Cricopharyngeal Myotomy Workup

  • Author: Neil Bhattacharyya, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 16, 2012
 

Imaging Studies

Video fluoroscopic swallowing study

  • Traditionally, this study has been the primary tool in the diagnosis of cricopharyngeal achalasia. During VFSS, the patient is asked to swallow barium-coated material of different varieties, including liquid barium, while cineradiographic data are collected as the bolus is followed from swallow initiation in the oral cavity to the delivery of the bolus to the stomach. This provides real-time dynamic assessment of the swallow; the video can subsequently be slowed down and analyzed in more detail.
  • The classic finding on a diagnostic VFSS of cricopharyngeal achalasia is the presence of the horizontal bar (often called the cricopharyngeal bar) at the level of the cricoid cartilage. This makes a posterior indentation in the barium column that persists throughout the swallow. The VFSS also provides information about the presence or absence of laryngeal spillover, aspiration, nasopharyngeal regurgitation, and pharyngeal stasis, each of which may accompany cricopharyngeal dysfunction.
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Other Tests

Recent interest in manometric study of the upper esophageal sphincter (UES) has surfaced in the literature. Lack of data and standardization for this study has prevented the widespread use of manometry in the assessment of cricopharyngeal dysfunction. This is further complicated because manometric measurements may be taken in the anteroposterior direction, lateral direction, or as a radial force. In addition, the presence of the manometer may stimulate cricopharyngeal spasm. Several studies have also demonstrated that the results of UES manometry may contradict findings on VFSS examination. At this point, the diagnostic value of UES manometry has not been thoroughly assessed in the literature.

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Histologic Findings

In most instances, a muscle biopsy is not taken during a standard cricopharyngeal myotomy. However, because some authors advocate removing a strip of muscle to prevent reattachment of the sectioned fibers, some data are available on the histopathology of the cricopharyngeus in cricopharyngeal dysfunction. In most cases, the cricopharyngeus muscle is normal on light microscopy. Patients with cricopharyngeal dysfunction related to neuromuscular disorders may demonstrate variable pathology including atrophy, hypertrophy, replacement with fibrotic tissue, or evidence of frank myositis. Special cases of myositis include muscle inflammation associated with dermatomyositis or inclusion body myositis.

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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, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Entellus, Inc Consulting fee Consulting; IntersectENT, Inc Consulting fee Consulting

Specialty Editor Board

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 Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

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, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

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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.
 
 
 
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