Cricopharyngeal Dysfunction

What is cricopharyngeal dysfunction?

The esophagus, the muscular tube that connects the throat and the stomach, has a muscular sphincter at its upper end that controls the passage of food into the stomach. This upper esophageal sphincter (UES)—also called the cricopharyngeus—is a semi-circular muscle located in the neck about three inches below the Adam’s apple. To prevent the reflux of foods from the esophagus into the throat, the cricopharyngeus remains contracted and tight at most times. When a person swallows, though, it relaxes and allows food to pass through. In people with cricopharyngeal dysfunction, the muscle doesn’t relax, and the food is blocked from passing into the esophagus. They generally have a harder time swallowing solid foods than liquids because liquids flow more easily through the limited opening in the sphincter. The problem tends to progress gradually and slowly over time, and people with cricopharyngeal dysfunction may limit their diet to only very soft foods such as pasta or pureed foods. In severe cases, those with this disorder change their diet so drastically that they lose a lot of weight. Cricopharyngeal dysfunction is also called upper esophageal sphincter dysfunction or cricopharyngeal achalasia.

How is cricopharyngeal dysfunction diagnosed?

Physicians diagnose cricopharyngeal dysfunction using a number of means. A visual examination of the back of a patient’s throat will often reveal a small amount of food or saliva pooled there. They also use the following diagnostic tests:

• Esophageal Manometry: An esophageal manometry measures the rhythmic muscle contractions, and the coordination and force exerted by the muscles, that occur in the esophagus when a person swallows. During this test, a thin, flexible tube (catheter) that contains sensors is passed through the nose, down the esophagus, and into the stomach. (The throat and nose are numbed for this test.) Patients will be asked to take small sips of water and swallow on command during the test.
• Modified Barium Swallow Study (MBS): During this test patients are asked to swallow a variety of substances that are coated with barium, a whitish paste that lights up during an X-ray, enabling the examiner to determine how well these substances are moving through the mouth, pharynx, and esophagus. The test will show if the upper esophageal sphincter is not relaxing or if foods or liquids are blocked as they pass through the esophagus.

How is cricopharyngeal dysfunction treated?

In some cases physicians treat cricopharyngeal dysfunction by temporarily paralyzing the UES with an injection of botulinum (Botox). This approach is not effective for every patient, and the injections need to be repeated every 3-6 months. The definitive treatment for cricopharyngeal dysfunction is a procedure called cricopharyngeus muscle myotomy in which physicians cut the UES in a way that prevents it from over-contracting, so food is no longer blocked from entering the esophagus. This procedure can be performed through an incision made on the outside of the neck. More recently, the endoscopic cricopharyngeal myotomy, a procedure popularized by Dr. Pitman, is becoming the treatment of choice at advanced centers.  This is a minimally invasive procedure performed by introducing a laser through the mouth. The newer endoscopic procedure offers patients a faster recovery and may be safer than traditional surgery.

What is the outlook for people with cricopharyngeal dysfunction?

If a patient’s swallowing problem is caused just by the UES, and the rest of his or her swallowing function is normal, then treating that muscle will almost always result in a return to normal swallowing and the resolution of difficulty swallowing food. If other aspects of his/her swallowing mechanism is abnormal, however, then the treatment is likely to be more complicated.