Laryngology seminarLaryngology seminar

Cricopharyngeal Cricopharyngeal dysphagiadysphagia

December 27,2007December 27,2007

R3R3王彥斌王彥斌

Anatomy Anatomy

Inferior to inferior constricInferior to inferior constrictor muscletor muscle

Transverse fiber without Transverse fiber without midline raphemidline raphe

Innervations : pharyngeal Innervations : pharyngeal plexus (CN 10, 9 , cervicaplexus (CN 10, 9 , cervical sympathetic trunk)l sympathetic trunk)

Physiology Physiology

Swallowing 3 phase Swallowing 3 phase Oral – Pharyngeal – Esophageal Oral – Pharyngeal – Esophageal

Pharyngeal phasePharyngeal phase Tongue base propels bolusTongue base propels bolus Pharyngeal contraction : clear residuePharyngeal contraction : clear residue Larynx-hyoid complex : elevated Larynx-hyoid complex : elevated Cricopharyngeal muscle relaxCricopharyngeal muscle relax

PhysiologyPhysiology

Resting : constant tonus Resting : constant tonus Relax before arrival of peristaltic wave to aRelax before arrival of peristaltic wave to a

llow bolus passllow bolus pass Then contract to higher of equal pressureThen contract to higher of equal pressure Vagus n section : Vagus n section :

unilateral unilateral ↓: relaxation phase↓: relaxation phase Bilateral : abolish relaxation Bilateral : abolish relaxation Stimulation : sharp relaxationStimulation : sharp relaxation

Stimulation of SCG : pressure ↑Stimulation of SCG : pressure ↑

Dysfunction of CPmDysfunction of CPm

3 categories3 categories Fail to completely relax (achalasia)Fail to completely relax (achalasia) Incompetence of the UES (chalasia)Incompetence of the UES (chalasia) Delayed opening of the cricopharyngeusDelayed opening of the cricopharyngeus

Cricopharyngeal AchalasiaCricopharyngeal Achalasia

Idopathic Idopathic Neurological CPANeurological CPA

StrokeStroke C.N. palsy (vagal, CN9)C.N. palsy (vagal, CN9) ParkinsonismParkinsonism Poliomyositis Poliomyositis Dermatomyositis Dermatomyositis Amyotrphic lateral sclerosis Amyotrphic lateral sclerosis

Symptoms Symptoms

Dysphagia in lower neckDysphagia in lower neck ChokingChoking Vague throat discomfortVague throat discomfort Globus sensationGlobus sensation

Diagnosis Diagnosis

Hx taking Hx taking Barium swallowing : non-specificBarium swallowing : non-specific

Classic cricopharyngeal bar Classic cricopharyngeal bar Transient partial obstructionTransient partial obstruction

Manometric pressureManometric pressure VFSSVFSS

Treatment Treatment

Cricopharyngeal myotomyCricopharyngeal myotomy Botox (botulium toxin)Botox (botulium toxin)

Cricopharyngeal myotomyCricopharyngeal myotomy

1926 Jackson & Shallow : CP muscle rela1926 Jackson & Shallow : CP muscle relaxation xation dierticulumdierticulum

1946 dilatation of CPm 1946 dilatation of CPm 1950 Asherson : For CP achalasia1950 Asherson : For CP achalasia 1951 Kaplan : For cervical dysphagia of po1951 Kaplan : For cervical dysphagia of po

liomyelitisliomyelitis

External CP myotomyExternal CP myotomy Incision along ant border of SCMIncision along ant border of SCM Divide omohyoid m. Divide omohyoid m. Identify CPm myotomy to cervical esophagusIdentify CPm myotomy to cervical esophagus 4-5 cm long : thy-hyo mem to sup esophagus4-5 cm long : thy-hyo mem to sup esophagus 7-10 cm long : sup cornu of thy cartilage to cla7-10 cm long : sup cornu of thy cartilage to cla

viclevicle Unroof underlying mucosaUnroof underlying mucosa Pharyngeal muscle distentionPharyngeal muscle distention

Endoscopic approachEndoscopic approach Balloon dilatationBalloon dilatation

Indication Indication Purely defective relaxation of CPmPurely defective relaxation of CPm Tongue/pharyngeal propulsion : okTongue/pharyngeal propulsion : ok Laryngeal-hyoid elevation : okLaryngeal-hyoid elevation : ok

Zenker’s diverticulumZenker’s diverticulum Pharyngeal propulsion Pharyngeal propulsion herniation of mucos herniation of mucos

aa Diverticulectomy or diverticulopexyDiverticulectomy or diverticulopexy

Neurogenic disorderNeurogenic disorder CVA : good responseCVA : good response Parkinson’s : goodParkinson’s : good Oculopharyngeal dystrophy : good Oculopharyngeal dystrophy : good AML : poorAML : poor

Head and neck surgery : controversialHead and neck surgery : controversial 1961 Ogura JH et al : improved swallowing by 1961 Ogura JH et al : improved swallowing by

myotomy after ablative H&N surgery (supraglomyotomy after ablative H&N surgery (supraglottic laryngectomy)ttic laryngectomy)

1999 Jacob JR et al : 125 pt H&N ca 1999 Jacob JR et al : 125 pt H&N ca Tongue base resection, supraglottic laryngectomyTongue base resection, supraglottic laryngectomy Oropharyngeal swallowing not changedOropharyngeal swallowing not changed Prevention aspiration after supraglottic laryngectoPrevention aspiration after supraglottic laryngecto

mymy

Botox injection Botox injection

Discovery in 1897 Discovery in 1897 1990 NIH : strabismus, blepharospasm, he1990 NIH : strabismus, blepharospasm, he

mifacial spasm, adductor spasmodic dyspmifacial spasm, adductor spasmodic dysphonia, cervical dystoniahonia, cervical dystonia

8 subtypes: A B,C1,C2,DEFG8 subtypes: A B,C1,C2,DEFG BTX-A used in USABTX-A used in USA

Binding to pre-synaptic cholinergic nerve tBinding to pre-synaptic cholinergic nerve terminals (block release of Ach at NM junc)erminals (block release of Ach at NM junc)

TemporaryTemporary Works 3 days laterWorks 3 days later Lasting up to 6 monthsLasting up to 6 months

In cricopharyngeal achalasiaIn cricopharyngeal achalasia Treatment and diagnosisTreatment and diagnosis General anesthesiaGeneral anesthesia Short-term muscle relaxantShort-term muscle relaxant Percutaneous injection : EMG, CT videofluoroscopyPercutaneous injection : EMG, CT videofluoroscopy Direct way : esophagoscope, laryngoscopeDirect way : esophagoscope, laryngoscope Flexible scopeFlexible scope Dorsomedial and both ventrolateral side (100U)Dorsomedial and both ventrolateral side (100U)

65-90% successful rate65-90% successful rate Average 4 months duration (longest 17m)Average 4 months duration (longest 17m)

Results Results

Type of dietType of diet BW gainBW gain Aspiration Aspiration Feeding tube Feeding tube

® hypoglossal neuroma® hypoglossal neuroma 25 y female25 y female Unilateral hypoglossal paralysis ®Unilateral hypoglossal paralysis ® MRI proved hypoglossal neuromaMRI proved hypoglossal neuroma Suboccipital craniotomy tumor excisioSuboccipital craniotomy tumor excisio

n (2004-12)n (2004-12) CN 7 8 9 10 12 palsyCN 7 8 9 10 12 palsy Persisted dysphagia Persisted dysphagia VFSS : severe pharyngeal dysphagiaVFSS : severe pharyngeal dysphagia

2005-082005-08 Dysport 500U ( clostridium botulinum type A toxiDysport 500U ( clostridium botulinum type A toxi

n-hemaggluttin complex)n-hemaggluttin complex) Mix n/s to 2.5 ml ( 200U/ml)Mix n/s to 2.5 ml ( 200U/ml) 0.6 ml / each site : 3 sites 0.6 ml / each site : 3 sites

2005-10 2005-10 Gastrostomy due to persisted dysphagiaGastrostomy due to persisted dysphagia

2006-042006-04 Improved swallowing (removal of gastrostomy oImproved swallowing (removal of gastrostomy o

n 2006-06n 2006-06

References References Jacob JR et al : Failure of cricopharyngeal myotomy to improve dysphagia following h

ead and neck cancer surgery. Arch Otolaryngol Head Neck Surg. 1999 Sep;125(9):942-6.

Wisdom G, Blitzer A. : Surgical therapy for swallowing disorders. Otolaryngol Clin North Am. 1998 Jun;31(3):537-60.

Lerut T et al : Zenker's diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology. 1992 Apr;39(2):127-31.

Kelly JH. : Management of upper esophageal sphincter disorders: indications and complications of myotomy.Am J Med. 2000 Mar 6;108 Suppl 4a:43S-46S.

Ellis FH Jr et al : Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy.Ann Surg. 1981 Sep;194(3):279-89.

McKenna JA, Dedo HH. : Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol. 1992 Mar;101(3):216-21.

Ahsan SF et al : Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngol Head Neck Surg. 2000 May;122(5):691-5.

Atkinson SI, Rees J. : Botulinum toxin for cricopharyngeal dysphagia: case reports of CT-guided injection.J Otolaryngol. 1997 Aug;26(4):273-6.

Blitzer A, Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia.Otolaryngol Head Neck Surg. 1997 Mar;116(3):328-30.