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13 Sept 2019
Jeffrey Marino, MD
Otorhinolaryngology and Communication Sciences
Ochsner Medical Center
Outline
• Anatomy
• Function/Dysfunction
• Evaluation
• Procedural treatment• Dilation
• Botulinum toxin injection
• CP myotomy (endoscopic)
Anatomy
• Upper esophageal sphincter (UES) • High pressure zone between
pharynx and esophagus
• 2.5 cm to 4.5 cm
• Pharyngoesophageal segment• Inferior pharyngeal constrictor
• Cricopharyngeus (CP)
• Proximal-most cervical esophagus
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What opens the CP?
1. Relaxation✓ neural inhibition of tonic contraction
2. Distraction✓ hyolaryngeal excursion
3. Distension✓ pliability of walls
✓ velopharyngeal competency
✓ intact base of tongue strength
✓ intact pharyngeal strength
Causes of CP Dysfunction
Impaired relaxation Impaired distraction Impaired distension
Neoplasm – CNSCVATBIParkinson’sNeuromuscular diseasePeripheral neuropathyACDF denervation
Head/neck radiationParkinson’sNeuromuscular diseasePeripheral neuropathy
Neoplasm – pharynx/esophagusHead/neck radiationStrictureSclerodermaHyper/hypothyroidismACDF hardware
• Often multifactorial
• Often compounded by patient factors (frailty, comorbidities)
Evaluation
• Anatomic assessment• Flexible laryngoscopy (awake)
• Rigid laryngoscopy/esophagoscopy (sedated)
• Flexible esophagoscopy (awake/sedated)
• Functional assessment• Modified barium swallow study
• Bedside swallow evaluation
• Flexible endoscopic evaluation of swallowing
• High resolution pharyngeal manometry/impedance
Modified barium swallow study
• Challenges• Access to images/video
• Variability in SLP expertise
• Esophagram?• Lateral cervical view
• Maximally distended view via large liquid bolus
Cricopharyngeal dysfunction: a spectrum
Belafsky et al. Laryngoscope, 120:889–894, 2010
Normal Nonobstructive CP bar(< 50%)
Obstructive CP bar(> 50%)
Obstructive CP bar + Zenker’s diverticulum
Treatment considerations
• Those most likely to benefit from procedural intervention✓ Solid food dysphagia
✓ Objective signs of PES obstruction
✓ Intact pharyngeal squeeze
✓ Intact hyolaryngeal excursion
• Other options to consider• SLP swallowing therapy
• Acid suppression
Dilation
• Bougie vs. Savary vs. balloon
• Setting – OR vs. office (TNE)
• Main risk• Perforation
• Shared decision making• Temporary
• Trial prior to more definitive intervention
• Poor candidate for myotomy surgery
• Risk-adverse patient
Botulinum toxin
• 10 U to 100 U
• Setting – OR vs. office
• Main risk – inadvertent diffusion• Bilateral vocal fold palsy, airway obstruction
• Profound pharyngeal weakness
• Shared decision making• May be done in conjunction with dilation in OR
• Not always a good predictor of benefit from myotomy
CP myotomy (endoscopic)
• 1994: 1st description (Halvorson/Kuhn)
• Intraoperative details• General anesthesia
• 1 hr duration
• Microscope
• 5 mm mucosal incision (CO2 laser vs. KTP laser)
• Myotomy in cranial-caudal vector
• Usually no mucosal closure
• Fully awake extubation
• Not a substitution for open operation
“Laser”
CP myotomy (endoscopic)
Pitman MJ, Weissbrod P: Endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope 119:45-53, 2009
CP myotomy (endoscopic)
• Postoperative course• NPO overnight• POD#1 clear liquids → full liquids, then DC• Regular diet by week 3
• Main risk• Uncontrolled perforation
• Shared decision making• Definitive intervention• May still experience symptoms
• Pharyngeal dysfunction• Zenker’s diverticulum• Esophageal dysfunction• Reflux
Summary
• The UES requires 3 components for opening: relaxation, distraction, distention
• Mainstay of assessment of the UES: modified barium swallow study
• CP dysfunction – a spectrum of phenotypes
• SLP collaboration is optimal
• Procedural treatment requires careful patient selection and shared decision making