1. Laryngology seminar Cricopharyngeal dysphagia
December 27,2007
R3王彥斌

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

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

4. 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 ↑

5. Dysfunction of CPm 3 categories Fail to completely relax (achalasia)
Incompetence of the UES (chalasia)
Delayed opening of the cricopharyngeus

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

7. Symptoms Dysphagia in lower neck Choking Vague throat discomfort
Globus sensation

8. Diagnosis Hx taking Barium swallowing : non-specific
Classic cricopharyngeal bar
Transient partial obstruction
Manometric pressure
VFSS

9. Treatment
Cricopharyngeal myotomy
Botox (botulium toxin)

10. 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

11. 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

12. Endoscopic approach
Balloon dilatation

13. Indication Purely defective relaxation of CPm
Tongue/pharyngeal propulsion : ok
Laryngeal-hyoid elevation : ok

14. Zenker’s diverticulum
Pharyngeal propulsion  herniation of mucosa
Diverticulectomy or diverticulopexy
Neurogenic disorder
CVA : good response
Parkinson’s : good
Oculopharyngeal dystrophy : good
AML : poor

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

16. 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)

17. Temporary
Works 3 days later
Lasting up to 6 months

18. 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)

19. 65-90% successful rate
Average 4 months duration (longest 17m)

20. Results
Type of diet
BW gain
Aspiration
Feeding tube

21. ® hypoglossal neuroma 25 y female Unilateral hypoglossal paralysis ®
MRI proved hypoglossal neuroma
Suboccipital craniotomy tumor excision ( )
CN palsy
Persisted dysphagia
VFSS : severe pharyngeal dysphagia

23.
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
Gastrostomy due to persisted dysphagia
Improved swallowing (removal of gastrostomy on

24. References
Jacob JR et al : Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery. Arch Otolaryngol Head Neck Surg Sep;125(9):942-6.
Wisdom G, Blitzer A. : Surgical therapy for swallowing disorders. Otolaryngol Clin North Am Jun;31(3):
Lerut T et al : Zenker's diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology Apr;39(2):
Kelly JH. : Management of upper esophageal sphincter disorders: indications and complications of myotomy.Am J Med Mar 6;108 Suppl 4a:43S-46S.
Ellis FH Jr et al : Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy.Ann Surg Sep;194(3):
McKenna JA, Dedo HH. : Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol Mar;101(3):
Ahsan SF et al : Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngol Head Neck Surg May;122(5):691-5.
Atkinson SI, Rees J. : Botulinum toxin for cricopharyngeal dysphagia: case reports of CT-guided injection.J Otolaryngol Aug;26(4):273-6.
Blitzer A, Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia.Otolaryngol Head Neck Surg Mar;116(3):