Laryngology seminar Cricopharyngeal dysphagia

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Laryngology seminarCricopharyngeal dysphagia

• December 27,2007
• R3???

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Anatomy

• Inferior to inferior constrictor muscle
• Transverse fiber without midline raphe
• Innervations pharyngeal plexus (CN 10, 9 ,
  cervical sympathetic trunk)

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Physiology

• Swallowing 3 phase
• Oral Pharyngeal Esophageal
• Pharyngeal phase
• Tongue base propels bolus
• Pharyngeal contraction clear residue
• Larynx-hyoid complex elevated
• Cricopharyngeal muscle relax

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Physiology

• Resting constant tonus
• Relax before arrival of peristaltic wave to allow
  bolus pass
• Then contract to higher of equal pressure
• Vagus n section
• unilateral ? relaxation phase
• Bilateral abolish relaxation
• Stimulation sharp relaxation
• Stimulation of SCG pressure ?

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Dysfunction of CPm

• 3 categories
• Fail to completely relax (achalasia)
• Incompetence of the UES (chalasia)
• Delayed opening of the cricopharyngeus

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Cricopharyngeal Achalasia

• Idopathic
• Neurological CPA
• Stroke
• C.N. palsy (vagal, CN9)
• Parkinsonism
• Poliomyositis
• Dermatomyositis
• Amyotrphic lateral sclerosis

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Symptoms

• Dysphagia in lower neck
• Choking
• Vague throat discomfort
• Globus sensation

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Diagnosis

• Hx taking
• Barium swallowing non-specific
• Classic cricopharyngeal bar
• Transient partial obstruction
• Manometric pressure
• VFSS

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Treatment

• Cricopharyngeal myotomy
• Botox (botulium toxin)

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Cricopharyngeal myotomy

• 1926 Jackson Shallow CP muscle relaxation
  ?dierticulum
• 1946 dilatation of CPm
• 1950 Asherson For CP achalasia
• 1951 Kaplan For cervical dysphagia of
  poliomyelitis

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• External CP myotomy
• Incision along ant border of SCM
• Divide omohyoid m.
• Identify CPm myotomy to cervical esophagus
• 4-5 cm long thy-hyo mem to sup esophagus
• 7-10 cm long sup cornu of thy cartilage to
  clavicle
• Unroof underlying mucosa
• Pharyngeal muscle distention

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• Endoscopic approach
• Balloon dilatation

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• Indication
• Purely defective relaxation of CPm
• Tongue/pharyngeal propulsion ok
• Laryngeal-hyoid elevation ok

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• Zenkers diverticulum
• Pharyngeal propulsion ? herniation of mucosa
• Diverticulectomy or diverticulopexy
• Neurogenic disorder
• CVA good response
• Parkinsons good
• Oculopharyngeal dystrophy good
• AML poor

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• Head and neck surgery controversial
• 1961 Ogura JH et al improved swallowing by
  myotomy after ablative HN surgery (supraglottic
  laryngectomy)
• 1999 Jacob JR et al 125 pt HN ca
• Tongue base resection, supraglottic laryngectomy
• Oropharyngeal swallowing not changed
• Prevention aspiration after supraglottic
  laryngectomy

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Botox injection

• Discovery in 1897
• 1990 NIH strabismus, blepharospasm, hemifacial
  spasm, adductor spasmodic dysphonia, cervical
  dystonia
• 8 subtypes A B,C1,C2,DEFG
• BTX-A used in USA
• Binding to pre-synaptic cholinergic nerve
  terminals (block release of Ach at NM junc)

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• Temporary
• Works 3 days later
• Lasting up to 6 months

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• In cricopharyngeal achalasia
• Treatment and diagnosis
• General anesthesia
• Short-term muscle relaxant
• Percutaneous injection EMG, CT videofluoroscopy
• Direct way esophagoscope, laryngoscope
• Flexible scope
• Dorsomedial and both ventrolateral side (100U)

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• 65-90 successful rate
• Average 4 months duration (longest 17m)

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Results

• Type of diet
• BW gain
• Aspiration
• Feeding tube

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hypoglossal neuroma

• 25 y female
• Unilateral hypoglossal paralysis
• MRI proved hypoglossal neuroma
• Suboccipital craniotomy tumor excision (2004-12)
• CN 7 8 9 10 12 palsy
• Persisted dysphagia
• VFSS severe pharyngeal dysphagia

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• 2005-08
• Dysport 500U ( clostridium botulinum type A
  toxin-hemaggluttin complex)
• Mix n/s to 2.5 ml ( 200U/ml)
• 0.6 ml / each site 3 sites
• 2005-10
• Gastrostomy due to persisted dysphagia
• 2006-04
• Improved swallowing (removal of gastrostomy on
  2006-06

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References

• Jacob JR et al Failure of cricopharyngeal
  myotomy to improve dysphagia following head and
  neck cancer surgery. Arch Otolaryngol Head Neck
  Surg. 1999 Sep125(9)942-6.
• Wisdom G, Blitzer A. Surgical therapy for
  swallowing disorders. Otolaryngol Clin North Am.
  1998 Jun31(3)537-60.
• Lerut T et al Zenker's diverticulum is a
  myotomy of the cricopharyngeus useful? How long
  should it be? Hepatogastroenterology. 1992
  Apr39(2)127-31.
• Kelly JH. Management of upper esophageal
  sphincter disorders indications and
  complications of myotomy.Am J Med. 2000 Mar 6108
  Suppl 4a43S-46S.
• Ellis FH Jr et al Cervical esophageal
  dysphagia indications for and results of
  cricopharyngeal myotomy.Ann Surg. 1981
  Sep194(3)279-89.
• McKenna JA, Dedo HH. Cricopharyngeal myotomy
  indications and technique. Ann Otol Rhinol
  Laryngol. 1992 Mar101(3)216-21.
• Ahsan SF et al Botulinum toxin injection of the
  cricopharyngeus muscle for the treatment of
  dysphagia. Otolaryngol Head Neck Surg. 2000
  May122(5)691-5.
• Atkinson SI, Rees J. Botulinum toxin for
  cricopharyngeal dysphagia case reports of
  CT-guided injection.J Otolaryngol. 1997
  Aug26(4)273-6.
• Blitzer A, Brin MF. Use of botulinum toxin for
  diagnosis and management of cricopharyngeal
  achalasia.Otolaryngol Head Neck Surg. 1997
  Mar116(3)328-30.