Cricopharyngeal Muscle Dysfunction Research Articles

Retrograde cricopharyngeal dysfunction and treatment with botulinum toxin: a systematic review.

Retrograde cricopharyngeal dysfunction (RCPD) is a disease first described systematically in 2019. The main symptom is inability to belch due to cricopharyngeal muscle dysfunction. Other symptoms include gurgling noises, chest pain, bloating, and excessive flatulence. This paper aims to describe RCPD, the aetiology and diagnosis, treatment options, follow-up, and treatment with botulinum toxin (BT). A systematic review was done according to the PRISMA guidelines, using the databases PubMed, Embase, and Cochrane at 8/3/2024. The search combined BT with different descriptions of RCPD. All papers were screened by two authors. 120 papers were identified in the search. After screening 13 papers describing 472 patients in total were included. Mean age was 29.3years with 51.1% men. Diagnosis was established in 82.4% of the cases by symptomatology, 2.1% by high-resolution manometry, and 15.3% by oesophagoscopy. The mean amount of BT was 66 units (U). Mean follow-up time was 13months. After 1-4weeks 93.7% had an effect post-treatment and 81.0% after 6months. Common symptoms were inability to belch (99.8%), chest pain and/or bloating (95.4%), gurgling noises (84.9%), and excessive flatulence (75.9%). Common complications were mild and transient dysphagia (59.4%) and reflux (35.4%). The accumulated numbers of patients with RCPD indicates a growing attention to the plausible condition. Injection with BT is a good and safe treatment of RCPD. Most patients only experience mild and transient complications to the treatment. Much is still unknown about RCPD and conditions for setting the diagnosis needs to be evaluated and established internationally.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. Level III Laryngoscope, 134:2678-2683, 2024.

Endoscopic Botulinum Toxin Injection for Infantile Cricopharyngeal Achalasia: Long Term Effects of a Single Procedure - A Case Report

Background: The cricopharyngeus muscle forms the Upper Esophageal Sphincter and separates the esophagus from the hypopharynx. Its main function is to prevent reflux of gastric contents causing Laryngo-Pharyngeal Reflux. Achalasia secondary to cricopharyngeal muscle dysfunction is more common in adults, the treatment of which would be a cricopharyngeal myotomy. However when this is encountered in the pediatric age group, the challenge lies in accurately diagnosing it and choosing the appropriate management option. We would like to report one such case of cricopharyngeal spasm causing achalasia in an infant presenting with failure to thrive and aspiration pneumonitis and was diagnosed and treated with endoscopic botulinum toxin injection, a minimally invasive procedure and associated with less morbidity, early recovery times and significant improvement of symptoms. Positive response to the minimally invasive method of Inj.Botulinum Toxin with minimal morbidity can always be reassuring of a successful cricopharyngeal myotomy, if required, at a later date. Hence, a trial of Inj.Botulinum Toxin in an otherwise rare condition with a difficult diagnosis can be a safe approach in the pediatric age group and can help prognosticate the role of second stage cricopharyngeal myotomy, if required. Objectives: Minimally invasive procedure on an infant with achalasia secondary to cricopharyngeal spasm presenting with failure to thrive and aspiration pneumonia. Methods: Injecting Botulinum toxin into cricopharyngeal sphincter endoscopically. Results: Positive response seen in the infant evidenced by weight gain and tolerance to solid feeds. Conclusion: Positive response to the minimally invasive method of Inj.Botulinum Toxin with minimal morbidity can always be reassuring of a successful cricopharyngeal myotomy, if required, at a later date. Keywords: Cricopharyngeus, Achalasia, Infant, Endoscopic Botulinum toxin injection

Comparison studies of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in the treatment of neurogenic cricopharyngeal muscle dysfunction.

Cricopharyngeal muscle dysfunction (CPD) management has been challenging in clinical practice. To compare the efficacy and safety of ultrasound-guided botulinum toxin injection and balloon catheter dilatation in treating CPD. Forty patients with CPD were randomly divided into two groups, namely the botulinum toxin injection group (BTX group) and balloon dilatation group (BD group). Patients in the BTX group received a single ultrasound-guided injection of 50 units of botulinum toxin type A, while the BD group received dilatation therapy five times per week, consecutively for two weeks. Relative opening percentage of the upper esophageal sphincter (UES), the penetration-aspiration scale (PAS), and the Dysphagia Outcome Severity Scale (DOSS) were evaluated by a videofluoroscopic swallowing study (VFSS) at baseline, 1-month, and 3-months posttreatment. The Functional Oral Intake Scale (FOIS) and Standardized Swallowing Assessment (SSA) were also used to evaluate participants' swallowing function at baseline and the 1-week, 2-week, 1-month, and 3-month follow-ups. A generalized estimating equation (GEE) model revealed the significant main effect for time in UES, PAS, DOSS, FOIS, and SSA compared to baseline (P <0.05), while no group-by-time interactions (except for the PAS assessment) or main effect for treatment was detected among the above multiple variances. No systematic complications or severe adverse effects were noted. Both ultrasound-guided botulinum toxin type A injections and balloon dilatation therapy have been proven as safe and effective treatments for CPD patients. Future clinical trials with longer follow-up periods and more participants are warranted.

Endoscopic botulinum toxin injection for treatment of pharyngeal dysphagia in patients with cricopharyngeal dysfunction

Background: Dysphagia associated with neurologic disorders is a problem worldwide. However, few studies have assessed the efficacy of endoscopic botulinum toxin injections into the cricopharyngeal muscle using a pharyngoscope.Methods: Fourteen patients who received an endoscopic botulinum toxin injection due to cricopharyngeal muscle dysfunction and a neurological disorder from 2006 to 2017 were retrospectively reviewed at a single tertiary medical center. The toxin was injected at a 100 international unit (IU) total dose under direct endoscopic vision. The success of the procedure was evaluated comprehensively using the following: clinical resolution of the previous symptoms, functional oral intake scale (FOIS) for the clinical evaluation of swallowing, and videofluoroscopic swallowing study (VFSS) to check decreased retention of barium at the pyriform sinus and the epiglottic vallecula.Results: The study included 12 males and 2 females (mean age, 58 years old; range, 37–82 years). Three patients (21.4%) were confirmed clinically and eleven were confirmed by VFSS. Eleven patients (78.6%) were managed successfully with the injection. Three patients (21.4%) did not improve despite the injection.Conclusion: An endoscopic botulinum toxin injection may be a good treatment option for patients with dysphagia and cricopharyngeal dysfunction due to a neurological disorder. Large, prospective, long-term follow-up studies are needed in the future.

Endoscopic approach to cricopharyngeal hypertonicity and hypopharyngeal diverticulum

Cricopharyngeal (CP) muscle dysfunction may be an etiology for oropharyngeal dysphagia. The CP muscle may fail to relax fully, or in a coordinated fashion during the swallowing reflex. Alone this may cause dysphagia, but may also precipitate a pulsion diverticulum, known as Zenker's diverticulum. When symptom severity and radiographic and endoscopic evaluation warrant intervention, endoscopic and open surgical options to manage these issues are available. This article strives to describe the techniques of endoscopic CP myotomy and Zenker's diverticulostomy. Patient selection, contraindications for the surgery, and potential complications are described.

Endoscopic cricopharyngeal myotomy

Dysphagia secondary to cricopharyngeal muscle dysfunction (achalasia) is not uncommon. Dysfunction can be seen in isolation, in association with Zenker's diverticulum, or as a contributing component to more global dysfunction of the swallowing mechanism. Treatment has traditionally involved an open transcervical approach under general anesthesia, with complete lysis of the muscle fibers and concomitant extraction of the associated diverticulum when indicated. In select patients, the muscle can be divided endoscopically. Endoscopic myotomy offers several advantages over traditional open myotomy, including the avoidance of an incision, no risk of recurrent laryngeal nerve or great vessel injury, and low risk of perforation and fistula. In addition, endoscopic myotomy affords precise targeting of the affected muscle. This article will describe the technique, its indications, and its potential complications.

Cervical Esophageal Perforation and Cricopharyngeal Dysfunction

Spontaneous perforation of the esophagus is an uncommon event; when it does occur, it usually affects the thoracic esophagus. We present a rare and fatal case of spontaneous perforation of the cervical esophagus in a 68-year-old woman. We believe this rupture was related to a proximal outlet obstruction secondary to cricopharyngeal muscle dysfunction.

Dysphagia in Inclusion Body Myositis

To evaluate the clinical features, treatment strategies, and outcome of dysphagia in patients with inclusion body myositis. Retrospective review of all 26 patients (20 women, 6 men, mean age of 72.2 yrs) with inclusion body myositis-associated dysphagia seen in 1997-2001 at our institution. Twenty-four patients (92%) had a dysphagia evaluation. Cricopharyngeal muscle dysfunction was noted in all nine patients who had barium swallow studies. Eighteen patients (69%) underwent one or more interventional procedures: cricopharyngeal myotomy (10), pharyngoesophageal dilation (6), percutaneous endoscopic gastrostomy (6), and botulinum injection of the upper esophageal sphincter (2). Dysphagia tended to worsen with time. Symptomatic improvement was noted with cricopharyngeal myotomy (63%) and pharyngoesophageal dilation (33%). The Mendelsohn maneuver seemed helpful in maintaining oral intake in the three patients in whom it was recommended. Thirteen patients died during follow-up at a mean age of 81 yrs. The cause of death was identified in eight and in all cases was because of the respiratory complications of aspiration. Dysphagia is a progressive condition in patients with inclusion body myositis and often leads to death from aspiration pneumonia. Treatment targeting cricopharyngeal muscle dysfunction, such as the Mendelsohn maneuver, will benefit from further investigation.

PR_146: Dysphagia in Patients With Inclusion Body Myositis: Management and Clinical Outcome

Objective: To assess the clinical features, treatment strategies, and clinical outcome of patients with inclusion body myositis (IBM) and dysphagia. Design: Retrospective review. Setting: Multidisciplinary group practice. Participants: 26 consecutive patients (mean age, 72.2y) with IBM-associated dysphagia seen in 1997 to 2001. Interventions: Not applicable. Main Outcome Measures: Presence of dysphagia, and response to rehabilitation and interventional treatment. Results: Dysphagia in patients with IBM was more common in women (20:6). 11 patients (42.3%) presented with dysphagia as an initial presenting symptom. The common dysphagia-related symptoms included the sensation of food sticking, coughing while eating, and difficulty eating solid and dry foods. Cricopharyngeal muscle dysfunction was noted in all patients who had barium swallow studies. Swallowing compensation techniques and exercises were of unclear benefit, but the Mendelsohn maneuver as an exercise appears to help in maintaining oral intake. 18 (69%) patients underwent interventional procedures: 10, cricopharyngeal myotomy; 6, pharyngoesophageal dilation; 6, percutaneous endoscopic gastrostomy; and 2, botulinum injection. The mean follow-up duration was 55.5 months. Dysphagia tended to worsen with time, with improvement noted only in those who were treated interventionally: 5 with cricopharyngeal myotomy and 1 with pharyngoesophageal dilation. 13 (50%) patients died, with the mean age at death of 80.8 years and the mean interval of 110.4 months after the diagnosis of IBM. When the cause of death was identified in 7 patients, it was respiratory complications of aspiration in all 7. Conclusions: Dysphagia may precede weakness of the extremities and be a presenting symptom of IBM. Treatment involves both conservative and interventional measures. Despite interventional procedures in 69% of the patients, dysphagia in IBM was generally progressive. Selective patients may benefit from cricopharyngeal myotomy. Aspiration was the main cause of death in this population.

Botulinum Toxin Type A for Poststroke Cricopharyngeal Muscle Dysfunction

Kim DY, Park C, Ohn SH, Moon JY, Chang WH, Park S. Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction. Objective To evaluate the therapeutic effectiveness of botulinum toxin type A (BTX-A) in poststroke patients with cricopharyngeal muscle dysfunction. Design Before-after trial. Setting University hospital. Participants Eight poststroke patients. Intervention BTX-A injection into the cricopharyngeal muscle under endoscope guidance for poststroke cricopharyngeal muscle dysfunction. Main Outcome Measures Clinical symptom score, disability rating scale for swallowing impairment, videofluoroscopic swallowing study, and upper esophageal sphincter (UES) manometry. Results Clinical symptom score, disability rating scale for swallowing impairment, residue in piriform sinus, and UES pressure were all significantly improved at 2 weeks after BTX-A injection compared with evaluations before injection ( P<.05). The effects on the clinical symptom score and disability rating scale for swallowing impairment continued to be significantly improved to 12 weeks after injection ( P<.05). However, the residue in piriform sinus and the UES pressure at 12 weeks postinjection were reduced compared with before-injection evaluations; these results were not significant. The pharyngeal transit time was not changed after injection. There were no side effects observed in the patients studied. Conclusions The results of the present study suggest that BTX-A injection may be an effective and safe treatment in patients with poststroke cricopharyngeal muscle dysfunction.

SUCCESSFUL TREATMENT OF LONG-STANDING POST-STROKE DYSPHAGIA WITH BOTULINUM TOXIN AND REHABILITATION

Cricopharyngeal myotomy is the most common treatment used to restore normal swallowing in patients with persistent (>6 months) cricopharyngeal muscle dysfunction post-stroke. We describe 2 patients whose dysphagia was due to cricopharyngeal muscle over-activity and who significantly improved after a percutaneous botulinum toxin injection in the cricopharyngeal muscle in combination with a rehabilitation treatment (dietary modifications, postural techniques, airflow protection manoeuvres). Swallowing was assessed clinically and by fibreoptic endoscopic evaluation of swallowing and videofluoroscopy; the degree of dysphagia was scored using the penetration-aspiration scale. Two months after the botulinum toxin injection the patients, who were previously fed via percutaneous endoscopic gastrostomy, returned to independent oral feeding and at 6, 12 and 24 months follow-up, both were still able to maintain an adequate oral intake with no signs of aspiration (by videofluoroscopy) or clinical complications. No further botulinum toxin injections or rehabilitation treatments were required. Our findings strongly suggest that even long-standing dysphagia can improve dramatically in selected patients. To the best of our knowledge, there are no other reports with such a long follow-up.

Solving dysphagia due to cricopharyngeal muscle dysfunction with botulinum toxin

Solving dysphagia due to cricopharyngeal muscle dysfunction with botulinum toxin

Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO2 laser have been described. Endoscopic cricopharyngeal myotomy using a CO2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker's diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy. In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure. Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction.

Videofluoroscopic swallow studies in unilateral cricopharyngeal dysfunction.

Although the cricopharyngeus muscle is a ring-like structure, unilateral cricopharyngeal dysfunction can produce significant dysphagia. This entity has not been well described in the literature. The aims of the study were to identify the characteristic findings on videofluoroscopic swallow studies in patients with dysphagia secondary to unilateral cricopharyngeal dysfunction, to note the associated vagal nerve injury, and to evaluate patient outcomes following ipsilateral cricopharyngeal myotomy. Retrospective clinical investigation. The clinic charts, electromyographic tests, videostroboscopic examinations, and videofluoroscopic swallow studies were reviewed from a series of patients who presented to our institution from 1993 to 2001 with dysphagia and findings on videofluoroscopic swallow studies suggestive of unilateral cricopharyngeal dysfunction on posterior-anterior view. In patients treated with ipsilateral cricopharyngeal myotomy, postoperative findings on swallow studies and patient outcomes were also reviewed. Eighteen patients demonstrated findings characteristic of unilateral cricopharyngeal muscle dysfunction on videofluoroscopic swallow study. The common feature was a unilateral shelf-like barrier at the cricopharyngeus on the posterior-anterior view with pooling of liquid bolus in the ipsilateral pyriform sinus and episodic shunting to the contralateral side. Eight patients did not have evidence of cricopharyngeal dysfunction (ie, cricopharyngeal bar) on lateral films. Of the 18 patients, 14 had histories consistent with vagal injury secondary to trauma (n = 2), neoplastic involvement (n = 7), iatrogenic injury (n = 2), or central nervous system disease (n = 3). Results of videostroboscopic examinations demonstrated vocal fold motion impairment in 14 patients, and electromyographic test results confirmed unilateral vagal injuries in those who underwent electromyographic testing (n = 6). In the remaining 4 of 18 patients, videostroboscopic examinations demonstrated normal vocal fold abduction but impaired lengthening with a posterior glottic gap, and electromyographic test results (n = 4) indicated unilateral superior laryngeal nerve involvement. Of the 15 patients treated with ipsilateral cricopharyngeal myotomy, 1 patient required postoperative esophageal dilations for an esophageal stricture distal to the cricopharyngeus, whereas the remaining 14 patients had functional resolution of their dysphagia. In patients presenting with dysphagia and evidence of unilateral vagal injury, careful assessment of posterior-anterior view on videofluoroscopic swallow study should be included to evaluate for unilateral cricopharyngeal dysfunction.

Botulinum toxin in the treatment of cricopharyngeal dysphagia.

Dysphagia is a common symptom in various neurological disorders affecting pharyngeal functions. Cricopharyngeal dysfunction is one of the major findings in these patients. The most effective treatment for restoring normal swallowing function in persistent cricopharyngeal dysfunction is cricopharyngeal myotomy, especially when mechanical obstruction or a well-localized neuromuscular dysfunction, such as a cricopharyngeal muscle spasm, is present. However, when there is a more diffuse neurological disorder present the results of surgery are more disappointing. In unclear cases, or in patients with temporary problems, no good method other than swallowing training, bougienage, and tube feeding are available. During the past decade, botulinum toxin has been found to be of therapeutic value in the treatment of a variety of neurological disorders associated with inappropriate muscular contractions such as torticollis and spasmodic dysphonia. Recently, injections of botulinum toxin in patients with cricopharyngeal muscle dysfunction have been reported to result in marked relief of dysphagia. In this article we describe our experiences with botulinum toxin injections to treat four patients suffering from deglutition problems and cricopharyngeal dysphagia of different origins. Botulinum toxin was injected into the cricopharyngeus muscle that was identified by endoscopy under general anesthesia. In this study, no major side effects were observed. Three patients obtained a significant improvement of esophageal symptoms after the first injection. The treatment had limited effect in one patient who had reflux disease and only slight cricopharyngeus dysfunction.

Improvement of dysphagia following cricopharyngeal myotomy in a group of elderly patients. Histochemical and biochemical assessment of the cricopharyngeal muscle.

Cricopharyngeal myotomy is not effective in all cases of dysphagia. However, it should be the specific treatment in cases of dysphagia caused by a primary cricopharyngeal muscle dysfunction. Of a group of 10 patients with swallowing disorders in the absence of any defined cause, 7 (mean age, 81.6 years) were improved by a myotomy and 3 were not. The cricopharyngeal muscle was studied histologically and biochemically and compared to muscle obtained from nondysphagic subjects. In the muscle of the 7 improved patients, homogeneous histologic abnormalities were demonstrated: connective tissue infiltration, inflammatory cell infiltration, and degenerative changes of the muscle fibers. Conversely, muscles of the nonimproved patients and of the controls did not present the same degree of histologic lesions.

Analysis of intrabolus forces in patients with Zenker's diverticulum.

This report presents 10 patients with Zenker's diverticulum who were evaluated with simultaneous solid-state manometry and fluoroscopy. With this method, intrabolus forces are determined. Each patient had abnormal intrabolus forces regardless of the size of the diverticulum and cricopharyngeal muscle dysfunction. In the literature, there has been conflicting manometry results when studying Zenker's diverticulum. The use of analysis of intrabolus forces increases the sensitivity of manometric evaluation. This study establishes pressure abnormality in the pharyngoesophageal segment of patients with Zenker's diverticulum. The pathogenesis of Zenker's is presented based on these findings.

윤상인두근장애에 의한 연하장애 1례

윤상인두근장애에 의한 연하장애 1례

Altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases.

Swallowing disorder is an increasing problem in our aging population. A majority of these patients have a functional abnormality of the oral, pharyngeal, and/or esophageal stage of swallowing. However, what constitutes normalcy is not well understood, and baseline swallowing in elderly persons without dysphagia has not been adequately described. We therefore evaluated 56 persons with a mean age of 83 years who had no symptoms of dysphagia or eating difficulty. Videofluoroscopy and radiographs with the subject erect and recumbent were obtained. Normal deglutition, as defined in young persons, was present in only 16%. Oral abnormalities (difficulty ingesting, controlling, and delivering bolus relative to swallowing initiation) were seen in 63%. Pharyngeal dysfunction (bolus retention and lingual propulsion or pharyngeal constrictor paresis) was seen in 25%. Pharyngoesophageal segment abnormalities were observed in 39% (mostly cricopharyngeal muscle dysfunction). Esophageal abnormalities (mostly motor in nature) were observed in 36%. What has been described as swallowing dysfunction in young persons may not be abnormal in very elderly persons. It is difficult to distinguish the effect of normal aging from the effects of specific diseases or gradual degenerative changes.