Ins and outs of myotomy of the upper oesophageal sphincter in swallowing disorders

Ins and outs of myotomy of the upper oesophageal sphincter in swallowing disorders. Objectives: Upper oesophageal dysfunction generally leads to severe dysphagia and aspiration. Several treatment modalities are available: dilatation, external myotomy of the cricopharyngeal muscle, local infiltration with botulinum toxin, and endoscopic transmucosal myotomy using a CO2 laser. The aim of this study is to assess the outcome of trans-oral cricopharyngeal myotomy in three groups of patients suffering from upper oesophageal sphincter dysfunction.

Method: We retrospectively evaluated a group of 31 patients with upper oesophageal dysfunction (10 neurological diseases, 8 after chemoradiation, 12 failure of cricopharyngeal relaxation), all of whom were treated with endoscopic laserassisted myotomy. A minimum follow-up of one year was required before inclusion in this study. Preoperative and postoperative assessments included videofluoroscopic and flexible endoscopic evaluations of the swallow as well as patients’ subjective ratings for dysphagia and aspiration. These investigations and self-assessments were rated from 0 (poor or abnormal) to 4 (good or normal).

Results: The trans-oral approach was feasible without complications in all patients. Symptoms improved in most patients. There was no recurrence in the group of cricopharyngeal muscle relaxation failure; 5 out of 8 patients in the irradiation group suffered recurrence, as did 4 out of 10 neurological patients.

Conclusions: Endoscopic laser-assisted cricopharyngeal myotomy seems to be a safe and effective technique for treating upper oesophageal dysfunction. However, complex pathology involving more than cricopharyngeal muscle leads to a high recurrence rate.