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Pittala K, Reinhart N, Sujka JA, Velanovich V, DuCoin CG. Novel Per-Oral Cricopharyngotomy for Cricopharyngeal Bar: Feasibility Study With Emphasis on Technical Limitations. Cureus 2023; 15:e36663. [PMID: 37102013 PMCID: PMC10124148 DOI: 10.7759/cureus.36663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2023] [Indexed: 04/28/2023] Open
Abstract
Per-oral endoscopic cricopharyngotomy (c-POEM) is a treatment for cricopharyngeal dysfunction, specifically cricopharyngeal bars (CPB). C-POEM differs from other endoscopic surgical procedures, such as per-oral endoscopic myotomy (POEM), gastric per-oral endoscopic myotomy (g-POEM), and Zenker per-oral endoscopic myotomy (z-POEM). We report three patients who underwent c-POEM for CPB, their clinical course, and outcomes. We underwent a single institution retrospective chart review of three patients who underwent c-POEM and their immediate postoperative course. These three patients represent all patients who underwent c-POEM. The operating surgeons were experienced endoscopists who regularly performed endoscopic myotomy. The three patients were female, over 50 years old, and presented with dysphagia secondary to the CPB. All three patients had perioperative complications consistent with esophageal leaks requiring prolonged hospital courses and recovery. All three patients had improved but persistent dysphagia up to nine months following the procedure. The results of this small case series exemplify the high rate of complications, specifically postoperative esophageal leak, when performing c-POEM for CPB. Thus, we stress caution and recommend against performing c-POEM for CPB.
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Affiliation(s)
- Karthik Pittala
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Nolan Reinhart
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Joseph A Sujka
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Vic Velanovich
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christopher G DuCoin
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
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Al Saleh HA, Malikowski T, Patel DA, Ali IA, Mahmood S. Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions. Dig Dis Sci 2022; 67:5416-5424. [PMID: 35397698 DOI: 10.1007/s10620-022-07451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/15/2022] [Indexed: 01/05/2023]
Abstract
Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.
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Affiliation(s)
- Hassan Ali Al Saleh
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA. .,Department of Medicine, University at Buffalo, Buffalo, NY, USA.
| | - Thomas Malikowski
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Dhyanesh Arvind Patel
- Center for Esophageal Disorders, Division of Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ijlal Akbar Ali
- Digestive Diseases and Nutrition Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sultan Mahmood
- Division of Gastroenterology, Department of Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Medicine, University at Buffalo, Buffalo, NY, USA
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Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker's diverticulum. Surg Endosc 2020; 35:3896-3904. [PMID: 32748264 DOI: 10.1007/s00464-020-07861-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/28/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.
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Patel RV, Hirano I. Endoscopic diagnosis and treatment of disorders of upper esophageal sphincter function. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sami SS, Haboubi HN, Ang Y, Boger P, Bhandari P, de Caestecker J, Griffiths H, Haidry R, Laasch HU, Patel P, Paterson S, Ragunath K, Watson P, Siersema PD, Attwood SE. UK guidelines on oesophageal dilatation in clinical practice. Gut 2018; 67:1000-1023. [PMID: 29478034 PMCID: PMC5969363 DOI: 10.1136/gutjnl-2017-315414] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 01/10/2023]
Abstract
These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.
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Affiliation(s)
- Sarmed S Sami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea Medical School, Swansea University, Swansea, UK
| | - Yeng Ang
- Department of GI Sciences, University of Manchester, Manchester, UK,Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip Boger
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John de Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester, Leicester, UK
| | - Helen Griffiths
- Department of Gastroenterology, Wye Valley NHS Trust, Wye Valley, UK
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, UK
| | - Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Praful Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Stuart Paterson
- Department of Gastroenterology, NHS Forth Valley, Stirling, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Queens Medical Centre, Belfast, UK
| | - Peter Watson
- Faculty of Medicine Health and Life Sciences, Queen’s University Belfast, Belfast, UK
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Randall DR, Evangelista LM, Kuhn MA, Belafsky PC. Improved symptomatic, functional, and fluoroscopic outcomes following serial "series of three" double-balloon dilation for cricopharyngeus muscle dysfunction. J Otolaryngol Head Neck Surg 2018; 47:35. [PMID: 29764478 PMCID: PMC5952613 DOI: 10.1186/s40463-018-0278-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/29/2018] [Indexed: 11/22/2022] Open
Abstract
Background Cricopharyngeus muscle dysfunction (CPMD) is a common cause of dysphagia. We employ a progressive series of three double-balloon dilations separated by 4–6 weeks between procedures as a primary treatment option. The purpose of this study was to evaluate subjective, functional and objective improvement in swallowing after three serial dilations for CPMD. Methods We retrospectively evaluated patients between June 1, 2014, and June 30, 2016, who underwent a series of three double-balloon dilations for CPMD. Pre- and post-dilation Eating Assessment Tool-10 (EAT-10), Functional Oral Intake Scale (FOIS), pharyngeal constriction ratio, pharyngeal area, and pharyngoesophageal segment (PES) opening were compared. Results Seventeen patients with CPMD underwent serial double-balloon dilation procedures separated by one month. Mean age of the cohort was 73.5 (SD ± 13.3) years, and 53% were female. The mean EAT-10 improved from 24.7 (SD ± 7.8) to 15.9 (SD ± 10.2) [p = 0.0021]. Mean FOIS improved from 5.4 (SD ± 1.4) pre- to 6.3 (SD ± 0.9) post-treatment (p = 0.017). Mean UES opening increased from 1.05 (SD ± 0.34) cm to 1.48 (SD ± 0.41) cm (p = 0.0003) in the anteroposterior fluoroscopic view and from 0.58 (SD ± 0.18) to 0.76 (SD ± 0.30) cm (p = 0.018) in the lateral view. Pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength, improved from 0.49 (SD ± 0.37) to 0.24 (SD ± 0.15) (p = 0.015), however pharyngeal area (PA) was unchanged. Conclusions A progressive series of three double-balloon dilations for cricopharyngeus muscle dysfunction resulted in improved patient reported dysphagia symptom scores and objective fluoroscopic swallowing parameters.
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Affiliation(s)
- Derrick R Randall
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA. .,Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, T2W 3K2, Canada.
| | - Lisa M Evangelista
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Maggie A Kuhn
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology - Head & Neck Surgery, University of California Davis, Sacramento, CA, USA
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Johnson CM, Venkatesan NN, Siddiqui MT, Cates DJ, Kuhn MA, Postma GM, Belafsky PC. Outcomes of laryngohyoid suspension techniques in an ovine model of profound oropharyngeal dysphagia. Laryngoscope 2017; 127:E422-E427. [PMID: 28699193 DOI: 10.1002/lary.26754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/30/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the efficacy of various techniques of laryngohyoid suspension in the elimination of aspiration utilizing a cadaveric ovine model of profound oropharyngeal dysphagia. STUDY DESIGN Animal study. METHODS The head and neck of a Dorper cross ewe was placed in the lateral fluoroscopic view. Five conditions were tested: baseline, thyroid cartilage to hyoid approximation (THA), thyroid cartilage to hyoid to mandible (laryngohyoid) suspension (LHS), LHS with cricopharyngeus muscle myotomy (LHS-CPM), and cricopharyngeus muscle myotomy (CPM) alone. Five 20-mL trials of barium sulfate were delivered into the oropharynx under fluoroscopy for each condition. Outcome measures included the penetration aspiration scale (PAS) and the National Institutes of Health (NIH) Swallow Safety Scale (NIH-SSS). RESULTS Median baseline PAS and NIH-SSS scores were 8 and 6, respectively, indicating severe impairment. THA scores were not improved from baseline. LHS alone reduced the PAS to 1 (P = .025) and NIH-SSS to 2 (P = .025) from baseline. LHS-CPM reduced the PAS to 1 (P = .025) and NIH-SSS to 0 (P = .025) from baseline. CPM alone did not improve scores. LHS-CPM displayed improved NIH-SSS over LHS alone (P = .003). CONCLUSIONS This cadaveric model represents end-stage profound oropharyngeal dysphagia such as what could result from severe neurological insult. CPM alone failed to improve fluoroscopic outcomes in this model. Thyrohyoid approximation also failed to improve outcomes. LHS significantly improved both PAS and NIH-SSS. The addition of CPM to LHS resulted in improvement over suspension alone. LEVEL OF EVIDENCE NA. Laryngoscope, 127:E422-E427, 2017.
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Affiliation(s)
- Christopher M Johnson
- Department of Otolaryngology, Medical College of Georgia, Augusta University, Augusta, Georgia, U.S.A.,Department of Otolaryngology, Naval Medical Center, San Diego, California, U.S.A
| | - Naren N Venkatesan
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - M Tausif Siddiqui
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Daniel J Cates
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Maggie A Kuhn
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
| | - Gregory M Postma
- Department of Otolaryngology, Medical College of Georgia, Augusta University, Augusta, Georgia, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology, University of California, Davis, Sacramento, California, U.S.A
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Chandrasekhara V, Koh J, Lattimer L, Dunbar KB, Ravich WJ, Clarke JO. Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction. World J Gastrointest Endosc 2017; 9:183-188. [PMID: 28465785 PMCID: PMC5394725 DOI: 10.4253/wjge.v9.i4.183] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/05/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement.
METHODS All balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES).
RESULTS Four hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission.
CONCLUSION UES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.
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Marston AP, Maldonado FJ, Ravi K, Kasperbauer JL, Ekbom DC. Treatment of oropharyngeal dysphagia secondary to idiopathic cricopharyngeal bar: Surgical cricopharyngeal muscle myotomy versus dilation. Am J Otolaryngol 2016; 37:507-512. [PMID: 27522437 DOI: 10.1016/j.amjoto.2016.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/15/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar. METHODS All patients had an idiopathic CP bar without a history of Zenker's diverticulum, head and neck cancer, or systemic neurologic disease treated between 2000 and 2013. The Functional Outcome Swallowing Scale (FOSS) was utilized to assess dysphagia symptoms. RESULTS Twenty-three patients underwent 46 dilations and 20 patients had a myotomy. Nineteen of 23 (83%) patients in the dilation group and all patients in the myotomy group reported improved swallow function. The median difference in pre- versus post-intervention FOSS scores was not statistically significant (p=0.07) between the dilation and myotomy groups with mean reductions of 1.3 and 1.8, respectively. Seventeen of 23 (74%) dilation patients had persistent or recurrent dysphagia with 13 (57%) requiring repeat dilation and 4 (17%) undergoing CP myotomy. The median time to first reintervention in the dilation group was 13.6months. Nineteen of 20 (95%) surgical myotomy patients did not experience recurrent dysphagia. CONCLUSION Both endoscopic CP dilation and myotomy led to similar initial improvement in swallow function for patients with primary idiopathic CP bar; however, dilation is more likely to provide temporary benefit.
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Management of isolated cricopharyngeal dysfunction: systematic review. The Journal of Laryngology & Otology 2016; 130:611-5. [PMID: 27194375 DOI: 10.1017/s0022215116007994] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE A systematic review was performed to evaluate the safety and efficacy of different therapeutic interventions available for the management of isolated cricopharyngeal dysfunction. METHODS Studies were identified using the following databases: Ovid (Medline, Embase), the Cochrane Library, PubMed and Google Scholar. An initial search identified 339 articles. All titles and abstracts were reviewed. Fifty-six relevant articles were inspected in more detail; of these, 47 were included in the qualitative analysis. RESULTS No relevant randomised trials were found. A range of case series were used to perform a qualitative analysis. Botulinum toxin A injection and cricopharyngeal dilatation were associated with a higher risk of recurrence, but appear to be more suitable in elderly and co-morbid patients. In those patients requiring formal myotomy, endoscopic approaches appear to be as effective but less morbid when compared with classical open surgery. CONCLUSION There is good evidence for the safety and efficacy of the different therapeutic options for isolated cricopharyngeal dysfunction. However, further studies are required to compare the efficacy of the various treatment modalities.
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