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Laryngology seminar Cricopharyngeal dysphagia. December 27,2007 R3 王彥斌. Anatomy . Inferior to inferior constrictor muscle Transverse fiber without midline raphe Innervations : pharyngeal plexus (CN 10, 9 , cervical sympathetic trunk). Physiology . Swallowing 3 phase

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anatomy
Anatomy
  • Inferior to inferior constrictor muscle
  • Transverse fiber without midline raphe
  • Innervations : pharyngeal plexus (CN 10, 9 , cervical sympathetic trunk)
physiology
Physiology
  • Swallowing 3 phase
    • Oral – Pharyngeal – Esophageal
  • Pharyngeal phase
    • Tongue base propels bolus
    • Pharyngeal contraction : clear residue
    • Larynx-hyoid complex : elevated
    • Cricopharyngeal muscle relax
physiology4
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 ↑
dysfunction of cpm
Dysfunction of CPm
  • 3 categories
    • Fail to completely relax (achalasia)
    • Incompetence of the UES (chalasia)
    • Delayed opening of the cricopharyngeus
cricopharyngeal achalasia
Cricopharyngeal Achalasia
  • Idopathic
  • Neurological CPA
    • Stroke
    • C.N. palsy (vagal, CN9)
    • Parkinsonism
    • Poliomyositis
    • Dermatomyositis
    • Amyotrphic lateral sclerosis
symptoms
Symptoms
  • Dysphagia in lower neck
  • Choking
  • Vague throat discomfort
  • Globus sensation
diagnosis
Diagnosis
  • Hx taking
  • Barium swallowing : non-specific
    • Classic cricopharyngeal bar
    • Transient partial obstruction
  • Manometric pressure
  • VFSS
treatment
Treatment
  • Cricopharyngeal myotomy
  • Botox (botulium toxin)
cricopharyngeal myotomy
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
slide11
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
slide12
Endoscopic approach
  • Balloon dilatation
slide13
Indication
    • Purely defective relaxation of CPm
    • Tongue/pharyngeal propulsion : ok
    • Laryngeal-hyoid elevation : ok
slide14
Zenker’s diverticulum
    • Pharyngeal propulsion  herniation of mucosa
    • Diverticulectomy or diverticulopexy
  • Neurogenic disorder
    • CVA : good response
    • Parkinson’s : good
    • Oculopharyngeal dystrophy : good
    • AML : poor
slide15
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
botox injection
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)
slide17
Temporary
  • Works 3 days later
  • Lasting up to 6 months
slide18
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)
slide19
65-90% successful rate
  • Average 4 months duration (longest 17m)
results
Results
  • Type of diet
  • BW gain
  • Aspiration
  • Feeding tube
hypoglossal neuroma
® 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
slide23
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
references
References
  • Jacob JR et al : Failure of cricopharyngeal myotomy to improve dysphagia following head 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.