysphagia management, and gastroenterologists. The purpose of this paper is to review what is known about CPMD and identify areas of future research in CPMD diagnosis and treatment.

METHODS

An overview of CPMD, relative treatments and disorders, and a discussion of future areas of research needed to improve clinical care of CPMD.

RESULTS

Details regarding historical background, pathophysiology and treatment practiced for CPMD are included.

CONCLUSION

In summary, CPMD is a poorly defined disease due to a lack of understanding of its pathophysiology and the lack of consensus diagnostic criteria. Well-designed, prospective clinical trials are necessary to develop a better understanding of clinical incidence of CPMD, impact of the disorder on oropharyngeal swallowing, and how to approach treatment of the disorder surgically or in conjunction with therapy directed by a specialized speech-language pathologist.

Association of the "Jet Phenomenon" with Positive Symptom Outcome Following Surgical Treatment of Cricopharyngeus Muscle Dysfunction

OBJECTIVES

Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. Controversy exists whether CPMD is best managed with primary surgical treatment of the cricopharyngeus muscle and who represents a good surgical candidate.

METHODS

Retrospective review of patients diagnosed with CPMD who underwent surgical treatment were evaluated through prospectively collected pre- and postoperative Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Videofluoroscopic swallowing studies (VFSS) were reviewed for presence or absence of a high-pressure barium stream through the upper esophageal sphincter, termed the jet phenomenon (JP).

RESULTS

We identified 42 patients with CPMD who underwent surgical treatment and had serial Eating Assessment Tool (EAT-10) measures obtained pre- and postoperatively. Mean EAT-10 scores improved by 12.1 points (95%CI = 8.6-15.6), p < 0.0001. There was a significantly greater improvement among patients with JP (|∆EAT-10|= 17.0, 95%CI = 12.5-21.4) compared to those without (|∆EAT-10|= 6.2, 95%CI = 1.6-10.8), p = 0.0013. Patients with JP also showed improved FOIS score (p = 0.0023) while those without JP did not.

CONCLUSION

This study provides the initial report on the utility of JP as a VFSS feature that is strongly associated with improved outcomes following surgical treatment of CPMD. Further work determining the physiologic correlates responsible for JP will help clarify its predictive capabilities.

LEVEL OF EVIDENCE

Level 3.

[Minimally invasive surgery for motility disorders of the oesophagus]

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

Natural History of Cricopharyngeus Muscle Dysfunction Symptomatology

Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. There is a continuum between small, non-obstructive cricopharyngeus bars representing mild disease and severely obstructive bars or Zenker's diverticulum forming late-stage disease, but the natural history of untreated CPMD and the associated time course for progression is unknown. Retrospective longitudinal cohort study from a tertiary outpatient dysphagia centre. Patients diagnosed with CPMD by fluoroscopy and either awaiting surgical treatment or electing non-operative management were evaluated through prospectively collected Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Review of available imaging identified degree of CPMD. We identified 174 patients with CPMD diagnosed between July 1, 2016, and June 30, 2020; 52 patients had serial Eating Assessment Tool (EAT-10) measures obtained at time of diagnosis and follow up appointment without operative treatment. Mean EAT-10 scores increased from 17.1 to 20.6 (3.5 ± 8.1 points, p = 0.002) points. This change was related to those with a Zenker's diverticulum rather than an isolated cricopharyngeus bar. Dietary outcomes measured by FOIS were stable. While some patients showed fluoroscopic progression of bar size, no patients developed a Zenker's diverticulum from a pre-existing bar in this population. Our data indicate patients with a cricopharyngeus bar do not decline in subjective dysphagia score or diet tolerance, however those with a Zenker's diverticulum worsen over time. This has implications for treatment timing and counselling patients but also reflects a need to understand the pathophysiology behind CPMD and the subset of patients who show progression.

Correlating Dysphagia Severity with Fluoroscopic Parameters in Patients with Zenker's Diverticulum

Zenker's diverticulum (ZD) is an uncommon condition characterized by formation of a pseudodiverticulum in the hypopharynx that presents with considerable variability in swallowing symptomatology. Identifying radiographic features of ZD most associated with clinical impact could prove useful in counseling patients and predicting treatment response. This study was a retrospective case series of patients undergoing videofluoroscopic swallowing studies (VFSS) for Zenker's diverticulum at a tertiary dysphagia center. Anatomic parameters identified on VFSS of patients with ZD were correlated with subjective perception of swallowing using Eating Assessment Tool (EAT-10) scores. Upper esophageal sphincter (UES) opening at the point of maximal distention, area of diverticulum on the lateral view, height of the diverticulum, and entrance angle of the esophagus were measured. We identified 40 patients with ZD (52.5% male, mean age = 71.2 years). Narrow UES opening was significantly correlated with dysphagia severity (r = - 0.3445, p = 0.035). Largest area of diverticulum (r = 0.0188, p = 0.87), diverticulum height (r = 0.1435, p = 0.45), and esophageal entrance angle (r = 0.1677, p = 0.42) were not correlated with EAT-10 scores. Maximum UES opening size was predictive of severity of swallowing dysfunction in patients with ZD. Size of ZD and the angle of bolus entry in patients with ZD are not predictive of swallowing dysfunction. Understanding the predictors of swallowing dysfunction will assist in counseling patients on postoperative expectations.

Physics of chewing in terrestrial mammals

Previous studies on chewing frequency across animal species have focused on finding a single universal scaling law. Controversy between the different models has been aroused without elucidating the variations in chewing frequency. In the present study we show that vigorous chewing is limited by the maximum force of muscle, so that the upper chewing frequency scales as the -1/3 power of body mass for large animals and as a constant frequency for small animals. On the other hand, gentle chewing to mix food uniformly without excess of saliva describes the lower limit of chewing frequency, scaling approximately as the -1/6 power of body mass. These physical constraints frame the -1/4 power law classically inferred from allometry of animal metabolic rates. All of our experimental data stay within these physical boundaries over six orders of magnitude of body mass regardless of food types.

Comparative Neuromuscular Histopathology of Cricopharyngeal Achalasia Patients with and without Previous Botulinum Toxin Treatment

Objectives:

Botulinum toxin injection (BTX) and cricopharyngeal (CP) myotomy are performed in the treatment of CP achalasia (CA). The objective of this study was to examine the effects of BTX on neuromuscular histopathologic findings and to make direct comparisons between specimens of muscle from CA patients who had received BTX to the upper esophageal sphincter and from CA patients who had no previous exposure to BTX.

Methods:

We performed a retrospective review (2001 to 2005) of CP muscle specimens from all patients who underwent myotomy for CA. Cases of Zenker's diverticulum were excluded. Patient demographics, clinical course, and neuromuscular pathology findings were noted from the chart.

Results:

Nineteen patients with CA were identified: 10 male and 9 female, with a mean age of 57 years. Eleven had no prior BTX (6 male and 5 female; mean age, 62 years); 8 had previous treatment with BTX (4 male and 4 female; mean age, 51 years). Eight of the 11 BTX-naive patients revealed predominantly myopathic changes on histology. Those with previous BTX tended to be younger; 6 of the 8 had a clinical benefit from their BTX and ultimately went on to myotomy. The CP muscle specimens featured both mixed and neurogenic pathologic changes in 5 of the 8 patients with BTX. Although these findings suggest some impact of BTX on the CP muscle, the difference between the groups was not statistically significant (p < 20, x2 test).

Conclusions:

Treatment with BTX may have some clinical and histopathologic impact on the upper esophageal sphincter of patients with CA. Although neuropathic changes were noted in the CP muscle of previously injected patients at the time of their CP myotomy, the neuromuscular pathologic findings overall were not significantly different from those of BTX-naive patients.

Assessment of the Results of Surgical Treatment of Zenker'S Diverticulum in Own Material

Zenker diverticulum (ZD) is the most common type of diverticula of the esophagus. Most often refers to men with a peak incidence in the seventh and eighth decade of life. In the majority diverticula remains asymptomatic and in patients with symptomatic course of the disease symptoms are often nonspecific. Aim of the study was to present the authors' own experience in surgical treatment of Zenker diverticulum.

MATERIAL AND METHODS

In this paper we present an analysis of 31 patients with confirmed ZD treated surgically at the Clinic in 2004-2014. Patients were analyzed in terms of age, gender, clinical symptoms, diverticulum size, type of surgery, the time to return to the oral intake, hospital stay and perioperative complications.

RESULTS

22 men and 9 women were enrolled it this study. The mean age of the patients was 64.8 (SD, 10.7; in the range of 28 to 82 years). 29 patients (93.5%) underwent resection of the diverticulum, while diverticulopexy was performed in two patients. In 25 (80.6%) cases stapler device was used, while in 4 (12.9%) resection was performed manually. The average size of resected diverticulum was 4.9 cm (SD, 1.5). Following the surgery in four patients (12.9%) complications were present. The average operating time was 118.7 minutes (SD, 42.2, in the range of 50 to 240 minutes). The mean length of hospital stay was 9.3 (SD, 3.3).

CONCLUSIONS

Surgical treatment of ZD is associated with high effectiveness and low recurrence rate. Despite the advantages of endoscopic techniques, surgical treatment is characterized by one- stage procedure. The use of mechanical suture (stapler) significantly improves the operation, although on the basis of our own analysis there was no superiority revealed over hand sewn. Unquestionable adventage of classical technique is the opportunity to histopathological evaluation of resected diverticulum what is impossible to achieve in endoscopic techniques.

Speech pathologist practice patterns for evaluation and management of suspected cricopharyngeal dysfunction

Speech pathologists are often the first professionals to identify signs of a cricopharyngeal (CP) dysfunction and make recommendations for further care. There are many care options for patients with CP dysfunction, but it is unclear how certain interventions are used in practice. A paper-based survey employing two clinical cases involving suspected CP dysfunction (Case 1 with adequate pharyngeal strength and Case 2 with coexisting pharyngeal weakness) was sent to members of American Speech-Language Hearing Association's Special Interest Group 13. Respondents ranked the order of management approaches (swallowing therapy, further evaluation, and referral to another medical professional) and selected specific interventions under each approach that they would recommend for each case. Completed surveys from 206 respondents were entered into analysis. The majority of the respondents recommended swallowing therapy as a first approach for each case (Case 1: 64 %; Case 2: 88 %). The most prevalent swallowing exercises recommended were the Shaker (73 %), effortful swallow (62 %), and Mendelsohn maneuver (53 %) for Case 1 and effortful swallow (92 %), Shaker (84 %), and tongue-hold swallow (73 %) for Case 2. 76 % of respondents recommended a referral for Case 1, while 38 % recommended the same for Case 2. Respondents with access to more types of evaluative tools were more likely to recommend further evaluation, and those with access to only videofluoroscopy were less likely to recommend further evaluation. However, the high degree of variability in recommendations reflects the need for best practice guidelines for patients with signs of CP dysfunction.

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.

Cervical esophageal perforation and cricopharyngeal dysfunction

Spontaneous perforation of the esophagus is an uncommon event; when it does occur, it usually affects the thoracic esophagus. We present a rare and fatal case of spontaneous perforation of the cervical esophagus in a 68-year-old woman. We believe this rupture was related to a proximal outlet obstruction secondary to cricopharyngeal muscle dysfunction.

Effect of cricopharyngeus muscle surgery on the pharynx

OBJECTIVES/HYPOTHESIS

Cricopharyngeus muscle dysfunction (CPD) ranges from asymptomatic cricopharyngeal bar (CPB) to Zenker's diverticulum. Previous work suggests that CPD can result in dilation and weakening of the pharynx above the obstruction. The purpose of this investigation was to evaluate the ability of surgery on the cricopharyngeus muscle to improve pharyngeal area and strength.

STUDY DESIGN

Retrospective case study.

METHODS

Videofluoroscopic swallowing studies of all persons with CPD who underwent cricopharyngeus (CP) intervention followed by routine postoperative fluoroscopic study, between October 1, 1999 and January 1, 2010 were reviewed. Objective measures of pharyngeal area and constriction were obtained from pretreatment and post-treatment studies. Paired t tests and repeated measures analysis of variance were employed to compare results.

RESULTS

Fifty-four patients were included. Pharyngeal constriction and pharyngoesophageal segment (PES) opening improved significantly after intervention (P < .05).Pharyngeal dilation was unchanged (P > .05). PES opening improved more with CP myotomy than with dilation and botulinum toxin.

CONCLUSIONS

Relief of CP obstruction by surgery or dilation improves pharyngeal constriction and PES opening. Dilation of the pharynx possibly related to prolonged outlet obstruction does not improve. CP myotomy appears more effective than dilation or botulinum toxin in relieving obstruction.

Comparison between swallowing-related and limb muscle involvement in dermatomyositis patients

OBJECTIVE

To determine the relationship between the movement of the hyolaryngeal complex and the motor power of limb muscles and the differences in the hyolaryngeal movement according to the creatine kinase (CK) levels in dermatomyositis patients.

METHOD

We retrospectively selected 13 patients who had undergone a videofluoroscopic swallowing study (VFSS) for swallowing difficulty from patients diagnosed with dermatomyositis. The maximal anterior and superior displacements of the hyoid and larynx and the cricopharyngeal opening were acquired by frame-by-frame analysis using the VFSS. We investigated the motor power of the bilateral shoulder abductor, elbow flexor, hip flexor, and knee extensor muscles to determine the limb muscle involvement and used the American Speech-Language-Hearing Association (ASHA) National Outcomes Measurement System (NOMS) swallowing level (ASHA level) to assess dysphagia severity. Spearman's correlation test was used to identify the relationship between the kinematic data of the laryngeal structures, ASHA levels, and the total motor scores in dermatomyositis patients.

RESULTS

There was no significant correlation between the kinematic data of the laryngeal structures, ASHA levels, and total motor scores. Only the anterior movements of the hyoid and larynx had a significant relationship to the upper oesophageal sphincter opening.

CONCLUSION

Dysphagia evaluation should be considered separately in dermatomyositis patients irrespective of limb involvement or dysphagia severity because the swallowing-related muscle involvement had no relationship to the limb muscle involvement or the severity of dysphagia in dermatomyositis. It is hoped that our results can be used to evaluate the therapeutic effects of dysphagia management in dermatomyositis patients.

Pharyngeal dilation in cricopharyngeus muscle dysfunction and Zenker diverticulum

OBJECTIVES/HYPOTHESIS

Prolonged obstruction at the level of the lower esophageal sphincter is associated with a dilated, poorly contractile esophagus. The association between prolonged obstruction at the level of the upper esophageal sphincter (UES) and dilation and diminished contractility of the pharynx is uncertain. The purpose of this investigation was to evaluate the association between prolonged obstruction at the level of the UES and dilation and diminished contractility of the pharynx.

STUDY DESIGN

Case-control study.

METHODS

The fluoroscopic swallow studies of all persons with cricopharyngeus muscle dysfunction (CPD) diagnosed between January 1, 2006 and December 31, 2008 were retrospectively reviewed from a clinical database. Three categories of CPD were defined: nonobstructing cricopharyngeal bars (CPBs), obstructing CPBs, and Zenker diverticulum (ZD). The primary outcome measure was the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength on fluoroscopy. Secondary outcome measures included pharyngeal area in the lateral fluoroscopic view and UES opening. The outcome measures were compared between groups and to a cohort of nondysphagic age- and gender-matched controls with the analysis of variance.

RESULTS

A total of 100 fluoroscopic swallow studies were evaluated. The mean age (+ or -standard deviation) of the cohort was 70 years (+ or -10 years). Thirty-six percent were female. The mean PCR progressively increased, indicating diminishing pharyngeal strength, from the normal (0.08), to the nonobstructing CPB (0.13), to the obstructing CPB (0.22), to the ZD group (0.28) (P < .001 with trend for linearity). There was a linear increase in pharyngeal area from the normal (8.75 cm(2)) to the nonobstructing CPB (10.00 cm(2)), to the obstructing CPB (10.46 cm(2)), to the ZD group (11.82 cm(2)) (P < .01 with trend for linearity).

CONCLUSIONS

The data suggest that there is an association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of the pharynx. Laryngoscope, 2010.

Manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy for cricopharyngeal bar

OBJECTIVE

To investigate the manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy (ELCPM) for cricopharyngeal (CP) bar.

STUDY DESIGN

Case series with chart review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Review of patients undergoing ELCPM between 2001 and 2007 was undertaken to determine the demographic, clinical, and manofluorographic findings before and six months after surgery. Two groups were established according to pharyngeal driving pressures: normal pressure group (> 55 mm Hg) and low pressure group (< 55 mm Hg).

RESULTS

Fourteen patients underwent ELCPM for CP bar without a concomitant head and neck or Zenker's procedure. There were no major surgical complications. All 14 patients improved at least one stage on the Functional Outcome Swallowing Scale (FOSS) after surgery. There was a statistically significant decrease in the FOSS stages after surgery. Videofluoroscopy demonstrated a significant postoperative increase in the mean cross-sectional CP opening (CP-area) from 32.75 to 123.52 mm(2). Manofluorographic pressure recordings showed a significant postoperative decrease in the intrabolus pressure gradient across the cricopharyngeal region (IB-Gra) from 25.44 to 13.22 mm Hg. Despite significant overall results, the change in the IB-Gra showed no difference between the patient groups.

CONCLUSION

Subjective (FOSS) and objective manofluorographic (CP-area, IB-Gra) improvement in CP bar patients occurred after ELCPM. We suggest IB-Gra as a reliable objective indicator for patients who might benefit from ELCPM and as an appropriate parameter for follow-up after surgery. However, continued research on a larger patient population is required to enhance our understanding of CP bar and predictors of outcome after treatment of CP bar dysphagia.

Surgical treatment of dysphagia

The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.