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  • • Cervical dysphagia

    • Cricopharyngeal bar on barium swallow

    • Pharyngoesophageal diverticulum (Zenker diverticulum) in some patients

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Epidemiology

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  • • Most often occurs in patients over age 60

    • May occur as an isolated abnormality or in association with Zenker diverticulum

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Symptoms and Signs

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  • • Cervical dysphagia, more pronounced for solids than for liquids

    • Chronic cough from minor aspirations of saliva and ingested food

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Imaging Findings

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  • Upper GI contrast radiography nearly always shows a prominent cricopharyngeal bar

    Endoscopy shows an extrinsic constriction that allows passage of the endoscope as it is advanced

    Manometry often reveals imperfect coordination of relaxation of the cricopharyngeal sphincter, occurring at or just after initiation of the pharyngeal contraction, instead of just before

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  • • Patients with symptoms of cervical dysphagia, more pronounced for solids than for liquids, should be evaluated by upper GI contrast radiography, which will usually be diagnostic

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Rule Out

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  • • Esophageal neoplasms

    • Reflux resulting from lower esophageal sphincter incompetence

    • Thyroid enlargement

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  • • Symptoms of cervical dysphagia, more pronounced for solids than for liquids

    • Upper GI contrast radiography will usually be diagnostic

    • Upper GI endoscopy to rule out esophageal neoplasm

    • Cricopharyngeal and esophageal manometry to rule out reflux disease, as indicated

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When to Admit

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  • • Severe dysphagia prohibiting adequate enteral nutrition

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  • • Myotomy of the cricopharyngeus and upper 3-4 cm of the esophageal musculature, made in the midline posteriorly

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Surgery

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Indications

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  • • All confirmed cases of upper esophageal sphincter dysfunction

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Contraindications

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  • • Patients with gastroesophageal reflux because of the increased risk of aspiration after myotomy

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Complications

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  • • Aspiration

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Prognosis

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  • • Relief of symptoms is usually complete and permanent after myotomy

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References

Owen W. ABC of the upper gastrointestinal tract. Dysphagia. BMJ. 2001;323:850.  [PubMed: 11597971]
Hila A et al. Pharyngeal and upper esophageal sphincter manometry in the evaluation of dysphagia. J Clin Gastroenterol. 2001;33:355.  [PubMed: 11606849]

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