13 Sept 2019

Jeffrey Marino, MD

Otorhinolaryngology and Communication Sciences

Ochsner Medical Center

Outline

• Anatomy

• Function/Dysfunction

• Evaluation

• Procedural treatment• Dilation

• Botulinum toxin injection

• CP myotomy (endoscopic)

Anatomy

• Upper esophageal sphincter (UES) • High pressure zone between

pharynx and esophagus

• 2.5 cm to 4.5 cm

• Pharyngoesophageal segment• Inferior pharyngeal constrictor

• Cricopharyngeus (CP)

• Proximal-most cervical esophagus

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Anatomy

Anatomy

https://entokey.com/

Rigid esophagoscope

Pilling/Teleflex Medical

Diverticuloscope

Karl Storz

Diverticuloscope

Clinical Gastrointestinal Endoscopy 2019

Diverticuloscope

Karl Storz

Diverticuloscope

Karl Storz

What opens the CP?

1. Relaxation✓ neural inhibition of tonic contraction

2. Distraction✓ hyolaryngeal excursion

3. Distension✓ pliability of walls

✓ velopharyngeal competency

✓ intact base of tongue strength

✓ intact pharyngeal strength

Causes of CP Dysfunction

Impaired relaxation Impaired distraction Impaired distension

Neoplasm – CNSCVATBIParkinson’sNeuromuscular diseasePeripheral neuropathyACDF denervation

Head/neck radiationParkinson’sNeuromuscular diseasePeripheral neuropathy

Neoplasm – pharynx/esophagusHead/neck radiationStrictureSclerodermaHyper/hypothyroidismACDF hardware

• Often multifactorial

• Often compounded by patient factors (frailty, comorbidities)

Evaluation

• Anatomic assessment• Flexible laryngoscopy (awake)

• Rigid laryngoscopy/esophagoscopy (sedated)

• Flexible esophagoscopy (awake/sedated)

• Functional assessment• Modified barium swallow study

• Bedside swallow evaluation

• Flexible endoscopic evaluation of swallowing

• High resolution pharyngeal manometry/impedance

Flexible laryngoscopy – pharyngeal squeeze

Fuller et al. Otol Head and Neck Surg 2009

Modified barium swallow study

• Challenges• Access to images/video

• Variability in SLP expertise

• Esophagram?• Lateral cervical view

• Maximally distended view via large liquid bolus

Cricopharyngeal dysfunction: a spectrum

Belafsky et al. Laryngoscope, 120:889–894, 2010

Normal Nonobstructive CP bar(< 50%)

Obstructive CP bar(> 50%)

Obstructive CP bar + Zenker’s diverticulum

Treatment considerations

• Those most likely to benefit from procedural intervention✓ Solid food dysphagia

✓ Objective signs of PES obstruction

✓ Intact pharyngeal squeeze

✓ Intact hyolaryngeal excursion

• Other options to consider• SLP swallowing therapy

• Acid suppression

Procedural intervention

• Dilation

• Botulinum toxin injection

• Myotomy (endoscopic)

Procedural intervention

Kocdor et al. Laryngoscope, 126:135–141, 2016

* ZD excluded

Dilation

• Bougie vs. Savary vs. balloon

• Setting – OR vs. office (TNE)

• Main risk• Perforation

• Shared decision making• Temporary

• Trial prior to more definitive intervention

• Poor candidate for myotomy surgery

• Risk-adverse patient

Botulinum toxin

• 10 U to 100 U

• Setting – OR vs. office

• Main risk – inadvertent diffusion• Bilateral vocal fold palsy, airway obstruction

• Profound pharyngeal weakness

• Shared decision making• May be done in conjunction with dilation in OR

• Not always a good predictor of benefit from myotomy

Botulinum toxin

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CP myotomy (endoscopic)

• 1994: 1st description (Halvorson/Kuhn)

• Intraoperative details• General anesthesia

• 1 hr duration

• Microscope

• 5 mm mucosal incision (CO2 laser vs. KTP laser)

• Myotomy in cranial-caudal vector

• Usually no mucosal closure

• Fully awake extubation

• Not a substitution for open operation

“Laser”

CP myotomy (endoscopic)

Pitman MJ, Weissbrod P: Endoscopic CO2 laser cricopharyngeal myotomy. Laryngoscope 119:45-53, 2009

CP myotomy (endoscopic)

CP myotomy (endoscopic)

• Postoperative course• NPO overnight• POD#1 clear liquids → full liquids, then DC• Regular diet by week 3

• Main risk• Uncontrolled perforation

• Shared decision making• Definitive intervention• May still experience symptoms

• Pharyngeal dysfunction• Zenker’s diverticulum• Esophageal dysfunction• Reflux

Summary

• The UES requires 3 components for opening: relaxation, distraction, distention

• Mainstay of assessment of the UES: modified barium swallow study

• CP dysfunction – a spectrum of phenotypes

• SLP collaboration is optimal

• Procedural treatment requires careful patient selection and shared decision making

Thank you