Questions about Cricopharyngeus Myotomy (CPM) for Cricopharyngeus Muscle Dysfunction with or without Zenker’s Diverticulum

 

What is Cricopharyngeus Myotomy (CPM) and why is it done?

This procedure refers to division of a circular sphincter muscle that serves as a one-way valve or ‘gate’ at the top of the esophagus. This muscular ‘gate’ must open briefly every time we swallow, allow the food or liquid through, and then clamp shut the moment the material goes through. In some persons, the muscle fails to relax (the ‘gate’ fails to open). The surgery in essence leaves the gate 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.

 

What are the symptoms caused by this problem?

Cricopharyngeus muscle dysfunction (non-relaxation) may be mild at first and cause only occasional lodgment of a pill at the level of the mid-to lower neck. As the years pass, the problem becomes inexorably worse. Left untreated, the individual begins to avoid certain foods he or she has learned from prior experience do not go down well. Eventually, the affected individual can only swallow liquids and very soft foods with a thin, cream of
wheat consistency. Progression from first symptom to this final stage may take as little as a year, but more commonly several or even many years.

 

Does CPM always work?

The answer varies 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 xray 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.

 

How is the procedure 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.

 

What is the second way of doing the procedure, and why would it be done another way?

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. How will I know in advance which way the surgery will be done? We suggest that candidates for CPM agree to both
methods. That way, we can attempt our preferred method from within the esophagus. If that method is not possible, we switch to CPM through a neck incision. Most people want to know that when they leave the operating room, the problem will have been addressed, “one way or the other.” Still, the laser method is successful in at least 19 of 20 cases we attempt.By now this surgery is sounding horrible. Right? Actually, no. While we always see a variety of patient reactions to surgery, most people do not find this one that bad.

 

What are the risks of the procedure?

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

  1. A drug reaction, heart problem, etc., during general anesthesia.
  2. Dental trauma—e.g., chipped, scratched,
    broken, or dislodged tooth. We have a few instances per year of roughened enamel that doesn’t need a dentist’s attention, but
    can be smoothed off in the O.R. Beyond this, about once every couple of years something more significant, such as a broken
    or dislodged crown or tooth happens.
  3. 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).
  4. 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.
  5. The final “risk” or outcome is that we 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 we tend to know these before surgery, we can usually make a reasonably reliable estimate of the improvement we expect. The potential for harm to my teeth really bothers me. Actually, though dental injury happens so infrequently, this possibility bothers us too! That’s why we use not only a tooth guard, but also all the care and gentleness we can muster while doing this surgery. That said, please keep in mind that individuals who cannot personally accept the very small chance of a dental problem should not agree to undergo this surgery. To those entirely risk-averse for dental trauma: Risk of dental problems is reduced (not abolished) if one decides “in advance” to have the surgery through a neck incision, but risk of vocal fold paralysis is thereby added.

 

What other issues should I expect after surgery?

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 aftereffects. 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.

 

Are there any problems I might have that should prompt a call to my surgeon?

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

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

 

What if my teeth do feel loose?

We suggest that you 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 do I see my doctor after surgery?

Typically, our office will call you within a few days of your surgery, just to make sure all is proceeding as expected, and that you have no questions. You are also invited to call if any concerns. About six weeks after surgery we schedule a video-fluoroscopic swallowing study (VFSS) 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. Individualized arrangements may need to be made for persons from outside the metro area, and followup visits may sometimes need to be made with the “home” otolaryngologist.


Cricopharyngeal Myotomy

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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 (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 (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 (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 (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 (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 (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 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

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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: 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).

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).
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