INFLUENCE OF ESOPHAGEAL MOTILITY IMPAIRMENT ON UPPER AND LOWER ESOPHAGEAL SPHINCTER PRESSURE IN CHAGAS DISEASE.

BACKGROUND: Chagas disease causes digestive anatomic and functional changes, including the loss of the myenteric plexus and abnormal esophageal radiologic and manometric findings. OBJECTIVE: To evaluate the association of abnormal esophageal radiologic findings, cardiac changes, distal esophageal contractions, and complaints of dysphagia and constipation in upper (UES) and lower (LES) esophageal sphincter basal pressure in Chagas disease patients. METHODS: The study evaluated 99 patients with Chagas disease and 40 asymptomatic normal volunteers. The patients had normal esophageal radiologic examination (n=61) or esophageal retention without an increase in esophageal diameter (n=38). UES and LES pressure was measured with the rapid pull-through method in a 4-channel water-perfused round catheter. Before manometry, the patients were asked about dysphagia and constipation and submitted to electrocardiography and chest radiography. RESULTS: The amplitude of esophageal distal contraction decreased from controls to chagasic patients with esophageal retention. The proportion of failed and simultaneous contractions increased in patients with abnormal radiologic examination (P<0.01). There were no significant differences in UES and LES pressure between the groups. UES pressure was similar between Chagas disease patients with cardiomegaly (n=27, 126.5±62.7 mmHg) and those without it (n=72, 144.2±51.6 mmHg, P=0.26). Patients with constipation had lower LES pressure (n=23, 34.7±20.3 mmHg) than those without it (n=76, 42.9±20.5 mmHg, P<0.03). CONCLUSION: Chagas disease patients with absent or mild esophageal radiologic involvement had no significant changes in UES and LES basal pressure. Constipation complaints are associated with decreased LES basal pressure.

Oral and Pharyngeal Dysphagia in Adults.

Patients with oral and pharyngeal dysphagia have difficulty forming a cohesive bolus and/or transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process. This may be accompanied by nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Abnormalities affecting the upper esophageal sphincter, pharynx, larynx, or tongue, in isolation or combination, result in oropharyngeal dysphagia affecting either or both transit and airway protection. These issues can be addressed with a combination of management of the underlying systemic disease, with surgical intervention or with swallow therapy.

Inability to belch syndrome: what the gastroenterologist needs to know.

PURPOSE OF REVIEW: To review recent publications on the inability to belch syndrome. RECENT FINDINGS: Five recent retrospective case series indicate that the inability to belch syndrome usually starts in early childhood and is often accompanied by gurgling noises in the chest, pain in the chest or upper abdomen, bloating, and excessive flatulence. Currently, the vast majority of patients who have been identified with inability to belch have self-diagnosed the syndrome on the basis of information available on the internet. A favorable response to injection of botulinum toxin in the cricopharyngeus muscle is regarded as confirmation of the diagnosis. In a mechanistic study in eight patients, absence of reflexogenic relaxation of the upper esophageal sphincter upon rapid gaseous esophageal distension was confirmed to play a pivotal role in the pathogenesis of the syndrome. SUMMARY: The inability to belch syndrome, caused by failure of the upper esophageal sphincter to relax when the esophageal body is distended, clearly exists and may not be as rare as thought hitherto. However, overdiagnosis is also likely to occur because the diagnosis is usually made on the basis of symptoms only. The efficacy of botulinum toxin injection in the upper sphincter needs to be assessed in double-blind placebo-controlled studies.

Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry.

OBJECTIVES: The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD. METHODS: Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features. RESULTS: We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle. CONCLUSIONS: Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Bolus transit of upper esophageal sphincter on high-resolution impedance manometry study correlate with the laryngopharyngeal reflux symptoms.

Laryngopharyngeal reflux symptom is a troublesome upper esophageal problem, and reflux symptom index (RSI) is commonly applied for the assessment of clinical severity. We investigated the relationship between the upper esophageal sphincter impedance integral (UESII) and RSI scores in this study. Totally 158 subjects with high-resolution esophageal impedance manometry (HRIM) with RSI questionnaire assessment were recruited. There are 57 (36.08%), 74 (46.84%), 21 (13.29%), and 6 (3.79%) patients were categorized as normal, ineffective esophageal motility disorder, absent contractility, and achalasia by HRIM examination, respectively. Subjects with RSI > 13 were noted to have lower UESII than others with RSI ≦ 13 (7363.14 ± 1085.58 vs. 11,833.75 ± 918.77 Ω s cm; P < 0.005). The ROC analysis yielded a UESII cutoff of < 2900 Ω s cm for the best prediction of subjects with RSI > 13 (P = 0.002). Both female gender and UESII cutoff of < 2900 Ω s cm were significant predictors of RSI > 13 in logistic regression analysis (OR = 3.84 and 2.83; P = 0.001 and 0.01; respectively). Lower UESII on HRIM study, indicating poor bolus transit of UES during saline swallows, is significantly associated with prominent laryngopharyngeal reflux symptoms scored by RSI score.

Swallowing dysfunction in myasthenia gravis patients examined with high-resolution manometry.

OBJECTIVE: To prospectively compare oropharyngeal swallowing dysfunction in myasthenia gravis (MG) patients presenting with difficulty in swallowing between the neutral and chin-down positions, based on the results of high-resolution manometry (HRM) examination. METHODS: We prospectively compared the HRM results of swallowing studies of seven MG patients showing difficulty in swallowing (neutral and chin-down positions) at the Department of Neurology of our institution during the period February-December 2018. The HRM assessment parameters were as follows: maximum swallowing pressure (SP) at the soft palate, meso­hypopharynx, and upper esophageal sphincter (UES), and the duration of relaxation pressure at the UES. These parameters were compared between the two positions and their correlations with the results of neurological evaluations, such as the Quantitative Myasthenia Gravis (QMG) score (total and neck muscles alone), and grip strength, were also analyzed. RESULTS: In comparison with the neutral position, in the chin-down position the maximum SP at the meso­hypopharynx was significantly increased (p < 0.05), the maximum SP at the UES was significantly decreased (p < 0.05), and the duration of relaxing SP at the UES was significantly increased (p < 0.05). Interestingly, there were no correlations between the SP at any location and the results of the neurological evaluations. CONCLUSIONS: The chin-down position appears useful for improving pharyngeal clearance in MG patients, by promoting increased SP at the meso­hypopharynx, relaxing SP at the UES, and increasing the duration of relaxation pressure at the UES.

Ultrasound, electromyography, and balloon guidance for injecting botulinum toxin for cricopharyngeal achalasia: A case report.

INTRODUCTION: Botulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment. PATIENT CONCERNS: We describe the case of a 74-year-old man who could not swallow food or saliva for 8 months. DIAGNOSIS: The patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts. INTERVENTIONS: To manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound. OUTCOMES: The patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown. CONCLUSION: The unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches.

OBJECTIVE: Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates. METHODS: A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded. RESULTS: Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05). CONCLUSION: Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2426-E2431, 2021.

Evaluation of the pharynx and upper esophageal sphincter motility using high-resolution pharyngeal manometry for Parkinson's disease.

Parkinson's disease (PD) is associated with a high incidence of dysphagia. Aspiration pneumonia due to dysphagia is a major cause of death in patients with PD, and therefore accurately evaluating dysphagia should help improve prognosis. It has been reported that the severity of dysphagia does not always correlate with the Hoehn and Yahr (H&Y) stage for classifying PD severity. However, no reports have quantitatively evaluated the relationship between severity of dysphagia and H&Y stage. High-resolution pharyngeal manometry (HRPM) is a quantitative method that can be used to measure swallowing pressure from the velopharynx to the entry of the upper esophageal sphincter (UES). We used HRPM to measure swallowing pressure in 51 patients with PD. As PD progresses, atrophy and degeneration of the pharyngeal muscles become more pronounced, which contributes to dysphagia. However, thus far there is no quantitative clinical evidence for this pathological change. To evaluate the relationship between severity of underlying PD and dysphagia, patients were categorized by H&Y stage, as follows: stage II in four patients, stage III in 23, stage IV in 14, and stage V in 10. In patients with H&Y stages II, III, IV, and V, the respective velopharyngeal pressures were 179.8 ± 32.5, 157.6 ± 62.2, 172.2 ± 48.9, and 107.4 ± 44.0 mmHg, the mesopharyngeal pressures were 126.8 ± 53.2, 121.6.1 ± 50.4, 142.1 ± 57.8, and 61.4 ± 19.6 mmHg, the residual UES pressure were -8.0 ± 10.8, 10.3 ± 16.1, 16.5 ± 37.9, and 11.2 ± 16.2 mmHg, and the resting UES pressure were 49.5 ± 30.0, 15.8 ± 25.7, 1.85 ± 14.1, and -1.2 ± 12.2 mmHg. Patients with severe PD demonstrated significantly decreased velopharyngeal and oropharyngeal pressures, along with incomplete UES opening and contraction. HRPM can detect subtle abnormalities by quantifying swallowing pressure in patients with PD. Evaluating swallowing pressure with HRPM provides insights into neuromuscular dysfunction that causes abnormal pressure generation during pharyngeal swallowing in patients with PD.

Cricopharyngeal bar and dermatomyositis: A cause of rapidly progressive dysphagia.

BACKGROUND: Idiopathic inflammatory myopathies (IIM) are immune-mediated conditions that affect striated muscle, and are frequently associated with dysphagia. Dysphagia in these cases can be due to weakness of the muscles involved in swallowing or the presence of restrictive pharyngeal defects, such as cricopharyngeal bars. Treatment of dysphagia in IIM revolves around immunosuppressive therapies, and procedures to disrupt cricopharyngeus muscle when immunosuppressive therapies are unsuccessful. CASE REPORT: A 73-year-old female presented with rapidly progressive proximal muscle weakness and dysphagia to the point she could not swallow liquids or solids. She had a rash over the extensor surfaces of the limbs, and periorbital-edema. Her creatine kinase was elevated, and skin biopsy showed an interface inflammatory reaction; however, myositis line assay revealed no autoantibodies, and a muscle biopsy was unremarkable. She was diagnosed with dermatomyositis with life-threatening dysphagia, and was admitted to our institution and treated with corticosteroids, methotrexate and intravenous immunoglobulin. A videofluoroscopic swallowing study revealed a large esophageal protrusion at the level of C5-C6, which was thought to be consistent with a cricopharyngeal bar, with large boluses unable to pass, leading to aspiration. After 10 weeks of treatment, the cricopharyngeal bar remained present, but swallowing had improved to the point that she was successfully swallowing all consistencies. CONCLUSION: Dysphagia associated with IIM can be multifactorial, and can be due to the involvement of the muscles of swallowing in the inflammatory process, or due to restrictive pharyngeal defects, and determination of the cause of dysphagia can assist with management.

Biofeedback Training Improves Swallowing in a Unique Case of Upper Esophageal Sphincter Hypotonicity.

Hypotonicity of the upper esophageal sphincter (UES) has been reported only two times previously in the literature, with no reports of treatment options for this rarity. We present a third case of hypotonic UES found during high-resolution pharyngeal manometry. Although the patient had nearly absent resting pressures of the UES, pressures during and post-swallow were normal. It was hypothesized that the patient might be able to increase pre-swallow UES pressure using biofeedback. Using a chin up/out maneuver during manometry, the patient was able to achieve a more normal swallow pressure pattern. This case also highlights the need to complete manometry alongside other swallow imaging techniques for effective treatment planning and patient outcomes. Laryngoscope, 131:E1567-E1569, 2021.

Simultaneous double balloon dilatation using double channel therapeutic endoscope in patients with cricopharyngeal muscle dysfunction: An observative study.

The role of endoscopic balloon dilatation (EBD) using double-balloon catheters in patients with cricopharyngeal muscle dysfunction (CPD) is still unclear. Thus, the aim of this study was to compare the functional outcomes between patients receiving EBD and rehabilitative balloon swallowing (RBS).A total of 36 patients with CPD, who visited a teaching hospital from February 2014 to June 2017, were included in the study. Among them, 12 patients with severe dysphagia underwent EBD. After propensity score matching, 24 patients who underwent RBS were selected for comparison. We compared the effects of EBD and RBS using 4 functional swallowing parameters: functional dysphagia scale score, penetration-aspiration scale score, pharyngeal transit time, and percentage of pharyngeal remnant (PR) at baseline and after the first and second treatments. Using simple and multiple regression, we examined the associations between EBD/RBS and changes of 4 parameters after the treatments since the baselineAll functional parameters significantly decreased after RBS and EBD (P < .05). After the first therapy session, significant differences in the pharyngeal transit time (P = .034), percentage of PR (P = .008), and penetration-aspiration scale score (P = .014) were observed in the EBD group, compared with those in the RBS group. The regression analysis showed significant improvements in the PR after EBD compared with that after RBS (ß = 0.95, SE = 0.31, P = .005).EBD may be an alternative treatment for patients with severe CPD. A significant improvement would be expected in such patients with PR.

Ultrasonography-guided botulinum toxin injection to the cricopharyngeus muscle: a case report and technical notes.

Dysphagia associated with the cricopharyngeus muscle (CPm) dysfunction negatively influences the quality of life. This high-pressure region must relax and the lumen must open for smooth food passage. The CP muscle is therefore a common target of chemodenervation with botulinum toxin (BTX). Here we presented a patient with severe left lateral medullary syndrome and non-relaxation of the CPm. We described how to localize the CPm in the transverse and longitudinal views under ultrasonography and offered a video demonstrating ultrasonography-guided BTX injection. Ultrasonography-guided CPm injection with BTX may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

[Effect of electronic moxibustion on activity of parapharyngeal wall in patients with achalasia of cricopharyngeus muscle after stroke based on musculoskeletal ultrasound].

OBJECTIVE: To observe the clinical effect of electronic moxibustion on dysphagia in patients with achalasia of cricopharyngeus muscle after stroke. METHODS: Sixty patients with dysphagia of achalasia of cricopharyngeus muscle were randomly divided into an observation group and a control group, 30 cases in each group. One patient in the observation group and 2 cases in the control group dropped off. The patients in the control group were treated with routine medical treatment, acupuncture treatment and swallowing rehabilitation training; the patients in the observation group were additionally treated with electronic moxibustion at Lianquan (CV 23), Tiantu (CV 22), Tianding (LI 17) and Futu (LI 18), 30 min each treatment. Both groups were treated 5 times a week for 4 weeks. The musculoskeletal ultrasound (MSUS) was applied to test the activity of parapharyngeal wall and the dysphagia score of Ichiro Fujishima was compared before and after 4-week treatment. RESULTS: After treatment, the activity of the parapharyngeal wall and the dysphagia score of Ichiro Fujishima were increased in both groups (P<0.01, P<0.05). The changes of activity of parapharyngeal wall and dysphagia score of Ichiro Fujishima in the observation group were greater than the control group (P<0.05, P<0.01). CONCLUSION: Electronic moxibustion can improve the impaired swallowing function and reconstruct the normal swallowing process.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification.

BACKGROUND: Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia. METHODS: A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure. RESULTS: Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure. CONCLUSIONS: Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

Modified external approach to the pediatric cricopharyngeal myotomy: A case series.

OBJECTIVE: To assess the success of a modified approach to external pediatric cricopharyngeal myotomy in children with inappropriate upper esophageal sphincter relaxation as determined by video fluoroscopic swallow study (VFSS) and pediatric manometry findings. METHODS: This is a case series in which hospital records of all patients who underwent a modified external approach to pediatric cricopharyngeal myotomy 2017 to 2019 were reviewed at a single institution. The primary outcome measure was post-operative diet and presence of aspiration/penetration on post-operative VFSS. RESULTS: A total of 7 patients underwent modified external approach to pediatric cricopharyngeal myotomy. The average age of the child at the time of surgery was 5.6 (±3.7) years. The average duration (SD) of surgery was 90 (±30) minutes and no complications were observed. 6 of 7 patients (86%) demonstrated an improvement in swallow function after the procedure. The single child who did not was suffering from a posterior fossa tumor which was resected and radiated, which likely made their dysphagia multi-factorial. Although no pediatric normative data exists for upper esophageal sphincter pressure, we observed an average decrease in UES residual pressure of 8.5 (±15.1) mmHg and an average decrease in mean UES pressure of 21.2 (±35.1) mmHg. CONCLUSIONS: The modified external approach to the pediatric cricopharyngeal myotomy appears to be a safe and efficient procedure with no apparent complications to date. However, further longitudinal data is needed to formally evaluate the efficacy of this procedure when treating pediatric cricopharyngeal achalasia.

Swallowing Characteristics in Zenker's-like Diverticulum After Anterior Cervical Spine Surgery.

OBJECTIVES: A Zenker's diverticulum (ZD) is a hypopharyngeal pulsion diverticula caused by dysfunction of the cricopharyngeus muscle with herniation of hypopharyngeal mucosa through Killian's dehiscence. Anterior cervical spine surgery (ACSS) can cause a Zenker's-like traction diverticulum (ZTD) with a similar presentation but different pathophysiology. The purpose of this investigation was to compare the fluoroscopic parameters and surgical outcomes of ZTD after ACSS to those of typical ZD. STUDY DESIGN: Case-control study. METHODS: The charts of patients undergoing a videofluoroscopic swallow study after ACSS between January 1, 2014, and January 1, 2018, were evaluated for evidence of ZTD. Patients with ZTD were age and gender matched to persons with ZD. Fluoroscopic parameters and patient-reported outcomes were compared between groups. RESULTS: Eleven patients with ZTD were identified. The mean pharyngeal constriction ratio (PCR) was significantly higher for persons with ZTD (0.87 [±0.07] vs. 0.17 [±0.08]; P < 0.05). Mean hyolaryngeal elevation was significantly less (2.5 [±0.9] cm vs. 3.5 [±0.7] cm) and mean diverticulum size significantly smaller (1.3 [±1.0] cm vs. 2.3 [±2.0] cm) for persons with ZTD (P < 0.05). Five ZTD patients had exposed hardware necessitating open approach for removal. CONCLUSION: We report the largest cohort of ZTD after ACSS. ZTD are smaller than traditional Zenker's and associated with more pharyngeal weakness, poorer laryngeal elevation, and worse treatment outcomes. Although these diverticula can be managed endoscopically, the high percentage of exposed cervical hardware necessitates a thorough preoperative assessment and frequent need for open management and pharyngeal repair. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:1383-1387, 2020.

Three-dimensional analysis of the human pharyngoesophageal sphincter.

OBJECTIVES: Dysfunction of the pharyngoesophageal segment (PES) is a common cause of oropharyngeal dysphagia. Surgical dilation of the PES uses cylindrical dilators that expand radially in a circular shape. Animal studies, however, suggest that the PES is kidney-shaped. The purpose of this investigation was to evaluate the 3D shape of the human PES with a novel casting method. METHODS: A platinum-cured liquid silicone polymer was infused under pressure into the upper aerodigestive tract of nine fresh human cadavers to construct 3D casts of the maximally distended PES. Cross-sectional and volumetric analysis were performed using computed tomography and serial sectioning of the models. Canonical variate analysis was used to identify the shape features that best distinguishes the PES from the cervical esophagus. RESULTS: The mean age of the cadavers was 77.9 (SD ± 10.6) years, with 67% women. Analysis of the casts confirms that the human PES possesses a kidney-shaped structure at maximal distention, which is discretely different from the adjacent esophagus (P < 0.001). The posterior body of the cricoid cartilage formed the anterior wall of the PES, which provided a rigid structure responsible for preservation of the kidney shape during distention. The diameter of the maximally distended PES at the cricopharyngeus was highly variable (range = 0.86-4.68 cm2 ; SD = 1.33 cm2 ). CONCLUSION: The data suggest that the human PES is not round and that targeted expansion at the level of the cricopharyngeus with an eccentrically shaped dilator may provide improved distention. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

Botulinum Toxin A Injection Using Esophageal Balloon Radiography Combined with CT Guidance for the Treatment of Cricopharyngeal Dysphagia.

Cricopharyngeal dysfunction, especially cricopharyngeal achalasia, is a common cause of dysphagia, while patients with brainstem stroke and medullary damage have a relatively high risk of cricopharyngeal achalasia. The aim of this article was to introduce an improved method of CT-guided method of injecting botulinum toxin A into the cricopharyngeus muscle using esophageal balloon radiography, and to assess the effect of the botulinum toxin A injection on swallowing performance. Seventeen patients with cricopharyngeal dysphagia were treated with botulinum toxin A injection using esophageal balloon radiography combined with CT guidance to the cricopharyngeal muscle. Primary outcome measures, including Functional Oral Intake Scale and Deglutition Handicap Index, were performed at baseline, 1 week, and 1 month after treatment. The Levene method was used to test the homogeneity of variance, and the Kruskal-Wallis test was used to compare the scores between the timepoints. Botulinum toxin A injection resulted in obvious improvement in 15 patients (88.2%) and no improvement in two patients (11.8%). Compared with the scores prior to treatment, the Functional Oral Intake Scale and Deglutition Handicap Index scores were significantly improved at 1 week (P < 0.001 and P = 0.008, respectively) and 1 month after the treatment (P = 0.001 and P < 0.001, respectively). Thus, CT-guided percutaneous injection of botulinum toxin A is probably a relatively safe, well-tolerated, and viable technique for the treatment of cricopharyngeal dysphagia caused by brainstem injury. Localization with a balloon radiography made the needle guidance easier to visualize.