Esophageal Motility Disorders and Diverticula: Physiologic Implication and Surgical Considerations

Zenker’s diverticula are the most common diverticula of the esophagus and attributed to a hypertensive non-compliant cricopharyngeus muscle with reduced sphincter opening. Cricopharygeus myotomy is the treatment with variable management of the diverticulum. Mid-esophageal diverticula are classically attributed to traction, though many are associated with dysmotility similar to epiphrenic/distal esophageal diverticula. Myotomy is again key for symptomatic presentations. Resection of the diverticula and a partial fundoplication are other components in the surgical management. Although treatment of diverticula has evolved over the decades, it remains a rare condition often associated with significant pre-operative symptomatology and post-operative morbidity.

Efficacy and Safety of Electromyography-Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction

Objective To report the efficacy and safety of electromyography-guided percutaneous botulinum toxin injection into the cricopharyngeus muscle in an office setting for treatment of the inability to belch and associated symptoms caused by retrograde cricopharyngeus dysfunction (R-CPD). Study Design Retrospective case series of treated patients. Setting Tertiary care laryngology clinic. Methods A retrospective review was performed on 18 consecutive patients who were diagnosed syndromically with R-CPD. The combined diagnostic test and treatment—specifically, botulinum toxin injection into the cricopharyngeus muscle—was accomplished in an office setting by a single surgeon using electromyography guidance. Items assessed are efficacy, safety, complications, and duration of benefit. Results All 18 patients (100%) treated in the in-office setting gained the ability to burp with improvement in the associated symptoms of R-CPD at initial follow-up. Of those who had the in-office procedure performed initially, 80% maintained the ability to burp at 6 months with relief of all the associated symptoms of R-CPD. No patients experienced permanent complications from the injection, but 7 patients experienced varying degrees of noisy breathing within 1 week after the procedure, which was managed with breathing techniques and resolved. Conclusion In a case series of 18 patients with R-CPD, all patients gained the ability to burp with improvement in the majority of their symptoms of R-CPD at the time of their initial follow-up at 1 week. None experienced severe complications, and 7 experienced transient noisy breathing, which resolved.

Ultrasonography-guided botulinum toxin injection to the cricopharyngeus muscle: a case report and technical notes

Dysphagia associated with the cricopharyngeus muscle (CPm) dysfunction negatively influences the quality of life. This high-pressure region must relax and the lumen must open for smooth food passage. The CP muscle is therefore a common target of chemodenervation with botulinum toxin (BTX). Here we presented a patient with severe left lateral medullary syndrome and non-relaxation of the CPm. We described how to localize the CPm in the transverse and longitudinal views under ultrasonography and offered a video demonstrating ultrasonography-guided BTX injection. Ultrasonography-guided CPm injection with BTX may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

Esophagus

The esophagus is a hollow muscular tube approximately 25 cm in length, extending from the cricopharyngeus muscle to the gastroesophageal junction at the gastric cardia. It is the only organ that uses peristalsis. Achalasia is defined as failure of lower esophageal sphincter relaxation with concurrent esophageal aperistalsis. Esophageal manometry is the standard for diagnosing achalasia and DES. Achalasia is managed surgically with a Heller myotomy. Esophageal surgery may result in an iatrogenic perforation, thoracic duct injury, or anastomotic leak.

The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction

Objectives To report the percentage of patients with symptom relief 6 or more months after botulinum toxin injection into the cricopharyngeus muscle for retrograde cricopharyngeus dysfunction (R-CPD). Study Design Retrospective case series of consecutively treated patients. Setting Tertiary care laryngology clinic. Subjects and Methods A review was performed of the first 200 patients who were diagnosed with R-CPD and treated with botulinum toxin injection into the cricopharyngeus muscle by a single surgeon. The study group was limited to those for whom a minimum of 6 months has elapsed since the injection. Items assessed were efficacy, safety, complications, and duration of benefit. Results Of 200 patients treated, (99.5%) gained the ability to burp and 95% experienced relief of the cardinal symptoms of R-CPD: inability to belch, socially awkward gurgling noises, abdominal/chest pressure and bloating, and excessive flatulence. For those who experienced relief, 159 (79.9%) maintained a satisfactory ability to burp after 6 months. Of those who did not maintain the ability, 12 underwent a second injection, 1 patient underwent 3 subsequent injections, and 3 patients underwent partial myotomy. No patients experienced complications of botulinum toxin injection itself, and 4 patients had complications from esophagoscopy or anesthesia. Conclusion In a case series of 200 patients with retrograde cricopharyngeus dysfunction, 99% experienced relief of the cardinal symptoms and 79.9% experienced lasting relief of their symptoms beyond pharmacologic duration of action after a single injection of botulinum toxin into the cricopharyngeus muscle. Relief can be reestablished in the remainder via additional injection or cricopharyngeus myotomy.