Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cricopharyngeal Myotomy Treatment & Management

  • Author: Neil Bhattacharyya, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Aug 03, 2015
 

Medical Therapy

Cricopharyngeal dysfunction has been largely refractory to medical management, including therapy with muscle relaxants. Botulinum toxin injection into the cricopharyngeus muscle has recently been explored as a possible therapeutic intervention. Although experience with botulinum toxin in this clinical entity is rather limited, it may serve 2 useful purposes.

First, in patients in whom the diagnosis of cricopharyngeal achalasia may be in question, botulinum toxin treatment can be used as a trial of therapy. If the patient's dysphagia symptoms resolve after botulinum toxin injection, the diagnosis of cricopharyngeal achalasia is confirmed, and subsequent cricopharyngeal myotomy may be deemed appropriate.

In addition, patients who are medically infirm and cannot undergo external cricopharyngeal myotomy may be considered for botulinum toxin therapy. Unfortunately, the administration of the botulinum toxin into the cricopharyngeus is technically difficult and somewhat uncomfortable for the patient. Furthermore, because the effective botulinum toxin is temporary, patients are required to undergo repeat injections to maintain therapeutic efficacy. Finally, inadvertent injection outside the cricopharyngeus may result in temporary paralysis of the laryngeal musculature, causing dysphonia and, rarely, aspiration.

Next

Surgical Therapy

Several surgical approaches may be considered for treatment of cricopharyngeal dysfunction.

The classic approach is the external cricopharyngeal myotomy technique. This procedure may be performed with the patient under local or general anesthesia. Position the patient supine on the operating room table. After induction of anesthesia, intubate the cervical esophagus with a relatively large endotracheal tube to provide internal distention of the cervical esophagus at the time of the myotomy. Traditionally, a left-sided surgical approach is used. Make the skin incision in a favorable cervical skin crease roughly overlying the cricoid cartilage. Elevate the subplatysmal skin flaps superiorly and inferiorly to provide exposure to both the superior and inferior limits of the cricopharyngeus, and place self-retaining retractors. Identify the anterior border of the sternocleidomastoid muscle, and reflect it posteriorly to expose the carotid sheath. Develop a plane between the structures of the carotid sheath and the laryngotracheal complex with the greatvesselssubsequently being reflectedposteriorly.

Often, the omohyoid muscle is sectioned to provide additional exposure. Take care to protect the recurrent laryngeal nerve as it enters behind the ala of the thyroid cartilage. Rotate the larynx anteriorly into the right, bringing the internally distended cervical esophagus into view. The cricopharyngeus fibers are seen as a fan-shaped band that emanates from the posterior lateral border of the cricoid cartilage. Magnification with surgical loupes is often helpful in identifying these muscle fibers, which may blend into the surrounding submucosa. Sequentially cut the cricopharyngeus fibers with a sharp No-15 or No-10 blade until the mucosa is seen. Often, when all of the muscle fibers have been appropriately sectioned, the surgeon can see the writing on the endotracheal tube. Many authors have emphasized that the cricopharyngeal myotomy must be extended superiorly and inferiorly to ensure that all of the muscle has been released. This often translates into a myotomy length of 4-5 cm.

Some authors also advocate removing a 3- to 4-mm strip of muscle along the length of the myotomy or elevating and suturing the cut edge of muscle back onto itself. These additional techniques have been advocated to prevent reattachment and subsequent persistent cricopharyngeal dysfunction.

At the conclusion of the procedure, irrigate the wound and place and secure a standard closed suction drain system. Reapproximate the platysma in a watertight fashion. Close the skin according to surgeon preference. Remove the esophageal endotracheal tube before extubation.

Recently, investigators have been exploring a trans-oral approach for endoscopic cricopharyngeal myotomy. However, only limited case series have been published, and follow-up data are rather limited. Initial data suggest that this technique may have applications when the technique is refined and longer follow-up is available. Also, an endoscopic approach has the advantages of avoiding an external neck incision and, to some degree, less risk to surrounding structures.[4]

Previous
Next

Preoperative Details

Because patients have often had dysphagia for some time prior to surgical intervention, optimizing their nutritional and health status prior to surgical intervention is important. In certain cases, particularly with significant weight loss prior to surgery, a temporary nasogastric feeding tube may be required to administer nutritional supplementation to increased serum protein levels. In those patients with a history of preoperative aspiration, pulmonary insufficiency must also be corrected with appropriate medical consultation.

Patients with a myogenic cause for their CP dysfunction have a higher rate of postoperative complications after CP myotomy, including pulmonary aspiration and lethal respiratory distress. Such patients should be identified and placed under increasing surveillance postoperatively.

Previous
Next

Postoperative Details

Patients are usually observed in the hospital for one night following the procedure. Patients may initiate a standard oral diet the night of the procedure and advance as tolerated. The closed suction drain is usually removed on postoperative day 1, and the patient is discharged home.

Previous
Next

Follow-up

Patients are usually seen in routine postoperative follow-up care at 1 week postsurgery for a surgical wound check. In addition to the subjective evaluation of the patients' self-reported swallowing symptoms and improvement, patients also may undergo a follow-up VFSS to objectively assess the impact of the cricopharyngeal myotomy on the cervical dysphagia. Follow-up testing is particularly important in elderly, frail, and pulmonary insufficient patients, particularly when a preoperative history of aspiration exists. Recent follow-up radiologic data suggest that patients with cricopharyngeal dysfunction may continue to have pharyngeal stasis with dysphagia implications after surgery.

Previous
Next

Complications

The most common complication of external cricopharyngeal myotomy is inadvertent entry into the lumen of the cervical esophagus. Although thoroughly sectioning the entire cricopharyngeus muscle is important, the margin for error is small because the esophageal submucosa and mucosa are very thin. If the cervical esophageal lumen is entered, repair it with a watertight closure in a single layer. Avoid a double-layer closure because it may predispose the patient to stenosis in this area, defeating the original purpose of the procedure. In the setting of an inadvertent esophagotomy, maintain wound drainage and monitor the patient for evidence of salivary fistula through the drain site. Maintain perioperative and postoperative antibiotics to cover oral flora. If no evidence of air leakage or salivary fistula is present, the patient may resume a gradually advancing diet on postoperative day 3, with anticipated discharge 1-2 days later.

Other complications may occur during cricopharyngeal myotomy. A relatively uncommon occurrence is injury to the recurrent laryngeal nerve, which most often manifests as hoarseness after extubation and most often is due to a stretch injury to the nerve. Most injuries such as this resolve with time; however, recovery may require several months. During the recovery phase, monitor the patient for aspiration and pulmonary complications. If the main trunk of the recurrent laryngeal nerve is accidentally sectioned during the procedure, perform a primary neural anastomosis. If this occurs, the patient will likely have a permanent vocal cord weakness that results in dysphonia. This may be rehabilitated with vocal cord augmentation techniques or medialization thyroplasty.

Overall complication rates after cricopharyngeal myotomy are relatively small considering the generalized poor nutrition of many patients preoperatively. Pulmonary complications occur relatively commonly (5-10% of patients), particularly in those who suffer from myogenic CP dysfunction. Nine percent of patients may exhibit a transient fluid collections/inflammation in the retro pharyngeal space and 1.2% of patients may develop frank fistula formation.[5]

Previous
Next

Outcome and Prognosis

Reported success rates for cricopharyngeal myotomy and management of cervical dysphagia vary widely. To some degree, this variability may be caused by differences in the patient populations that undergo myotomy. Although some studies report results in patients who undergo cricopharyngeal myotomy for neuromuscular disease, other studies report on cricopharyngeal myotomy as a treatment of idiopathic cervical dysphagia. In properly selected patients, success rates that approach 75% may be expected. The chance of success usually decreases when an underlying neuromuscular disorder is present.

The one exception is found in patients with oculopharyngeal dysphagia; these patients generally have a good result from myotomy alone. More recently, reasonably positive outcomes have been achieved by treating patients who have oculopharyngeal dysphagia with simple repeated dilatation of the upper esophageal sphincter. Furthermore, patients with dysphagia secondary to inclusion body myositis within the CP muscle also have a relatively poorer prognosis than those with other causes for CP dysfunction.[6]

In general, the prognosis for dysphagia without treatment is unfavorable; few patients demonstrate spontaneous improvement in their cervical dysphagia. This forces many patients to opt for a chance of cure with surgery. Untreated patients with inclusion body myositis, for example, will often progress to death from aspiration pneumonia.

Previous
Next

Future and Controversies

Future work in the area of cervical dysphagia and cricopharyngeal dysfunction will likely center on more accurate and physiologic diagnostic techniques. Recent work has focused on integration of data from VFSS and manometric studies to more thoroughly define the entity of cricopharyngeal achalasia. Until this is performed, controversy is likely to continue with respect to the underlying pathophysiology or dysfunction of the cricopharyngeal muscle in this disease. Unfortunately, no randomized trials of treatment alternatives for cricopharyngeal dysfunction have been published. Furthermore, although medical and surgical treatments have evolved, published studies that use objective and validated outcomes measures are lacking; this should be addressed in the near future.

A role for botulinum toxin in the diagnosis and management of cricopharyngeal dysfunction has also emerged. Botulinum toxin may allow better patient selection by accurately identifying patients with cervical dysphagia in whom a cricopharyngeal myotomy would improve symptoms. The approach that has recently been validated is the primary use of botulinum toxin injections (in doses of 5-10 units per injection confirmed by electromyography). Cricopharyngeal myotomy is then reserved for patients with dysphagia that persists after 2 botulinum toxin injection failures. Success rates of about 40% have been reported for endoscopic botulinum toxin injection.

Other authors have reported on limited patient series that describe individuals who have undergone cricopharyngeal myotomy via an endoscopic technique. Using the potassium titanyl phosphate laser, investigators have successfully sectioned the cricopharyngeus muscle via the endoscope, obviating the need for an external incision. However, these clinical series are quite small, and follow-up data to this point are limited. In a recent series of 29 patients (mean age 62 y) after a mean follow-up of 18 months, investigators reported on the use of the CO2 laser to section the cricopharyngeus muscle endoscopically. Patients reported a significant subjective improvement in swallowing function, although not according to a validated scale. Similar corresponding radiographic improvements were noted based on swallowing videofluoroscopy. No complications were noted. Thus, with further confirmatory studies, an endoscopic laser myotomy approach may be feasible.

Several recent series that also had small sample sizes suggested that an endoscopic approach is feasible and safe. However, more long-term follow-up data are seriously lacking with respect to the effectiveness of the procedure, especially as it compares with the open cricopharyngeal myotomy approach. Investigators have also adapted the endoscopic approach to cricopharyngeal myotomy for those patients with swallowing dysfunction after extensive resection of oral and pharyngeal cancer. Such a procedure may improve dysphagia in up to 80% of those suffering from cricopharyngeal dysfunction and dysphagia after extensive resection of oral or oral pharyngeal cancer.[7, 8]

Another area of interesting research concerns the treatment of inflammatory myopathies that involve the cricopharyngeal muscle, such as inclusion body myositis and eosinophilic myositis. As further research develops concerning the pathogenesis of these entities, certain patients may benefit from percutaneous injection techniques for the delivery of anti-inflammatory medications or from the deposition of intraoperative time-release medications to inhibit the inflammatory myopathy.

Previous
 
Contributor Information and Disclosures
Author

Neil Bhattacharyya, MD Associate Professor of Otology and Laryngology, Harvard Medical School; Consulting Surgeon, Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital

Neil Bhattacharyya, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, The Triological Society, American Rhinologic Society, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Received consulting fee from Entellus, Inc for consulting; Received consulting fee from IntersectENT, Inc for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons

Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of Medicine

Disclosure: Nothing to disclose.

References
  1. Tieu BH, Hunter JG. Management of cricopharyngeal dysphagia with and without Zenker's diverticulum. Thorac Surg Clin. 2011 Nov. 21(4):511-7. [Medline].

  2. Clary MS, Daniero JJ, Keith SW, Boon MS, Spiegel JR. Efficacy of large-diameter dilatation in cricopharyngeal dysfunction. Laryngoscope. 2011 Dec. 121(12):2521-5. [Medline].

  3. Coiffier L, Perie S, Laforet P, Eymard B, St Guily JL. Long-term results of cricopharyngeal myotomy in oculopharyngeal muscular dystrophy. Otolaryngol Head Neck Surg. 2006 Aug. 135(2):218-22. [Medline].

  4. Ho AS, Morzaria S, Damrose EJ. Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy with primary mucosal closure. Ann Otol Rhinol Laryngol. 2011 Jan. 120(1):33-9. [Medline].

  5. Brigand C, Ferraro P, Martin J, Duranceau A. Risk factors in patients undergoing cricopharyngeal myotomy. Br J Surg. 2007 Aug. 94(8):978-83. [Medline].

  6. Oh TH, Brumfield KA, Hoskin TL, Kasperbauer JL, Basford JR. Dysphagia in inclusion body myositis: clinical features, management, and clinical outcome. Am J Phys Med Rehabil. 2008 Nov. 87(11):883-9. [Medline].

  7. Pitman M, Weissbrod P. Endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope. 2009 Jan. 119(1):45-53. [Medline].

  8. Fujimoto Y, Hasegawa Y, Yamada H, Ando A, Nakashima T. Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy. Laryngoscope. 2007 Aug. 117(8):1343-8. [Medline].

  9. Baredes S, Shah CS, Kaufman R. The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia. Am J Otolaryngol. 1997 May-Jun. 18(3):185-9. [Medline].

  10. 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. [Medline].

  11. Bonavina L, Khan NA, DeMeester TR. Pharyngoesophageal dysfunctions. The role of cricopharyngeal myotomy. Arch Surg. 1985 May. 120(5):541-9. [Medline].

  12. Dauer E, Salassa J, Iuga L, Kasperbauer J. Endoscopic laser vs open approach for cricopharyngeal myotomy. Otolaryngol Head Neck Surg. 2006 May. 134(5):830-5. [Medline].

  13. Ellis FH Jr, Gibb SP, Williamson WA. Current status of cricopharyngeal myotomy for cervical esophageal dysphagia. Eur J Cardiothorac Surg. 1996. 10(12):1033-8; discussion 1038-9. [Medline].

  14. Halvorson DJ, Kuhn FA. Transmucosal cricopharyngeal myotomy with the potassium-titanyl-phosphate laser in the treatment of cricopharyngeal dysmotility. Ann Otol Rhinol Laryngol. 1994 Mar. 103(3):173-7. [Medline].

  15. Hill M, Hughes T, Milford C. Treatment for swallowing difficulties (dysphagia) in chronic muscle disease. Cochrane Database of Systematic Reviews. 2004. (2):CD004303.

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

  17. Lacau St Guily J, Zhang KX, Perie S, Copin H, Butler-Browne GS, Barbet JP. Improvement of dysphagia following cricopharyngeal myotomy in a group of elderly patients. Histochemical and biochemical assessment of the cricopharyngeal muscle. Ann Otol Rhinol Laryngol. 1995 Aug. 104(8):603-9. [Medline].

  18. Lawson G, Remacle M, Jamart J, Keghian J. Endoscopic CO2 laser-assisted surgery for cricopharyngeal dysfunction. Eur Arch Otorhinolaryngol. 2003 Oct. 260(9):475-80. [Medline].

  19. Lindgren S, Ekberg O. Cricopharyngeal myotomy in the treatment of dysphagia. Clin Otolaryngol Allied Sci. 1990 Jun. 15(3):221-7. [Medline].

  20. Migliore M, Payne HR, Jeyasingham K. Pharyngo-oesophageal dysphagia: surgery based on clinical and manometric data. Eur J Cardiothorac Surg. 1996. 10(5):365-71. [Medline].

  21. Moerman MB. Cricopharyngeal Botox injection: indications and technique. Curr Opin Otolaryngol Head Neck Surg. 2006 Dec. 14(6):431-6. [Medline].

  22. Muñoz AA, Shapiro J, Cuddy LD, Misono S, Bhattacharyya N. Videofluoroscopic findings in dysphagic patients with cricopharyngeal dysfunction: before and after open cricopharyngeal myotomy. Ann Otol Rhinol Laryngol. 2007 Jan. 116(1):49-56. [Medline].

  23. Oh TH, Brumfield KA, Hoskin TL, Stolp KA, Murray JA, Bassford JR. Dysphagia in inflammatory myopathy: clinical characteristics, treatment strategies, and outcome in 62 patients. Mayo Clin Proc. 2007 Apr. 82(4):441-7. [Medline].

  24. Parameswaran MS, Soliman AM. Endoscopic botulinum toxin injection for cricopharyngeal dysphagia. Ann Otol Rhinol Laryngol. 2002 Oct. 111(10):871-4. [Medline].

  25. St Guily JL, Perie S, Willig TN, Chaussade S, Eymard B, Angelard B. Swallowing disorders in muscular diseases: functional assessment and indications of cricopharyngeal myotomy. Ear Nose Throat J. 1994 Jan. 73(1):34-40. [Medline].

  26. Takes RP, van den Hoogen FJ, Marres HA. Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery. Head Neck. 2005 Aug. 27(8):703-9. [Medline].

  27. Wilson JA, Pryde A, Allan PL, Maran AG. Cricopharyngeal dysfunction. Otolaryngol Head Neck Surg. 1992 Feb. 106(2):163-8. [Medline].

  28. Zaninotto G, Marchese Ragona R, Briani C, et al. The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia. J Gastrointest Surg. 2004 Dec. 8(8):997-1006. [Medline].

 
Previous
Next
 
Anatomic location of the cricopharyngeus muscle.
Typical appearance on swallowing videofluoroscopy of cricopharyngeal achalasia. Note the prominent posterior indentation in the barium column at the level of the larynx.
Relation of the recurrent laryngeal nerve to the cricoid cartilage.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.