ENDOSCOPIC MYOTOMY OF THE CRICOPHARYNGEAL MUSCLE WITH CO 2 LASER SURGERY

Transcription

1 ENDOSCOPIC MYOTOMY OF THE CRICOPHARYNGEAL MUSCLE WITH CO 2 LASER SURGERY Robert P. Takes, MD, PhD, Frank J. A. van den Hoogen, MD, PhD, Henri A. M. Marres, MD, PhD Department of Otolaryngology/Head and Neck Surgery, University Medical Center Nijmegen, P. O. Box 9101, 6500 HB Nijmegen, The Netherlands. r.takes@kno.umcn.nl Accepted 3 February 2005 Published online 10 May 2005 in Wiley InterScience ( DOI: /hed Abstract: Background. Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO 2 laser have been described. Methods. Endoscopic cricopharyngeal myotomy using a CO 2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker s diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy. Results. In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure. Conclusions. Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction. A 2005 Wiley Periodicals, Inc. Head Neck 27: , 2005 Keywords: dysphagia; cricopharyngeal; myotomy; laser surgery; endoscopy The upper esophageal sphincter is formed mainly by the cricopharyngeal muscle. In rest, Correspondence to: R. P. Takes B 2005 Wiley Periodicals, Inc. this muscle is in a state of tonic contraction. Hypertonus or delayed relaxation of the muscle can lead to dysphagia combined with aspiration. This dysfunction has several possible causes. It may be idiopathic, or it may be caused by neurologic and/or muscular disorders, neck surgery, or old age. The dysphagia resulting from this dysfunction often develops gradually and may lead to changes in dietary habits with a shift toward a (semi-) liquid diet, weight loss, and pulmonary infections caused by aspiration. One of the treatment options for this condition is cricopharyngeal myotomy. Several techniques have been used and described for cricopharyngeal myotomy. Since the first external cricopharyngeal myotomy by Kaplan in 1951, 1 several techniques have been described for extramucosal myotomy. Endoscopic or transmucosal cricopharyngeal myotomy for the treatment of Zenker s diverticulum was described by Dohlman and Mattsson in At the beginning of the 1990s, case reports were published on an endoscopic transmucosal approach using a laser in cases without Zenker s diverticulum, 3 followed by reports on larger, but still limited, numbers of patients. 4 6 However, published series are scarce, and the techniques, procedures, and outcome are not described uni- Endoscopic Cricopharyngeal Myotomy HEAD & NECK August

2 formly in these articles. In this article, we present a review of the data from previously published series and describe our own experience with 10 cases. MATERIAL AND METHODS In the period from January 2002 to December 2003, 10 consecutive patients with idiopathic cricopharyngeal dysfunction were identified (Table 1). Diagnosis was based on the history of the patient, fiberoptic examination, and videofluoroscopy of the hypopharynx and esophagus (Figure 1). Myotomy was performed using the same endoscopic technique as that used in the treatment of Zenker s diverticulum. A Weerda or Van Overbeek diverticuloscope was used. The scope was introduced down to the cricopharyngeal muscle. By lifting the larynx with the scope, the cricopharyngeal muscle was stretched, and it became visible, bulging posteriorly like the cricopharyngeal bar (Figure 2). A CO 2 laser (Sharplan 30C, Sharplan Laser Industries Ltd, Tel Aviv, Israel) was used with a power of 4 W in continuous-wave mode, equipped with a micromanipulator connected to the microscope. The muscle was cut transmucosally in the median line up to the prevertebral fatty tissue. All the patients received a feeding tube that was carefully introduced immediately after the myotomy under endoscopic sight of the operation field. Our postoperative protocol was similar to the one we use after the endoscopic treatment for Zenker s diverticulum. Patients received prophylactic antibiotic treatment for 24 hours. On postoperative day 1, x-rays were taken of the chest and lateral neck. If there were no signs of free air in the soft tissues on these radiographs and the patient had no signs of infection, oral intake could be started. If free air was visible on the x-rays, oral intake was delayed for 3 days. Swallowing was evaluated on two occasions by clinical assessment and history 2 weeks and 3 months after surgery. Furthermore, a questionnaire was used to evaluate preoperative and (3 months 2 years) postoperative complaints (Figure 2). A validated questionnaire was not available at the time, and therefore, a questionnaire was developed by the authors in cooperation with our multidisciplinary team for swallowing disorders (Table 2). RESULTS In all patients, the cricopharyngeal muscle could be visualized and transected transmucosally by endoscopic laser surgery. None of the patients had complications, although some had a slight rise in temperature temporarily that did not exceed 38jC. In four patients, signs of free air were visible in the soft tissues on the x-rays, and one patient had subcutaneous emphysema. These findings did not have any clinical sequelae (Table 1). Evaluation of the answers to the questionnaires showed that most patients had experienced improvements in their complaints (Table 3). One patient showed initial improvement but required a second operation 1 year later. It was our impression that the recurrence in this patient was due to fibrosis at the site of the laser incision. It seemed that the opposing wound surfaces of the cricopharyngeal muscle had grown together again. At the second operation, the cricopharyngeal bar was re-incised, and sutures were placed to close the mucosal defect to prevent restenosis. Swallowing was found to have improved once again 3 months after the second operation. Examples of videofluoroscopic images taken pre- Table 1. Population and postoperative course. Patient no. Patient age, y/sex Fever Free air in soft tissues on x-ray Subcutaneous emphysema Postoperative hospitalization, d 1 74/F No No No /F No No No /F No Yes No /M No Yes Yes /F No Yes No /M No No No /F No No No /F No No No /F No Yes No /M No No No Endoscopic Cricopharyngeal Myotomy HEAD & NECK August 2005

3 unless it is coupled with fluoroscopy. 10 This latter technique may provide useful additional data but is currently not available in every institution. Some authors state that because diagnostic tests for the evaluation of cricopharyngeal dysmotility are often unreliable, uncomfortable, and expensive, surgical intervention can be used as a diagnostic and a therapeutic tool. 11,12 However, many authors will see a need for an objective tool for preoperative and postoperative assessment. To date, the most important parameters seem to be the patient s history and videofluoroscopy. Traditionally, myotomy of the cricopharyngeal muscle is performed by an external approach. However, alternative methods have been developed for the treatment of cricopharyngeal dysfunction, most of which are intended to make the procedure simpler, save time, and reduce morbidity. FIGURE 1. Videofluoroscopic image of a patient with cricopharyngeal hypertrophy. Some aspiration of contrast is visible. operatively and 3 months after treatment are shown in Figure 3. DISCUSSION One of the main topics of discussion in cricopharyngeal myotomy is the indication for the procedure. In principle, myotomy is indicated for pharyngeal dysphagia when there is defective opening of the upper esophageal sphincter, good laryngeal elevation, and good oral and pharyngeal propulsion. The problem is how to obtain reliable data on these factors. Videofluoroscopy and dynamic contrast radiography are probably the most informative examination techniques, because they enable visualization of the cricopharyngeal muscle obstruction and laryngeal elevation. Manometry is also being used to evaluate upper esophageal sphincter dysfunction. It may provide information complementary to videofluoroscopy, but it seems to be much less informative than radiography. 7 9 Measurements in rest are unreliable, because there is wide overlap in the range of intraesophageal pressure between normal and abnormal subjects, and many physiologic factors influence the baseline pressure. In addition, catheter and sensor movements during swallowing decrease the value of this technique, FIGURE 2. Endoscopic images of the cricopharyngeal muscle before (A) and after (B) myotomy using the CO 2 laser. [Color figures can be viewed in the online issue, which is available at Endoscopic Cricopharyngeal Myotomy HEAD & NECK August

4 Table 2. Questionnaire. How long do your complaints exist? Did the complaints develop gradually or in a short period of time? Do you have difficulty with chewing? Does food get stuck in the back of the mouth? Does food come back through your nose? Do you have to cough during or after eating? Do you have to cough during or after drinking? Do you aspirate your saliva? Does food get stuck in your throat? Do you have the feeling that constantly something gets stuck in your throat even if you have not eaten anything at all? Does food get stuck in your esophagus? Does food sometimes come back up again? Are there certain foods you cannot eat? Did you lose weight and, if yes, how much? Table 3. Summary of the questionnaires on subjective symptoms before and after treatment. No. patients with positive finding (N = 10) Questionnaire summary Preoperative Postoperative Duration of complaints 1 8 y Weight loss 0 15 kg Nasal regurgitation 2 1 Aspiration with drinking 7 2 Aspiration eating solid food 9 3 Sensation of food getting stuck 9 2 Adjustment of diet 10 4 FIGURE 3. Videofluoroscopic images of a patient with cricopharyngeal hypertrophy before and after treatment. (A) The impression of the muscle in the lumen is clearly visible. (B) After treatment, the impression has largely disappeared. The endoscopic technique for cricopharyngeal myotomy has evolved from the use of this technique for Zenker s diverticulum, in which it has proven to be an effective and safe method. The original technique described by Dohlman and Mattsson 2 has been refined by the introduction of the operating microscope, the diverticuloscope, (CO 2 ) laser, and stapler Cricopharyngeal dysfunction without diverticulum can also be approached in the same way. Some authors therefore suggested that the diverticuloscope be renamed cricopharyngoscope. 4 In large series of patients with Zenker s diverticulum, the endoscopic approach has proven to be a safe procedure. 15,17 Publications on series of patients with cricopharyngeal dysfunction alone, without Zenker s diverticulum, did not report any major complications either, and this was confirmed in our series of patients. 3 6,18 An alternative method is to relax the upper esophageal sphincter with the injection of botulinum toxin. 19 However, this technique also requires treatment with the patient under general anesthesia, because these injections in the muscle are usually performed transmucosally under direct endoscopic guidance. Unfortunately, the effect is temporary and needs to be repeated. It may have a place as a diagnostic tool before definitive surgical treatment in uncertain cases in which it can be used as a trial of therapy. Dilatation therapy for dysphagia in patients with cricopharyngeal dysfunction has also been described in a limited number of patients, 20 but it is usually considered to be a temporary solution. 18 It may be the option of choice in patients with fibrosis of the cricopharyngeal muscle. Concerning the procedure itself, it may be disputed whether the measures we took, such as feeding tubes, antibiotics, postoperative x-rays, and the fairly long hospitalization, were all strictly necessary. However, because the technique involves potentially serious complications, we considered it wise to be cautious. Other authors used different protocols, although, unfortunately, most of them did not describe their protocols in detail. A summary of the published series compared with our own procedures is given in Table 4. The comparison of different studies shows that the protocols differed significantly insofar as they were described. Laser settings varied from 1.5 to 3.0 W continuous mode 5 to up to 20 W. 18 Oral intake initiation varied from immediate liquid to purified diet 4,18 to a feeding tube or 706 Endoscopic Cricopharyngeal Myotomy HEAD & NECK August 2005

5 even parenteral feeding for 3 days. 5,6 Discharge from the hospital varied from the day of operation 4 to at least 3 days. 6 Antibiotic treatment varied from perioperative 4,18 to 8 days. 6 Because there do not seem to be many differences in the results, it is difficult to determine which policy is best. With regard to the results and complications, in our series, one of the 10 patients required surgery 1 year after showing initial improvement. All the other patients improved, but not all of them were complaint-free. There were no procedure-related complications. Herberhold and Walther 18 mentioned improvement in all their cases but one. Two patients had complications. One patient required prolonged intubation because of transient supraglottic edema, and one patient was clinically suspected of imminent mediastinitis, but lateral cervicotomy did not reveal any mediastinal leakage. Lim 4 described 100% improvement in all the milder cases. Four patients with a complete stenosis, drooling, and severe dysphagia all refibrosed. Two of the 44 patients required revision after 6 to 12 months of improved swallowing, three of the 11 patients with aspiration continued to have aspiration, and two of the 44 patients had perforations that were drained externally. Although some of the patients in their series had Zenker s diverticulum, these complications were described in the patients without diverticulum. The overall success rate was 86%, but there was no mention of a questionnaire. Repeated videofluoroscopy was done after 6 to 8 months. In the series described by Halvorson and Kuhn 3 14 (78%) of the 18 cases had complete response ; four (22%) of the 18 showed appreciable improvement in swallowing. There was no mention of a questionnaire or complications. Brondbo 5 did not describe any complications. All but one of his patients improved. He evaluated the patients using a questionnaire, but it was not further specified. Lawson et al 6 performed preoperative and postoperative assessments of dysphagia, aspiration, flexible endoscopy, and videofluoroscopy. All but one patient improved, whereas three patients still had (intermittent) dysphagia and aspiration. There were no complications, and no revision surgery was necessary. All these results are comparable with those of external myotomy of the cricopharyngeal muscle, with success rates of 73% to 79% mentioned in review articles. 21 Complication rates seem to be comparable to those after endoscopic treatment for Zenker s diverticulum. 17,22,23 Comparison with the external approach is hampered by the fact that the study populations are heterogeneous, as are the presentations of the results. Known complications of the external approach are pharyngocutaneous fistula and recurrent laryngeal nerve injury, but both complications are rare. McKenna and Dedo 11 reported on 54 cricopharyngeal myotomies and had one wound infection and one fistula. Brouillette et al 24 in a Table 4. Summary of published series. Data by series Factor Herberhold 18 Lim 4 Halvorson 3 Bronbo 5 Lawson 6 Current study No. of patients 32* 44y Laser settings 5 20 W 1 12 W KTP laser W 10 W 4 W Postoperative Purified diet Feeding tube intake for d for 3 d Immediate liquid, followed by soft diet Liquid diet for 1 d, followed by a normal diet asap Parenteral feeding for 3 d, followed by a semisolid diet Feeding tube for 1 or 3 d, depending on free air in soft tissues Perioperative Yes Yes?? Yes, and continuation Yes antibiotics for 8 d Radiologic After 1 week After 4 h?? After 3 d After 3 mo evaluation Day of discharge After 2 d After 0 1 d?? After 3 d After 3 9 d Additional measurements Daily chest x-ray for 3 d Chest and lateral neck x-ray 1 d postoperatively * Including seven patients with Zenker s diverticulum, 12 secondary to pharyngolaryngeal tumor therapy, two after strumectomy, and four with neurologic disorders. yincluding four patients with Zenker s diverticulum. Endoscopic Cricopharyngeal Myotomy HEAD & NECK August

6 series of 205 patients (including patients with Zenker s diverticulum) had two patients (1%) with fistula formation and 11 (5.3%) with wound infection. Mortality directly related to the surgical procedure was seen in three patients (1.4%). Lindgren and Ekberg 25 in a series of 60 patients (37 of whom had a Zenker s diverticulum) had two patients in their series with a perforation of the esophagus intraoperatively, and one patient had a fistula develop. They reported 10% minor complications, including temporary paralysis of the recurrent laryngeal nerve in four patients and aspiration pneumonia in two. Other authors also reported that the procedure is safe and effective but not completely without complications. 26 Some authors did not mention the presence or absence of complications in their articles. 27,28 The external and the endoscopic approaches are potentially risky procedures. On the other hand, not treating these elderly and often frail patients with serious swallowing problems may also result in serious and potentially lethal complications such as aspiration pneumonia. On the basis of the data presented in the literature, both techniques seem to be comparable in complication rates and safety, with the endoscopic approach being a simpler and less invasive technique. The lack of uniformity in the presentation of the techniques, procedures, and results in the few series of endoscopic cricopharyngeal myotomy published in the literature encouraged us to describe our technique and procedures in detail. It is difficult to give strong recommendations on the basis of the literature, because with different, often partially described, regimens similar results have been obtained. Moreover, the number of series reported and the number of patients in these series is limited. On the basis of the findings in the literature and our own experience, the following recommendations and comments may be made. It is recommended that patients be evaluated by means of history taking, examination, and videofluoroscopy. In the evaluation of patients, it is particularly important to assess the adequacy of oral and pharyngeal propulsion and laryngeal function. The endoscopic myotomy procedure is relatively quick and easy to perform compared with the external approach, and it seems to be particularly suitable at centers that have experience with endoscopic treatment for Zenker s diverticulum. It is probably preferable to use the same procedures as those for the endoscopic treatment of Zenker s diverticulum. However, as with the endoscopic treatment of Zenker s diverticulum, it may sometimes be difficult to introduce the endoscope in the correct position because of anatomic variables (eg, cervical spine fixation, retrognathia, dentition) of the patient. With correct positioning of the patient with the head in extension, we managed to position the endoscope correctly in all patients. Patients in whom extension of the neck is contraindicated (eg, patients with cervical hernia) may be considered unsuitable for this approach. With regard to the safety of the procedure, it is probably wise not to extend the laser incision too much caudally and to stop immediately if the last muscle fibers of the cricopharyngeal muscle are cut. Whether the use of fibrin glue to seal the mucosal defect adds to the safety of the procedure is difficult to say, but it may be considered. However, in studies concerning the endoscopic treatment of Zenker s diverticulum, no convincing evidence was found that sealing the created defect by the use of a stapler is safer than the use of laser, 17 although this may seem so theoretically. The use of a stapler for this indication is at least difficult, if not impossible, because the anvils of the stapler cannot be positioned on both sides of the cricopharyngeal muscle if there is no diverticulum. The laser setting of 4 W in continuouswave mode that we used resulted in a controlled cutting of the muscle. Higher energy may result in less-controlled defects. As to the postoperative measurements, we would recommend giving prophylactic antibiotic treatment. As our postoperative radiographs show, in a significant number of patients, some free air is seen in the surrounding tissues. For the same reason, we think it is wise to decide on the start of oral intake after taking these lateral radiographs of the neck. If a larger defect exists, resulting in some air leakage, the start of oral intake is delayed. Mask ventilation during wake-up from anesthesia may also contribute to passage of air in the neck, and, therefore, vigorous mask ventilation should be avoided. Larger prospective studies are needed to judge the efficacy of endoscopic laser myotomy of the cricopharyngeal muscle compared with other management options. There are, however, several barriers to the development of well-designed clinical trials in this field. The population of patients involved is often heterogeneous, and the patients included in such studies should preferably meet uniform criteria. The means to select these patients, however, are limited. Therefore, there is a need for additional tools such as well-validated 708 Endoscopic Cricopharyngeal Myotomy HEAD & NECK August 2005

7 rating scales for dysphagia that can be used in addition to (mano-) videofluoroscopy to assess the problem and the outcome of the treatment. CONCLUSIONS Endoscopic myotomy of the cricopharyngeal muscle with a CO 2 laser has been shown to be a safe and effective technique for the treatment of cricopharyngeal dysfunction in this series of 10 patients. More prospective data are required to judge the results of endoscopic laser myotomy of the cricopharyngeal muscle compared with other management options. REFERENCES 1. Kaplan S. Paralysis of deglutition, a post-poliomyelitis complication treated by section of the cricopharyngeus muscle. Ann Surg 1951;133: Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. Arch Otolaryngol 1960;71: Halvorson DJ, Kuhn FA. Transmucosal cricopharyngeal myotomy with the potassium-titanyl-phosphate laser in the treatment of cricopharyngeal dysmotility. Ann Otol Rhinol Laryngol 1994;103: Lim RY. Endoscopic CO 2 laser cricopharyngeal myotomy. J Clin Laser Med Surg 1995;13: Brondbo K. Treatment of cricopharyngeal dysfunction by endoscopic laser myotomy. Acta Otolaryngol Suppl 2000; 543: Lawson G, Remacle M, Jamart J, Keghian J. Endoscopic CO 2 laser-assisted surgery for cricopharyngeal dysfunction. Eur Arch Otorhinolaryngol 2003;260: Berg HM, Jacobs JB, Persky MS, Cohen NL. Cricopharyngeal myotomy: a review of surgical results in patients with cricopharyngeal achalasia of neurogenic origin. Laryngoscope 1985;95: Malhi-Chowla N, Achem SR, Stark ME, Devault KR. Manometry of the upper esophageal sphincter and pharynx is not useful in unselected patients referred for esophageal testing. Am J Gastroenterol 2000;95: Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology 1999; 116: Olsson R, Kjellin O, Ekberg O. Videomanometric aspects of pharyngeal constrictor activity. Dysphagia 1996;11: McKenna JA, Dedo HH. Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol 1992;101: Halvorson DJ. The treatment of cricopharyngeal dysmotility with a transmucosal cricopharyngeal myotomy using the potassium-titanyl-phosphate (KTP) laser. Endoscopy 1998;30: van Overbeek JJ, Hoeksema PE, Edens ET. Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser. Ann Otol Rhinol Laryngol 1984;93: Holinger LD, Benjamin B. New endoscope for (laser) endoscopic diverticulotomy. Ann Otol Rhinol Laryngol 1987;96: van Overbeek JJ. Pathogenesis and methods of treatment of Zenker s diverticulum. Ann Otol Rhinol Laryngol 2003; 112: Scher RL, Richtsmeier WJ. Endoscopic staple-assisted esophagodiverticulostomy for Zenker s diverticulum. Laryngoscope 1996;106: Hoffmann M, Scheunemann D, Rudert HH, Maune S. Zenker s diverticulotomy with the carbon dioxide laser: perioperative management and long-term results. Ann Otol Rhinol Laryngol 2003;112: Herberhold C, Walther EK. Endoscopic laser myotomy in cricopharyngeal achalasia. Adv Otorhinolaryngol 1995;49: Schneider I, Thumfart WF, Pototschnig C, Eckel HE. Treatment of dysfunction of the cricopharyngeal muscle with botulinum A toxin: introduction of a new, noninvasive method. Ann Otol Rhinol Laryngol 1994;103: Hatlebakk JG, Castell JA, Spiegel J, Paoletti V, Katz PO, Castell DO. Dilatation therapy for dysphagia in patients with upper esophageal sphincter dysfunction manometric and symptomatic response. Dis Esophagus 1998;11: Kelly JH. Management of upper esophageal sphincter disorders: indications and complications of myotomy. Am J Med 2000;108(Suppl 4a):43S 46S. 22. van Overbeek JJ. Meditation on the pathogenesis of hypopharyngeal (Zenker s) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994;103: Scher RL, Richtsmeier WJ. Long-term experience with endoscopic staple-assisted esophagodiverticulostomy for Zenker s diverticulum. Laryngoscope 1998;108: Brouillette D, Martel E, Chen LQ, Duranceau, A. Pitfalls and complications of cricopharyngeal myotomy. Chest Surg Clin North Am 1997;7: Lindgren S, Ekberg O. Cricopharyngeal myotomy in the treatment of dysphagia. Clin Otolaryngol 1990;15: Bonafede JP, Lavertu P, Wood BG, Eliachar I. Surgical outcome in 87 patients with Zenker s diverticulum. Laryngoscope 1997;107: Berg HM, Jacobs JB, Persky MS, Cohen NL. Cricopharyngeal myotomy: a review of surgical results in patients with cricopharyngeal achalasia of neurogenic origin. Laryngoscope 1985;95: Duranceau A. Cricopharyngeal myotomy in the management of neurogenic and muscular dysphagia. Neuromuscul Disord 1997;7(Suppl 1): Endoscopic Cricopharyngeal Myotomy HEAD & NECK August