Abstract
Objective
To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar.
Methods
All patients had an idiopathic CP bar without a history of Zenker’s diverticulum, head and neck cancer, or systemic neurologic disease treated between 2000 and 2013. The Functional Outcome Swallowing Scale (FOSS) was utilized to assess dysphagia symptoms.
Results
Twenty-three patients underwent 46 dilations and 20 patients had a myotomy. Nineteen of 23 (83%) patients in the dilation group and all patients in the myotomy group reported improved swallow function. The median difference in pre- versus post-intervention FOSS scores was not statistically significant (p = 0.07) between the dilation and myotomy groups with mean reductions of 1.3 and 1.8, respectively. Seventeen of 23 (74%) dilation patients had persistent or recurrent dysphagia with 13 (57%) requiring repeat dilation and 4 (17%) undergoing CP myotomy. The median time to first reintervention in the dilation group was 13.6 months. Nineteen of 20 (95%) surgical myotomy patients did not experience recurrent dysphagia.
Conclusion
Both endoscopic CP dilation and myotomy led to similar initial improvement in swallow function for patients with primary idiopathic CP bar; however, dilation is more likely to provide temporary benefit.
1
Introduction
The cricopharyngeus muscle is located within the upper esophageal sphincter where it spans between 2.5 and 4.5 cm in length to prevent reflux of gastric contents and allow bolus passage during swallowing . Dynamic function and coordinated relaxation of the CP muscle is necessary for successful deglutition; however, CP dysfunction encompasses a broad spectrum of clinical manifestations and pathologies. Narrowing of the CP segment may represent an incidental radiographic finding for some individuals , while in others it is the cause of severe dysphagia, aspiration and gastrostomy tube dependence.
Abnormalities at the level of the CP muscle can be organized as either primary or secondary CP dysfunction . Secondary etiologies may include neurogenic, myopathic and local structural lesions, such as cerebrovascular accident, inclusion body myositis, and recurrent laryngeal nerve paralysis. Primary CP dysfunction is characterized by idiopathic narrowing of the pharyngoesophageal segment and can be due to restricted opening, hypertensive qualities, incomplete or abnormal relaxation, and impaired coordination of the CP muscle . Many cases of primary CP dysfunction are idiopathic ; however, gastroesophageal reflux disease , age-associated fibrosis , and underlying neuromuscular disorders are postulated as associated disease states.
Treatment interventions for primary CP dysfunction include endoscopic dilation, botulinum toxin injection and surgical myotomy. Many patients with CP-associated dysphagia are elderly with multiple comorbidities and non-surgical treatments are often most compatible with their overall state of health . Although dilation and botulinum toxin injection techniques have demonstrated excellent safety and efficacy, the gold standard of therapy remains surgical myotomy . This retrospective review seeks to compare the outcomes and complication rates of endoscopic CP dilation versus myotomy in patients with primary idiopathic CP dysfunction at a single multi-specialty tertiary care medical facility.
2
Materials and methods
The clinical database was retrospectively reviewed to identify patients with idiopathic oropharyngeal dysphagia secondary to isolated CP bar treated with endoscopic dilation in the gastroenterology department and CP myotomy, either open or endoscopic, in the otolaryngology department between 2000 and 2013. The Mayo Clinic Institutional Review Board approved the project prior to initiation of the study. As described by Wang et al., a CP bar is defined as a radiographic finding on video swallow fluoroscopy whereby a distinct posterior impression of the cervical esophagus is observed inferior to the level of the vocal cords . Patients were excluded from the study if obstruction at the CP segment was less than 50%. The original search criteria identified patients without a history of head, neck and esophageal cancer or radiation therapy, Zenker’s diverticulum larger than 1 cm in maximum length, vocal cord paralysis, anatomic stricture, cervical spine surgery, history of cerebrovascular accident leading to cranial nerve dysfunction, and systemic neuromuscular disease. Additionally, patients in the dilation group were excluded if they had prior dilation or surgical myotomy before the study period, while the myotomy group included patients with a history of prior CP dilation and botulinum toxin injection. Eighty-eight patients with oropharyngeal dysphagia were treated with endoscopic dilation of the cricopharyngeus muscle and 380 total CP myotomies were completed in the study time period between 2000 and 2013.
Diagnostic work-up included video fluoroscopic swallow study, esophagram and upper endoscopy. Patients with idiopathic CP dysfunction were counseled on their therapeutic options, including dietary modifications, swallow therapy, medical management, botulinum toxin injection, endoscopic dilation and surgical myotomy. Treatment decisions were based on patient age and comorbidity status, the severity of dysphagia, neck mobility, mouth opening and patient preference.
Endoscopic dilation was performed under conscious sedation in the outpatient gastroenterology procedure suite. Using an over-the-guidewire technique, sequential Savary dilators (Cook Medical, Bloomington, IN) were used to dilate the stenotic CP segment. At the conclusion of the dilation, endoscopic evaluation was performed to examine the dilated region for bleeding, mucosal tears and perforation.
In patients who underwent transoral endoscopic CO 2 laser CP myotomy, direct laryngoscopy was performed with either a Dohlman or Weerda laryngoscope. If adequate exposure of the cricopharyngeus muscle was achieved, the CO 2 laser was then used to incise through the mucosa and CP muscle with preservation of the underlying buccopharyngeal fascia. For the external CP myotomy, an incision was made along the anterior border of the sternocleidomastoid muscle. The carotid sheath was retracted laterally and the laryngotracheal structures were retracted anteromedially. The pharynx and esophagus were then identified and a 3–4 cm CP myotomy was completed. Patients were allowed to take clear liquids for the first 24 h and then advanced to soft solids for the next 3–4 days prior to advancing to a general diet.
The reviewer (APM) assigned a FOSS score to correlate with the patient’s clinical dysphagia history pre- and post-intervention ( Table 1 ) . The primary clinical outcome measure was defined as improvement in the FOSS score after the primary intervention, either dilation or myotomy, at the initial postoperative follow-up appointment. The reviewer was not blinded to the study objective. Due to less detailed clinical follow-up after revision dilation procedures, FOSS scores were only consistently available before and after primary dilation and myotomy. Secondary outcome measures included the need for revision treatment interventions, the time to reintervention and procedure-associated complication rates.
| Stage | Symptoms |
|---|---|
| 0 | Asymptomatic with normal function |
| 1 | Episodic or daily dysphagia symptoms with normal physiologic function |
| 2 | Compensated abnormal swallow function with significant dietary modification and/or prolonged meal time; no weight loss |
| 3 | Decompensated abnormal swallow function leading to weight loss (<10% of body weight) over 6 months; or dysphagia manifested as daily cough, gagging or aspiration |
| 4 | Severely decompensated abnormal function leading to weight loss (>10% of body weight) over 6 months; severe aspiration with bronchopulmonary complications; or non-oral feeding for >50% of nutrition |
| 5 | Nonoral feeding for all nutrition |
Kaplan–Meier and nonparametric analyses were used to calculate the median time to reintervention in the dilation groups. A Wilcoxon rank sum test was used to statistically compare the pre- versus post-FOSS scores in the dilation and myotomy patient groups.
2
Materials and methods
The clinical database was retrospectively reviewed to identify patients with idiopathic oropharyngeal dysphagia secondary to isolated CP bar treated with endoscopic dilation in the gastroenterology department and CP myotomy, either open or endoscopic, in the otolaryngology department between 2000 and 2013. The Mayo Clinic Institutional Review Board approved the project prior to initiation of the study. As described by Wang et al., a CP bar is defined as a radiographic finding on video swallow fluoroscopy whereby a distinct posterior impression of the cervical esophagus is observed inferior to the level of the vocal cords . Patients were excluded from the study if obstruction at the CP segment was less than 50%. The original search criteria identified patients without a history of head, neck and esophageal cancer or radiation therapy, Zenker’s diverticulum larger than 1 cm in maximum length, vocal cord paralysis, anatomic stricture, cervical spine surgery, history of cerebrovascular accident leading to cranial nerve dysfunction, and systemic neuromuscular disease. Additionally, patients in the dilation group were excluded if they had prior dilation or surgical myotomy before the study period, while the myotomy group included patients with a history of prior CP dilation and botulinum toxin injection. Eighty-eight patients with oropharyngeal dysphagia were treated with endoscopic dilation of the cricopharyngeus muscle and 380 total CP myotomies were completed in the study time period between 2000 and 2013.
Diagnostic work-up included video fluoroscopic swallow study, esophagram and upper endoscopy. Patients with idiopathic CP dysfunction were counseled on their therapeutic options, including dietary modifications, swallow therapy, medical management, botulinum toxin injection, endoscopic dilation and surgical myotomy. Treatment decisions were based on patient age and comorbidity status, the severity of dysphagia, neck mobility, mouth opening and patient preference.
Endoscopic dilation was performed under conscious sedation in the outpatient gastroenterology procedure suite. Using an over-the-guidewire technique, sequential Savary dilators (Cook Medical, Bloomington, IN) were used to dilate the stenotic CP segment. At the conclusion of the dilation, endoscopic evaluation was performed to examine the dilated region for bleeding, mucosal tears and perforation.
In patients who underwent transoral endoscopic CO 2 laser CP myotomy, direct laryngoscopy was performed with either a Dohlman or Weerda laryngoscope. If adequate exposure of the cricopharyngeus muscle was achieved, the CO 2 laser was then used to incise through the mucosa and CP muscle with preservation of the underlying buccopharyngeal fascia. For the external CP myotomy, an incision was made along the anterior border of the sternocleidomastoid muscle. The carotid sheath was retracted laterally and the laryngotracheal structures were retracted anteromedially. The pharynx and esophagus were then identified and a 3–4 cm CP myotomy was completed. Patients were allowed to take clear liquids for the first 24 h and then advanced to soft solids for the next 3–4 days prior to advancing to a general diet.
The reviewer (APM) assigned a FOSS score to correlate with the patient’s clinical dysphagia history pre- and post-intervention ( Table 1 ) . The primary clinical outcome measure was defined as improvement in the FOSS score after the primary intervention, either dilation or myotomy, at the initial postoperative follow-up appointment. The reviewer was not blinded to the study objective. Due to less detailed clinical follow-up after revision dilation procedures, FOSS scores were only consistently available before and after primary dilation and myotomy. Secondary outcome measures included the need for revision treatment interventions, the time to reintervention and procedure-associated complication rates.
| Stage | Symptoms |
|---|---|
| 0 | Asymptomatic with normal function |
| 1 | Episodic or daily dysphagia symptoms with normal physiologic function |
| 2 | Compensated abnormal swallow function with significant dietary modification and/or prolonged meal time; no weight loss |
| 3 | Decompensated abnormal swallow function leading to weight loss (<10% of body weight) over 6 months; or dysphagia manifested as daily cough, gagging or aspiration |
| 4 | Severely decompensated abnormal function leading to weight loss (>10% of body weight) over 6 months; severe aspiration with bronchopulmonary complications; or non-oral feeding for >50% of nutrition |
| 5 | Nonoral feeding for all nutrition |
Kaplan–Meier and nonparametric analyses were used to calculate the median time to reintervention in the dilation groups. A Wilcoxon rank sum test was used to statistically compare the pre- versus post-FOSS scores in the dilation and myotomy patient groups.
3
Results
Twenty-three patients with oropharyngeal dysphagia secondary to idiopathic CP bar were treated with endoscopic dilation and included in the study. Data results are summarized in Table 2 . There were a total of 46 dilations: 45 endoscopic Savary dilations and one balloon dilation. Ten patients were dilated with maximum Savary dilator sizes between 42 and 48 Fr and 12 patients were maximally dilated between 51 and 60 Fr. Ten patients were male and 13 were female. The mean age at first dilation was 74 years of age (range: 46–95 years). Five (22%) patients had cardiac disease, including atrial fibrillation, coronary artery disease, valvular disease or heart failure, 3 (13%) had chronic obstructive pulmonary disease, and 4 (17%) had diabetes mellitus type II. Four (17%) patients reported pre-treatment weight loss secondary to dysphagia.
