Long-term functional results after endoscopic cricopharyngeal myotomy with CO2 laser: a retrospective study of 32 cases

Dysphagia in Lateral Medullary Syndrome: A Narrative Review

Dysphagia is a common clinical feature of lateral medullary syndrome (LMS) and is clinically relevant because it is related to aspiration pneumonia, malnutrition, increased mortality, and prolonged hospital stay. Herein, the pathophysiology, prognosis, and treatment of dysphagia in LMS are reviewed. The pathophysiology, prognosis, and treatment of dysphagia in LMS are closely interconnected. Although the pathophysiology of dysphagia in LMS has not been fully elucidated, previous studies have suggested that the medullary central pattern generators coordinate the pharyngeal phases of swallowing. Investigation of the extensive neural connections of the medulla oblongata is important in understanding the pathophysiologic mechanism of dysphagia in LMS. Previous studies have reported that most patients with dysphagia in LMS have a relatively good prognosis. However, some patients require tube feeding for several months, even years, due to severe dysphagia, and little has been reported about conditions associated with a poor prognosis of dysphagia in LMS. Concerning specific therapeutic modalities for dysphagia in LMS, in addition to general modalities used for dysphagia treatment in stroke patients, non-invasive modalities, including repetitive transcranial magnetic stimulation and transcranial direct current stimulation, as well as invasive modalities, such as botulinum toxin injection, balloon catheter dilatation, and myotomy for relaxation of the cricopharyngeal muscle, have been applied. For the appropriate application of therapeutic modalities, clinicians should be aware of the recovery mechanisms and prognosis of dysphagia in LMS. Further studies on this topic, as well as studies involving large numbers of subjects on specific therapeutic modalities, should be encouraged.

Efficacy of fluoroscopy-guided endoscopic cricopharyngeal myotomy

BACKGROUND

In endoscopic cricopharyngeal myotomy, surgeons sometimes have concerns about performing an adequate incision with only a narrow intra-cavital view from one direction. In order to overcome these issues, fluoroscopic radiography was used during endoscopic cricopharyngeal myotomy.

METHODS

Peri-operative fluoroscopic radiography was utilised to check the position of the diverticuloscope, and to confirm the extent of the incision during surgery. A balloon catheter was used to determine whether the cricopharyngeal muscle was sufficiently resected. Blood loss, peri-operative complications, and functional oral swallowing scale and penetration aspiration scale scores were evaluated.

RESULTS

In 12 out of 15 patients, intra-operative fluoroscopic radiography showed the diverticuloscope positioned in the post-cricoid area, and the cricopharyngeal muscle was raised and the surgery completed without adverse effect. Swallowing functions improved following surgery.

CONCLUSION

Intra-operative fluoroscopy might improve endoscopic cricopharyngeal myotomy by allowing surgeons to confirm the extent of resection, and by reducing peri-operative morbidity and complication rates.

A novel endoscopic surgery for dysphagia after stroke

BACKGROUND

Dysphagia is a common complication in stroke patients, which severely affects quality of life. This study aimed to evaluate the effectiveness and safety of temperature-controlled plasma radiofrequency (coblation)-assisted endoscopic cricopharyngeal myotomy (CAECPM) for the treatment sustained (>6 months) dysphagia in stroke patients.

METHODS

This retrospective case-control study included a total of 24 stroke patients with sustained dysphagia, who were either treated with transcervical cricopharyngeal myotomy (CPM) (n = 16) or CAECPM (n = 12). The patients' swallowing function was evaluated by the Chinese version of the swallow quality-of-life questionnaire (CSWAL-QOL), and dysphagia and aspiration was evaluated using the videofluoroscopic swallowing study (VFSS) swallowing (VFSS-SWAL) score and VSSF aspiration (VFSS-ASPI) score. In each patient, esophageal pressure and complications were also recorded.

RESULTS

The CSWAL-QOL score was increased and the VFSS-SWAL and VFSS-ASPI scores were reduced after CAECPM treatment. The upper esophageal sphincter pressure was significantly reduced after CAECPM. Only 1 of 12 (8.3%) patients had subcutaneous and mediastinal emphysema, and 2 patients had gastric regurgitation.

CONCLUSION

This exploratory study demonstrates that CAECPM is worth further investigation for dysphagia after stroke. CAECPM may be an effective and safe treatment for sustained dysphagia in stroke patients. Larges and prospective studies are required to validate these results.

Effectiveness of endoscopic cricopharyngeal myotomy in adults with neurological disease: systematic review

OBJECTIVE

To determine the effectiveness of endoscopic cricopharyngeal myotomy on upper oesophageal sphincter dysfunction in adults with upper oesophageal sphincter dysfunction and neurological disease.

DATA SOURCES

Published and unpublished studies with a quasi-experimental design investigating endoscopic cricopharyngeal myotomy effects on upper oesophageal sphincter dysfunction in humans were considered eligible. Electronic databases, grey literature and reference lists of included studies were systematically searched.

REVIEW METHODS

Data were extracted by two independent reviewers. Methodological quality was assessed independently using the PEDro scale and MINORS tool.

RESULTS

Of 2938 records identified, 2 studies were eligible. Risk of bias assessment indicated areas of methodological concern in the literature. Statistical analysis was not possible because of the limited number of eligible studies.

CONCLUSION

No determinations could be made regarding endoscopic cricopharyngeal myotomy effectiveness in the cohort of interest. Reliable and valid evidence on the following is required to support increasing clinical usage of endoscopic cricopharyngeal myotomy: optimal candidacy selection; standardised post-operative management protocol; complications; and endoscopic cricopharyngeal myotomy effects on aspiration of food and laryngeal penetration, mean upper oesophageal sphincter resting pressure and quality of life.

Outcomes of endoscopic cricopharyngeal myotomy with CO2 laser surgery: A retrospective study of 47 patients

BACKGROUND

Endoscopic cricopharyngeal myotomy (ECPM) using CO2 laser surgery presents a less invasive treatment technique when compared to transcervical cricopharyngeal myotomy.

METHODS

Forty-seven patients who underwent ECPM from 2002 until 2013 were included in this study. Patient characteristics, and preoperative and postoperative outcome and complications were scored by retrospective chart review and by using the Deglutition Handicap Index (DHI).

RESULTS

Overall, 40 of 47 patients (85%) experienced relief of symptoms postoperatively. Ten patients (25%) developed recurrent symptoms of dysphagia requiring re-laser surgery. All 40 patients were satisfied at the postoperative visit after an average of 1.3 interventions. DHI scores were better in patients with idiopathic dysfunction and neurologic disease, compared to dysfunction because of prior treatment of head and neck cancer. One patient developed mediastinitis that was successfully treated with antibiotics. There was no mortality.

CONCLUSION

ECPM is an effective treatment for cricopharyngeal dysfunction with a low rate of surgical morbidity and complications. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1022-1027, 2016.

Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy

OBJECTIVES

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. The objective of this systematic review was to evaluate the existing studies on the effectiveness of myotomy, dilatation, and botulinum toxin (BoT) injection in the management of cricopharyngeal dysphagia.

METHODS

PubMed and Web of Science databases were searched to identify eligible studies by using the terms "cricopharyngeal dysfunction," "cricopharyngeal myotomy," "cricopharyngeal botox," "cricopharyngeal dilation," and their combinations from 1990 to 2013. This was supplemented by hand-searching relevant articles. Eligible articles were independently assessed for quality by two authors. Statistical analysis was performed.

RESULTS

The database search revealed 567 articles. Thirty-two articles met eligibility criteria and were further evaluated. The reported success rates of BoT injections was between 43% and 100% (mean = 76%), dilation 58% and 100% (mean = 81%), and myotomy 25% and 100% (mean = 75%). In logistic regression analysis of the patient-weighted averages, the 78% success rate with myotomy was significantly higher than the 69% success rate with BoT injections (P = .042), whereas the intermediate success rate of 73% with dilation was not significantly different from that of either myotomy (P = .37) or BoT (P = .42). There was a statistically significant difference between endoscopic and open myotomy success rates (P = .0025). Endoscopic myotomy had a higher success rate, with a 2.2 odds ratio.

CONCLUSIONS

The success rate of myotomy is significantly higher than the success rate of BoT injections in cricopharyngeal dysfunction. Moreover, endoscopic myotomy was found to have a higher success rate compared to open myotomy.

Treatment of cricopharyngeal dysfunction: a comparative pilot study

Background

Cricopharyngeal dysfunction is a narrowing at the level of the upper oesophageal sphincter caused by failed or incomplete sphincter opening as a result of lack of pharyngoesophageal coordination or reduction in the muscular compliance of the upper oesophageal sphincter. Oropharyngeal dysphagia is a typical symptom. Videomanometry allows direct comparison of pressure readings with dynamic anatomy during swallowing.

Methods

This is a prospective randomized pilot study that compares the effect of balloon dilatation and laser myotomy in cricopharyngeal dysfunction. We used videomanometry as an objective measure and the Swedish version of Sydney Swallowing Questionnaire as patient’s self-assessment at baseline and 1 and 6 months after treatment.

Results

The UES sagittal diameter increased from 5.6 mm pre-operatively to 8.4 mm 6 months post-operatively with no differences between treatment groups. Preoperative mean Sydney Swallowing Questionnaire score was 770 and 6 months post-operative score 559, with no difference between the treatments in our cohort.

Conclusion

Cricopharyngeal dysfunction treatment by either laser myotomy or balloon dilatation improved upper oesophageal sphincter opening during at least 6 months.

Trial registration: ISRCTN84905610, date: 081214

Management of cricopharyngeus muscle dysfunction

The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter (UES). In dysphagia, cricopharyngeus muscle dysfunction (CPD) refers to the muscle's failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD, and the resultant clinical manifestation is solid food or solid and liquid dysphagia. Several diagnostic tools are available for dysphagia clinicians to distinguish CPD from other causes of UES dysfunction. For CPD, accurate diagnosis is paramount for the recommendation of appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia.