Antegrade Cricopharyngeal Dysfunction (A-CPD)

Antegrade cricopharyngeal dysfunction (A-CPD) is the failure of the tonically contracted upper esophageal sphincter to relax and open when one swallows. It is also known as cricopharyngeal achalasia. The cause is usually unknown.

The upper esophageal sphincter is also known as the cricopharyngeus muscle and is located at the lower level of the voicebox or larynx. This muscle is always contracted except at the moment of swallowing, when it relaxes briefly to let food or liquid pass through.

Symptoms

Typically, individuals with A-CPD first notice that pills or solid food begin to lodge at the level of the lower part of the larynx. The problem tends to progress inexorably, though often slowly, as the years pass, until the individual must limit himself or herself to liquid and soft foods.

Treatment

Cricopharyngeal dysfunction is fully resolved through a straightforward surgical procedure (cricopharyngeal myotomy), performed through the mouth with the laser or, only occasionally, through a neck incision.

Early A-CPD

The cricopharyngeus muscle (CPM) and upper esophageal sphincter (UES) are virtually synonymous terms. That muscle/sphincter is located at the junction between the lower throat (pharynx) and upper esophagus.

When not in use it is (paradoxically) contracted. It only relaxes, momentarily, when one swallows saliva, liquid, food, pills, etc. (It must also relax momentarily to permit burping or vomiting. Those who swallow normally but can’t burp have retrograde cricopharyngeus dysfunction [R-CPD], described elsewhere.)

What Are the Symptoms of A-CPD?

In some people, the muscle begins failing to relax completely when swallowing. Across many years, the degree of relaxation for the moment of swallowing progressively decreases. At first, one may experience lodgment at the level of mid-to-lower neck of pills, steak, etc. After a few years, the person begins to eat only soft, well-chewed food, avoiding things like meat and bread. As time passes, even formerly easy foods become difficult.

If the problem is ignored long enough, the person becomes limited to (in the words of one elderly patient who had been symptomatic for 20 years), “cream of wheat and canned peaches.”

Fortunately, the problem can be resolved by cricopharyngeus myotomy. That is mostly done endoscopically (through the mouth) using a laser. This procedure has been described elsewhere.

CP Muscle thumb in larynx x-ray — CP Thumb (1 of 4)

This shows a swallow of liquid, with the CP muscle “thumb” projecting into the barium stream at the star. Though the incompletely relaxed muscle narrows the barium stream, it is still reasonably wide at the narrowest point (red arrow). One can almost “imagine” an incipient Zenkers—or where a diverticulum might be beginning to develop—as a tiny pointed projection from the barium stream, indicated by the white arrow.

x-ray showing trouble swallowing due to CP muscle — Bottleneck in X-ray (2 of 4)

This is different swallow of a bolus of puree-consistency barium. Here, the degree of projection of the “thumb” of the muscle is a bit less. This illustrates why not every swallow may be experienced the same by the patient. Between individual swallows, all of the following can vary: consistency of the bolus, its volume, the time chewed, and even the effort put into the swallow. The reasonably wide barium stream at the “bottleneck,” suggests that this person might only have trouble swallowing large pieces of solid food or perhaps a large pill.

Incipient Zenker's Diverticulum in X-ray — Incipient Zenker’s Diverticulum (3 of 4)

Here is another swallow showing a more convincing “incipient Zenker’s” outpouching (white arrow). It might take many more years to develop a persistent diverticulum of any size.

x-ray showing Swallow-To-Swallow Variability — Swallow-To-Swallow variability (4 of 4)

This subsequent swallow of puree is the most successful one documented in the entire videoendoscopic swallow study (VESS). For reference, the star again indicates the (here, mostly relaxed) cricopharyngeus muscle. Note that the barium stream seems virtually normal in caliber. This illustrates again the swallow-to-swallow variability the patient may experience early in their journey. As muscle dysfunction progresses over years, gradual increase of symptoms is expected, but this patient may not yet be ready to undergo cricopharyngeal myotomy.

A-CPD, before, during, and after Myotomy.

Non-relaxing cricopharyngeus muscle (1 of 4)

View of hypertrophied, non-relaxing cricopharyngeus muscle, and resultant narrowed entry into the esophagus, at arrows.

Opening the esophageal orifice (2 of 4)

Suction cannula is being used to forcefully stretch open the esophageal orifice, by pressing posteriorly against the cricopharyngeus muscle.

Laser cricopharyngeus myotomy (3 of 4)

Laser cricopharyngeus myotomy in progress. Notice the horizontally-directed fibers of the cricopharyngeus muscle which are being transected. Red dot is aiming beam of the laser.

Cricopharyngeus myotomy nearly complete (4 of 4)

Only a few fibers remain at arrow. Notice widely patent opening to esophagus resulting from myotomy.

The Cricopharyngeus Muscle Seen During Swallowing

This person struggles to swallow due to a combination of prior tongue cancer surgery decades ago, and longterm radiation effects. Solid foods are the most problematic, and so this sequence shows an attempt to swallow water stained with blue food coloring.

Swallowing crescent (1 of 5)

Panoramic view of the hypopharynx and larynx during breathing. E = epiglottis. Arrows point to the open vocal cords with triangular entrance to airway between them. Dotted line indicates the “swallowing crescent” including part of pyriform sinuses and post-arytenoid space.

Swallowing water (2 of 5)

Blue-stained water is collected in the “swallowing crescent” and about to enter the upper esophagus. The larynx is closed anteriorly (lower photo). The V marks the same post-arytenoid location in subsequent photos.

Relaxed CPM (4 of 5)

With the blue water now passed into the esophagus, the partially relaxed sphincter is seen more clearly, again marked CPM.

Partially open esophagus due to A-CPD (5 of 5)

A closer view, showing only partially open esophageal entrance because of antegrade cricopharyngeus muscle dysfunction: it refuses to relax fully and this is part of the explanation for why this person cannot swallow solid foods through a less-than-half-opened sphincter.

A-CPD, Before and After Myotomy

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.

X-ray after myotomy — 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).

Example 2

VFSS of the neck while swallowing barium — 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).

Very High-pitched Voice Elicits the Same Pharynx Contraction as Swallowing

Secretions (1 of 4)

This person has cricopharyngeus dysfunction–the “catcher” problem described in the teaching video “Swallowing Trouble 101.” One small indication in the first glimpse of the throat area is the pooling of secretions (here, mucus) in an “organized” fashion in the swallowing crescent right behind the larynx.

Contracted pharynx (2 of 4)

As part of VESS part 1, assessment of the patient’s swallowing “equipment,” pharyngeal squeeze elicitation is always performed. Here the patient produces the highest pitch she can make on ” EEEE!” Note the major contraction of the pharynx as it “hugs” the larynx and closes the pyriform sinuses.

Cracker residue (3 of 4)

After chewing and swallowing a cheese cracker, some residue remains in the vallecula and also in the swallowing crescent.

Pharyngeal walls (4 of 4)

As the patient swallows, the pharyngeal walls come to near-approximation from lateral to medial, just before the view is lost during the upheaval of the swallow.

Reflux Into Hypopharynx, Characteristic of Antegrade Cricopharyngeal Dysfunction

Cricopharyngeus Non-Relaxation and Zenker’s Sac Seen During VESS

Immediately after swallow (1 of 4)

During VESS, after administration of several boluses of blue-stained applesauce. Trace applesauce on pharyngeal walls, immediately after a completed swallow. The postcricoid area is “clean” in this view, at *.

applesauce appears having been ejected upwards from a presumed Zenker’s diverticulum — One second later (2 of 4

Approximately a half second later, applesauce appears at the *, having been ejected upwards from a presumed Zenker’s diverticulum.

Un-relaxed cricopharyngeus muscle (3 of 4)

During water administration, a glimpse of the un-relaxed cricopharyngeus muscle is seen (concentric dotted lines). Esophageal entrance at ‘E’ and Zenker’s pouch, still containing some previously-administered blue applesauce, at ‘Z’.

When to Have Surgery for A-CPD

Does one proceed to surgery early when the problem is intermittent and only with things like meat, bread, and large pills? Or does one wait until diet is severely restricted to purée consistency and liquid?

Dr. Bastian offers a systematic discussion that may help the viewer decide…

A-CPD Can Be Treated with Cricopharyngeal Myotomy

A small percentage of (mostly) older people develop A-CPD. They have difficulty initially with solid foods and pills. As the months and years pass, the tendency for food to lodge in the throat gradually increases.

Eventually, they must limit their diets to softer and “easier” things more and more like “baby food.” Special focus is placed on an effective endoscopic (through the mouth) laser procedure

Cricopharyngeal Dysfunction: Difficulty Swallowing, Especially Solid Foods

Dr. Bastian explains this progressive swallowing problem and presents options for treatment. Cricopharyngeal dysfunction is caused by failure of relaxation of the upper esophageal sphincter—cricopharyngeus muscle—during eating. Typically it is solid foods that tend to lodge in the mid-neck area where this muscle is located.

Before and After Cricopharyngeal Myotomy

This video shows x-rays of barium passing through the throat, first with a narrowed area caused by a non-relaxing upper esophageal sphincter (cricopharyngeus muscle), and then after laser division of this muscle.

Preoperatively, food and pills were getting stuck at the level of the mid-neck, and the person was eating mostly soft foods. After the myotomy (division of the muscle), the patient could again swallow meat, pizza, pills, etc. without difficulty.

Swallowing Trouble 101

This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or A-CPD), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).

Antegrade Cricopharyngeal Dysfunction (A-CPD)

Symptoms

Treatment

Early A-CPD

What Are the Symptoms of A-CPD?

CP Thumb (1 of 4)

Bottleneck in X-ray (2 of 4)

Incipient Zenker’s Diverticulum (3 of 4)

Swallow-To-Swallow variability (4 of 4)

A-CPD, before, during, and after Myotomy.

Non-relaxing cricopharyngeus muscle (1 of 4)

Opening the esophageal orifice (2 of 4)

Laser cricopharyngeus myotomy (3 of 4)

Cricopharyngeus myotomy nearly complete (4 of 4)

The Cricopharyngeus Muscle Seen During Swallowing

Swallowing crescent (1 of 5)

Swallowing water (2 of 5)

Cricopharyngeus muscle (3 of 5)

Relaxed CPM (4 of 5)

Partially open esophagus due to A-CPD (5 of 5)

A-CPD, Before and After Myotomy

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Cricopharyngeal dysfunction: after myotomy, resolved (2 of 2)

Example 2

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Cricopharyngeal dysfunction: after myotomy, resolved (1 of 2)

Very High-pitched Voice Elicits the Same Pharynx Contraction as Swallowing

Secretions (1 of 4)

Contracted pharynx (2 of 4)

Cracker residue (3 of 4)

Pharyngeal walls (4 of 4)

Reflux Into Hypopharynx, Characteristic of Antegrade Cricopharyngeal Dysfunction

Reflux into hypopharynx (1 of 3)

Water flows into the swallowing crescent (2 of 3)

Larynx opens up (3 of 3)

Cricopharyngeus Non-Relaxation and Zenker’s Sac Seen During VESS

Immediately after swallow (1 of 4)

One second later (2 of 4

Un-relaxed cricopharyngeus muscle (3 of 4)

More water (4 of 4)

Table of Contents

When to Have Surgery for A-CPD

A-CPD Can Be Treated with Cricopharyngeal Myotomy

Cricopharyngeal Dysfunction: Difficulty Swallowing, Especially Solid Foods

Before and After Cricopharyngeal Myotomy

Swallowing Trouble 101

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