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Iwanaga K, Fujishima I, Omori K. Combined laryngeal framework surgery and cricopharyngeal muscle-origin transection: a novel effective surgery for dysphagia with pharyngolaryngeal palsy and cricopharyngeal dysfunction under local anesthesia. Eur Arch Otorhinolaryngol 2023; 280:5655-5660. [PMID: 37707618 DOI: 10.1007/s00405-023-08225-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Cricopharyngeal myotomy and laryngeal framework surgery can improve swallowing function in patients with severe dysphagia. We developed a novel surgical technique for severe dysphagia associated with pharyngolaryngeal paralysis and cricopharyngeal dysfunction, performed under local anesthesia, and investigated its effectiveness. METHODS We included nine patients who underwent cricopharyngeal muscle-origin transection with laryngeal framework surgery through a horizontal skin incision under local anesthesia. CONCLUSIONS All patients demonstrated significant improvement in the Food Intake LEVEL Scale without complications. Thus, this surgical technique may serve as a useful and less invasive treatment option for patients with severe dysphagia.
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Affiliation(s)
- Ken Iwanaga
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Ichiro Fujishima
- Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Shizuoka, Japan
| | - Koichi Omori
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Ito H, Nagao A, Maeda S, Nakahira M, Hyodo M. Clinical Significance of Surgical Intervention to Restore Swallowing Function for Sustained Severe Dysphagia. J Clin Med 2023; 12:5555. [PMID: 37685624 PMCID: PMC10488804 DOI: 10.3390/jcm12175555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Owing to rapid population aging, patients with dysphagia are significantly increasing in society. Dysphagia treatment is aimed at the restoration of the swallowing function and the prevention of recurrent aspiration-induced pulmonary infection. However, despite intensive rehabilitation, oral food intake remains inadequate in many patients with severe dysphagia, which results in the deterioration of patients' quality of life and joy of living. Surgical intervention may serve as a useful therapeutic strategy to restore swallowing function in these patients. The study included 25 patients (mean, 70.4 years; male/female ratio, 20:5) with chronic dysphagia. Dysphagia was associated with cerebrovascular diseases in sixteen patients; with age-induced physiological deterioration in five patients; and with miscellaneous etiologies in four cases. Cricopharyngeal and infrahyoid myotomies were performed in all patients. Laryngeal elevation and the medialization of the paralyzed vocal fold were performed in 15 and 3 patients, respectively. The Food Intake Level Scale (FILS) and videoendoscopic examination score (VEES) were used to evaluate swallowing function. The FILS showed a restoration of oral food intake alone in 72% of patients, and 64% of patients maintained this improvement at their last follow-up visit. We observed significantly improved VEES scores postoperatively. However, patients with cognitive impairment or advanced age showed poor outcomes. In conclusion, surgical intervention may be an effective therapeutic option to restore swallowing function in cases of sustained severe dysphagia; however, surgical indications require careful consideration.
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Affiliation(s)
- Hiroaki Ito
- Department of Otolaryngology, Kochi Medical School, Kohasu, Okou-cho, Nankoku 783-8505, Japan; (H.I.); (A.N.); (S.M.)
| | - Asuka Nagao
- Department of Otolaryngology, Kochi Medical School, Kohasu, Okou-cho, Nankoku 783-8505, Japan; (H.I.); (A.N.); (S.M.)
| | - Suguru Maeda
- Department of Otolaryngology, Kochi Medical School, Kohasu, Okou-cho, Nankoku 783-8505, Japan; (H.I.); (A.N.); (S.M.)
| | - Maya Nakahira
- Department of Rehabilitation, Kochi Medical School Hospital, Kohasu, Okou-cho, Nankoku 783-8505, Japan;
| | - Masamitsu Hyodo
- Department of Otolaryngology, Kochi Medical School, Kohasu, Okou-cho, Nankoku 783-8505, Japan; (H.I.); (A.N.); (S.M.)
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Kanazawa H, Fujishima I, Ohno T, Kunieda K, Shigematsu T, Yamawaki M. Cricopharyngeal muscle origin transection for oropharyngeal dysphagia, a novel surgical technique. Eur Arch Otorhinolaryngol 2023; 280:483-486. [PMID: 35960351 DOI: 10.1007/s00405-022-07588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/03/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cricopharyngeal myotomy improves pharyngeal dysphagia by resecting the cricopharyngeal muscle. METHODS Our procedure, cricopharyngeal muscle origin transection (CPM-OT) is performed through a midline skin incision at the cricoid cartilage level under local anesthesia. CONCLUSIONS Sixteen patients demonstrated preservation of vocal fold movement without laryngeal nerve injury immediately after CPM-OT in the awake state during aspiration prevention surgery using the glottic closure technique. Postoperative videofluoroscopic examination of swallowing revealed the cricopharyngeal bar was absent and pharyngeal passage of the bolus and Food Intake LEVEL Scale was improved in all patients. CPM-OT is a feasible and less invasive treatment option.
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Affiliation(s)
- Hideaki Kanazawa
- Department of General Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Swallowish Clinic, Tokyo, Japan
| | - Ichiro Fujishima
- Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, 1-6-1 Wagokita, Naka-ku, Hamamatsu, Shizuoka, 433-8511, Japan.
| | - Tomohisa Ohno
- Department of Dentistry, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Japan
| | - Kenjiro Kunieda
- Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, 1-6-1 Wagokita, Naka-ku, Hamamatsu, Shizuoka, 433-8511, Japan
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takashi Shigematsu
- Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, 1-6-1 Wagokita, Naka-ku, Hamamatsu, Shizuoka, 433-8511, Japan
| | - Masanaga Yamawaki
- Department of Medical Education Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
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Piccillo EM, Adkins D, Elrakhawy M, Carr MM. Cricopharyngeal Myotomy in National Surgical Quality Improvement Program (NSQIP): Complications for Otolaryngologists Versus Non-otolaryngologists. Cureus 2021; 13:e19021. [PMID: 34853748 PMCID: PMC8608034 DOI: 10.7759/cureus.19021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Comparing outcomes after cricopharyngeal myotomy (CM) performed by otolaryngologists (OTO) and non-otolaryngologists (NO). Methods: A retrospective analysis of the 2014-19 ACS-NSQIP database (American College of Surgeons National Surgical Quality Improvement Program) of patients who underwent open CM (CPT code 43030) as their primary procedure. Analyzed variables include medical comorbidities, operative time, the total length of stay, readmission, reoperation, concurrent procedures, postoperative complications, and postoperative diagnoses. 183 patients were included, 97 (53%) females and 86 (47%) males. 120 had surgery by OTO and 63 by NO. Results: There were no differences in preoperative morbidity. OTO had more outpatient surgeries compared to NO (p<.001). OTO had a longer mean operating time (p=.008). OTO had a higher proportion of concurrent laryngeal procedures and other unspecified procedures compared to NO, while NO had a higher proportion of concurrent esophageal procedures (p=.028). The total length of stay was not significantly different between the two groups. 5.8% OTO and 7.9% NO patients were readmitted for a related reason (p=.586). Complications were similar between the two groups (p>.05). NO had more postop diagnoses of acquired diverticula and achalasia of the stomach cardia, while OTO had more diagnoses of dysphagia and muscular dystrophy (p<.001). Conclusion: There were differences in the surgical setting, length of procedure, concurrent procedures, and postop diagnoses between NO and OTO surgeons but similar complication rates.
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Affiliation(s)
- Ellen M Piccillo
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - David Adkins
- Otolaryngology, University of Kentucky, Lexington, USA
| | - Mohamed Elrakhawy
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Michele M Carr
- Otolaryngology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
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Allen J, Dewan K, Herbert H, Randall DR, Starmer H, Stein E. Aspects of the assessment and management of pharyngoesophageal dysphagia. Ann N Y Acad Sci 2020; 1482:5-15. [PMID: 32794195 DOI: 10.1111/nyas.14456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023]
Abstract
Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.
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Affiliation(s)
- Jacqueline Allen
- Department of Surgery, the University of Auckland, Auckland, New Zealand
| | - Karuna Dewan
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Hayley Herbert
- Department of Otolaryngology, University of Western Australia, Perth, Western Australia, Australia
| | - Derrick R Randall
- Division of Otolaryngology, the University of Calgary, Calgary, Alberta, Canada
| | - Heather Starmer
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical School, Baltimore, Maryland
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Togashi T, Baba H, Kitazawa M, Takahashi N, Samejima Y, Yumoto E, Horii A. Surgical treatment of enterovirus D68 brainstem encephalitis-induced dysphagia. Auris Nasus Larynx 2018; 45:1093-1097. [PMID: 29366609 DOI: 10.1016/j.anl.2017.12.004] [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: 09/17/2017] [Revised: 12/23/2017] [Accepted: 12/26/2017] [Indexed: 11/26/2022]
Abstract
Cluster of acute flaccid paralysis and cranial nerve dysfunction was associated with a 2014 outbreak of enterovirus D68 (EV-D68) respiratory illness in US. We describe a 33 year-old male patient of refractory dysphagia due to EV-D68-induced brainstem encephalitis successfully treated by surgery. Following acute upper respiratory tract infection, he developed dysphagia and bilateral facial paralysis. A coughing reflex was readily produced when the laryngopharyngeal fiberscope touched the epiglottis, however, water infusion induced only very weak and slow swallowing reflex, suggesting that only motor component was impaired but sensory function was preserved during swallowing. Despite eight months-conservative rehabilitations, Food Intake Level Scale (FILS) remained level 4. Therefore, corrective surgeries including cricopharyngeal myotomy, laryngeal suspension, and pharyngeal flap were performed. Thirty-six days after surgery, FILS rapidly and dramatically improved to level 8. This is the first report describing a successful surgical intervention for EV-D68-induced refractory dysphagia. Surgical treatment was suitable for EV-D68-induced dysphagia, perhaps because sensory function was preserved and only motor disturbance was present during the pharyngeal stage of swallowing.
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Affiliation(s)
- Takafumi Togashi
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Hironori Baba
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Meiko Kitazawa
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nao Takahashi
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yasuhiro Samejima
- Department of Otolaryngology Head and Neck Surgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Eiji Yumoto
- Department of Otolaryngology, Asahino General Hospital, Kumamoto, Japan
| | - Arata Horii
- Department of Otolaryngology Head and Neck Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Matsubara M, Tohara H, Hara K, Shinozaki H, Yamazaki Y, Susa C, Nakane A, Wakasugi Y, Minakuchi S. High-speed jaw-opening exercise in training suprahyoid fast-twitch muscle fibers. Clin Interv Aging 2018; 13:125-131. [PMID: 29403269 PMCID: PMC5784581 DOI: 10.2147/cia.s152821] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study was aimed to examine the effectiveness of a high-speed jaw-opening exercise, which targets the contraction of fast-twitch muscle fibers, in improving swallowing function. Subjects and methods Twenty-one subjects (mean age 74.0±5.7 years) with dysphagia-related symptoms, such as coughing or choking during eating, performed the exercise. None of the included subjects had neurological symptoms or history of surgery that could cause significant dysphagia. All subjects took regular meals, and maintained independent activities of daily life. The exercise schedule consisted of 3 sets of 20 repetitions each of rapid and maximum jaw-opening movement with a 10-second interval between sets. The exercise was performed twice daily for 4 weeks. Results Following the intervention, there was a significant increase in the vertical position of the hyoid bone at rest. Furthermore, during swallowing, the elevation of the hyoid bone and the velocity of its movement and esophageal sphincter opening increased significantly while the duration of the hyoid elevation and the pharyngeal transit time reduced significantly. Conclusions Our results demonstrated that high-speed jaw-opening exercise resulted in increased elevation velocity of the hyoid bone during swallowing, indicating its role in effectively strengthening the fast-twitch muscle fibers of suprahyoid muscles. Furthermore, since the rest position of the hyoid bone appeared to have improved, this exercise may be especially useful in elderly individuals with a lower position of the hyoid bone at rest and those with decreased elevation of the hyoid bone during swallowing, which are known to be associated with an increased risk of aspiration.
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Affiliation(s)
- Mariko Matsubara
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo.,Department of Oral Surgery, Ichigao Carillon Hospital, Kanagawa, Japan
| | - Haruka Tohara
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Koji Hara
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Hiromichi Shinozaki
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Yasuhiro Yamazaki
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Chiaki Susa
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Ayako Nakane
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Yoko Wakasugi
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
| | - Shunsuke Minakuchi
- Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo
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8
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Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration. Dysphagia 2018. [DOI: 10.1007/174_2017_141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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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: 14] [Impact Index Per Article: 1.8] [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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12
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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: 21] [Impact Index Per Article: 2.3] [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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Kocdor P, Siegel ER, Tulunay-Ugur OE. Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy. Laryngoscope 2015; 126:135-41. [PMID: 26360122 DOI: 10.1002/lary.25447] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. The objective of this systematic review was to evaluate the existing studies on the effectiveness of myotomy, dilatation, and botulinum toxin (BoT) injection in the management of cricopharyngeal dysphagia. METHODS PubMed and Web of Science databases were searched to identify eligible studies by using the terms "cricopharyngeal dysfunction," "cricopharyngeal myotomy," "cricopharyngeal botox," "cricopharyngeal dilation," and their combinations from 1990 to 2013. This was supplemented by hand-searching relevant articles. Eligible articles were independently assessed for quality by two authors. Statistical analysis was performed. RESULTS The database search revealed 567 articles. Thirty-two articles met eligibility criteria and were further evaluated. The reported success rates of BoT injections was between 43% and 100% (mean = 76%), dilation 58% and 100% (mean = 81%), and myotomy 25% and 100% (mean = 75%). In logistic regression analysis of the patient-weighted averages, the 78% success rate with myotomy was significantly higher than the 69% success rate with BoT injections (P = .042), whereas the intermediate success rate of 73% with dilation was not significantly different from that of either myotomy (P = .37) or BoT (P = .42). There was a statistically significant difference between endoscopic and open myotomy success rates (P = .0025). Endoscopic myotomy had a higher success rate, with a 2.2 odds ratio. CONCLUSIONS The success rate of myotomy is significantly higher than the success rate of BoT injections in cricopharyngeal dysfunction. Moreover, endoscopic myotomy was found to have a higher success rate compared to open myotomy.
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Affiliation(s)
- Pelin Kocdor
- Department of Otolaryngology-Head and Neck Surgery
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A
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14
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Abakumov MM, Avdyunina IA. [Treatment of upper esophageal sphincter achalasia as a little-known chapter of surgery]. Khirurgiia (Mosk) 2015:4-12. [PMID: 26271558 DOI: 10.17116/hirurgia201574-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is presented the results of survey and treatment of 32 patients with upper esophageal sphincter achalasia. In 29 of them achalasia was consequence of stroke in brain stem (Zakharchenko-Wallenberg syndrome). 28 patients were operated using P. Chodoch method in 7 cases and author's technique of myotomy with pharyngoesophageal junction plasty in 21 patients. Plastic myotomy gives excellent and good results in 81% of observations due to preservation of innervation of muscles providing function of epiglottis and pharyngeal constrictors. Severe condition of patients and elderly age are indication for P. Chodoch myotomy.
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Affiliation(s)
- M M Abakumov
- N.V. Sklifosovskiy Research Institute for Emergency Care
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Zenker's diverticulum: carbon dioxide laser endoscopic surgery. BIOMED RESEARCH INTERNATIONAL 2014; 2014:516231. [PMID: 24729975 PMCID: PMC3963375 DOI: 10.1155/2014/516231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/28/2014] [Indexed: 11/25/2022]
Abstract
Nowadays endoscopic diverticulotomy is the surgical approach of the first choice in treatment of Zenker's diverticulum. We report our experience with this procedure and try to sum up recent recommendations for management of surgery and postoperative care. Data of 34 patients with Zenker's diverticulum, treated by endoscopic carbon dioxide laser diverticulotomy at the Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic, were prospectively stored and followed in relatively short period from May 2009 to December 2013. The average length of diverticulum was 32 mm. The average duration of surgery was 32 min. The patients were fed via feeding tube for 6.1 days and antibiotics were administered for 7 days. Mean hospitalization time was 7.4 days. We observed one transient recurrent laryngeal nerve paralysis and no other serious complications. Recurrence rate was 3%. We recommend complete transection of the diverticular septum in one procedure, systemic antibiotic treatment and exclusion of transoral intake for minimally 5 days, and contrast oesophagogram before resumption of oral intake to exclude fistula. Open diverticulectomy should be reserved for cases with inadequate endoscopic exposure and for revision surgery for multiple recurrences from endoscopic diverticulotomies.
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16
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Silver N, Gal TJ. Endoscopic CO2 laser management of chemoradiation-related cricopharyngeal stenosis. Ann Otol Rhinol Laryngol 2014; 123:252-6. [PMID: 24595625 DOI: 10.1177/0003489414525019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT. METHODS A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined. RESULTS Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed. CONCLUSION Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed.
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Affiliation(s)
- Natalie Silver
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA
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Bergeron JL, Chhetri DK. Indications and outcomes of endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope 2013; 124:950-4. [PMID: 24114581 DOI: 10.1002/lary.24415] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 07/31/2013] [Accepted: 08/26/2013] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Jennifer L Bergeron
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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18
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Abstract
The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter (UES). In dysphagia, cricopharyngeus muscle dysfunction (CPD) refers to the muscle's failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD, and the resultant clinical manifestation is solid food or solid and liquid dysphagia. Several diagnostic tools are available for dysphagia clinicians to distinguish CPD from other causes of UES dysfunction. For CPD, accurate diagnosis is paramount for the recommendation of appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia.
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Affiliation(s)
- Maggie A Kuhn
- Department of Otolaryngology/Head and Neck Surgery, Center for Voice and Swallowing, University of California, Davis, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817, USA
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Esophageal sarcoidosis: a review of cases and an update. ISRN GASTROENTEROLOGY 2013; 2013:836203. [PMID: 23533794 PMCID: PMC3603204 DOI: 10.1155/2013/836203] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/30/2013] [Indexed: 12/19/2022]
Abstract
Sarcoidosis is a chronic disorder that can virtually affect any organ system in the body. Histologically, it is characterized by the presence of T lymphocytes, mononuclear phagocytes, and noncaseating granulomas. Most commonly affected are the intrathoracic structures, with 90% of the reported cases involving the lungs. Esophageal involvement in sarcoidosis is extremely rare. Dysphagia is the most common presentation in these patients and can be attributed to various mechanisms such as direct esophageal wall infiltration, extrinsic compression, cranial neuropathy, and brainstem involvement. A thorough online literature review revealed only 23 reported cases of esophageal involvement in sarcoidosis. This paper reviews these reported cases in detail along with newer diagnostic and treatment options, including direction of future therapy.
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Wada S, Tohara H, Iida T, Inoue M, Sato M, Ueda K. Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter. Arch Phys Med Rehabil 2012; 93:1995-9. [PMID: 22579648 DOI: 10.1016/j.apmr.2012.04.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 04/27/2012] [Accepted: 04/28/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Satoko Wada
- Department of Dysphagia Rehabilitation, Nihon University School of Dentistry, Tokyo, Japan
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21
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Berzofsky CE, Holiday RA, Pitman MJ. Variability of postoperative esophagrams after endoscopic cricopharyngeal myotomy: technique dependence. Ann Otol Rhinol Laryngol 2012; 121:145-50. [PMID: 22530472 DOI: 10.1177/000348941212100301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We illustrate the dependence of postoperative day (POD) 1 esophagram findings on the closure technique used after endoscopic cricopharyngeal myotomy (ECPM). METHODS We performed a retrospective chart review of POD 1 fluoroscopic examinations of the cervical esophagus utilizing contrast dye after ECPM to assess radiologic findings associated with three different techniques of addressing the exposed buccopharyngeal fascia (BPF). RESULTS Each technique resulted in specific and different findings on the POD 1 esophagram. When the BPF was untreated, the esophagram demonstrated a pseudodiverticulum with free flow of contrast dye. When a fibrin glue seal was used, the esophagram demonstrated a curvilinear focus of contrast dye projected over the retropharyngeal soft tissue persisting after the swallow, similar to a leak. When fibrin glue application was combined with single-suture reapproximation of the mucosal incision, the pattern was similar to esophagrams performed 6 weeks after myotomy. CONCLUSIONS Different techniques used to address the exposed BPF following ECPM result in specific findings on the POD 1 esophagram. Recognition of these imaging differences and open communication with the fluoroscopist will avoid a misdiagnosis of a pharyngeal leak, which might cause an unnecessary delay of oral feeding and hospital discharge.
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Affiliation(s)
- Craig E Berzofsky
- Voice and Swallowing Institute, Department of Otolaryngology, New York Eye and Ear Infirmary, New York, NY 10003, USA
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22
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A rare manifestation of cricopharyngeal myopathy presenting with dysphagia in sarcoidosis. Rheumatol Int 2011; 33:1089-92. [PMID: 22116526 DOI: 10.1007/s00296-011-2242-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 10/22/2011] [Indexed: 12/13/2022]
Abstract
Sarcoidosis is a systemic inflammatory granulomatous disease that affects multiple organs in the body; however, dysphagia is a relatively rare manifestation at early stages. Dysphagia in sarcoidosis is attributed to many mechanisms, such as mediastinal lymphadenopathy, esophageal or laryngeal involvement, cranial neuropathy, and brainstem infiltration. In this article, we report an extremely rare case with sarcoidosis who presented with dysphagia due to isolated cricopharyngeal myopathy. The 75-year-old woman presented with slowly progressive swallowing difficulty and videofluorography showed insufficient opening of the upper esophageal sphincter. On presentation, she had no cranial nerve or central nervous system impairments. A cricopharyngeal myotomy was performed, and histopathological study revealed a significant inflammatory change with non-necrotizing granulomas within the muscle tissue. We concluded that this was a very rare case of sarcoidosis presenting with localized cricopharyngeal myopathy. Postoperatively, a contracture of the esophageal entrance was successfully released and the dysphagia was alleviated.
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23
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Tieu BH, Hunter JG. Management of Cricopharyngeal Dysphagia With and Without Zenker's Diverticulum. Thorac Surg Clin 2011; 21:511-7. [DOI: 10.1016/j.thorsurg.2011.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Suda K, Takeuchi H, Seki H, Yoshizu A, Yasui N, Matsumoto H, Shimada A, Ishikawa H, Kitagawa Y. Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: report of a case. Surg Today 2011; 41:1238-1242. [PMID: 21874422 DOI: 10.1007/s00595-010-4449-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 05/16/2010] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Koichi Suda
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Ho AS, Morzaria S, Damrose EJ. Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy with primary mucosal closure. Ann Otol Rhinol Laryngol 2011; 120:33-9. [PMID: 21370678 DOI: 10.1177/000348941112000105] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Allen S Ho
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California 94305, USA
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26
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Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration. Dysphagia 2011. [DOI: 10.1007/174_2011_357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bergamini G, Presutti L, Alicandri Ciufelli M, Masoni F. Surgical rehabilitation. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2010; 30:248-53. [PMID: 21804689 PMCID: PMC3040586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- G Bergamini
- ENT Department, University Hospital of Modena, Italy
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28
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Peretti G, Piazza C, Del Bon F, Cocco D, De Benedetto L, Mangili S. Endoscopic treatment of Zenker's diverticulum by carbon dioxide laser. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2010; 30:1-4. [PMID: 20559466 PMCID: PMC2881603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 11/17/2009] [Indexed: 05/29/2023]
Abstract
The management of Zenker's diverticulum remains controversial, as both external and endoscopic procedures are potentially associated with post-operative complications and risks. The endoscopic approach is based on cricopharyngeal myotomy or myectomy by laser, cautery or stapling. A retrospective chart review has been made from December 1994 to April 2009 of all patients with Zenker's diverticulum treated by endoscopic cricopharyngeal myectomy using CO(2) laser at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy. Of the 28 patients (19 males, 9 females; mean age, 64 years; range, 46-95) scheduled for the trans-oral procedure, 27 (96%) were endoscopically treated. Diagnosis was based on the patient's history, flexible fiberoptic examination of the larynx, hypopharynx, and oesophagus, and videofluoroscopy with barium. Exclusion criteria included severe medical co-morbidities, impossibility to endoscopically expose the diverticulum, and small (< 2 cm) or large (> 6 cm) diverticula. The endoscopic procedure was performed using a CO(2) laser to section the cricopharyngeal muscle and remove the posterior part in order to obtain partial myectomy. Major complications occurred in 2 (7%) patients. No cases of recurrent nerve paralysis, pharyngo-cutaneous fistula, neck emphysema, post-operative bleeding, mediastinitis or aspiration pneumonia were observed in the present series. A swallow survey was obtained by telephone: 85% of patients reported improved swallowing (without symptoms in 11 and with moderate dysphagia in 7). Based on the present series, endoscopic CO(2) laser cricopharyngeal myectomy for Zenker's diverticulum can be considered an effective and safe procedure, with reduced hospitalization time and complication rate.
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Affiliation(s)
- G Peretti
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Brescia, piazza Spedali Civili 1, Brescia, Italy
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29
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Kos MP, David EF, Klinkenberg-Knol EC, Mahieu HF. Long-term results of external upper esophageal sphincter myotomy for oropharyngeal Dysphagia. Dysphagia 2009; 25:169-76. [PMID: 19760460 PMCID: PMC2929428 DOI: 10.1007/s00455-009-9236-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Accepted: 05/20/2009] [Indexed: 11/25/2022]
Abstract
The aim of this work was to assess the efficacy of external myotomy of the upper esophageal sphincter (UES) for oropharyngeal dysphagia. In the period 1991-2006, 28 patients with longstanding dysphagia and/or aspiration problems of different etiologies underwent UES myotomy as a single surgical treatment. The main symptoms were difficulties in swallowing of a solid-food bolus, aspiration, and recurrent incidents of solid-food blockages. Pre- and postoperative manometry and videofluoroscopy were used to assess deglutition and aspiration. Outcome was defined as success in the case of complete relief or marked improvement of dysphagia and aspiration and as failure in the case of partial improvement or no improvement. Initial results showed success in 21 and failure in 7 patients. The best outcomes were observed in patients with dysphagia of unknown origin, noncancer-related iatrogenic etiology, and neuromuscular disease. No correlation was found between preoperative constrictor pharyngeal muscle activity and success rate. After follow-up of more than 1 year, 20 patients were marked as success and 3 as failure. All successful patients had full oral intake with a normal bolus consistency without clinically significant aspiration. We conclude that in select cases of oropharyngeal dysphagia success may be achieved by UES myotomy with restoration of oral intake of normal bolus consistency.
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Affiliation(s)
- Martijn P Kos
- Department of Otolaryngology/Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands.
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30
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Abstract
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.
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Affiliation(s)
- Michael Pitman
- Department of Otolaryngology, The New York Eye and Ear Infirmary, New York, New York 10003, USA.
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31
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Hillel AT, Flint PW. Evolution of endoscopic surgical therapy for Zenker's diverticulum. Laryngoscope 2009; 119:39-44. [DOI: 10.1002/lary.20019] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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ARDRAN GM, KEMP FH, LUND WS. The Ætiology of the Posterior Pharyngeal Diverticulum: A Cineradiographic Study. The Journal of Laryngology & Otology 2007; 78:333-49. [PMID: 14142982 DOI: 10.1017/s0022215100062162] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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HARRISON MS. The Etiology, Diagnosis and Surgical Treatment of Pharyngeal Diverticula. The Journal of Laryngology & Otology 2007; 72:523-34. [PMID: 13564023 DOI: 10.1017/s0022215100054293] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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BRUNNER H. X-ray Examination of the Cricopharyngeal Sphincter—“Hypopharyngeal Bar”. The Journal of Laryngology & Otology 2007; 66:276-82. [PMID: 14928030 DOI: 10.1017/s0022215100047630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Brigand C, Ferraro P, Martin J, Duranceau A. Risk factors in patients undergoing cricopharyngeal myotomy. Br J Surg 2007; 94:978-83. [PMID: 17497757 DOI: 10.1002/bjs.5760] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death.
Methods
A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon.
Results
A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1·2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10·3 per cent).
Conclusion
Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.
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Affiliation(s)
- C Brigand
- Department of Surgery, Division of Thoracic Surgery, University of Montreal Hospital Centre, 1560 Sherbrooke Street East, Montreal, Quebec H2L 4M1, Canada
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Lawson G, Remacle M. Endoscopic cricopharyngeal myotomy: indications and technique. Curr Opin Otolaryngol Head Neck Surg 2007; 14:437-41. [PMID: 17099353 DOI: 10.1097/moo.0b013e3280106314] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Cricopharyngeal muscle myotomy to treat swallowing disorders has a definite role in the management of cervical dysphagia. Several reports emphasize the benefits of the endoscopic approach compared with the transcervical technique. This review examines recent surgical management of cricopharyngeus dysmotility. RECENT FINDINGS Several investigations have provided pertinent information on selecting patients for cricopharyngeal myotomy. Manofluorography appears to be more accurate in detecting intrabolus pressure anomalies during swallowing. Isolated cricopharyngeus dyscoordination, however, is not easily identified using this method. Electromyographic activity of the inferior pharyngeal constrictor and cricopharyngeus recorded by transcutaneous electrodes at rest and during deglutition has shown different dysfunction patterns. Ambulatory 24 h double probe pH monitoring and the triple sensor combination pH test demonstrate clinical correlation between pH results and symptoms in patients suffering from dysphagia related to laryngopharyngeal reflux. Transoral cricopharyngeal myotomy for the treatment of cricopharyngeus dysmotility is now established as a safe and effective method. The development of new devices has enhanced the procedure's efficacy and the overall success rate without major complications. SUMMARY Diagnosis of cricopharyngeus dysfunction is based on anamnesis and videoradiograph findings. In doubtful cases manofluorography and electromyography should be performed. Endoscopic cricopharyngeal myotomy is a safe and effective treatment option for patients with cricopharyngeus dysphasia.
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Affiliation(s)
- Georges Lawson
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Louvain at Mont-Godinne, UCL, Belgium.
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Dauer E, Salassa J, Iuga L, Kasperbauer J. Endoscopic laser vs open approach for cricopharyngeal myotomy. Otolaryngol Head Neck Surg 2006; 134:830-5. [PMID: 16647543 DOI: 10.1016/j.otohns.2005.12.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 12/22/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To illustrate the safety and efficacy of the endoscopic laser approach for cricopharyngeal myotomy (CPM) compared to the traditional transcervical approach. STUDY DESIGN AND SETTING Retrospective chart review of 22 patients undergoing CPM from 1996 to 2003 at the Mayo Clinic, Jacksonville. RESULTS The laser CPM technique was used in 14 patients, and an open approach in 8. The mean hospital stay and operative times were shorter for the laser group. Functional outcome analyses showed improvement in both groups. There were no major complications in the laser group, while 1 patient in the transcervical group had a pharyngocutaneous fistula. CONCLUSIONS The laser technique is at least as effective as the transcervical approach for CPM to improve dysphagia symptoms in the properly selected patient, with a low risk of major complications. SIGNIFICANCE In this report, we provide the reader with data to support the safety and efficacy of laser CPM. EBM RATING B-3b.
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Affiliation(s)
- Eileen Dauer
- Department of Otolaryngology-Head and Neck Surgery, Malcolm Grow Medical Center, Andrews AFB, MD 20762, USA.
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Takes RP, van den Hoogen FJA, Marres HAM. Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery. Head Neck 2006; 27:703-9. [PMID: 15887217 DOI: 10.1002/hed.20201] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO2 laser have been described. METHODS Endoscopic cricopharyngeal myotomy using a CO2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker's diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy. RESULTS In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure. CONCLUSIONS Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction.
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Affiliation(s)
- Robert P Takes
- Department of Otolaryngology/Head and Neck Surgery, University Medical Center Nijmegen, P. O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Abstract
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.
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Affiliation(s)
- S Singh
- Department of GI Sciences, Hope Hospital, Manchester, UK
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Zaninotto G, Marchese Ragona R, Briani C, Costantini M, Rizzetto C, Portale G, Zanetti L, Masiero S, Costantino M, Nicoletti L, Polidoro A, Feltrin G, Angelini C, Ancona E, Guidolin D, Parenti AR. The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia. J Gastrointest Surg 2004; 8:997-1006. [PMID: 15585387 DOI: 10.1016/j.gassur.2004.09.037] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aims of this study were to assess the efficacy and safety of botulinum toxin (BoTox) injection in the cricopharyngeus muscle (CP) and CP myotomy in patients with oropharyngeal dysphagia (OPD) and to identify factors predicting the outcome of these treatments. The study involved patients with persistent OPD despite 2-6 months of rehabilitation, who all underwent clinical evaluation, esophageal manometry, upper gastrointestinal endoscopy, and videofluoroscopy (VFS). Patients received 5-10 BoTox units injections in the CP, identified by electromyography. Surgical myotomy of the upper esophageal sphincter was performed when dysphagia persisted after two BoTox injections. After treatment, patients were reevaluated with clinical interviews and VFS. The study population included 21 patients (15 mean and 6 women; median age, 68 years), classified into three groups, based on the etiology of their OPD: eight (38%) had central nervous system abnormalities, five (24%) had peripheral nerve disease, and eight (38%) were classified as idiopathic. The median time since the onset of dysphagia was 18 months. Thirteen of 21 patients (62%) needed supplemental/total gastrostomy feeding, and 5 of 21 (24%) had tracheostomy. One patient died, on posttreatment day 7, due to massive aspiration. No other BoTox-related complications were observed. After BoTox injection, dysphagia improved in 9 of 21 (43%) patients. Severely altered VFS findings and CP incoordination or low activity predicted BoTox failure at multivariate analysis. Dysphagia improved in 8 of 11 (72.7%) patients who failed to respond to BoTox and underwent myotomy. A mild impairment of VFS findings and a higher pressure of pharyngeal contractions best predicted response to BoTox with or without myotomy. BoTox injection can be used as the first therapeutic option in patients with OPD: it is safe and simple and relieves dysphagia in 43% of cases. If BoTox fails, CP myotomy can be offered to patients with preserved oral and tongue activity at VFS and an intact bolus propulsion ability on manometry.
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Affiliation(s)
- Giovanni Zaninotto
- Department of Medical and Surgical Sciences, Clinica Chirurgica 3, University of Padova School of Medicine, Padova, Italy.
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Solt J, Bajor J, Moizs M, Grexa E, Horváth PO. Primary cricopharyngeal dysfunction: treatment with balloon catheter dilatation. Gastrointest Endosc 2001; 54:767-71. [PMID: 11726859 DOI: 10.1067/mge.2001.118442] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- J Solt
- I. Department of Medicine, Baranya County Hospital, Pécs, Hungary
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Abstract
OBJECTIVE The objective of this study was to evaluate the clinical presentation of children with cricopharyngeal achalasia and to document the diagnostic process followed and evaluate the immediate and long-term results of those children treated with a cricopharyngeal myotomy. METHODS Five children who underwent cricopharyngeal myotomies since 1976 were identified and the hospital records were reviewed in detail. Four patients were followed up to establish the long-term results of surgery. RESULTS The age of initial presentation ranged from birth to 6 months with a universal delay in establishing the diagnosis ranging from 11 to 138 months. Two children had pre- and post-operative manometry of the upper esophageal sphincter. Post-operative upper esophageal sphincter pressures were reduced to 29 and 47% in relation to pre-operative values. Nissen fundoplications were performed in two patients to control documented gastro esophageal reflux. No post-operative complications were noted and complete symptomatic relief was obtained in all children. The long-term follow up was 2, 10, 12 and 14 years with all children remaining free of symptoms. CONCLUSION Cricopharyngeal achalasia is an important but relatively seldom diagnosed cause of dysphagia in children. The diagnosis is almost always delayed because the condition is not widely recognised amongst physicians. If the diagnosis and effective treatment is delayed significant morbidity or even mortality, mainly due to pulmonary aspiration, may result. Cricopharyngeal myotomy is a safe and effective operation with excellent results. Symptomatic relief is immediate and complete with no long-term recurrence documented in this series.
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Affiliation(s)
- A Brooks
- University of Cape Town, Department of Paediatric Surgery, Institute of Child Health, Red Cross War Memorial Children's Hospital, 7701, Rondebosch, South Africa.
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43
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Abstract
Since 1951, when it was first used as a treatment for post-poliomyelitis dysphagia, cricopharyngeal myotomy (CPM) has been used in the treatment of various neurogenic, myogenic, structural, and idiopathic disorders. Yet, the efficacy of CPM in treating patients with upper esophageal sphincter (UES) disorders remains controversial. Despite favorable reports regarding its success, too few studies about indications, complications, and outcomes of CPM have been conducted to quell the controversy. Swallowing is accomplished when three primary conditions exist: (1) the cricopharyngeus muscle (CP) relaxes--that is, it is not tonically contracted, (2) the laryngo-hyoid complex elevates in an anterior-superior direction to open the sphincter, and (3) pharyngeal pressure is sufficient to propel a bolus through the open sphincter. CPM is indicated when the second and third conditions are "adequate" but the first is inadequate, thus resulting in pharyngeal dysphagia associated with a defective opening of the UES. UES dysfunction is determined most often through patient history, physical examination, and testing. Patients with Zenker's (pharyngoesophageal) diverticulum, oculopharyngeal dystrophy, or inclusion body myositis are among those reported to have the most positive responses to CPM. Modified barium swallow is the most common measurement of UES dysfunction; manometry also is used, but to a lesser degree because of catheter motion during swallowing. There are four approaches to CPM, including: (1) the external technique, which is indicated when a muscle biopsy or neck exploration is needed; (2) the endoscopic approach, which is reported to work best with patients with Zenker's diverticulum and offers the choice of electrocautery, laser, or the surgical stapler--the last option being the best choice for high-risk patients; (3) balloon dilatation of the UES, a low-risk option that reportedly works best in patients with fibrosis of the CP; and (4) botulinum toxin injection of the CP transcervically or endoscopically, which offers low risk and minimal or no anesthesia. This approach best serves cases of failed relaxation of the CP. Each approach has potential complications, but reports of such are few and rarely severe. In all cases, massive reflux should be controlled before CPM and the patient should be medically stable. Patient selection for CPM remains inadequate. To assess the efficacy of CPM, more multi-institutional outcome studies need to be conducted. In the meanwhile, clinical judgment and selective testing via modified barium swallow are the best methods for identifying patients who may derive the most benefit from CPM.
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Affiliation(s)
- J H Kelly
- Department of Otolaryngology, Head and Neck Surgery, Greater Baltimore Medical Center, Maryland 21204, USA
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Sideris L, Chen LQ, Ferraro P, Duranceau AC. The treatment of Zenker's diverticula: a review. Semin Thorac Cardiovasc Surg 1999; 11:337-51. [PMID: 10535375 DOI: 10.1016/s1043-0679(99)70078-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A historical review reveals that the treatment of Zenker's diverticula has paralleled its presumed pathophysiology. With the development of technical facilities to better evaluate the pharyngoesophageal region, incomplete relaxation of the upper esophageal sphincter (UES) seems to represent the key element in the development of high pharyngeal pressures with a subsequent outpouching responsible for the diverticulum formation. Many studies have justified myotomy as an essential component in the treatment of pharyngoesophageal diverticula because it represents an efficient therapy with little morbidity. A diverticulopexy should be added for pouches between 1 and 4 cm and a diverticulectomy should be performed for sacs greater than 5 cm to expect the best relief of symptoms. Other treatment modalities have recently been used such as the endoscopic division of the common wall between the cervical esophagus and the diverticulum with either electrocautery (Dohlman's procedure), a laser, or a stapling device. This method is gaining popularity because it achieves a good clinical outcome, especially in high-risk patients. However, more studies are needed to confirm its long-term effectiveness.
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Affiliation(s)
- L Sideris
- Department of Surgery, Centre Hospitalier de l'Université de Montréal, QC, Canada
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45
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Abstract
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.
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Affiliation(s)
- G Wisdom
- Department of Otolaryngology-Head and Neck Surgery, St. Luke's-Roosevelt Hospital, New York, New York, USA
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46
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47
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Baredes S, Shah CS, Kaufman R. The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia. Am J Otolaryngol 1997; 18:185-9. [PMID: 9164621 DOI: 10.1016/s0196-0709(97)90080-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Dysphagia associated with cricopharyngeal dysfunction (CPD) is of particular interest to the otolaryngologist because it may respond to cricopharyngeal myotomy. There is a wide variation in the reported incidence of cricopharyngeal dysfunction in patients with dysphagia. This can be attributed to the different populations being studied, the lack of uniform criteria for diagnosis, and to different techniques used to evaluate patients. We have reviewed videofluoroscopic swallowing studies (VSS) conducted on 443 consecutive patients with complaints of dysphagia to identify the incidence of cricopharyngeal dysfunction. PATIENTS AND METHODS The patient population consists of 443 veterans with complaints of dysphagia who were evaluated by videofluoroscopic swallowing studies at the Department of Veterans Affairs Medical Center, East Orange, NJ, between November 1988 and March 1993. RESULTS Cricopharyngeal dysfunction was diagnosed radiologically as the appearance of a shelf in the posterior column of barium at the level of the cricoid cartilage. It was identified in 10 of 177 (5.7%) patients with neurological disorders, in 7 of 142 (4.9%) patients with head and neck or esophageal tumors, and in 11 of 124 (8.9%) patients with other medical problems. CONCLUSION These results do not support the notion that cricopharyngeal dysfunction is an important factor in a significant proportion of patients with dysphagia. It is recognized that videofluoroscopy may not always detect cricopharyngeal dysfunction and that better criteria for identifying this entity are needed.
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Affiliation(s)
- S Baredes
- Section of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry-New Jersey Medical School, Newark 07103, USA
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Blitzer A, Brin MF. Use of Botulinum Toxin for Diagnosis and Management of Cricopharyngeal Achalasia. Otolaryngol Head Neck Surg 1997; 116:328-30. [PMID: 9121784 DOI: 10.1016/s0194-59989770267-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- A Blitzer
- New York Center for Voice and Swallowing Disorders and the Head and Neck Surgical Group, Mt. Sinai Medical Center, New York, New York 10019, USA
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50
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Poirier NC, Bonavina L, Taillefer R, Nosadini A, Peracchia A, Duranceau A. Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia. J Thorac Cardiovasc Surg 1997; 113:233-40; discussion 240-1. [PMID: 9040615 DOI: 10.1016/s0022-5223(97)70318-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months). RESULTS Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40). CONCLUSIONS Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.
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Affiliation(s)
- N C Poirier
- Department of Surgery, Université de Montréal, Hôtel-Dieu de Montréal, Quebec, Canada
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