Esophageal Sphincter Dysfunction, Upper

• • Cervical dysphagia

  • Cricopharyngeal bar on barium swallow

  • Pharyngoesophageal diverticulum (Zenker diverticulum) in some patients

Epidemiology

• • Most often occurs in patients over age 60

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

Symptoms and Signs

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

  • Chronic cough from minor aspirations of saliva and ingested food

Imaging Findings

• • 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

• • 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

Rule Out

• • Esophageal neoplasms

  • Reflux resulting from lower esophageal sphincter incompetence

  • Thyroid enlargement

• • 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

When to Admit

• • Severe dysphagia prohibiting adequate enteral nutrition

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

Surgery

Indications

• • All confirmed cases of upper esophageal sphincter dysfunction

Contraindications

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

Complications

• • Aspiration

Prognosis

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

References