Aspiration Of Barium Research Articles

Swallowing study using water-soluble contrast agents may increase aspiration sensitivity and antedate oral feeding without respiratory and drug complications: A STROBE-compliant prospective, observational, case-control trial.

Although the modified barium swallowing study (MBSS) is considered the gold standard for assessing aspiration risk, aspiration of lipid-soluble barium can cause chemical pneumonitis or impair radiologic interpretation of the lungs. Water-soluble contrast agents (WSCAs) may avoid these complications while maintaining sensitivity on aspiration.This prospective, observational, case-control cohort trial evaluated all patients >3 years old referred for swallowing study from September 2015 to November 2017. Repeat evaluations of individuals were excluded. High-risk patients were evaluated by WSCA (iohexol)-based swallowing study (WSS) and others by MBSS.The study included 829 evaluations of 762 patients. After excluding 74 evaluations, 365 WSSs and 390 MBSSs were performed. The most frequent underlying condition was brain lesion, followed by aspiration pneumonia. Aspiration occurred more frequently in WSS (147 patients: 40.3%) than in MBSS (36 patients: 9.2%) (P = .00). However, neither aspiration volume (6.72 cc [3.09-10.35] vs 5.53 cc [2.21-8.85]) nor radiographic alterations differed between the 2 groups (P > .05). Moreover, the swallowed (16.62 cc [8.45-24.79]) and aspirated amounts of iohexol were not correlated with radiologic changes or deterioration (P > .05). Switching to oral feeding following WSS was more frequent (164 patients: 44.9%), whereas aspiration pneumonia was not (P = .00). WSS did not prolong the interval to patient discharge (P = .06) or induce an allergic reaction or chemotoxicity over 1 week.The absence of aspiration-induced complications and adverse drug effects suggests that, compared with MBSS, WSS may increase aspiration sensitivity and early switching to oral feeding.

Barium sulfate aspiration pneumonia: A fatal case of death.

Accidental aspiration of barium is a rare event. We present the case of a patient who, after the administration of barium, he showed sudden cough with dyspnea and vomiting and chemical pneumonia with areas of consolidation. The case emphasizes caution when administering barium to patients at risk of aspiration.

Clinical predictors of laryngotracheoesophageal clefts and tracheoesophageal fistulae in children with dysphagia.

Medical records of children aged 0-18 years who underwent flexible and rigid bronchoscopy for evaluation of dysphagia with aspiration were collected and analyzed to identify predictors of LTEC and TEF. Seventy-two children age 2 months to 9 years were identified. LTEC was identified in 19 (26%) and TEF was identified in 1 (1.3%). One-third of the cohort was born preterm (median gestational age 34 weeks). The proportion of LTEC in those born preterm was lower than that of those born full-term (12% vs. 34%, p = .03). There was no statistically significant difference in LTEC prevalence based on age, midline defects, laryngomalacia, tracheomalacia, history of TEF repair, silent aspiration, or viscosity of barium aspirated during videofluoroscopic swallowing studies. Bronchoalveolar lavage fluid cytology, lipid-laden macrophage proportions, and culture results were similar among those with and without LTEC. Children with dysphagia and tracheal aspiration born full-term are three times more likely to have LTEC than those born preterm. Dysphagia in children with a history of preterm birth is more likely to be functional as opposed to structural, however, LTEC was identified in approximately 10% of these children and must be considered. These results support the role of bronchoscopy in children with dysphagia with tracheal aspiration.

S2004 A Hard Pill to Swallow: Oropharyngeal Dysphagia Secondary to Antipsychotics

INTRODUCTION: Dysphagia can be anatomically categorized as either oropharyngeal or esophageal based on where and when the patient endorses difficulty swallowing and oropharyngeal dysphagia secondary to antipsychotic medications is often overlooked. Antipsychotics, especially the first generation, have been classically associated with extrapyramidal symptoms such as dystonia, akathisia, tremors and tardive dyskinesia. Dysphagia is an uncommon side effect of antipsychotics which can lead to choking, asphyxiation, or even aspiration pneumonia. Antipsychotic medications block the D2 receptors in the nigrostriatal pathway which are also hypothesized to regulate motor neurons responsible for complex muscle movements such as swallowing. Here, we present a case of severe dysphagia leading to failure to thrive in an adult after initiation of a first-generation antipsychotic. CASE DESCRIPTION/METHODS: A 69-year-old male with a history of schizoaffective disorder who presented with a one-month history of difficulty swallowing. Three days before this symptom, he was started on Haloperidol for his schizoaffective disorder. He complained of difficulty in initiating a swallow, pointing towards his neck region, which was soon followed by coughing and choking with both solid and liquid food. He stopped eating and drinking due to the overwhelming fear of choking leading to significant weight loss and cachexia. His physical examination was significant for temporal wasting, bradykinesia, cogwheel rigidity and diffuse hyperreflexia. Labs were unremarkable. A barium swallow revealed a difficulty in initiation of swallow, aspiration of thin barium with no spontaneous cough and poor pharyngeal constriction. CT soft tissue/neck revealed no evidence of extrinsic compression and MRI brain was done to rule out a stroke. An upper endoscopy was not performed as the barium swallow provided sufficient information to clinch the diagnosis. The patient’s antipsychotics were discontinued, and his nutritional status had to be optimized with NG tube feedings. After two weeks, the patient was transitioned to a liquid diet and discharged from the hospital. DISCUSSION: Antipsychotic-related oropharyngeal dysphagia is an uncommon side effect; however, it has been reported in case reports. It is important to identify this side effect, especially in elderly patients or patients with pre-existing anatomical or functional changes as it can lead to complications such as asphyxiation and aspiration pneumonia contributing to mortality.Figure 1.: Barium swallow study showing heavy pooling of barium in vallecula and pyriform sinuses.Figure 2.: Barium swallow revealing poor pharyngeal constriction leading to aspiration of thin barium without coughing.

Barium sulphate aspiration during upper gastrointestinal examinations: two cases report and review of the literature

Objective:To investigate the causes of barium aspiration,death rate and the cause of death in the upper gastrointestinal examinations,and to help the doctor selecting a reasonable method in upper gastrointestinal tract examination.Method:Two cases in our hospital was reported,and totally 25 patients in 22 articles were obtained in pubmed or google shchoolar form 1989 to 2014.Purpose of radiologic studies of the upper digestive tract,distribution of the aspirate,clinical presentation and prognosis after aspiration of the sulfate barium in literature were collected.Result:①Aspiration of barium sulfate mainly happened in elderly patients and infant.The age of died group were older than survive group,however,there were no significant difference statistically(F=0.909, P=0.355).②The directly mortality rate associated with barium aspiration was up to 38.1% in adult,and ten patients of them(47.6%) recovered.All the infants were recovered completely form the respiratory distress cause by the aspiration of barium sulfate.③Aspiration may more likelyoccur in certain conditions involving dysphagia and esophageall obstruction by tumor or foreign body.Further,the gastro-esophageal reflux,recent esophageal surgery,eructation and vomiting may also increase the risk of aspiration of the aspiration of barium sulfate.④About 84.0% patients were with initial dyspnea,hypotension,respiratory distress or respiratory failure.A minority of patients without significant reactions,only suffered fever and cough(16.0%).⑤The deposition of barium sulphate were commonly affected both lungs(80.0%).Barium sulfates distributed in unilateral lung only were found in five patients 20.0%.Conclusion:Aspiration may easier occur in certain conditions involving dysphagia and esophageall obstruction by tumor or foreign body.Further,the gastro-esophageal reflux,recent esophageal surgery,eructation and vomiting may also increase the risk of aspiration of the aspiration of barium sulfate.Most of the patients after aspiration of barium were presented with initial dyspnea,hypotension,respiratory distress or respiratory failure.When considerable amounts of barium sulfate are aspirated into the lung leading to arterial hypoxemia and dyspnea,it is mandatory that aggressive treatment with steroids,antibiotics,respiratory physiotherapy,oxygen,and bronchoalveolar lavage is initiated without delay.

Acute necrotiserende pneumonie na bariumaspiratie bij een kat

Bariumsulfaat is een niet-oplosbare contrastvloeistof die bij radiografisch onderzoek van het spijsverteringsstelsel routinematig wordt gebruikt. Tijdens het onderzoek kan er bariumaspiratie optreden, wat ernstige complicaties kan veroorzaken bij zowel mens als dier. In deze casuïstiek wordt een geval van bariumaspiratie beschreven bij een gastro-intestinaal onderzoek van een vier jaar oude, gesteriliseerde pers. Radiografisch en pathologisch onderzoek bevestigde de diagnose van bariumaspiratie.

Accidental severe bronchial aspiration of barium uncovers diagnosis of bronchiectasis

A 77-year-old man, with a history of chronic obstructive pulmonary disease (COPD) and radiotherapy-treated laryngeal malignancy diagnosed 15 years prior, presented with a 1-year history of intermittent dysphagia. As a part of his investigations, a barium swallow was obtained; but during the initial phases of the procedure, the patient aspirated the contrast agent of barium sulphate. A chest radiograph (Fig. 1a), taken few minutes after the aspiration, showed barium within the different segments and subsegments of the bronchial tree bilaterally, and uncovered features, such as irregular dilatation of the bronchial tree, non-tapering of the bronchi, luminal filling defects and lack of bronchial side branches, characteristic of bronchiectasis. This incident precipitated an exacerbation of COPD with type II respiratory failure, requiring bronchodilators, intravenous antibiotics and non-invasive ventilation using a bilevel positive airway pressure machine. On recovery, direct laryngoscopy revealed post-radiotherapy changes but no evidence of tumour recurrence. A speech and language pathology assessment using a few millilitres of water revealed weak laryngeal elevation, and immediate aspiration of water on swallowing. Given the high risk of further aspirations, advice regarding the benefits and risks of nasogastric tube insertion or percutaneous endoscopic gastrostomy tube insertion were given to the patient, but he declined both procedures. Six months following discharge, he was readmitted with an episode of food aspiration. A chest radiograph (Fig. 1b) revealed residual barium in both lung bases. This event precipitated another exacerbation of the COPD and bronchiectasis, which caused the patient to succumb to the disease. As early as the 1920s, the concept of utilizing contrast agents to aid in the diagnosis of pulmonary diseases, in particular bronchiectasis, had transpired. This involved instilling the contrast medium within the bronchial tree, by means of a catheter introduced in the trachea, and followed by the acquisition of various radiographs; a procedure known as bronchography. The initial contrast agents that were used in this regard were mainly waterand oil-based solutions. Subsequently in 1950s, barium sulphate, an inert and non-toxic agent, became a popular bronchographic medium that produced similar images as the earlier contrast agents, until the mid-1970s, when computed tomography became the gold standard imaging study for the investigation of pulmonary diseases. Although the earlier contrast agents, as well as barium sulphate, were considered safe bronchographic media, reports of pneumonitis and even death had been described with both [1]. The instilled contrast agent was found to cause obstruction of the small bronchi, followed by atelectasis of lung tissue and pneumonitis [2]. COPD patients often developed exacerbations after such procedures, as seen in our case. To minimize these risks, after the acquisition of the radiographs, patients were asked to cough and expectorate as much contrast dye as possible in an attempt to clear the airways. However, this mechanism would have been ineffective in cases of extensive small airway filling or ‘alveolarization’ with the contrast medium, as the alveoli lies outside the range of the normal mechanisms (cough and ciliary action) for cleansing the bronchial tree. The case we present demonstrates bronchographic features of bronchiectasis following accidental aspiration of E. Gerada (&) J. Gerada Department of Medicine, Mater Dei Hospital, Msida MSD 2090, Malta e-mail: egerada@gmail.com

Aspiration of barium sulphate in swallow study

Barium swallow is the simple, common routine procedure for the examination of the oropharynx and oesophagus. Aspiration of barium sulphate is a well known complication, occurs accidentally during contrast enhanced examinations of the upper gastrointestinal system. It is reported either as rare or frequent, based on severity of the cases. Certain conditions affecting the anatomical and functional integrity of the oropharynx and oesophagus act as predisposing factors Due to relatively non-irritant nature of barium sulphate, aspiration into the lungs not expected to cause severe lung injury. However, acute inflammation or even death due to high or low density preparations of barium sulphate, have been reported. We present a case of dysphagia, who developed aspiration of barium, during swallow study and managed conservatively without any delayed complications.

The Effect of Nasogastric Tubes on Swallowing Function in Persons With Dysphagia Following Stroke

Wang T-G, Wu M-C, Chang Y-C, Hsiao T-Y, Lien I-N. The effect of nasogastric tubes on swallowing function in persons with dysphagia following stroke. Objective To determine whether the use of a nasogastric tube influences swallowing function in stroke patients with dysphagia. Design Before-after trial. Setting Primary care center. Participants A total of 22 patients with stroke (12 men, 10 women; mean age, 69.7y; range, 19−85y) participated in the study. Time from onset of stroke to time of assessment averaged 20.3 days (range, 14−38d). All participants continued to use a nasogastric tube for nutrition supply and had either minor or no aspiration of barium on videofluoroscopic examination of swallowing (VFES). Intervention The swallowing function was evaluated by VFES with thin and thick bariums (5mL each) as a contrast medium. Main Outcome Measures The oral transit, swallowing trigger, and pharyngeal transit times were measured and compared before and after the removal of the nasogastric tube. The patients were also observed for changes in velopharyngeal closure, pharyngeal contraction, epiglottic tilt, valleculae stasis, pyriform sinus stasis, penetration, and aspiration. Results Transit times were reduced by 0.2 to 0.6 seconds after removal of the nasogastric tube, but the reduction was not statistically significant. These transit times were slightly longer with thick barium than with thin barium, but were without statistical significance. Similarly, most of the patients had no change in nontemporal assessment of swallowing function after the tube was removed. Conclusions The placement of a nasogastric tube did not affect temporal and nontemporal measurement of swallowing in stroke patients with dysphagia with or without minor aspiration.

FDG-PET Findings in Barium Aspiration

A 47-year-old man had nasopharyngeal carcinoma (NPC). He received radiotherapy 10 years ago and was cancer-free after the treatment. However, diplopia occurred 1 year ago and became more progressive recently. An FDG-PET scan was performed to rule out the possibility of recurrence. No abnormal FDG uptake was demonstrated in the head and neck. However, an irregular area of increased FDG uptake was noted in the right lower lung. The plain chest x-ray showed barium retention in the same area, which might have resulted from aspiration of barium during gastrointestinal barium examination 2 years ago. A follow-up chest x-ray showed no apparent change and there was no evidence of metastases in the lung 6 months later.

Barium sulphate aspiration

Correspondence to: Dr Kyoichi Kaira k-kaira@maebashi.jrc.or.jp An asymptomatic 70-year-old man had a barium swallow to screen for gastric cancer. During the examination, the patient aspirated high-density barium contrast medium (200% weight/volume) into his lungs. After 1 h, the patient developed fever, so doctors gave him faropenem 600 mg orally. Chest radiographs showed massive barium sulphate depositions in both lower lobes, middle lobe, and lingula (figure). 48 h later, he became dyspnoeic with worsening hypoxaemia (PaO2 57·2 mm Hg, PaCO2 32·1 mm Hg, breathing room air), and was transferred to our hospital. We treated him with intravenous meropenem 1 g/day and clindamycin 1200 mg/day, physical therapy with postural drainage, and oxygen. He recovered, and was discharged 7 days later. Aspiration of large amounts of barium sulphate is a rare incident during radiographic contrast procedures. In spite of the inert character of barium sulphate, the aspiration of highdensity barium is potentially life-threatening. Barium sulphate aspiration

Unexpected death in association with an occult posterior lingual abscess

An 82 year old woman was found unexpectedly dead in bed on the day of admission to hospital for the investigation of difficulty breathing. During a barium swallow examination after admission she was thought to have aspirated contrast material. At autopsy a large posterior lingual abscess was found, with barium in the airways. Death was attributed to a combination of upper airway narrowing associated with the abscess, chronic lung disease and possible aspiration of barium. This case demonstrates an unusual sequence of events associated with localised upper airway sepsis. It also confirms the importance of careful examination of the upper aerodigestive tract at autopsy in individuals of all ages.

Aspiration in chest compression alone without mechanical ventilation in the head down position in dogs

Background: Previous work by the authors has shown that chest compressions alone without mechanical ventilation during cardiopulmonary resuscitation in the natural supine position was associated with pulmonary aspiration in dogs. The purpose of this investigation was to test the hypothesis that a head down position may prevent aspiration during chest compressions alone and whether oxygenation can be improved by simply insufflation of oral oxygen 10 min after cardiac arrest. Methods: Cardiac arrest was induced in ten mongrel dogs which were anesthetized and paralysed. Eight underwent chest compressions alone in different head down positions using an automatic compressor at 9 kg compression force and 3 cm compression depth. The study was composed of two parts. Part 1 evaluated the effect of insufflation of 10 l/min O 2, into the mouth of the dogs, 10 min after initiation of resuscitation, using chest compressions alone. Part 2 was designed to test our hypothesis that the head down position may protect the lungs from aspiration during chest compression alone. The mouths of the dogs were filled with mixed barium and the dogs underwent serial episodes of chest compressions, for 10 min each, in the 20°head down, 10° head down and the natural supine positions. Chest X-rays with antero-posterior and lateral views were taken to evaluate pulmonary aspiration. Two additional dogs underwent direct chest compression alone in the natural supine position and the time of chest compression was shortened to 5 min. Results: All dogs in the natural position showed evidence of pulmonary aspiration of barium, five or six of the dogs showed tracheal aspiration in the 10° head down position, while no any barium was visualized in the tracheo-broncheal trees of the dogs in the 20° head down position. Supplemental oxygen in the mouth improved the mean Pa O 2 from 67±26 to 160±97 mmHg during chest compressions alone. Conclusion: Chest compression alone without mechanical ventilation in the supine position caused pulmonary aspiration in the unprotected airway in dogs. This complication could be prevented by adopting a 20° head down position. The10° head down position seemed to reduce the severity of the pulmonary aspiration, but not enough to eliminate the danger altogether. Supplemental oxygen in the mouth can improve oxygenation in chest compressions alone.

Modified barium swallow does not affect how often PEGs are placed after stroke.

Dysphagia frequently follows stroke, but often resolves quickly. Percutaneous endoscopic gastrostomy (PEG) or other feeding tubes are placed to improve nutrition and hydration, and reduce the risk of aspiration pneumonitis. We evaluated the impact of modified barium swallow in determining PEG placements and the influence of specific swallowing abnormalities on PEG placement. The abnormalities assessed were presence of pharyngeal stasis and/or visualization of posterior pharyngeal transfer problems and aspiration of liquid or solids. A total of 302 patients with stroke were admitted to our hospital between 1989 and 1993, but only those with hemorrhagic or nonhemorrhagic stroke by computed tomographic (CT) scans or magnetic resonance imaging (MRI) or autopsy were included in our study. Patients with transient ischemic attacks (TIAs), central nervous system tumors, and traumas were excluded. Barium swallow studies were performed on 69 (23%) of patients; 49 (71%) were abnormal, based on aspiration of barium, pharyngeal stasis, or postpharyngeal transfer dysphagia. PEGs were placed in only 18% of those with abnormal studies. Of the patients with normal barium swallow studies, 25% had a PEG placed. Two hundred thirty-three patients underwent no barium swallow studies, but 11 (4.72%) of these had PEG placed. The rate of PEG placement was not related to any one of the abnormalities noted on the modified barium swallow. Rather, patients who received PEG had significant neurological deficits and increased prevalence of aspiration pneumonitis. The decision to insert PEG was made on clinical grounds and not on abnormal barium studies alone.

Effect of posture strategies on preventing aspiration

The purpose of this study was to determine the effect of postural change on preventing aspiration, and the types of swallowing disorder that were influenced by posture. Ninety-five patients that were examined by aspiration of barium during videofluoroscopic examination of oropharyngeal swallow assumed one of four postures (chin down, head rotation, chin down + head rotation, and head back to chin down). Postural strategies were successful in eliminating aspiration in 68(72%) of the 95 patients. Twenty five of the 68 patients, however, needed an additional change in bolus volume to eliminate aspiration. Effective postures eliminating aspiration were chin down for 43 patients, head rotation for 10 patients, chin down + head rotation for 12 patients, and head back to chin down for 3 patients. The successes rates of posture changes for each swallowing abnormality were 76% for reduced tongue base retraction, 74% for delay in triggering pharyngeal swallow, 74% for reduced laryngeal elevation, 73% for laryngeal paralysis, 68% for inefficient oral transit, and in 57% for cricopharyngeal dysfunction. Among individuals with cricopharyngeal dysfunction or with than three swallowing motility problems, the frequency of unsuccessful swallow despite postural change was significantly higher than that of successful swallow. These results indicated that the posture strategies in addition to control of bolus volume could prevent aspiration in more than 70% of patients, but the efficacy of posture techniques differed with the different types of swallowing disorder identified as causing the aspiration, and suggested that the posture strategies were less beneficial in individuals with cricopharyngeal dysfunction or exhibiting multiple swallowing disorders.

Globus sensation: Value of static radiography combined with videofluoroscopy of the pharynx and oesophagus

Pharyngo-oesophageal abnormalities are found in a high proportion of patients with globus sensation. This study compares the diagnostic value of static single- and double-contrast radiography of the pharynx and oesophagus with videofluoroscopy and with videofluoroscopy combined with static radiography in these patients. Pharyngeal and oesophageal morphology and motor function were studied in 130 consecutive patients with globus sensation (46 males, 84 females; mean age, 47 years) by means of static single and double-contrast radiography and by videofluoroscopy. Videofluoroscopy revealed significantly more functional and structural abnormalities compared to static radiography. Pharyngeal and/or oesophageal disorders were found in 89 vs. 47 patients (chi2 [1] = 19.82, P = 0.0001), pharyngeal abnormalities in 54 vs. 27 patients (chi2 [1] = 13.5, P < 0.0002), and oesophageal abnormalities in 72 vs. 27 patients (chi2 [1] = 28.13, P < 0.0001). Videofluoroscopy combined with static radiography revealed significantly more abnormalities than videofluoroscopy alone (chi2 [1] = 4.23, P < 0.05), and assessed mucosal details more reliably than videofluoroscopy alone. The most frequent abnormalities found were nonspecific oesophageal motor disorders, pharyngo-oesophageal sphincter dysfunction, pharyngeal stasis, achalasia, and laryngeal penetration or aspiration of barium. In most patients with globus sensation, pharyngeal and/or oesophageal abnormalities can be detected radiographically. Videofluoroscopy revealed significantly more functional but not morphological abnormalities than did static radiography. Videofluoroscopic studies combined with static radiography had a higher diagnostic value than videofluoroscopic studies alone.

Fatal Pulmonary Aspiration of Barium during Oesophagography

Fatal Pulmonary Aspiration of Barium during Oesophagography

Acute Respiratory Failure Caused by Aspiration of High Density Barium: A Case Report

Acute Respiratory Failure Caused by Aspiration of High Density Barium: A Case Report

Colonic interposition: radiographic evaluation.

This report reviews the clinical and radiographic features of 40 patients who underwent visceral esophageal substitution with colon for benign or malignant lesions of the esophagus. The incidence and radiographic identification of complications are discussed. All patients were routinely examined with barium esophagrams on postoperative day 10. If an anastomotic leak was suspected clinically before this time, studies were performed using water-soluble iodinated contrast material. Follow-up barium esophagrams were obtained 1-96 months after operation (average, 60 months) in 24 patients. Eight patients (21%) demonstrated asymptomatic "jejunization" of the colonic mucosa with no attributable clinical manifestations; this finding resolved in 1-3 months, without sequelae, and has not been reported before. The spectrum of ischemic changes in the colonic segment included mucosal edema, spasm, ulceration, loss of haustration, and frank necrosis. Radiographically detectable early postoperative complications included anastomotic leak in six (three pharyngocolic, three cervical esophagocolic) and aspiration of barium into the tracheobronchial tree due to incoordinated swallowing in eight. Late postoperative complications included anastomotic narrowing (12) malfunctioning of the colon due to impaired emptying (five), recurrent aspiration pneumonia (three), small bowel obstruction (three), transhiatal herniation of small bowel through the diaphragmatic hiatus (one), and reflux into the retained bypassed esophagus (one).

Cricopharyngeal myotomy as a method of treating cricopharyngeal dysphagia secondary to gastroesophageal reflux

Food obstruction at the cricopharyngeal level is a common symptom of gastroesophageal reflux. In selected patients, cricopharyngeal myotomy is effective in relief of symptoms. We have used myotomy in patients whose only symptom was dysphagia, in patients too debilitated for major surgery, and in patients with persistent pharyngoesophageal dysphagia following hiatal hernia repair. All were studied by barium esophagogram, endoscopy, and manometry. Radiologic aspiration of barium was apparent in five of 19 patients. High-speed manometric tracings showed intermittent cricopharyngeal incoordination in the six consecutive patients most recently studied. This finding of incoordination has been shown to be present in 38 patients with reflux and in all with major cricopharyngeal symptoms. Myotomy was effective in relieving symptoms in patients in whom this was the only reflux symptom and in the five patients too debilitated for major surgery. Good symptomatic improvement was obtained in nine of the 12 with persistent dysphagia following hernia repair, but in three relief was partial, with persistent symptoms being secondary to distal esophageal obstruction. Investigation is necessary to exclude other causes of dysphagia. However, withcareful selection, myotomy has proved to be an effective method of treatment.