Cricopharyngeal Sphincter Research Articles

Retrograde Cricopharyngeal Dysfunction: A Review.

Retrograde cricopharyngeal dysfunction (RCPD), also referred to as retrograde cricopharyngeus dysfunction, is a condition characterized by the inability to burp. The pathophysiology of this condition is thought to result from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension, which leads to patients' bothersome symptoms. RCPD negatively impacts patients' quality of life and is associated with bloating, gurgling, avoidance of carbonation, self-imposed dietary and lifestyle changes designed to minimize discomfort, and flatulence. Complaints often start during adolescence, and many patients search for a diagnosis for years before obtaining treatment. A recent increase in awareness through patient-led social media discussion boards describing the 'no burp' syndrome is leading to an increasing incidence of presentations, often with patients making a self-diagnosis. The increased incidence of RCPD is fueling a larger case series investigating treatment options and outcomes. In this review, we discuss what is known about the pathophysiology of this condition, the otolaryngologic perspective on diagnosis and treatment, the patients' lived experience of this condition, and the influence of social media on RCPD.

Experiences of Patients Living with Retrograde Cricopharyngeal Dysfunction.

Retrograde cricopharyngeal dysfunction (RCPD) is a newly described condition resulting from failure of cricopharyngeal sphincter relaxation during periods of esophageal distension that results in the inability to burp. Patients' perspectives on symptom experiences, barriers to care, and treatment benefits were investigated. Qualitative semi-structured interviews were conducted with patients diagnosed with RCPD who had been treated with botulinum toxin injection into the cricopharyngeus muscle. Interview questions centered on their experience living with RCPD. Conventional content analysis was performed on interview transcripts. Thematic saturation was reached with 13 participants. All participants were diagnosed with RCPD by an otolaryngologist and underwent botulinum toxin injection into the cricopharyngeus muscle with or without dilation of the upper esophageal sphincter in the operating room. Participants described having no memories of ever being able to burp, and all started experiencing RCPD symptoms during adolescence. Patients with RCPD experienced increased social isolation, lost productivity, and worsened mental health. Unanimously, participants first learned about RCPD on social media. All patients were seen by physicians in non-otolaryngology specialties regarding their symptoms prior to learning about their RCPD diagnosis and undergoing treatment by an otolaryngologist. Dilation and chemodenervation resulted in complete resolution of RCPD symptoms for 84.6% of participants. Participants emphasized a desire for more health providers to learn about RCPD and the impact it has on quality-of-life. The lived experience of patients with RCPD significantly impacts quality of life and is often met with diagnostic barriers in the medical community. Although social media plays a significant role in increasing awareness of RCPD, physician education about the impact of RCPD is essential to improve diagnosis and treatment. 4 Laryngoscope, 134:2136-2143, 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

Cross-System Integration of Respiration and Deglutition: Function, Treatment, and Future Directions.

Swallowing occurs preferentially in the expiratory phase of the quiet breathing cycle and at mid-to-low tidal volume. This coordinative pattern imparts important biomechanical advantages to swallowing and airway protection and facilitate laryngeal elevation, laryngeal vestibular and vocal fold closure, and cricopharyngeal sphincter opening. This preferred coordinative relationship between breathing and swallowing is impaired in a variety of patient populations, including head and neck cancer survivors with dysphagia. We developed a training protocol to re-establish more optimal phasing of swallowing with breathing in these patients with striking outcomes, including reduced swallowing physiological impairments and improved airway protection. This motivated us to continue to refine and expand this training protocol and develop new assistive technologies for swallowing monitoring outside of the lab. In this review, we highlight the origins of our optimal respiratory-swallowing coordination hypothesis, describe the biomechanical advantages it provides, carefully describe our training protocol and findings, and chart a course for the next phase of this work. Our overall goal is to harness technology combined with carefully constructed learning paradigms to improve the lives of patients with impaired respiratory-swallowing coordination consequent to a variety of pathologies including head and neck cancer and degenerative neurological conditions such as Parkinson's disease.

Retrospective Study of the Round Radiopaque Foreign Bodies in the Oesophagus

Introduction Ingested foreign bodies (FBs) of the digestive tract can be divided into radiolucent and radiopaque, based on their appearance in Roentgenogram. Coins and button-batteries (BBs) constitute majority of the radiopaque FBs that are round in shape. Materials and Methods Medical records of children admitted with foreign bodies in the GI tract during the last 5 years have been reviewed. We have taken into our study, round radio-opaque FBs and analyzed the results. Results Out of 120 radiopaque FBs, in 112 cases they are lodged in cricopharyngeal sphincter (CPS), which were removed. Of these, 103 were coins and 9 were BBs. Five coins, which had crossed the CPS, ultimately passed out naturally with faeces. Three BBs, impacted in the oesophagus, distal to the CPS, were removed via esophagoscopy, on emergency basis. One child with impacted BB developed mediastinitis and died. Conclusion A round opaque disc shaped FB which is impacted or seen below CPS should not be treated as coin every time. High index of suspicion is needed to rule out BB ingestion as it is associated with high morbidity and mortality. Aim of this study is to stress on the need for educating primary care physicians and rural medical practitioners to avoid wait and watch policy, thus reducing misdiagnosis of coins for BBs.

An Unusual Foreign body in Esophagus; Report of a Case

Foreign body (FB) ingestion, a common and serious problem in children, can present with a wide variety of symptoms. This case report describes an unusual esophageal foreign body (EFB), in which the patient presented with dysphagia, odynophagia, vomiting, and regurgitation with history of ingesting her mother’s pin. Plain radiograph of the soft tissue neck revealed the presence of a radio-opaque ingested foreign body (the pin) that located at the lower level of cricopharynx. We performed rigid esophagoscopy under general anesthesia. On esophagoscopy the pin was visualized in lower border of the cricopharynx trapped by the cricopharyngeal sphincter at its base. It was hard metallic in consistency and of approximately 2 cm in size

Pharyngoesophageal foreign bodies: clinical presentation and treatment outcome in a tertiary health center

Background: Foreign body (FB) ingestion is a commonly encountered problem in both children and adults in emergency departments. Aim and Objective: This study reviewed the pattern and outcome of rigid esophagoscopic management of pharyngoesophageal FBs in our center. Materials and Methods: The records of patients managed for impacted pharyngoesophageal FBs at the study center over a period of 10 years were reviewed. Information obtained was collated and analyzed using SPSS version 18. Results: A total of 153 patients were reviewed. Among these, 96 (62.7%) were males with sex ratio (M:F) of 1.6:1. The mean age was 23.5 ± 2.3 years. The main presenting complaint was dysphagia 127 (83%). Coin was the most common FB, 33 (21.6%). The most common site of impaction was at the cricopharyngeal sphincter, 58 (37.9%). Complication was encountered in 43 (28.1%) patients. The most common complication encountered during rigid esophagoscopy was mucosal tear, 35 (22.9%). Most patients [97 (63.4%)] stayed for 1 to 3 days on admission; 151 (98.7%) had successful rigid esophagoscopic removal of their FBs. There is a statistically significant correlation between type of FB and duration of impaction with development of complication following rigid esophagoscopy (P value = 0.006 and 0.014, respectively). Conclusion: Rigid esophagoscopy was highlighted in this study as an effective method of removal of pharyngoesophageal FBs; however, ion disc battery and artificial denture are relatively associated with increased complications.

Karakteristik penderita dengan benda asing dalam esofagus di RSUP Sanglah Denpasar periode Januari 2012- Desember 2013

Impaksi benda asing di esofagus adalah keadaan darurat yang sering ditemukan pada berbagai kelompok umur. Anak-anak dan orang tua adalah kelompok umur yang paling sering mengalami impaksi benda asing di esofagus. Penelitian ini bertujuan untuk memberikan gambaran karakteristik pasien dengan benda asing di esofagus di RSUP Sanglah periode Januari 2012-Desember 2013. Penelitian ini adalah penelitian deskriftif retrospektif. Data dikumpulkan dari rekam medis penderita dengan benda asing di esofagus yang datang ke RSUP Sanglah periode Januari 2012-Desember 2013.  Penelitian ini melibatkan 42 penderita sebagai sampel. Enam belas penderita (38,09%) adalah anak dibawah umur 10 tahun. Perbandingan rasio lelaki dengan perempuan adalah 1,6:1. Odinofagia adalah keluhan utama yang paling sering dijumpai (47,62%). Koin adalah benda asing tersering pada anak (87,50%) sedangkan pada orang dewasa adalah tulang (84,61%). Esofagoskopi kaku adalah prosedur baku yang dilakukan pada kasus benda asing di esofagus. Sfingter krikofaring menjadi tempat yang paling sering tertahannya benda asing di esofagus. Sebagian besar benda asing dapat diekstraksi tanpa komplikasi. Sebagian besar benda asing diekstraksi kurang dari 24 jam (66,67%). Lama perawatan sebagian besar kurang dari 3 hari (42,86%). Karakteristik penderita dengan benda asing di esofagus bervariasi pada populasi anak dan dewasa. Pada anak, koin adalah benda asing yang paling sering, sedangkan  pada orang dewasa adalah tulang. Esofagoskopi adalah prosedur  baku yang dilakukan apabila menemukan kasus benda asing di esofagus. Sebagian besar penderita tidak mengalami komplikasi.Â

In this issue – July 2017

In this issue – July 2017

Study using endoscopic procedures for removal of foreign bodies from aero-digestive tract conducted in Jahurul Islam Medical College Hospital, Bangladesh

Foreign bodies (FB) in the aero-digestive tract continue to be a common problem that contributes significantly to high morbidity and mortality worldwide. This study was conducted to describe our own experience with endoscopic procedures for removal of FB in the aero-digestive tract, in our local setting and compare with what is described in literature. This was a prospective descriptive study, which was conducted at Jahurul Islam Medical College Hospital between January, 2011 and January, 2014. Data were collected using a structured questionnaire and analyzed using SPSS computer software version 15. A total of 72 patients were studied. Males outnumbered females by a ratio of 1.4:1. Patients aged 2 years and below were the majority (75.9%). The commonest type of FB in airways was peanuts and coins. The trachea (52.2%) was the most common site of lodgment of FB in the airways, whereas cricopharyngeal sphincter (68.5%) was the commonest site in the esophagus. Rigid endoscopy with forceps removal under general anesthesia was the main treatment modality performed in 87.8% of patients. The FB were successfully removed without complications in 90.8% of cases. Complication rate was 7.1% and bronchopneumonia was the most common complication accounting for 42.8% of cases. The mean duration of hospital stay was 3 days and mortality rate was 4.1%. Aero-digestive tract FB continue to be a significant cause of childhood morbidity and mortality in our setting. Rigid endoscopic procedures under general anesthesia are the main treatment modalities performed. Prevention is highly recommended whereby parents should be educated to keep a close eye on their children and keep objects that can be FB away from children’s reach.Mediscope Vol. 3, No. 1: January 2016, Pages 22-27

Disorders Involving the Pharynx and Upper Esophagus

A wide variety of disorders can affect the pharynx and upper esophagus, such as inherited or acquired structural abnormalities, malignancies, and inflammation secondary to a number of etiologies including bacterial, yeast and viral infections, irradiation, and gastroesophageal reflux disorder. Laryngoceles and peritonsillar abscess can also lead to pain and dysfunction. However, this review will focus on the main motility disorders that affect the pharynx and upper esophagus, namely oropharyngeal dysphagia, disorders associated with globus pharyngeus, and Zenker’s diverticulum. Figures show the anatomy of the three stages of normal swallow, various findings on functional endoscopic evaluation of swallowing, electromyography of the cricopharyngeal sphincter and submental muscles, and Zenker’s diverticulum. Tables list causes of oropharyngeal dysphagia, neuromuscular control of the pharyngeal phase (with identified cranial and cervical spinal nerve roots), pathophysiology of oropharyngeal dysplasia, diagnostic tests for oropharyngeal dysplasia, behavioral treatments to improve swallow and reduce aspiration, and potential overlapping causes of impaired upper esophageal sphincter relaxation. This review contains 4 highly rendered figures, 6 tables, and 40 references Key words: Oropharyngeal dysphagia; Globus; Upper esophageal sphincter dysfunction; Swallowing disorder; Dysphagia; Zenker’s diverticulum; Swallow assessment; Globus pharyngeus

Quantitative Measures of Swallowing Deficits in Patients With Parkinson's Disease.

Dysphagia and associated aspiration pneumonia are commonly reported sequelae of Parkinson's disease (PD). Previous studies of swallowing in patients with PD have described prolonged pharyngeal transit time, delayed onset of pharyngeal transit, cricopharyngeal (CP) achalasia, reduced pharyngeal constriction, and slowed hyolaryngeal elevation. These studies were completed using inconsistent evaluation methodology, reliance on qualitative analysis, and a lack of a large control group, resulting in concerns regarding diagnostic precision. The purpose of this study was to investigate swallowing function in patients with PD using a norm-referenced, quantitative approach. This retrospective study includes 34 patients with a diagnosis of PD referred to a multidisciplinary voice and swallowing clinic. Modified barium swallow studies were performed using quantitative measures of pharyngeal transit time, hyoid displacement, CP sphincter opening, area of the pharynx at maximal constriction, and timing of laryngeal vestibule closure relative to bolus arrival at the CP sphincter. Reduced pharyngeal constriction was found in 30.4%, and a delay in airway closure relative to arrival of the bolus at the CP sphincter was the most common abnormality, present in 62% of patients. Previously reported findings of prolonged pharyngeal transit, poor hyoid elevation, and CP achalasia were not identified as prominent features.

Cricopharyngeal achalasia in an old dog

Abstract : A 10-year-old castrated male papillon presented with nasal discharge, coughing and chronic dysphagia. Onphysical examination, the dog exhibited sneezing, gurgling and movement of the throat with repeated attempts toswallow fluids. A diagnosis of cricopharyngeal achalasia (CPA) was made based on video fluoroscopic demonstrationof failure of relaxation of the upper esophageal sphincter. This report describes the diagnosis of CPA in an old dog,which is rarely diagnosed in older animals.Keywords: cricopharyngeal achalasia, dog, dysphagia, upper esophageal sphincter Cricopharyngeal achalasia (CPA) is a rare swallowing dis-order of the upper esophageal sphincter (UES) in dogs andother young animals [1, 2, 10]. Swallowing disorders may beclassified functionally into oropharyngeal, esophageal andgastroesophageal dysphagia [2, 12]. The oropharyngeal orpreesophageal swallowing disorders can be further subdi-vided into oral phase deficits, pharyngeal phase deficits, def-icits of the cricopharyngeal sphincter and lack of coordinationbetween pharyngeal contraction and cricopharyngeal pas-sage [1, 9, 12]. Both of the latter two deficits, achalasia andasynchrony, have been called CPA [6, 11, 12].Clinical signs of CPA are dysphagia, regurgitation, cough-ing, gurgling, excessive salivation, nasal reflux of fluids, goodappetite with poor growth and possible aspiration pneumo-nia [3, 6, 12]. A tentative diagnosis of CPA can be basedupon history, clinical signs, and survey radiographic findingsbut definitive diagnosis is made by using contrast enhancedvideo fluoroscopy [7, 9, 12]. The conventional and preferredtreatment for CPA is surgical intervention, a cricopharyngealmyotomy or myectomy. If there are no underlying diseasesthat have a negative influence on clinical signs of dysphagia,the prognosis is good for quality of life [1, 3, 10].The most common signalment of CPA is the development ofdysphagia after weaning which is commonly seen in animalsunder a year of age. In a recent study, the median age of dogswho presented clinical sings of CPA was 15 months [1]. Thisreport describes the diagnosis of CPA in an old papillon dog thathas showed clinical signs of dysphagia for almost all his life.A 10-year-old, castrated male, papillon (2.7 kg) was pre-sented to the referring veterinarian with nasal discharge,coughing and chronic dysphagia. According to the owner, thepatient was reported to have been intermittent vomiting since4 months of his age. At that time, he was tentatively diag-nosed with megaesophagus. Since then he has eaten fre-quently with small, high-calorie meals in a cranially elevatedposition. Exclusive of intermittent vomiting, he was wellmanaged before he showed signs of nasal discharge, cough-ing and difficulty respiration. The referring veterinarian wassuspicious of aspiration pneumonia, so initial therapy withvarious antibiotics was performed. But the clinical signs didnot improve.On physical examination the dog appeared bright and alert,but had low body condition score. He exhibited sneezing,gurgling and movement of throat with repeated attempts toswallow saliva. A cough was readily induced on palpatingthe trachea. The temperature, heart and respiratory rates werewithin the normal range and normal respiratory sound wasfound on lung auscultation. Results of complete blood counts(CBC) showed a mild leukocytosis (19.36 × 10

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

P442: The value of SSR recordings in the assessment of autonomic nervous dysfunction in patients with sacral-pudendal impairment

Altered Pharyngeal Muscles in Parkinson Disease

Dysphagia (impaired swallowing) is common in patients with Parkinson disease (PD) and is related to aspiration pneumonia, the primary cause of death in PD. Therapies that ameliorate the limb motor symptoms of PD are ineffective for dysphagia. This suggests that the pathophysiology of PD dysphagia may differ from that affecting limb muscles, but little is known about potential neuromuscular abnormalities in the swallowing muscles in PD. This study examined the fiber histochemistry of pharyngeal constrictor and cricopharyngeal sphincter muscles in postmortem specimens from 8 subjects with PD and 4 age-matched control subjects. Pharyngeal muscles in subjects with PD exhibited many atrophic fibers, fiber type grouping, and fast-to-slow myosin heavy chain transformation. These alterations indicate that the pharyngeal muscles experienced neural degeneration and regeneration over the course of PD. Notably, subjects with PD with dysphagia had a higher percentage of atrophic myofibers versus with those without dysphagia and controls. The fast-to-slow fiber-type transition is consistent with abnormalities in swallowing, slow movement of food, and increased tone in the cricopharyngeal sphincter in subjects with PD. The alterations in the pharyngeal muscles may play a pathogenic role in the development of dysphagia in subjects with PD.

Esophageal Foreign Bodies in Pediatric Patients: A Thirteen-Year Retrospective Study

We discuss clinical symptoms and radiological findings of variable esophageal foreign bodies as well as therapeutic procedures in Caucasian pediatric patients. A retrospective study of 192 cases of suspected esophageal foreign bodies between 1998 and 2010 was conducted. Data were statistically analyzed by chi-square test. A foreign body was removed from a digestive tract of 163 children aged 6 months to 15 years (mean age 4.9). Most objects were located within cricopharyngeal sphincter. Dysphagia occurred in 43%, followed by vomiting (29%) and drooling (28%). The most common objects were coins. Plain chest X-rays demonstrated aberrations in 132 cases, and in doubtful situations an esophagram test was ordered. In the group of thirty-seven patients whose radiograms were normal, esophagoscopy revealed fifteen more objects, which were eventually successfully removed. No major complications occurred. Esophagram should be a second X-ray examination if an object is not detected in plain chest X-ray. We recommend a rigid esophagoscopy under general anesthesia in doubtful cases as a safe treatment for pediatric patients.

Endoscopic procedures for removal of foreign bodies of the aerodigestive tract: The Bugando Medical Centre experience.

BackgroundForeign bodies in the aerodigestive tract continue to be a common problem that contributes significantly to high morbidity and mortality worldwide. This study was conducted to describe our own experience with endoscopic procedures for removal of foreign bodies in the aerodigestive tract, in our local setting and compare with what is described in literature.MethodsThis was a prospective descriptive study which was conducted at Bugando Medical Centre between January 2008 and December 2009. Data were collected using a structured questionnaire and analyzed using SPSS computer software version 15.ResultsA total of 98 patients were studied. Males outnumbered females by a ratio of 1.1:1. Patients aged 2 years and below were the majority (75.9%). The commonest type of foreign bodies in airways was groundnuts (72.7%) and in esophagus was coins (72.7%). The trachea (52.2%) was the most common site of foreign body's lodgment in the airways, whereas cricopharyngeal sphincter (68.5%) was the commonest site in the esophagus. Rigid endoscopy with forceps removal under general anesthesia was the main treatment modality performed in 87.8% of patients. The foreign bodies were successfully removed without complications in 90.8% of cases. Complication rate was 7.1% and bronchopneumonia was the most common complication accounting for 42.8% of cases. The mean duration of hospital stay was 3.4 days and mortality rate was 4.1%.ConclusionAerodigestive tract foreign bodies continue to be a significant cause of childhood morbidity and mortality in our setting. Rigid endoscopic procedures under general anesthesia are the main treatment modalities performed. Prevention is highly recommended whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.

Postsurgical dysphagia: evaluation and rehabilitation

Surgical resection of a malignant tumor in the head and neck regions quite often alters the complex act of swallowing. The goal of dysphagia rehabilitation is to return the patient’s swallowing to as near normal as possible. Although surgical procedures in the oral cavity, tongue, pharynx can affect preparation, control and transport of the bolus, functional disorders following laryngeal surgery are most common and severe. The larynx serves two critical functions during swallowing. First, it elevates anteriorly moving itself from the path of the bolus and contributing to the opening of the cricopharyngeal sphincter. Second, it protects the airways from inhaling acting as a three level valve -- the epiglottis, false vocal folds, and true vocal folds. Any surgical intervention affecting this closure will likely results in aspiration during the swallow. Patients undergoing total laryngectomy have few swallowing problems due to the separation of the airways from the esophagus. On the contrary both partial and reconstructive procedures can significantly affect both the respiratory and the alimentary function. Supraglottic laryngectomy can interfere with laryngeal elevation and sometimes with vocal fold adduction especially when the surgical procedure includes portions of the hyoid bone, base of tongue, aryepiglottic folds, or false vocal folds. Vertical laryngectomies reduce laryngeal closure. When the intervention is limited to one focal fold (cordectomy), the swallowing recovery is usually easily achieved. In frontolateral laringectomy the removal of tissues extends to the opposite vocal fold: in such cases swallowing recovery is still possible with a combination of increased effort and compensatory head posturing. In sub-total/reconstructive laryngectomies (Crico-Hyoido-Epiglotto-Pexy, CHEP and Crico-HyoidoPexy, CHP) the surgeon intends to create a neoglottis able to contracts during swallowing. In such cases critical factors in recovery of swallowing are considered the airway closure at the laryngeal entrance, the propulsive movement of the tongue base and its contact with the posterior pharyngeal wall. Two pernicious, life-threatening complications can slowly compromise the patient’s life aspiration, pneumonia and malnutrition. Diagnostic procedures of swallowing disorders are mainly represented by radiographic contrast examination and by fiberoptics endoscopic evaluation. Compensatory treatment strategies include postural changes, increasing sensory input, modifying volume, consistency and viscosity of foods. Rehabilitative procedures are designed to improve a range of movements of oral or pharyngo-laryngeal structures and increase their sensory-motor integration and timing. Exercises and manoeuvres designed to achieve such goals are considered in detail.

Reversible oropharyngeal dysphagia secondary to cricopharyngeal sphincter achalasia in a patient with myasthenia gravis: a case report.

Bulbar weakness and fatigue resulting in dysphagia and dysarthria is common in myasthenia gravis. In chronic MG it is often assumed that these symptoms herald an exacerbation of the patient's disease and doses of cholinergic agents and immunomodulatory therapies may be increased, along with initiation of plasma exchange. A case is presented in which dysphagia was refractory to standard MG therapy, leading to the subsequent discovery of cricopharyngeal sphincter achalasia as the primary cause of the patient's symptoms rather than an assumed myasthenia gravis exacerbation. The patient's dysphagia resolved after esophageal dilatation. Cricopharyngeal sphincter achalasia is a common disorder producing dysphagia in the elderly and needs to be considered in the evaluation of a myasthenic patient with worsening dysphagia when standard myasthenia gravis therapy fails. Discussion of myasthenia gravis, cholinergic therapy and cricopharyngeal sphincter achalasia is undertaken. Clinicians are encouraged to consider non-neurologic causes of worsening dysphagia in the myasthenic patient.

Reversible oropharyngeal dysphagia secondary to cricopharyngeal sphincter achalasia in a patient with myasthenia gravis: a case report

Bulbar weakness and fatigue resulting in dysphagia and dysarthria is common in myasthenia gravis. In chronic MG it is often assumed that these symptoms herald an exacerbation of the patient's disease and doses of cholinergic agents and immunomodulatory therapies may be increased, along with initiation of plasma exchange. A case is presented in which dysphagia was refractory to standard MG therapy, leading to the subsequent discovery of cricopharyngeal sphincter achalasia as the primary cause of the patient's symptoms rather than an assumed myasthenia gravis exacerbation. The patient's dysphagia resolved after esophageal dilatation. Cricopharyngeal sphincter achalasia is a common disorder producing dysphagia in the elderly and needs to be considered in the evaluation of a myasthenic patient with worsening dysphagia when standard myasthenia gravis therapy fails. Discussion of myasthenia gravis, cholinergic therapy and cricopharyngeal sphincter achalasia is undertaken. Clinicians are encouraged to consider non-neurologic causes of worsening dysphagia in the myasthenic patient.