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Laryngology seminar Cricopharyngeal dysphagia

Laryngology seminar Cricopharyngeal dysphagia. December 27,2007 R3 王彥斌. Anatomy . Inferior to inferior constrictor muscle Transverse fiber without midline raphe Innervations : pharyngeal plexus (CN 10, 9 , cervical sympathetic trunk). Physiology . Swallowing 3 phase

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Laryngology seminar Cricopharyngeal dysphagia

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  1. Laryngology seminarCricopharyngeal dysphagia December 27,2007 R3王彥斌

  2. Anatomy • Inferior to inferior constrictor muscle • Transverse fiber without midline raphe • Innervations : pharyngeal plexus (CN 10, 9 , cervical sympathetic trunk)

  3. Physiology • Swallowing 3 phase • Oral – Pharyngeal – Esophageal • Pharyngeal phase • Tongue base propels bolus • Pharyngeal contraction : clear residue • Larynx-hyoid complex : elevated • Cricopharyngeal muscle relax

  4. Physiology • Resting : constant tonus • Relax before arrival of peristaltic wave to allow bolus pass • Then contract to higher of equal pressure • Vagus n section : • unilateral ↓: relaxation phase • Bilateral : abolish relaxation • Stimulation : sharp relaxation • Stimulation of SCG : pressure ↑

  5. Dysfunction of CPm • 3 categories • Fail to completely relax (achalasia) • Incompetence of the UES (chalasia) • Delayed opening of the cricopharyngeus

  6. Cricopharyngeal Achalasia • Idopathic • Neurological CPA • Stroke • C.N. palsy (vagal, CN9) • Parkinsonism • Poliomyositis • Dermatomyositis • Amyotrphic lateral sclerosis

  7. Symptoms • Dysphagia in lower neck • Choking • Vague throat discomfort • Globus sensation

  8. Diagnosis • Hx taking • Barium swallowing : non-specific • Classic cricopharyngeal bar • Transient partial obstruction • Manometric pressure • VFSS

  9. Treatment • Cricopharyngeal myotomy • Botox (botulium toxin)

  10. Cricopharyngeal myotomy • 1926 Jackson & Shallow : CP muscle relaxation dierticulum • 1946 dilatation of CPm • 1950 Asherson : For CP achalasia • 1951 Kaplan : For cervical dysphagia of poliomyelitis

  11. External CP myotomy • Incision along ant border of SCM • Divide omohyoid m. • Identify CPm myotomy to cervical esophagus • 4-5 cm long : thy-hyo mem to sup esophagus • 7-10 cm long : sup cornu of thy cartilage to clavicle • Unroof underlying mucosa • Pharyngeal muscle distention

  12. Endoscopic approach • Balloon dilatation

  13. Indication • Purely defective relaxation of CPm • Tongue/pharyngeal propulsion : ok • Laryngeal-hyoid elevation : ok

  14. Zenker’s diverticulum • Pharyngeal propulsion  herniation of mucosa • Diverticulectomy or diverticulopexy • Neurogenic disorder • CVA : good response • Parkinson’s : good • Oculopharyngeal dystrophy : good • AML : poor

  15. Head and neck surgery : controversial • 1961 Ogura JH et al : improved swallowing by myotomy after ablative H&N surgery (supraglottic laryngectomy) • 1999 Jacob JR et al : 125 pt H&N ca • Tongue base resection, supraglottic laryngectomy • Oropharyngeal swallowing not changed • Prevention aspiration after supraglottic laryngectomy

  16. Botox injection • Discovery in 1897 • 1990 NIH : strabismus, blepharospasm, hemifacial spasm, adductor spasmodic dysphonia, cervical dystonia • 8 subtypes: A B,C1,C2,DEFG • BTX-A used in USA • Binding to pre-synaptic cholinergic nerve terminals (block release of Ach at NM junc)

  17. Temporary • Works 3 days later • Lasting up to 6 months

  18. In cricopharyngeal achalasia • Treatment and diagnosis • General anesthesia • Short-term muscle relaxant • Percutaneous injection : EMG, CT videofluoroscopy • Direct way : esophagoscope, laryngoscope • Flexible scope • Dorsomedial and both ventrolateral side (100U)

  19. 65-90% successful rate • Average 4 months duration (longest 17m)

  20. Results • Type of diet • BW gain • Aspiration • Feeding tube

  21. ® hypoglossal neuroma • 25 y female • Unilateral hypoglossal paralysis ® • MRI proved hypoglossal neuroma • Suboccipital craniotomy tumor excision (2004-12) • CN 7 8 9 10 12 palsy • Persisted dysphagia • VFSS : severe pharyngeal dysphagia

  22. 2005-08 • Dysport 500U ( clostridium botulinum type A toxin-hemaggluttin complex) • Mix n/s to 2.5 ml ( 200U/ml) • 0.6 ml / each site : 3 sites • 2005-10 • Gastrostomy due to persisted dysphagia • 2006-04 • Improved swallowing (removal of gastrostomy on 2006-06

  23. References • Jacob JR et al : Failure of cricopharyngeal myotomy to improve dysphagia following head and neck cancer surgery. Arch Otolaryngol Head Neck Surg. 1999 Sep;125(9):942-6. • Wisdom G, Blitzer A. : Surgical therapy for swallowing disorders. Otolaryngol Clin North Am. 1998 Jun;31(3):537-60. • Lerut T et al : Zenker's diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology. 1992 Apr;39(2):127-31. • Kelly JH. : Management of upper esophageal sphincter disorders: indications and complications of myotomy.Am J Med. 2000 Mar 6;108 Suppl 4a:43S-46S. • Ellis FH Jr et al : Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy.Ann Surg. 1981 Sep;194(3):279-89. • McKenna JA, Dedo HH. : Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol. 1992 Mar;101(3):216-21. • Ahsan SF et al : Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngol Head Neck Surg. 2000 May;122(5):691-5. • Atkinson SI, Rees J. : Botulinum toxin for cricopharyngeal dysphagia: case reports of CT-guided injection.J Otolaryngol. 1997 Aug;26(4):273-6. • Blitzer A, Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia.Otolaryngol Head Neck Surg. 1997 Mar;116(3):328-30.

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