Cricopharyngeal Myotomy (CPM)

Q: What post-op symptoms would require immediate attention?

All of the following are very unlikely, but they are:Inability to swallow liquids.Chest or back pain increasing in severity from the time of surgery.Fever or chills.Anything else at all that causes you concern!

Cricopharyngeal myotomy (CPM) is a procedure in which the cricopharyngeus muscle, which makes a “ring” around the upper esophagus, is divided or cut across in order to break its grip. This is done in cases where this cricopharyngeus muscle (i.e., the upper esophageal sphincter) fails to relax when one swallows (antegrade cricopharyngeal dysfunction [A-CPD]), resulting in a functional obstruction. CPM leaves the muscle open all the time, and allows the person to resume swallowing relatively normally.

In a percentage of those with cricopharyngeus muscle non-relaxation, the continual high pressures of swallowing may eventually cause a “hernia” in the swallowing passage called a Zenker’s diverticulum.

CPM Procedure

CPM is accomplished under general anesthesia, in one of two ways: The preferred, newer methodology, is performed endoscopically. Using this method, a hollow, lighted “tube”—called an esophagoscope—is inserted into the throat and upper esophagus to examine the area and plan the next step. Then, a special laser scope is placed in the upper esophagus. A microscope permits a magnified, brightly-lit view of the offending ring of muscle.

The laser is used to divide the muscle and break its “grip.” If a Zenker’s sac is apparent, it is “marsupialized,” which means that its opening is widened in order to be sure the sac doesn’t retain food, but instead empties its contents directly into the esophagus.

Depending upon patient and surgical issues, a suction drain may be placed within the upper esophagus and brought out through the nose. A second small tube for feeding may also be placed through the nose, and down into the stomach. When placed, both tubes are removed the morning following surgery.

If a clear view cannot be achieved during esophagoscopy due to difficult patient anatomy (e.g., jaws won’t open well, small lower jaw, short neck, large upper teeth), then we return to a more traditional approach through an incision on the lower left neck. In this case, the muscle is divided from outside in. Depending on a number of issues, an associated Zenker’s diverticulum may or may not be removed at the same time.

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.

Success rate of CPM

The success rate can vary according to the degree to which the person is an ideal candidate for this surgery. When solid food dysphagia is the main symptom, and when x-ray studies show non-relaxation of the muscle, the procedure can dramatically restore the individual’s ability to swallow.

Patient satisfaction with the results is routinely very high. “I can eat anything I want again,” is frequently-heard after surgery. Once in awhile an individual has more than one swallowing deficit, of which CPMD is only one. In this case, swallowing may be better, but still not perfect after CPM.

Risks of CPM

Unless you have significant health issues, risks added together are very small. Risks may include:

A drug reaction, heart problem, etc., during general anesthesia.
Dental trauma—e.g., chipped, scratched, broken, or dislodged tooth.
If surgery is done within the esophagus there is a small risk of a special, potentially severe infection called mediastinitis. (We’ve not seen this problem with a BVI total of an estimated 120 CPM surgeries).
If the surgery is done through a neck incision, there is an added small risk of temporary—or rarely, permanent—paralysis of one vocal fold, which is managed in a relatively straightforward manner.
The final “risk” or outcome is that the doctor cannot guarantee the precise degree of improvement—whether the result will be “good,” “very good,” or “spectacular.” That depends to large degree on the precise components of the original problem; as the doctor tends to know these before surgery, he or she can usually make a reasonably reliable estimate of the expected improvement.

What to expect post-CPM

After surgery, patients return home either later the day of surgery, or the morning after, with rare exception. Of course, a family member or friend must do the driving. Most individuals have minimal anesthesia after-effects. Nausea, for example, has become relatively uncommon.

Pain medication consists of either Tylenol or Tylenol with Codeine, barring allergy or sensitivity. Water may be swallowed immediately after surgery.

The first five days, diet should consist of liquids and very soft foods. Water is always the last thing swallowed after every “meal,” to “rinse out” the area of surgery. Some find that salty or acidic food / liquids will burn the area of surgery.

Occasionally the teeth feel a little sore and loose, especially the upper central incisors.

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.

A-CPD X-ray, 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).

Example 3

X-ray of cricopharyngeus muscle which narrows the swallowed barium stream — 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.

x-ray of a month after endoscopic cricopharyngeus myotomy — 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).

Cricopharyngeus Myotomy for Recreational Eating and Management of Saliva

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.

98 year-old before and after Myotomy

swallow of saliva — 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 of Zenker’s diverticulum — X-ray showing Zenker’s (5 of 10)

An x-ray image showing the Zenker’s diverticulum immediately following her swallow.

x-ray of swallowed barium discharging into the hypopharynx — Moments later (6 of 10)

A moment later, some swallowed barium has discharged upwards into the hypopharynx.

Vocal cords a week after endoscopic cricopharyngeus myotomy — 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.

x-ray of Zenker’s sac puddling at its apex — 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.

Great View of Fresh Cricopharyngeus Myotomy Surgical Wound

CPM dysfunction (1 of 4)

After administration of blue-stained applesauce during VESS, small and organized residue in the post-arytenoid area suggests possible cricopharyngeus muscle dysfunction. At this time, the patient noted only occasional pill lodgement.

VFSS six years later (2 of 4)

Six years later, the patient returned saying that swallowing had gradually become extremely difficult. Swallowing pills and eating food were nearly impossible. A VFSS shows narrowing of the barium stream at the arrow, due to a cricopharyngeus bar or “thumb” at *.

post-arytenoid area — Five days post-op (3 of 4)

Five days after endoscopic laser cricopharyngeus myotomy, the patient says that while surgical pain is still significant, she can already swallow pills and solid food easily, a dramatic change from 5 days earlier. The area of surgery is not seen in this resting view. The * is for orientation with the following photo.

Cervical esopagus (4 of 4)

The patient is puffing her cheeks and this is enough to open the cervical esophagus (E). This allows visualization of the raw surface where the muscle was divided with the laser. It is stained by recently administered blue applesauce. The * is for orientation with the prior photo.

Bolus Stream before and after Cricopharyngeus Myotomy

x-ray of broad bolus stream at the level of the hypopharynx becomes a thin pencil line in the cervical esophagus — Pre-myotomy (1 of 2)

This older man has swallowing difficulty with all consistencies, but particularly with solids. Note how the broad bolus stream at the level of the hypopharynx becomes a thin pencil line in the cervical esophagus due to non-relaxation of the cricopharyngeus muscle (M).

Post-myotomy (2 of 2)

Some months after cricopharyngeus myotomy, the bolus width is the same throughout its course.

VESS Findings after Radiotherapy

narrowing of the pharyngeal wall from radiation scarring — Narrowed pharyngeal wall (1 of 7)

After radiation and chemotherapy for larynx cancer several years earlier. Note the dry secretions. There is narrowing of the pharyngeal wall (dotted line) due to radiation scarring.

Swallowing applesauce (2 of 7)

After the second bolus of blue-stained applesauce. The propulsive ability (“pitcher of swallowing”) is inadequate, leaving a lot of post-swallow residue.

cleaned esophagus with bits of blue applesauce — After sipping water (3 of 7)

After three sips of blue-stained water, much of the applesauce has been washed away.

Gravity aiding in swallowing (4 of 7)

Additional water washes nearly all of the residue in the “swallowing crescent” away–mostly by gravity as seen in the next photo.

Lifting larynx (5 of 7)

Each swallow looks like this. The pharynx “bird swallow” mechanism lifts larynx forward so that the swallowing crescent opens down to the cricopharyngeus muscle, indicated by double dotted lines. (PC = post-cricoid.)

A closer look (6 of 7)

At closer range, the cricopharyngeus muscle bulge is seen more clearly, along with the small opening into the esophagus.

Gravity aiding again in swallowing (7 of 7)

Blue-stained water flowing into the esophagus mostly by gravity.

The Evolution of a Cricopharyngeus Myotomy Wound

Difficulty swallowing solid foods (1 of 8)

This ~80 year old man is having considerable trouble swallowing, particularly for solid foods. In this panoramic view at the start of VESS, saliva is noted in the swallowing crescent (outlined) and clinging to the posterior pharyngeal wall (arrows).

Pooled saliva (2 of 8)

At closer range, the pooled saliva in the swallowing crescent is more clearly seen, as is some saliva within the laryngeal vestibule (arrows). Organized pooling of saliva or food / liquid can indicate cricopharyngeus dysfunction (non-relaxation).

Muscle bulge (3 of 8)

The patient has swallowed some water to clear away the saliva, and the pre-myotomy cricopharyngeus muscle bulge (between dotted lines) is seen with only a slit of opening into the esophagus at the arrow.

Residue in swallow crescent (4 of 8)

After many boluses of blue-stained applesauce, the swallowing crescent remains full of residue, but laryngeal vestibule is not soiled. Both propulsive and receptive functions of swallowing are impaired but a significant part is outlet obstruction caused by incomplete cricopharyngeus muscle relaxation.

less salivary pooling in swallowing crescent — Three weeks later (5 of 8)

About 3 weeks after cricopharyngeus myotomy, note that the salivary pooling in the swallowing “crescent” is less than pre-operation.

residual "wound" from the myotomy is stained blue — Residual “wound” (6 of 8)

After administering blue-stained applesauce and water, the residual “wound” from the myotomy is stained blue. After myotomy, the cut ends of the muscle retracts laterally as suggested by the curved lines. Compare with the muscle bulge in Photo 3.

deep "notch" in the cricopharyngeus muscle bulge — Three months post-op (7 of 8)

Nearly 3 months after myotomy, both the patient and his wife say swallowing is much improved. Note the deep “notch” in the muscle bulge as compared with photo 3.

Zenker’s Diverticulum a Week after Cricopharyngeus Myotomy

mucosal "septum" between sac and esophagus — Zenker’s Sac (2 of 3)

Not only the muscle, but also the elongated mucosal “septum” between sac and esophagus must be divided on both esophageal (anterior) and sac (posterior) surfaces. This view is mostly on the esophageal side. Note the large caliber of the esophageal opening, explaining dramatic resolution of this 90-something year-old woman’s difficulty swallowing.

Zenker’s Sac (3 of 3)

Looking here more directly into the esophagus, one can see that the enlarged esophageal opening as compared with pre-myotomy explains why swallowing pills and solid food is already no longer a problem for this person.

A-CPD Can Be Treated with Cricopharyngeal Myotomy

A small percentage of (mostly) older people develop a progressive but treatable swallowing disorder called antegrade cricopharyngeal dysfunction (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 myotomy.

Cricopharyngeal Dysfunction: Before and After CPM

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 (myotomy) 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, 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).

What if my teeth feel loose after CPM?

Refrain from wiggling them, or from biting into tough foods until they tighten back up on their own. Most often this takes a week or so.

When should I see my doctor after the procedure?

About six weeks after surgery a video-fluoroscopic swallowing study (VFSS) is scheduled to compare with the one you had before surgery.

You bring a videotape copy of that study with you to a postoperative visit with your surgeon later the same day the VFSS was done.

What post-op symptoms would require immediate attention?

All of the following are very unlikely, but they are:

Inability to swallow liquids.
Chest or back pain increasing in severity from the time of surgery.
Fever or chills.
Anything else at all that causes you concern!

How will I know in advance which way the surgery will be done?

Candidates for CPM should agree to both methods. That way, the surgeon can attempt his or her preferred method from within the esophagus. If that method is not possible, they will switch to CPM through a neck incision.

Most people want to know when they leave the operating room if the problem will have been addressed, “one way or the other.”

If dysphagia occurs years after surgery, can CPM be performed again?

The 2 primary explanations I have encountered in a large series:

The prior surgeon did not perform a complete myotomy, and/or;
It is now many years later, the individual is truly elderly, and having trouble not with the sphincter but with the vigor of the propulsive side of swallowing.

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Cricopharyngeal Myotomy (CPM)

CPM Procedure

Cricopharyngeal myotomy (1 of 7)

Cricopharyngeal myotomy (2 of 7)

Cricopharyngeal myotomy (3 of 7)

Cricopharyngeal myotomy (4 of 7)

Cricopharyngeal myotomy (5 of 7)

Cricopharyngeal myotomy (6 of 7)

Cricopharyngeal myotomy (7 of 7)

Success rate of CPM

Risks of CPM

What to expect post-CPM

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)

A-CPD X-ray, 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)

Example 3

Cricopharyngeal dysfunction: before myotomy (1 of 2)

Cricopharyngeal dysfunction: after myotomy (2 of 2)

Cricopharyngeus Myotomy for Recreational Eating and Management of Saliva

Panormaic view, post CPM (1 of 4)

Trumpet maneuver (2 of 4)

Closer view (3 of 4)

Well-managed saliva (4 of 4)

98 year-old before and after Myotomy

Immediately after swallowing (1 of 10)

Zenker’s (2 of 10)

Dysphagia (3 of 10)

Residue from Zenker’s (4 of 10)

X-ray showing Zenker’s (5 of 10)

Moments later (6 of 10)

After myotomy (7 of 10)

No residue (8 of 10)

Zenker’s gone (9 of 10)

No barium in hypopharynx (10 of 10)

Great View of Fresh Cricopharyngeus Myotomy Surgical Wound

CPM dysfunction (1 of 4)

VFSS six years later (2 of 4)

Five days post-op (3 of 4)

Cervical esopagus (4 of 4)

Bolus Stream before and after Cricopharyngeus Myotomy

Pre-myotomy (1 of 2)

Post-myotomy (2 of 2)

VESS Findings after Radiotherapy

Narrowed pharyngeal wall (1 of 7)

Swallowing applesauce (2 of 7)

After sipping water (3 of 7)

Gravity aiding in swallowing (4 of 7)

Lifting larynx (5 of 7)

A closer look (6 of 7)

Gravity aiding again in swallowing (7 of 7)

The Evolution of a Cricopharyngeus Myotomy Wound

Difficulty swallowing solid foods (1 of 8)

Pooled saliva (2 of 8)

Muscle bulge (3 of 8)

Residue in swallow crescent (4 of 8)

Three weeks later (5 of 8)

Residual “wound” (6 of 8)

Three months post-op (7 of 8)

At close range (8 of 8)

Zenker’s Diverticulum a Week after Cricopharyngeus Myotomy

Zenker’s Sac (1 of 3)

Zenker’s Sac (2 of 3)

Zenker’s Sac (3 of 3)

A-CPD Can Be Treated with Cricopharyngeal Myotomy

Cricopharyngeal Dysfunction: Before and After CPM

Swallowing Trouble 101

What if my teeth feel loose after CPM?

When should I see my doctor after the procedure?

What post-op symptoms would require immediate attention?

How will I know in advance which way the surgery will be done?

If dysphagia occurs years after surgery, can CPM be performed again?

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Teleconversation
with Dr Bastian