Cricopharyngeal myotomy (1 of 7)
Upon initial approach to the upper esophagus. The small dark opening in the center is the entrance to the Zenker’s diverticulum or pouch. The point of entry to the esophagus is at the dotted line. The cricopharyngeus muscle lies between the entrances to the Zenker’s pouch and the esophagus.

Cricopharyngeal myotomy (2 of 7)
When the scope is inserted and lifted additionally, the Zenker’s pouch is opened further, and retained food material is seen within. The cricopharyngeus muscle’s contour is seen more clearly (faint dotted line), and the actual opening of the esophagus can be seen at the arrow.

Cricopharyngeal myotomy (3 of 7)
Similar view to photo 2, except that the suction cannula is now inserted into the esophageal opening, further accentuating the contour of the cricopharyngeus muscle.

Cricopharyngeal myotomy (4 of 7)
The food material has been removed from the Zenker’s pouch, and the suction cannula is placed within the esophagus.

Cricopharyngeal myotomy (5 of 7)
Division of the cricopharyngeus muscle is underway, using the CO2 laser. The red aiming beam is visible at the lower end of the incision.

Cricopharyngeal myotomy (6 of 7)
The muscle is now approximately half-divided, along with mucosa lining the anterior wall of the sac (arrow).

Cricopharyngeal myotomy (7 of 7)
The muscle is entirely divided, and the sac marsupialized. The suction cannula (blurry here, but marked by a faint dotted line) now lies within the trough created by the laser. The esophagus is now gaping open; compare with photos 1 through 4 of this series.

Cricopharyngeal dysfunction: before myotomy (1 of 2)
Lateral x-ray of the neck while swallowing barium (seen as a dark column). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)
After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction: before myotomy (1 of 2)
Lateral x-ray of the neck while swallowing barium (the dark material seen here in the throat). The non-relaxing cricopharyngeus muscle (light-grey bulge outlined by a dotted line) is causing narrowing of the upper esophageal passageway, as highlighted by the narrowed stream of dark barium at that point (arrow). Liquids and very soft foods can squeak through this narrow opening, but solid foods tend to get stuck.

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)
After myotomy. The surgically divided muscle can no longer narrow the upper esophageal passageway, as seen by the widened stream of dark barium at the level of the muscle (arrows).

Cricopharyngeal dysfunction: before myotomy (1 of 2)
Elderly patient with nearly a year’s duration of frequent lodgment of solid food at the level of the cricoid cartilage (at the mid-neck level). Note here the cricopharyngeus muscle “bar” which narrows the barium stream (indicated by green dotted line). This narrowing is due to incomplete relaxation of the muscle (aka upper esophageal sphincter) causing a smaller entrance to the esophagus. Liquids and very soft foods can still get through, but solid foods tend to get stuck or to require repeated swallows.

Cricopharyngeal dysfunction: after myotomy (2 of 2)
A month after endoscopic (through the mouth) cricopharyngeus myotomy (division of the muscle with a laser). The patient’s initial swallowing symptoms are completely resolved and the barium stream no longer shows narrowing and the cricopharyngeus bar is no longer seen (see green arrows).

Panormaic view, post CPM (1 of 4)
Panoramic view of larynx and hypopharynx in elderly man with both propulsive/ pitcher and receptive/ catcher swallowing problem. Here, after cricopharyngeus myotomy, the remaining, unaddressed propulsive problem is seen as salivary pooling/ clinging. Laryngeal vestibule is unsoiled, however.

Trumpet maneuver (2 of 4)
Trumpet maneuver opens the hypopharynx including at the level of the divided cricopharyngeus muscle. The curved line and 'X' are to orient this photo in comparison with the next (photo 3).

Closer view (3 of 4)
Closer view of myotomized and therefore non-functional cricopharyngeus muscle, again during trumpet maneuver. Gravity alone could take secretions and small amounts of food down into the esophagus (arrow).

Well-managed saliva (4 of 4)
After 6 boluses of blue-stained applesauce, intentionally given in rapid-pressured fashion to test limits, laryngeal vestibule remains very clean, and pooling does not tend to be deep enough to easily spill over into the laryngeal vestibule. Still g-tube dependent, this man enjoys some food, and manages saliva better than before myotomy.

Immediately after swallowing (1 of 10)
This 98 year-old woman experiences dysphagia that is most noticeable for solids. She is also aware of constant “phlegm” in her throat. In this photo, she has just completed a swallow of her own saliva. See what happens a moment later in the next photo.

Zenker's (2 of 10)
A second later, saliva emerges from below, as her known Zenker’s diverticulum discharges some of its contents upwards into the hypopharynx rather than downwards into the esophagus.

Dysphagia (3 of 10)
During VESS, part 2, she has just completed a swallow of blue-stained applesauce without leaving any immediate post-swallow residue.

Residue from Zenker's (4 of 10)
A second later, the applesauce and saliva retained in her Zenker’s diverticulum is pushed upwards from below.

X-ray showing Zenker's (5 of 10)
An x-ray image showing the Zenker’s diverticulum immediately following her swallow.

Moments later (6 of 10)
A moment later, some swallowed barium has discharged upwards into the hypopharynx.

After myotomy (7 of 10)
A week after endoscopic cricopharyngeus myotomy. The patient says her swallowing has become normal. This view verifies her observation. Here, she has just completed a swallow and after waiting considerable time, no saliva reappears. Compare with photo 2.

No residue (8 of 10)
After not only blue-stained applesauce, but also a cheese cracker, there is no return of material and only a fleck of cracker in the left pyriform sinus (arrow). Compare with photo 4.

Zenker's gone (9 of 10)
After myotomy, note that the Zenker’s sac only puddles at its apex, because the rest of the sac has been marsupialized into the esophagus. Patients with this finding have no swallowing symptoms. Compare with photo 5.

No barium in hypopharynx (10 of 10)
While watching throughout the study, no barium ever emerges upwards into the hypopharynx, in constrast to pre-operatively. Compare with photo 6.