Cricopharyngeal myotomy: management of cervical dysphagia

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches

OBJECTIVE

Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates.

METHODS

A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded.

RESULTS

Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05).

CONCLUSION

Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2426-E2431, 2021.

Swallowing dysfunction following surgery for well-differentiated thyroid cancer with extrathyroid invasion

BACKGROUND

Differentiated thyroid carcinoma (DTC) can invade the surrounding aerodigestive tract. Radical surgery for locally advanced DTC will require resection of the trachea, recurrent laryngeal nerve (RLN), inferior pharyngeal constrictor muscles (IPCMs), or a part of the esophagus. The purpose of this study was to demonstrate the effect of resection of these surrounding tissues combined with total thyroidectomy and neck dissection on swallowing function following surgery.

METHODS

We performed total thyroidectomy combined with neck dissection and resection of the RLN in 24 patients with DTC with extrathyroidal invasion (19 unilateral, 1 bilateral), IPCMs (n = 5), or muscle layers of esophagus (n = 9). Nine patients received a tracheostomy placement due to a window resection of the trachea for tumor invasion (n = 6) and necessary upper airway management (n = 3). We used the duration of nasogastric tube feeding to evaluate swallowing function following surgery.

RESULTS

Patients who underwent tracheostomy or IPCM resection showed significantly longer periods of tube feeding (p = 0.0057 and 0.0017, respectively). In contrast, resection of the unilateral RLN or esophageal muscle layer showed no difference in tube feeding duration. Multiple regression analysis indicated that tracheostomy and IPCM resection were significant independent predictors of longer periods of tube feeding (p = 0.04583 and 0.00087, respectively).

CONCLUSION

These results indicate that tracheostomy placement and resection of the IPCMs, together with total thyroidectomy, extends the tube feeding duration in the postoperative period.

Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction

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.

Anatomic Study of Laser-Assisted Endoscopic Cricopharyngeus Myotomy

Objectives:

Laser-assisted endoscopic cricopharyngeus muscle (CPM) myotomy has been used to correct dysphagia caused by CPM dysfunction. The aim of this study was to anatomically characterize this procedure in hopes of demonstrating its safety and efficacy.

Methods:

A Dohlman endoscope was used to isolate the CPM in 5 lightly preserved, thawed cadavers. A carbon dioxide laser at 10 W continuous power was used to section through the CPM in conjunction with a micromanipulator connected to an operating microscope. The specimens were then carefully dissected and photographed to demonstrate the anatomy of the pharyngoesophageal segment, including the location of the incision and the condition of the tissue planes. The CPM was harvested for histologic studies, sectioned, and prepared with modified Gomori trichrome stain.

Results:

Gross examination of the retropharyngeal region revealed the presence of intact buccopharyngeal fascia between the lasered region and the retropharyngeal space. Histologic analysis demonstrated sectioning of the CPM with preservation of this fascia layer. Placement of the endoscope was difficult in 1 cadaver, in which we were unable to properly identify the CPM.

Conclusions:

The carbon dioxide laser-assisted endoscopic CPM myotomy is a potentially anatomically safe and viable procedure when properly performed. However, the potential for violation of the retropharyngeal space is real.

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.

Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy with primary mucosal closure

OBJECTIVES

Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy (ECPM) has emerged as a viable therapy for dysphagia. The risks of the procedure include pharyngoesophageal perforation and mediastinitis, which may discourage adoption of this technique. To address these complications, we examined outcomes of ECPM with primary mucosal closure.

METHODS

A case series of 7 patients who underwent ECPM between 2006 and 2008 were reviewed for length of operation, length of hospitalization, postoperative complications, and outcomes by use of the M. D. Anderson Dysphagia Index (MDADI) and the Functional Outcome Swallowing Scale (FOSS). The results were compared to those of a control group of 7 patients treated during the same period via open cricopharyngeal myotomy.

RESULTS

All patients who had ECPM were treated successfully without complications. The operative times averaged 128 minutes. The hospitalization averaged 2.1 days. Statistically significant improvements in swallowing were seen (MDADI score from 51.3 to 77.7, p < 0.0006; FOSS score from 3.7 to 1.3, p < 0.0005), and were similar to those in the patients who had the open procedure (FOSS score from 3.0 to 1.0, p <0.006). Trends toward decreased blood loss, a shorter hospital stay, and a lower complication rate were observed in the patients who had ECPM.

CONCLUSIONS

ECPM is beneficial as a primary treatment for cricopharyngeal dysfunction. Closure of the mucosal defect may help reduce the incidence of postoperative cervical emphysema and mediastinitis, and does not appear to compromise functional outcome.

Endoscopic CO2 laser cricopharyngeal myotomy

OBJECTIVES

Over the past 10 years, endoscopic cricopharyngeal myotomy laser surgery has been proposed as an alternative to transcervical cricopharyngeal myotomy. We will describe the technique and review the literature so that it may gain credence as a viable option for the treatment of cricopharyngeal achalasia.

METHODS

A literature review of endoscopic and transcervical cricopharyngeal myotomy will be performed. The technical aspects of endoscopic cricopharyngeal myotomy will be presented and accompanied by intraoperative photographs, illustrations, and an online video demonstration.

RESULTS

Endoscopic cricopharyngeal myotomy is a well-tolerated procedure with low morbidity and good outcomes. It can be performed by surgeons who are comfortable with transoral laryngopharyngeal laser surgery.

CONCLUSIONS

Endoscopic cricopharyngeal myotomy is a viable alternative to classic transcervical cricopharyngeal myotomy with equivalent outcomes and comparable if not less morbidity.

Long-lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: a pilot study

OBJECTIVE

To evaluate the efficacy of botulinum toxin (BTX-A) injection in the cricopharyngeus muscle in patients with neurological dysphagia caused by alteration in the upper esophageal sphincter (UES) opening and with preserved pharyngeal contraction.

MATERIAL AND METHODS

A prospective pilot study was undertaken in 10 patients (7 brain lesions and 3 cervical spinal cord injuries), with a minimum time-lapse of 6 months from neurological lesion to BTX-A injection. Dysfunction of the UES opening and the presence of pharyngeal contraction were diagnosed by videofluoroscopy (VDF) and esophageal manometry (EM). The BTX-A (100 U) injection was guided by endoscopy. Clinical, VDF, and EM follow-ups were carried out at 3 weeks, 3 and 6 months, and at 1 year post-injection.

RESULTS

Prior to treatment, 6 patients were fed by nasogastric tube. VDF showed impairment of the UES opening, residue in pyriform sinuses, and aspiration in all cases. During follow-up, there was a decrease in the number of patients that had aspiration: 3 patients at one year. During swallowing, EM showed a mean UES relaxation of 90% (range: 74.5-100%), residual pressure 3.2 mmHg (range: 0-13 mmHg) and pharyngeal amplitude 52 mmHg (range: 25-80 mmHg). At follow-up, a significant improvement in UES relaxation (98% (89-100%)) and pharyngeal contraction (97 mmHg (35-165 mmHg)) was observed. At 3 months, 6 patients were eating exclusively by mouth.

CONCLUSIONS

One single injection of BTX-A in the UES has long-lasting effectiveness in patients with neurological dysphagia caused by alteration in the UES opening and with pharyngeal contraction. Nevertheless, a randomized control trial should be done to confirm these results and rule out the effect of potential spontaneous improvement of neurological injury.

[Efficacy of rehabilitation in oropharyngeal dysphagia]

BACKGROUND

efficacy of rehabilitation in oropharyngeal dysphagia. In our country the practice of speech-language pathology in oropharyngeal dysphagia has increased significantly and, at this moment, deserves attention since practice needs to be based on scientific evidence. Therapeutic techniques and the outcome of rehabilitation in oropharyngeal dysphagia have been studied since the 70s, reaching its high point during the 80s and 90s. Few studies have investigated the efficacy of therapy in the rehabilitation of oropharyngeal dysphagia, the vast majority have tried to prove the effects of therapy on the dynamics of swallowing. In Brazil, the studies about oropharyngeal dysphagia have, in great part, investigated assessment procedures, and only a few have worried about rehabilitation.

AIM

to present a critical analysis about the efficacy of rehabilitation in oropharyngeal dysphagia.

CONCLUSION

this review of the literature indicates that non-randomized studies have compromised the results, once the casuistic of the researches are very heterogeneous--they include neurogenic and mechanical oropharyngeal dyshagia caused by different etiologies. Besides that, therapeutic programs which are used are not sufficiently described, compromising the reproduction of the methodology by other researchers. These results suggest the need for more randomized studies, which can be initially developed as case studies in order to exclude the control variables of therapy efficacy. Another suggestion is, as proposed by present researches, to use scales that can measure the impact of swallowing training in the nutritional and pulmonary condition of dysphagic patients. An important research area, related to the control of therapeutic efficacy and efficiency, are the studies that aim to establish the decrease in hospital and home care costs as a consequence of speech-language intervention with patients with oropharyngeal dyspahgia.

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.

The upper oesophageal sphincter

The upper oesophageal sphincter (UOS) is a high-pressure zone comprising functional activity of three adjacent muscles together with cartilage and connective tissue. Its primary function is to allow food into the oesophagus and prevent air ingestion. However, it must also allow the reflux of material during belching or vomiting. Cricopharyngeus is the most important muscle with contributions from inferior pharyngeal constrictor and cervical oesophagus. Basal tone within the UOS is contributed to by all three muscles with asymmetry in the axial plane. Relaxation of the UOS occurs during swallowing as well as in sleep while UOS pressure rises with stress, slow oesophageal distension, intra-oesophageal acid infusion and pharyngeal stimulation with air or water. Many physiological characteristics have been attributed to UOS function following videofluoroscopic swallow examinations, manometry and electromyography but a range of normal values remains controversial and their utility uncertain. The result has been that pathological change is inconsistently characterized and management is instigated without a satisfactory evidence base. In this article, we review the anatomy, physiology and pathophysiology of the UOS along with the current opinions on investigation and treatment of UOS dysfunction.

Cricopharyngeal spasm and Zenker's diverticulum

Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment.

Endoscopic botulinum toxin injection for cricopharyngeal dysphagia

Twelve patients underwent 17 endoscopic injections of botulinum toxin type A in the cricopharyngeus muscle for the treatment of dysphagia and cricopharyngeal spasm over a 3-year period. The patient's charts were reviewed. Preoperative and postoperative symptoms, examination, and swallowing studies were reviewed. Eleven of the 12 patients had improvement in their symptoms, which lasted for a mean of 3.8 months. Two patients elected cricopharyngeal myotomy for permanent correction of their dysphagia. There was 1 case of postoperative neck cellulitis in an immunocompromised patient undergoing simultaneous excision of a thyroglossal duct cyst. We conclude that endoscopic injection of botulinum toxin is a relatively safe and viable technique for the treatment of dysphagia associated with cricopharyngeal spasm. It requires simple tools readily available to otolaryngologists. Larger, prospective controlled studies are necessary to establish its effectiveness and role in the management of this condition.

Videomanofluorometric study in amyotrophic lateral sclerosis

OBJECTIVE

To elucidate the time-course changes of swallowing function in amyotrophic lateral sclerosis (ALS) by videomanofluorometry.

STUDY DESIGN

Videomanofluorometry was conducted on 21 patients with ALS, who were divided into five groups according to type of disease and according to the length of time following the appearance of bulbar symptoms.

METHODS

Videomanofluorometry, which is videofluoroscopic and manometric study conducted simultaneously, was performed on patients in the five groups, and swallowing function in each group was evaluated. Some of the patients were followed up by videomanofluorometry performed several times, and their swallowing function changes over time were investigated.

RESULTS

A decrease of swallowing pressure first appeared in the oropharynx, then the hypopharynx became involved. Oropharyngeal swallowing pressure had already decreased to approximately 50 mm Hg within 6 months after the appearance of bulbar symptoms; however, hypopharyngeal swallowing pressure was relatively maintained until 1 year after the onset of bulbar symptoms. Most of the patients with ALS maintained normal upper esophageal sphincter relaxation, but upper esophageal sphincter spasm was seen in some patients with ALS. Aspiration was seen in eight cases, five of which showed upper esophageal sphincter spasm.

CONCLUSIONS

Patients with ALS gradually face the danger of aspiration as decreases of oropharyngeal and hypopharyngeal swallowing pressure progress. Upper esophageal sphincter spasm occurs in some patients with ALS, and it is an important cause of aspiration. Both videofluoroscopic and manometric evaluation are necessary to assess these conditions, and they are quite useful for follow-up of swallowing function in patients with ALS.

Primary cricopharyngeal dysfunction: treatment with balloon catheter dilatation

BACKGROUND

Primary cricopharyngeal dysfunction (PCD) is a rare, idiopathic, functional disorder of the upper esophageal sphincter, characterized by dysphagia, frequent aspiration, and functional narrowing at the level of the upper esophageal sphincter.

METHODS

Five of 29 patients with oropharyngeal dysphagia were found to have PCD. Patients presented with severe dysphagia and predisposition to aspiration. Radiography demonstrated narrowing at the level of the upper esophageal sphincter and aspiration. An endoscope could be introduced into the esophagus in only 2 patients before dilation.

OBSERVATIONS

In contrast to organic stenoses, these functional upper esophageal sphincter stenoses were dilated without difficulty with a balloon catheter. After low-pressure (1.5-2 atm) progressive balloon dilation (to 20 mm), superficial mucosal injury was observed only in one patient. After dilatation, symptoms resolved and barium swallow demonstrated normal passage through the upper esophageal sphincter. During a mean follow-up of 21 months (7-33), redilation was necessary in only 1 case.

CONCLUSIONS

Balloon catheter dilatation of PCD is minimally invasive and provides both important diagnostic information and effective therapy. It should be the first choice of therapy for PCD.

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.

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.

Dysphagia in patients with inclusion body myositis

OBJECTIVES

Inclusion body myositis (IBM) is an inflammatory myopathy with a 40% reported incidence of dysphagia. A protracted course, refractory to medical therapy, frequently leads to consultation with an otolaryngologist for dysphagia management. We studied the incidence, symptoms, and mechanisms of dysphagia in patients with IBM.

STUDY DESIGN

Retrospective study of medical records and self-reported follow-up survey; dysphagia is defined as difficulty in swallowing.

MATERIALS

Twenty-two patients with biopsy-proven IBM.

RESULTS

The rate of dysphagia was more than 80% (16 of 19), twice as high as previously reported. Progressive dysphagia was associated with a significantly worse functional class. Relevant management guidelines are established, including the timing for appropriate surgical intervention.

CONCLUSION

Progressive dysphagia may signify more aggressive IBM or an episodic worsening in status. Recognition of the disease manifestations will afford proper patient management. Informed otolaryngologists can have a favorable impact on the dysphagia associated with IBM.

Surgical therapy for swallowing disorders

In a physiologic act as complex as swallowing, there are myriad causes of dysfunction that can disorder feeding and respiration with grave consequences. The appropriate diagnostic evaluation of dysphagia and aspiration along with a review of a range of surgical strategies to correct swallowing and aspiration disorders are presented in this article.

The risk and complications of aspiration following cricopharyngeal myotomy

This article reviews a series of patients undergoing cricopharyngeal myotomy and determines whether clinically dangerous aspiration is seen postoperatively. A total of 23 patients underwent myotomy. Indications included Zenker's diverticulum (14), anticipated or real dysphagia from skull base lesions (5), dysphagia from stroke (2), and dysphagia from glossectomy and radiation therapy (2). Surgical procedures, complications, and effectiveness were reviewed. Of patients with Zenker's diverticula, 13 of 14 had clinically useful improvement in dysphagia. Of patients with skull base lesions, all 5 had improvement (4 of these also had thyroplasites and cervical plexus-to-superior laryngeal nerve anastomoses). Of the patients with strokes, neither had significant improvement. Of the patients with glossectomy and radiation, 1 had useful improvement. Complications were seen in 5 patients: 2 had self-limiting pharyngeal leaks, and 3 had pneumonia 1-4 months postoperatively. One patient also had a postoperative ipsilateral recurrent laryngeal nerve injury. There were no postoperative deaths. In conclusion, cricopharyngeal myotomy has definite utility in the management of cervical dysphagia, even though the etiology of the dysphagia can be multifactorial. Risks directly attributable to the procedure are usually self-limiting; serious complications are usually associated with the underlying disease. The addition of adjunctive procedures, such as thyroplasty and superior laryngeal nerve reinnervation, may be of additional benefit to patients with high extracranial vagal injuries.

A pilot study on upper esophageal sphincter dilatation for the treatment of dysphagia in patients with oculopharyngeal muscular dystrophy

Upper esophageal sphincter (UES) dilatation was done for the treatment of moderate to severe dysphagia with a Maloney bougie in 14 patients with oculopharyngeal muscular dystrophy (OPMD) or with an achalasia dilator in three patients. The severity of dysphagia prior to UES dilatation was evaluated by a 15-point dysphagia score, a pharyngeal and esophageal manometry and a radionuclide pharyngoesophageal transit study. Using actuarial life table, the improvement rate after dilatation with Maloney bougie was 64.3% (95% CI 39.2-89.4) at 3- and 6-month follow-ups, and was 55.7% (95% CI 28.9-82.5) at 12- and 18-month follow-ups. At 3-month post-dilatation, we observed a significant reduction of the mean dysphagia score from 9.6 to 7.2 (P = 0.05). No significant manometric or radionuclide factors were found to predict effective dilatation. The results of this pilot study showed that UES dilatation with Maloney bougie or achalasia dilator may be an effective treatment of moderate dysphagia in patients with OPMD. However, further studies with larger sample sizes are needed to corroborate these results and to assess long-term outcome.

Use of Botulinum Toxin for Diagnosis and Management of Cricopharyngeal Achalasia

Cricopharyngeal achalasia produces dysphagia in many patients. The spasm has been treated in the past with medication, bouginage, pharyngeal plexus neurectomy, and cricopharyngeal myotomy. In some patients the cause of dysphagia may be elusive, or the patient may be a poor risk for a surgical intervention. We have found that cricopharyngeal muscle injections of botulinum toxin can be useful in the diagnosis and therapy of cricopharyngeal spasm.

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.

Endoscopic CO2 laser cricopharyngeal myotomy

Cricopharyngeal dysfunction due to various causes can lead to severe upper pharyngeal dysphagia with or without laryngeal penetration. Resurgence of Dohlman's endoscopic diverticulotomy for Zenker's diverticulum has been brought about by the development of the diverticuloscope, improved intravenous analgesia, and the advent of the laser. Recent use of videofluoroscopy for swallowing documents a frame-by-frame picture of swallowing with special focus on the cricopharyngeal function and its stages of malfunction. The "cricopharyngeal crescent" (cricopharyngeal bar) as termed by Jackson is visible during endoscopy and can be incised in layers under the operating microscope with the CO2 or contact Nd:YAG laser. This paper introduces the staging of cricopharyngeal dysfunction regarding its initiation and progression in correlation with its symptoms and videofluoroscopic pictures. It also reports the application of endoscopic laser cricopharyngeal myotomy for 44 patients with cricopharyngeal dysfunction besides 4 with Zenker's diverticulum. This procedure is found to be effective, safe, brief, and prompt in restoring swallowing.

Analysis of the Pharyngoesophageal Pressure Profile in Amyotrophic Lateral Sclerosis

Treatment of dysphagia resulting from bulbar amyotrophic lateral sclerosis has included cricopharyngeal myotomy for many years but is successful in only a minority of cases. The purpose of this study was to explore the rationale for this procedure with modern manometric techniques. The results of pharyngoesophageal manometry in 13 patients with amyotrophic lateral sclerosis were compared with 13 age- and sex-matched healthy volunteers by Mann-Whitney analysis. There was no significant difference between patients and control subjects in distal esophageal or lower esophageal sphincter motility nor any pressure parameter of pharyngoesophageal motility. Separate analysis of the seven significantly dysphagic subjects showed a significantly reduced upper esophageal sphincter after-contraction amplitude during water and bread swallows in patients than in control subjects. These data suggest that the dysphagia of amyotrophic lateral sclerosis is not due to upper esophageal sphincter spasm and that treatment by cricopharyngeal myotomy may be inappropriate.

Cricopharyngeal myotomy may be effective treatment for selected patients with neurogenic oropharyngeal dysphagia

The role of cricopharyngeal (CP) myotomy in the management of neurogenic oropharyngeal dysphagia remains controversial. A review of the literature regarding outcomes of CP myotomy for dysphagia in the setting of a variety of neurological disorders indicates a preponderance of favorable results. There are several potential explanations for reported improvement after CP myotomy for neurogenic dysphagia, including the possibility that it is an effective treatment, at least for selected patients. If this is true, appropriate selection criteria for this treatment of neurogenic dysphagia may include (1) intact voluntary initiation of swallowing, (2) adequate propulsive force generated by the tongue and pharyngeal constrictors, (3) videofluorographic demonstration of obstruction to bolus flow at the CP segment (rather than merely retention in the pharyngeal recesses), (4) manometric evidence of relatively elevated CP pressure in relation to the pharynx, and (5) relatively favorable neurological prognosis. The effectiveness and safety of CP myotomy for patients with neurogenic dysphagia are unlikely to be resolved without a prospective, controlled multicenter study enrolling patients who meet such criteria.

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.

The surgical management of motility disorders

Surgical treatment is either the therapy of choice or a facultative procedure in various types of esophageal motility disorders. In achalasia, cardiomyotomy, frequently combined with fundoplasty, achieves good or excellent results in > 80% of cases, and is, therefore, advised in cases when pneumostatic dilatation fails. Diverticulectomy and myotomy of the upper or lower esophageal sphincter are proven procedures to treat cervical and epiphrenic diverticula, leading to good/excellent results or at least an improvement in more than 95%. If, exceptionally, parabronchial diverticula require therapy, they should be excised transthoracically. Cervical myotomy is indicated in cases of cervical achalasia, when sufficient pharyngeal propulsion is preserved. In systemic diseases like scleroderma reflux induced complications may require surgical intervention in medically intractable cases. In these rather few cases, subtotal gastrectomy with a Roux-en-Y anastomosis is advised. In patients suffering from diffuse esophageal spasm or symptomatic "nutcracker" esophagus, extended esophageal myotomy can relieve symptoms. If a clear diagnosis is provided, about 75% of patients will have an improvement of symptoms.

Cricopharyngeal myotomy: indications and technique

Available diagnostic tests evaluating cricopharyngeal dysmotility are expensive, uncomfortable, and unreliable for predicting the results of cricopharyngeal myotomy. Cricopharyngeal myotomy should be performed as a diagnostic test when a patient has "block" dysphagia (in which the food bolus stops rather than the swallow's being painful) localized to the cricoid level, and when no cancer is seen on esophagram. An effective surgical technique relies on the muscular distention provided by the inflated balloon cuff of a large endotracheal tube, and requires cutting the muscle fibers of the upper esophagus, the cricopharyngeus, and the hypopharynx in the posterior midline from a point 1 cm below the cricoid cartilage to the level of the thyrohyoid membrane. The cricopharyngeal limits are indistinct until the muscle fibers have been cut. Bougies, esophagoscopes, and cuffless endotracheal tubes insufficiently distend these muscle fibers. A "peanut" sponge in a Kelly clamp is used to identify and separate the last muscle fibers from the mucosa so they can be divided. These techniques minimize the risks of esophageal perforation and incomplete muscular transection. Our experience performing 54 cricopharyngeal myotomies is reported.

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.

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.

Electromyography of the inferior constrictor and cricopharyngeal muscles during swallowing

Electromyography (EMG) of the inferior pharyngeal constrictor (IC) and the cricopharyngeal (CP) muscle was recorded in 18 patients with swallowing and/or aspiration problems who were candidates for cricopharyngeal myotomy. The EMG recordings were compared to those of 13 "normal" subjects who did not suffer from such problems. Differences in EMG activity between the control group and the patient group were considered with respect to the clinical symptoms in the patient group. Recording of EMG in the CP and IC muscles is relatively safe, useful, and easily mastered. The technique may provide important information regarding the function of some of the muscles involved in deglutition.