Primary cricopharyngeal dysfunction: Treatment with balloon catheter dilatation

doi:10.1067/mge.2001.118442

Gastrointestinal Endoscopy

Volume 54, Issue 6, December 2001, Pages 767-771

Presented at the Groupe Europien d'Etude des Maladies de l'Oesophage meeting, March 2-4, 2000, Würzburg, Germany.

https://doi.org/10.1067/mge.2001.118442 Get rights and content

Abstract

Background: Primary cricopharyngeal dysfunction (PCD) is a rare, idiopathic, functional disorder of the upper esophageal sphincter, characterized by dysphagia, frequent aspiration, and functional narrowing at the level of the upper esophageal sphincter. Methods: Five of 29 patients with oropharyngeal dysphagia were found to have PCD. Patients presented with severe dysphagia and predisposition to aspiration. Radiography demonstrated narrowing at the level of the upper esophageal sphincter and aspiration. An endoscope could be introduced into the esophagus in only 2 patients before dilation. Observations: In contrast to organic stenoses, these functional upper esophageal sphincter stenoses were dilated without difficulty with a balloon catheter. After low-pressure (1.5-2 atm) progressive balloon dilation (to 20 mm), superficial mucosal injury was observed only in one patient. After dilatation, symptoms resolved and barium swallow demonstrated normal passage through the upper esophageal sphincter. During a mean follow-up of 21 months (7-33), redilation was necessary in only 1 case. Conclusions: Balloon catheter dilatation of PCD is minimally invasive and provides both important diagnostic information and effective therapy. It should be the first choice of therapy for PCD.

Section snippets

Patients and methods

Twenty-nine patients with OPD were evaluated between 1995 and 1999. To exclude secondary causes of OPD, a medical history, physical examination, and radiographic swallowing study (fluoroscopic or video) were performed, followed by upper endoscopy (with biopsies if necessary). Esophageal manometry was performed before and after UES dilation. Synchronous fluoromanometry was not performed. To exclude extraluminal organic processes, radiologic studies and CT were obtained. Neurologic and

Observations

Balloon dilation of the UES was initiated at 15 mm in 2 cases, 18 mm in 1, and at 20 mm in 2 patients. The maximum diameter achieved in all cases was 20 mm (Table 2). With a distention pressure of 2 atm, the waist on the balloon disappeared in all cases. Superficial mucosal splitting was observed in 1 patient in whom a 20-mm diameter balloon catheter was used at the first dilation.

After balloon dilation, all patients were free of dysphagia, coughing, and aspiration, and radiographically the

Discussion

PCD is a rarely diagnosed disorder that usually goes untreated. The leading symptoms are dysphagia, weight loss, regurgitation, aspiration, and coughing. The symptoms are evoked by functional obstruction of the UES, which can be detected by endoscopy and radiographic swallowing studies. In most cases there is either incomplete relaxation of the UES or a functional lack of coordination between the pharynx and UES. Premature closure is often demonstrated in patients with Zenker's diverticulum,⁹

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Cited by (61)

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Citation Excerpt :
In a small retrospective case series of 6 patients undergoing balloon or bougie dilation, all patients noted immediate improve in dysphagia and 3/6 patients had long-term resolution of dysphagia [55]. Other small case series have shown success rates between 80% and 100% for dilation of CP bars [56,57]. In a larger retrospective study of patients undergoing bougie dilation for CP bars, 81% had improvement in swallowing scores lasting at least 1 month following dilation and greater than half of patients (18/31) did not require repeat dilation [58].
The upper esophageal sphincter functions to facilitate antegrade transit during deglutition and restrict retrograde flow of refluxed material from the esophagus. Neuropathic, myopathic, and inflammatory conditions can result in upper esophageal sphincter dysfunction and lead to detrimental consequences of dysphagia and aspiration. Proper evaluation of oropharyngeal swallowing is critical to diagnosing upper esophageal sphincter pathology. The aim of this review is to describe the diagnosis and treatment of disorders of the upper esophageal sphincter.
Treatment of oropharyngeal dysphagia secondary to idiopathic cricopharyngeal bar: Surgical cricopharyngeal muscle myotomy versus dilation
2016, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
To compare swallowing outcomes following cricopharyngeal (CP) dilation versus surgical myotomy in patients with dysphagia secondary to idiopathic CP bar.
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.
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.
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.
Effective management of cricopharyngeal achalasia in infants and children with dilatation alone
2016, Journal of Pediatric Surgery
Citation Excerpt :
Anamnesis and VFS swallowing studies are usually enough for diagnosis. In VFS there is an obstruction at the cricopharyngeal level [1,2,9,10]. Laryngeal penetration, tracheobronchial aspiration, pharyngeal stasis, and nasal regurgitation can be seen in VFS [3].
Cricopharyngeal achalasia (CPA) is a rare clinical condition that is characterized by aspiration, choking, and nasopharyngeal regurgitation. The aim of this study is to introduce the outcomes of dilatation alone in children with CPA.
After the evaluation of upper esophageal sphincter with endoscopy, dilatation was performed. All patients underwent videofluoroscopic evaluation and swallowing therapy after the surgical procedure. A retrospective chart review was performed in children with CPA.
Thirty children who were videofluoroscopically proven to have CPA were included in the study. Their age range was 15 days–7 years (median 11 months). Twenty-one of them were neurologically impaired. Two children were lost to follow-up. Nineteen patients (68%) had a total resolution of CPA and were symptom-free with 1–6 dilatations (median 2). Three of the children (11%) who were severely neurologically impaired had resistant CPA. Three children (11%) treated recently with short follow-up were added to the group. Their VFS evaluations demonstrated improvement, thus we accepted their result as successful. There were two perforations in the series. Three patients died; one 2-month-old (2500 g) baby who was accepted from the intensive care unit passed away on postoperative on the 7th day. Two other babies who were unresponsive to dilatation therapy died on follow-up.
Dilatation can be a safe and effective method on children who are correctly diagnosed to have CPA.
Management of isolated cricopharyngeal dysfunction: Systematic review
2016, Journal of Laryngology and Otology
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^☆: Reprint requests: Jenö Solt, MD, I. Department of Medicine, Baranya County Hospital, Raksczi u. 2., 7623, Pécs, Hungary.

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Case StudiesPrimary cricopharyngeal dysfunction: Treatment with balloon catheter dilatation☆

Abstract

Section snippets

Patients and methods

Observations

Discussion

J Thorac Cardiovasc Surg

Gastroenterology

Lancet

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Pediatric Surg

Achalasia of cricopharyngeus sphincter: record of cases with profile pharyngograms

J Laryngol Otol

Approach to the patent with dysphagia

Biomechanics of cricopharyngeal bars

Gastroenterology

Cricopharyngeal myotomy: management of cervical dysphagia

Otolaryngol Head Neck Surg

Pharyngoesophageal diverticulum: its management and complications

Ann Surg

Paralysis of deglution, a post-poliomyelitis complication treated by section of the cricopharyngeus muscle

Ann Surg

Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia

Otolaryngol Head Neck Surg

Cricopharyngeal myotomy for pharyngeal diverticulum

Ann Surg

Case Studies
Primary cricopharyngeal dysfunction: Treatment with balloon catheter dilatation☆