Cricopharyngeal myotomy (CPM)

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. A cricopharyngeal myotomy is done in cases where this cricopharyngeus muscle (i.e., the upper esophageal sphincter) fails to relax when one swallows (cricopharyngeal dysfunction), resulting in a functional obstruction.

Cricopharyngeal dysfunction can be seen alone, or, as illustrated below, in combination with a Zenker’s diverticulum. Symptoms of cricopharyngeal dysfunction include dysphagia, with solids more so than with liquids. If a Zenker’s diverticulum is present, the patient may also experience late “regurgitation” of undigested food retained for hours or longer in the sac.


Photos:

Cricopharyngeal myotomy: Series of 7 photos

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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 and after myotomy: Series of 2 photos

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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 and after myotomy: Series of 2 photos

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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 and after myotomy: Series of 2 photos

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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).

Cricopharyngeus myotomy for recreational eating and management of saliva: Series of 4 photos

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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: Series of 10 photos

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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.

Great view of fresh cricopharyngeus myotomy surgical wound: Series of 4 photos

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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 *.

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: Series of 2 photos

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VESS (videoendoscopic swallow study) findings after radiotherapy: Series of 7 photos

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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.

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: Series of 8 photos

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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.

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" (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.

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.

At close range (8 of 8)

At very close range with some clockwise rotation of the view. The muscle can no longer impede passage of food or liquid into the esophagus.

Zenker’s diverticulum a week after cricopharyngeus myotomy: Series of 3 photos

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Zenker's Sac (1 of 3)

Shown in operating position, E = esophageal opening; PPW = posterior pharyngeal wall at the level of hypopharynx; S= residual Zenker's sac, now marsupialized into the esophagus; CPM = lateral bulges of completely divided cricopharyngeus muscle. The actual wound (W) is stained by the blue applesauce this elderly patient just swallowed.

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.

 

Videos:

https://youtu.be/_dBPKBg8jXM
Swallowing Trouble 101
This video gives an overview of how swallowing works, how it can sometimes go wrong (presbyphagia or cricopharyngeal dysfunction), and possible ways to treat those problems (swallowing therapy or cricopharyngeal myotomy).