Cricopharyngeal Muscle Hypertrophy: “Bar”rier Causing Upper Esophageal Food Impaction

Abstract

Introduction: Esophageal food impaction occurs in 13 per 100,000 people, usually in the distal esophagus due to luminal compromise from a peptic stricture or obstructing Schatzki's ring. Impactions in the upper third of the esophagus are less common and can occur due to cricopharyngeal muscle (CPM) dysmotility, cervical spur, Zenker's diverticulum, or esophageal webs. Antegrade bolus propulsion occurs when adequate pharyngeal pressure propels ingested bolus in the presence of coordinated relaxation of the CPM. Management of proximal esophageal food impaction is a challenge given the proximity of the impacted bolus to the airway and technical difficulties encountered during disimpaction maneuvers with a flexible endoscope. Case Report: 59 year old female with a history of hypertension, alcohol and drug abuse, cervical spine injury presented an hour after choking on pork. She reported similar symptoms and intermittent dysphagia to solids for many years without prior endoscopic evaluation. Occasional solid food impaction was usually completely relieved after drinking copious amounts of fluids or Heimlich maneuver delivered by her husband. She visited emergency room after none of the previous interventions provided relief. She had been drooling since the choking event, but was able to talk in full sentences. She did not have a laryngeal stridor. Vital signs and oral exam were unremarkable. Chest xray and lateral neck X ray did not reveal opaque intraluminal esophageal density. Neck CT showed a food bolus in upper third of esophagus, figure 1. At endoscopy, solid food bolus was encountered just below the upper esophageal sphincter (figure 2). Zenker's diverticulum was not seen either on CT or endoscopy. The impacted food bolus was removed piecemeal using multiple endoscopic accessories including Roth net, snare and tripod. The adult gastroscope was switched to a pediatric endoscope and the remaining food bolus was pushed into the distal esophagus and subsequently the stomach. Following removal of the impacted bolus, a barium swallow to rule out esophageal injury showed CPM hypertrophy (hypopharyngeal bar), figure 3. As the patient's dysphagia relieved, she had immediate travel plan, she elected to defer further evaluation for her dysphagia with a modified barium swallow and esophageal manometry.Figure 1Figure 2Discussion: CPM hypertrophy should be considered in patients who present with food bolus impaction in the proximal esophagus. Cricopharyngeal bar causing dysphagia is encountered more commonly in the older adult. Treatment options include endoscopic or surgical myomectomy, botulinum toxin injection, or esophageal dilatation.