SWALLOWING  |  Conditions We Treat

The cricopharyngeus muscle is located at the junction of the pharynx (throat) and esophagus, and is the major muscular component of what is called the upper esophageal sphincter (UES). At rest, the UES closes the passageway between the pharynx and esophagus. It protects the airway and lungs from damaging stomach contents that might be refluxed up through the esophagus into the throat. When something is swallowed, the cricopharyngeus relaxes and opens allowing what was ingested to be swept from the pharynx into the esophagus.

What is the effect?
The cricopharyngeal (CP) bar can form from a thickening of the cricopharyngeus muscle caused by replacement of its muscle with fibrous connective. This is thought by many to be a reaction to chronic reflux of stomach contents into the esophagus. Fibrosis makes the muscle stiffer so that it does not open fully during swallowing; thereby, obstructing flow into the esophagus, and increasing pressure in the pharynx during the swallow. The CP bar can also be present in neurologic disease when muscle relaxation does not function properly. The most common symptom produced by the CP dysfunction is pharyngeal dysphagia (the sensation of food getting stuck in the neck within about a second of swallowing). When severe, patients might have weight loss or even aspiration of food that is not cleared from the pharynx.

How is it diagnosed?
Diagnosis of the CP bar is made with fluoroscopic swallow study of the pharynx and proximal esophagus, typically in the lateral view. The bar appears as an indentation on the barium column at the posterior aspect of the esophagus between the C3 and C6 vertebral levels (see image)

How is it treated?
Treatment of the CP bar depends upon symptoms. If the patient is not having symptoms, no therapy is needed.

Symptomatic bars can be treated with dilation or myotomy. Dilation can be accomplished with Savary dilators passed over a guide wire or through-the-scope balloon dilators positioned visually at the time of endoscopy. While safe and effective, dilation does not produce a durable relief of dysphagia in up to half of patients.

Cricopharyngeal myotomy can be performed via open neck surgery through a left cervical incision to expose and transect the muscle, or with an endoscope to identify the thick muscle and cut it with a laser. While both procedures have a high rate of success, and improve pharyngeal and UES function, the endoscopic approach has gained favor in recent years.

More information on Cricopharyngeal Achalasia: Management and Associated Outcomes at https://pubmed.ncbi.nlm.nih.gov/32571156/

Zenker's Diverticulum is a pouch that develops in the upper esophagus and possibly collects food and liquids, making swallowing difficult. The pouch forms in the throat at the very beginning of the digestive tract just above the upper esophageal sphincter (UES).

What is the cause?
The cause of Zenker’s Diverticulum is abnormal tightening of the upper esophageal sphincter (also called the cricopharyngeus muscle). As a result of tightening of this muscle, pressure builds along the wall of the throat above this sphincter muscle. Just above this muscle there is a relative weak point of the throat wall and the diverticulum forms as a result of the relative increased pressure exerted on this weak area during swallowing. Because the UES below the pouch is tighter than normal, food and liquids are harder to pass into the esophagus and instead tend to pass into the diverticulum pocket or even back into the throat causing regurgitation.

What are the symptoms?
Symptoms include difficulty swallowing, feeling material sticking in the throat, regurgitation, weight loss, bad breath, choking, and coughing. Swallowed material may accumulate in the diverticulum and be regurgitated long after a meal. Pills may be difficult to swallow. Some people with a Zenker’s diverticulum may have only mild symptoms but over time the pouch continues to grow and becomes more symptomatic.

How is it diagnosed?
Zenker's diverticulum is diagnosed during esophagoscopy or esophagram (aka barium swallow), or a modified barium swallow study (MBSS) (see figure).

How is it treated?
The goal of treatment of Zenker’s diverticulum is to relieve the obstruction to swallowing caused by the tight UES and eliminate the preferential passage and accumulation of swallowed material into the diverticulum. For a large or complicated diverticulum, open neck surgery may be necessary to remove the diverticulum sac, but most patients with symptomatic Zenker’s diverticulum are now treated in a minimally invasive endoscopic approach.

Endoscopic cricopharyngeal myotomy has become a primary and important means of treatment of Zenker’s diverticulum. This procedure involves cutting the tight UES muscle and the party wall between the esophagus and the pouch to eliminate the obstruction. This procedure remodels the anatomy of the esophagus relative to the diverticulum so that swallowed material easily passes from the diverticulum into the esophagus. Commonly, swallow therapy with a Speech Language Pathologist is needed after surgery.

Patients with cancerous tumors of the oral cavity, pharynx, or larynx will usually be treated for their disease with surgical removal of the tumor, radiotherapy, chemotherapy, or a combination of these procedures. Each type of cancer treatment may result in some degree of dysphagia. The type and severity of dysphagia will depend upon the size and location of the original tumor, the structures involved, and the treatment modality used for cure.

The team at the Ark-LA-Tex Center for Voice, Airway and Swallowing has extensive experience managing patients with dysphagia from head and neck cancer treatment. The laryngologist and head and neck surgeons work closely with speech language pathologists to evaluate, manage, and improve swallowing in head and neck cancer patients.

Through early evaluation of swallowing we aim to provide long-term monitoring and preservation of swallowing function in head and neck cancer patients. We are actively involved in the survivorship program at the Feist-Weiler Cancer Center.

When indicated our laryngologist performs a novel surgery to treat epiglottic dysfunction after head and neck cancer treatment.

More information is available here: https://pubmed.ncbi.nlm.nih.gov/39370743/

Eosinophilic esophagitis (EOE) is a chronic immune system disease that causes inflammation in your esophagus, which is the tube that connects your throat to your stomach. People who have EOE have high levels of blood cells called eosinophils that build up in their esophagus as a reaction to allergens or acid reflux. This buildup causes inflammation that can damage your esophagus.

What is the effect?
Damage to the esophagus as a result of EoE may cause difficulty swallowing (dysphagia) and food getting stuck in the esophagus (impaction). Other symptoms include abdominal pain, GERD symptoms that do not improve with medication, chest pain that doesn’t get better after taking antacids and heartburn. Infants and children may experience these symptoms in addition to difficulty eating, vomiting and/or poor growth or malnutrition.

How is it diagnosed?
EoE is typically diagnosed by looking in the esophagus (esophagoscopy) and sometimes with some samples of the esophageal tissue (biopsies).

How is it treated?
Treatment of EoE require a combination of change in diet, control of allergies, and medication. Here at the Ark-LA-Tex Center for Voice, Airway and Swallowing we work closely with our colleagues in the division of Allergy and Immunology as well as the division of Gastroenterology to diagnosis and treat patients with EoE.

The official name for this rare condition is retrograde cricopharyngeus dysfunction. In this condition the muscle at the top of the esophagus (cricopharyngeus muscle) doesn’t relax properly, preventing the release of trapped gas, leading to bloating and discomfort. These symptoms can make social interactions embarrassing and, as a result, people with R-CPD often experience social anxiety or may even avoid social gatherings.

What is the effect?
With each bite of food and sip of a beverage, some air also gets swallowed and makes its way into the esophagus and stomach. Drinking carbonated beverages also delivers gas into the stomach. When enough air builds up in the stomach, it makes its way into the esophagus and causes the cricopharyngeus muscle to relax to allow the air to escape into the throat. This is known as a burp or belch. It is an important biological process that allows the body to rid itself of excess air in the stomach and esophagus.

In people with R-CPD, the cricopharyngeus muscle does not work properly. During swallowing, it relaxes as it should to allow food, liquid, and some air to enter the esophagus, but it does not relax to allow excess air in the stomach and esophagus to escape. As a result, air accumulates in the stomach, esophagus, and intestines, causing bloating and pressure in the abdomen, chest, and lower neck, and gurgling sounds from the chest and neck. In people with R-CPD, the abdomen may be distended or swollen, and because the air cannot leave through the esophagus, it instead passes through the intestines and exits the body as flatulence, which is often excessive.

What is the cause?
While doctors don’t know what causes R-CPD, in most cases, it is a lifelong condition. It can affect both children and adults, and many with the condition have never burped. Most people with R-CPD experience significant symptoms on a daily basis. Fortunately, with treatment, outcomes for most people are excellent.

What are the symptoms?
Symptoms of R-CPD include: abdominal and/or chest bloating and pain, excessive flatulence, nausea, gurgling noises from the neck and chest, and difficulty vomiting or fear of vomiting.

How is it diagnosed?
To diagnose R-CPD the team at the Ark-LA-Tex Center for Airway, Voice and Swallowing will collect and review your medical history, perform a physical exam, and order one or more diagnostic tests.

Your doctor will usually begin to make a diagnosis by asking about your symptoms, including their severity and when they began. During a physical exam, your doctor will examine your throat and may perform a flexible nasopharyngoscopy. In this in-office procedure, your doctor will insert a flexible endoscope—a thin tube equipped with a light and camera—through your mouth or nose, down to your throat and upper esophagus.

How is it treated?
The primary treatment for R-CPD is botulinum toxin (Botox) injection into the circopharyngeus muscle. This is done under general anesthesia during an esophagoscopy. Most patients are able to burp and experience significant symptom relief within a week after a single injection. Swallow therapy can be helping in “teaching” a patient how to burp. In some cases, however, doctors may recommend an additional Botox injection given several months later to patients whose symptoms continue.

Side effects of Botox injections can include a feeling that food “hangs” or gets stuck in the throat, a feeling of a lump in the throat, or acid reflux. These side effects typically resolve on their own after a few days or weeks.

With treatment, outcomes for most people with R-CPD are very good. One study found that after receiving a Botox injection into the cricopharyngeus muscle, over 99% of people were able to burp, and 95% experienced substantial symptom relief. The effects of a single Botox injection are expected to last around three months, but in practice, symptom relief often lasts for six to 12 months or longer. And for about 80% of people, the effects are thought to be permanent. For some, however, after Botox treatment, symptoms return, and an additional injection may be necessary to maintain symptom relief and the ability to burp.

At the Ark-LA-Tex Center for Voice, Airway and Swallowing, we take pride in providing comprehensive care to those suffering from retrograde cricopharyngeus dysfunction. We listen to our patients, tailoring treatments to their preferences, and strive to make them active partners in their journey to relief. With a dedicated focus on this under-recognized disorder, our team conducts cutting-edge research to continually advance our understanding of R-CPD to ensure the best possible outcome for each and every patient.