Cricopharyngeal Myotomy in the Presence of GERD: A Case Study

Anne is your newest patient. She is 76 years old and suffered a brainstem stroke with a resultant Wallenberg syndrome, which compromised the opening of the upper esophageal sphincter. Following her stroke, she was able to swallow some liquids but could no longer swallow solids.

The medical team decided to perform a cricopharyngeal myotomy in the hopes that surgical relaxation of the UES might make swallowing solids easier for her. For three months following surgery, she was able to eat normally, but shes now six months post-surgery and tells you that solids and liquids have become harder to swallowso much so, that shes now started to lose weight.

When you review her medical history, you learn that she has had GERD, hypertension, and COPD. In addition to her challenges with swallowing, she also notes that she has been experiencing laryngopharyngeal reflux on a regular basis.

What We Know

When you sit down to consider Annes situation, you identify these key elements:

• A brainstem stroke with resultant failure of relaxation of the UES

• UES myotomy with some relief of swallowing symptoms

• Recurring dysphagia ostensibly without aspiration pneumonia

• A history of GERD without any information about how well it was controlled

• Apparent new symptoms of laryngopharyngeal reflux by patient report

Your evaluation shows normal oropharyngeal and mental status, so you decide to order a videofluoroscopic swallow exam. You can view the results of this exam below.

 

 

Interpreting the Videofluoroscopic Exam

Anne was given normal amounts of thin fluids and pudding-thick boluses. With both bolus types, a long stricture can be seen extending from C3 to C6. On the thicker boluses, the UES fails to fully open.

Based on this information, you determine that Anne is a candidate for balloon dilation to open the pharyngeal stricture that extends to the UES.

Following dilation, Anne is once again able to swallow both solids and liquids without difficulty and maintain her weight. She does require repeat dilations three and six months after the initial dilation, and you prescribe an aggressive program to control her GERD.

What Does Annes Case Reveal?

From working with Anne, you learn a few important things:

1. Patients with a history of GERD may not be the best candidates for myotomy. In Annes case, relaxation of the UES by myotomy might have allowed refluxate to enter the pharynx, resulting in stricture from acid irritation.

2. A thorough history of your patients GERD must be part of the initial work-up when determining whether your patient is a candidate for myotomy.

3. Videofluoroscopy proved to be a valuable tool in detailing Annes problem, leading to an appropriate recommended treatment.

4. Managing pharyngeal strictures with balloon dilation may require repeated dilations for symptom relief.

Be prepared for other complex dysphagia patients like Anne with my Medbridge course, Treatment Approaches to Upper Esophageal Sphincter Disorders.