Efficacy of Adjunctive Cricopharyngeus Myotomy inSupraglottic Laryngectomy

Clarence T. Sasaki, MD, John K. Joe, MD, and Susan Albert, RN, BSNSchool of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA

Abstract. This study investigates prospectively the ef-fect of concurrent cricopharyngeus myotomy (CPM) onswallowing following horizontal supraglottic laryngecto-my (SL) using fiberoptic, radiographic, and manometricevaluations and suggests possible mechanisms regardingthe role of CPM following SL. Six patients undergoinghorizontal SL between 1995 and 1997 were enrolled in aprospective evaluation with a followup of 0.5–2.25years. Three patients underwent concurrent CPM andthree did not. Fiberoptic, radiographic, and manometricassessments were performed postoperatively. Althoughmean resting pressures at the upper esophageal sphincterwere reduced significantly by myotomy (12 mm Hg)compared with nonmyotomized patients (57 mm Hg),p< 0.01, no rehabilitative advantage was observed in theformer group. In fact, of the myotomized patients, tworequired feeding gastrostomy tubes with resumption ofan oral diet in one year and in two months, respectively,while the nonmyotomized patients were all capable ofresuming a full oral diet within four weeks. It appearsthat CPM provides no rehabilitative advantage in pa-tients undergoing SL.

Key words: Supraglottic laryngectomy — Cricopha-ryngeus myotomy — Deglutition — Deglutition disor-ders.

Supraglottic laryngectomy (SL) has been demonstratedto treat selected malignant neoplasms of the supraglottissuccessfully, while preserving the sphincteric, respirato-

ry, and phonatory functions of the larynx. The horizontalSL technique involves the removal of supraglottic struc-tures, including the roof of the ventricle, the ventricularbands, the epiglottis, and the anterior aspect of the ary-epiglottic folds in continuity with the pre-epiglotticspace. The theoretical basis for SL is that the supraglotticterritory of the larynx has an embryological origin andlymphatic drainage independent and separate from thatof the glottis and subglottis [1,2].

The clinical value of supraglottic laryngectomy issuccessful eradication of supraglottic carcinoma [3,4]with preservation of laryngeal function. Disruption of theswallowing mechanism, however, may occasionally re-sult after surgery, as demonstrated by cineradiographicand clinical evaluations, and is often attributed to sensorydenervation and loss of anterosuperior suspensory func-tion [5].

While suggesting that spasm of the cricopharyn-geus is one of the contributing etiologies for postopera-tive dysphagia and aspiration, some authors have advo-cated concurrent cricopharyngeus myotomy (CPM) tofacilitate normal swallowing function after SL [1,6].Electromyographic studies of swallowing in dogs afterSL have shown spasmodic contraction of the cricopha-ryngeus relieved with concurrent CPM [7]. Other retro-spective descriptions of SL, however, have supportedthe notion that such a myotomy is unnecessary [8],and controversy remains as to whether CPM improvespostoperative deglutition. Cineradiographic and mano-metric evaluations of swallowing in dogs following SLhave shown no difference with or without cricopharyn-geus myotomy [9]. Additional retrospective analyses ofswallowing in patients have not demonstrated a statisti-cally significant difference when CPM was performed[10,11]. Cineradiographic evaluations for aspiration afterconcurrent CPM have shown equivocal results [12]. Fi-nally, in a recent prospective multi-institutional studyinvolving 125 patients undergoing various head and neck

This project was supported by the McFadden Endowment, the HarmonEndowment, and the Mirikitani Endowment.Correspondence to:Clarence T. Sasaki, M.D., Department of Surgery,Section of Otolaryngology, P.O. Box 208041, New Haven, CT 06520-8041, USA. E-mail:

Dysphagia 16:19–22 (2001)DOI: 10.1007/s004550000039

© Springer-Verlag New York Inc. 2001

cancer resections, Jacobs et al. [13] could identify nosignificant long-term improvement in dysphagia reha-bilitation by myotomy. Although this study did not cor-relate the effect of myotomy and manometric changes, itpresumed myotomy produced enough of a physical ef-fect to generate potential changes in the mechanics ofswallowing.

The purpose of the present study is to investigateprospectively the effect of concurrent cricopharyngeusmyotomy on swallowing following horizontal supraglot-tic laryngectomy through the correlation of fiberoptic,radiographic, and manometric evaluations and to suggestpossible mechanisms regarding the role of CPM follow-ing SL.

Materials and Methods

Patients

We report on 6 patients (4 men, 2 women) at Yale–New Haven Hos-pital who underwent horizontal SL during the period from August 1995to May 1997; they also had adjunctive postoperative external beamradiation therapy. Patients ranged in age from 52 to 72 years old witha mean age of 63.5 (Table 1).

Patients underwent a thorough general physical and head andneck examination. All patients underwent endoscopy and biopsy undergeneral anesthesia to confirm the diagnosis of squamous cell carcinomawas confined to the supraglottis and did not involves the true vocalcords. Followup ranged from 2.0 to 3.75 years after SL. All patientswere cognitively intact pre- and postoperatively and were motivated toresume normal deglutition following surgery.

Surgical Technique

In all six patients, anesthesia was provided through a tracheotomy.Bilateral functional neck dissections were performed because of thehigh incidence of nodal metastasis from supraglottic cancer.

The same surgeon performed all six horizontal SL procedures,which proceeded in the following manner: The infrahyoid muscleswere dissected from the hyoid bone and reflected to the upper edge ofthe thyroid cartilage. Subperichondrial dissection exposed the superiorportions of the thyroid alae permitting a horizontal incision to be madeacross both thyroid alae with an oscillating saw. A lateral pharyn-gotomy was extended across the vallecula, preserving the hyoid bone,as the epiglottis was retracted anteriorly. An incision through the ary-epiglottic fold was carried into the ventricle forward towards the an-terior commissure, sparing the true vocal cords. A similar incision wasmade through the aryepiglottic fold into the ventricle anteriorly on thecontralateral side, allowing for the entire supraglottic larynx to beremoved with a free margin around the tumor. In all six patients, thebase of the tongue remained intact and preserved.

Following insertion of a nasogastric tube under direct vision,three of the six patients were randomly assigned to undergo a concur-rent right posterolateral cricopharyngeus myotomy. Closure was ac-complished for all six patients in a similar fashion. In all six patients,it was oncologically possible to preserve the hyoid bone and to reap-proximate it to the remaining thyroid cartilage. Perichondrium of thethyroid alae was sutured to the periosteum of the hyoid bone, accom-

plishing a near-watertight closure of the pharynx. The remaining strapmuscles were sutured to the suprahyoid musculature and the woundwas closed over suction drains.

Evaluation of Swallowing

Nasogastric tube feedings were started in all patients between two andthree days following surgery. Removal of the nasogastric tube andattempted swallowing trials were performed between 7 and 12 dayspostoperatively. With the initiation of swallowing trials with a pureeddiet, all patients underwent fiberoptic endoscopic evaluation of swal-lowing to investigate for aspiration. Aspiration was defined as penetra-tion of a bolus below the level of the true vocal cords. Two patientswho demonstrated postoperative aspiration underwent further evalua-tion of swallowing with modified barium esophagram.

Approximately two weeks following SL, all patients underwentmanometric evaluation of the lower esophageal sphincter, esophagealbody, and upper esophageal sphincter. Manometric data were obtainedusing a water-perfused Arndorfer esophageal manometric catheter(Arndorfer, Greendale, WS) and a solid-state computerized SandHillesophageal manometric catheter (SandHill Science, Highlands Ranch,CO). The Arndorfer catheter measured esophageal pressures throughthree radially oriented leads with sensors 5 cm apart, and its channelswere perfused by a pneumohydraulic capillary infusion pump. TheSandHill catheter measured esophageal pressures through circumfer-entially oriented intraluminal transducers with sensors separated by 3and 2 cm.

Manometric recordings with each catheter system were per-formed in a similar manner. The esophageal manometric catheter waspassed transnasally into the stomach. Resting pressures were recordedfirst at the lower esophageal sphincter; relaxation of the sphincter withswallowing was noted. The catheter was then slowly withdrawn toallow measurements more proximally. End expiratory resting pressureswere recorded at the esophageal body and compared with intragastricpressure. Configurations of contractions upon swallowing were noted.Following identification of the upper esophageal sphincter by continu-ing the pull-through technique, resting pressures were measured andrelaxation and coordination with pharyngeal contractions were noted.Finally, pharyngeal pressures were recorded and the catheter was with-drawn, completing the procedure.

Statistical Analysis

Student’st test of paired data was used to assess for differences in timeof adequate swallowing for myotomized patients compared with thetime of adequate swallowing for nonmyotomized patients. Time ofadequate swallowing was defined as the number of postoperative days

Table 1. Patient data

Age Gender Tumor stage

Myotomized patients1 61 Male IV2 57 Female IV3 69 Female II

Nonmyotomized patients4 61 Male II5 53 Male IV6 61 Male IV

20 C.T. Sasaki et al.: Cricopharyngeus Myotomy

required for the patient (1) to rely solely on peroral nutrition withoutthe need for supplementation and (2) to swallow without aspiration.

Results

Fiberoptic laryngoscopy postoperatively revealed no evi-dence of vocal cord paralysis in any of the six patients.Barium esophagrams in patients who aspirated typicallydemonstrated absence of hypopharyngeal distension,fragmented bolus, and prolonged transit time. Manomet-ric resting pressures at the upper esophageal sphincterand time of adequate swallowing were recorded for pa-tients following supraglottic laryngectomy with andwithout concurrent cricopharyngeus myotomy. Thesedata are summarized in Table 2. Mean resting pressure ofthe upper esophageal sphincter for patients with concur-rent myotomy was 12 mm Hg, while that of patientswithout myotomy was 57 mm Hg. This differenceproved statistically significant (p < 0.01).

Despite this difference in resting pressures, thetime of adequate swallowing for myotomized patientsranged from 2 months to 1 year postoperatively, withpatients 1 and 2 requiring placement of a feeding gas-trostomy tube until adequate swallowing was obtained.In contrast, nonmyotomized patients were able to takeadequate peroral diet within 2 to 4 weeks postopera-tively. None of the nonmyotomized patients requiredplacement of a feeding gastrostomy tube.

Discussion and Conclusions

Manometry, which records changes in pressure duringpharyngoesophageal motility [14–20] is a useful tool forevaluating swallowing disorders. Although mean restingpharyngeal pressures were significantly reduced by my-otomy (12 mm Hg) compared with nonmyotomized pa-tients (57 mm Hg) (p < 0.01), no rehabilitative advantagewas observed in the former group. In fact, of the myoto-mized patients, two required feeding tubes with resump-tion of an oral diet in one year and in two months, re-

spectively, while the nonmyotomized patients were allcapable of resuming a full oral diet in three weeks. Al-though our sample size was small, our two patient groupswere significantly different, suggesting that CPM pro-vided no rehabilitative advantage in patients undergoingSL. In fact, because of the apparent negative effects ofmyotomy, continuation of our prospective study couldnot be justified and thus resulted in early termination ofprospective randomization and a small sample size. Al-though these findings support the conclusions of a largerstudy by Jacobs et al. [13], our observations extend theunderstanding of both short- and long-term effects ofmyotomy while correlating the physical effects of myot-omy on a negative rehabilitative outcome.

Our observations allow us to speculate on pos-sible causes for group differences. It is possible that in-tact cricopharyngeus sphincter tone is necessary for suc-cessful swallow by at least several mechanisms:

1. An intact sphincter transiently retains the passing bo-lus causing distension of the proximal hypopharynx.Both the magnitude and rate of distension likely rep-resent important sensory cues necessary for the re-flexive coordination of pharyngeal deglutition [14].

2. As an intact sphincter transiently retains the bolus, itactively assists in shaping or “packaging” it as asingle unit, unlike the fragmented bolus seen radio-graphically in SL patients who aspirate [15].

3. It is also likely that an intact sphincter assists in gen-erating subatmospheric hypopharyngeal pressure asthe larynx ascends during the early phase of the pha-ryngeal swallow [14–18]. Since sufficient negativepressure assists in propelling the bolus into the upperesophagus, its absence likely prolongs transit time,increasing vulnerability to aspiration.

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Table 2. Data from patients undergoing supraglottic laryngectomy with and without cricopharyngeus myotomy

Patientidentifier

Cricopharyngeusmyotomy

Resting pressure at theupper esophageal sphincter(mm Hg)

Time ofadequateswallowing(postoperative)

1 Yes 0 1 year2 Yes 26 4 months3 Yes 10 2 months4 No 60 2 weeks5 No 70 4 weeks6 No 40 4 weeks

C.T. Sasaki et al.: Cricopharyngeus Myotomy 21

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