Cricopharyngeal Dysfunction in Chronic Obstructive Pulmonary Disease* Myron Stein, M.D., F.C.C.P.; Adrian]. Williams, M.B., F.C.C.P.; Frederick Grossman, M.D.; Amy S. Weinberg, M.D.; and Lionel Zuckerbraun, M.D. Dysphagia due to cricopharyngeal dysfunction is well known; however, there have been no previous data indicating an association between cricopharyngeal dysfunction and COPD. After observing marked cricopharyngeal dysfunction with aspiration in three patients who had frequent and severe exacerbations of COPD, we performed pharyngoesophageal examinations with videotaping in another 22 nonrandomized patients. Cineradiography or videoftuoroscopic recording with capabilities of slow-motion and freezeframe playback is mandatory, since the transit time of the bolus through the pharynx is rapid. Severe cricopharyogeal dysfunction was observed in 17 elderly patients with COPD. Deglutition disorders were elicited by careful questioning
in 15 of these. In eight subjects, cricopharyngeal myotomy resulted in improvement of swallowing and complete or partial relief of acute exacerbations of respiratory distress. In one subject, myotomy relieved only the swallowing problem. The mechanism of cricopharyngeal dysfunction in elderly patients with COPD is unknown at this time, but may be related to gastroesophageal reftux, therapeutic agents, and/or alterations in pharyngoesophageal anatomic structures. We conclude that investigations for swallowing disorders should be considered in patients with COPD who have frequent acute exacerbations of respiratory distress. (Chat 1990; 97:347-52)
The intimate developmental and anatomic relationships of the tracheobronchial tree and gastrointestinal tract have demanded a complex system for separating their functions. The process of swallowing is one aspect. 1 Failure of all or part of this process may lead to aspiration of oropharyngeal contents, a recognized pathophysiologic entity which produces, for example, anaerobic pulmonary infections,2.3 cough, wheezing, and respiratory distress. In the setting of obvious oropharyngeal dysphagia (with disorders such as brain-stem lesions, muscular disease, eg, polymyositis or myasthenia, and Parkinson's disease), this association may be easily recognized; however, subtle difficulties in passage of solids or liquids from the oropharynx into the upper esophagus are currently little appreciated. In this report, we wish to highlight important aspects of this phenomenon in a group of patients with COPD. We have studied 25 patients with severe obstructive airways disease, 21 of whom had various degrees of cricopharyngeal achalasia. Due to favorable responses to cricopharyngeal myotomy in eight of these patients, we propose that there may be a causal relationship between the two conditions in some patients. While considerable literature on cricopharyngeal function and dysfunction+& has been produced, we are not aware of any report raising the possibility that cricopharyngeal dysfunction may be
related to or contribute to exacerbations ofCOPD.
*From the Medical, Radiologic, and Surgical Services, Brotman Medical Center, Culver City; the Medical and Research Services, Wadsworth VA Hospital, Los Angeles; and the Department of Medicine, UCLA, Los Angeles.
W;~:"f!'~~v~
~~
Hoapital, W8 Angeles 90073
~:::.a~&~\i!L!!OOrth
VA
MATERIALS AND METHODS
Protocol
Based on our experience with three patients with severe COPD and clinically overt swallowing difficulties in whom cricopharyngeal dysfunction was verified, we studied an additional 22 patients with severe COPD who were subject to frequent exacerbations. All studies were performed in a community hospital. These studies were neither consecutive nor randomized, but were based upon historical data and the patient's willingness to have pharyngoesophageal studies with videotaping. Clinical historical data included "a feeling of something stuck in my throat," necessity of cutting food into very small pieces prior to ingestion, coughing up particles of food, and histories of aspiration or aspiration pneumonia. Decisions regarding recommendations for cricopharyngeal myotomy were made by a head-and-neck surgeon (L.Z.) according to standard clinical criteria and were based on historical data, frequent exacerbations of COPD with coughing and respiratory distress at times requiring hospitalization, and radiographic observations of severe upper esophageal obstruction due to cricopharyngeal spasm. In addition, videoftuoroscopic studies of swallowing were performed in 128 unmatched adult patients aged 27 to 85 years, without known pulmonary disease. They were referred fur upper gastrointestinal examinations for various medical problems other than dysphagia. &dWgraphic Methods Preliminary roentgenograms of the chest and soft tissue of the neck were obtained in all patients. The radiologic pharyngoesophageal examination included either cineradiography or videoftuoroscopic recording with capability of playback analysis in slow-motion and freeze-frame modes. These studies are mandatory for an adequate evaluation, since the transit time of the bolus through the pharynx is quite rapid. Liquid barium swallows were supplemented by solid or semisolid materials such as barium-impregnated marshmallows or pieces of bagel coated with barium. Prior to administering contrast material, the motion of the sol\ palate was viewed ftuoroscopically in the lateral projection, and the CHEST I 97 I 2 I FEBRUARY. 1990
347
fimdion of the vocal rds was observed in the frontal projection. Upri~ht lateral and anteroposterior views were obtained with r laryn~eal penetration. Examinations of tlu• month. upper rwck, and lower neck were then performed, followt•d hy lateral dt·cuhihrs and prone ohlitJUe views of the pharynx and cervical and thoracic esopha~us. Radio~raphic spot films of the t • sopha~us wert' obtained. Additionally, examination was performed to search fC>r ~astroesopha~eal reflux. More sensitive techniques for dia~nosis of ~·L~Iroesopha~eal reflux (q~. nuclear scintiscan or t • sopha~eal motility studies) were not employed hecause of the additional inpharyn~eal muscle occurs. Failure of the muscle to swallowin~ is observed as a defect or posterior rt•lax durin~ indentation into tlw barium mlumn (Fi~ I). In thost• patients with crit.1>pharyn~eal achalasia , the dysfunction obS
in 15 of these. In eight subjects, cricopharyngeal myotomy resulted in improvement of swallowing and complete or partial relief of acute exacerbations of respiratory distress. In one subject, myotomy relieved only the swallowing problem. The mechanism of cricopharyngeal dysfunction in elderly patients with COPD is unknown at this time, but may be related to gastroesophageal reftux, therapeutic agents, and/or alterations in pharyngoesophageal anatomic structures. We conclude that investigations for swallowing disorders should be considered in patients with COPD who have frequent acute exacerbations of respiratory distress. (Chat 1990; 97:347-52)
The intimate developmental and anatomic relationships of the tracheobronchial tree and gastrointestinal tract have demanded a complex system for separating their functions. The process of swallowing is one aspect. 1 Failure of all or part of this process may lead to aspiration of oropharyngeal contents, a recognized pathophysiologic entity which produces, for example, anaerobic pulmonary infections,2.3 cough, wheezing, and respiratory distress. In the setting of obvious oropharyngeal dysphagia (with disorders such as brain-stem lesions, muscular disease, eg, polymyositis or myasthenia, and Parkinson's disease), this association may be easily recognized; however, subtle difficulties in passage of solids or liquids from the oropharynx into the upper esophagus are currently little appreciated. In this report, we wish to highlight important aspects of this phenomenon in a group of patients with COPD. We have studied 25 patients with severe obstructive airways disease, 21 of whom had various degrees of cricopharyngeal achalasia. Due to favorable responses to cricopharyngeal myotomy in eight of these patients, we propose that there may be a causal relationship between the two conditions in some patients. While considerable literature on cricopharyngeal function and dysfunction+& has been produced, we are not aware of any report raising the possibility that cricopharyngeal dysfunction may be
related to or contribute to exacerbations ofCOPD.
*From the Medical, Radiologic, and Surgical Services, Brotman Medical Center, Culver City; the Medical and Research Services, Wadsworth VA Hospital, Los Angeles; and the Department of Medicine, UCLA, Los Angeles.
W;~:"f!'~~v~
~~
Hoapital, W8 Angeles 90073
~:::.a~&~\i!L!!OOrth
VA
MATERIALS AND METHODS
Protocol
Based on our experience with three patients with severe COPD and clinically overt swallowing difficulties in whom cricopharyngeal dysfunction was verified, we studied an additional 22 patients with severe COPD who were subject to frequent exacerbations. All studies were performed in a community hospital. These studies were neither consecutive nor randomized, but were based upon historical data and the patient's willingness to have pharyngoesophageal studies with videotaping. Clinical historical data included "a feeling of something stuck in my throat," necessity of cutting food into very small pieces prior to ingestion, coughing up particles of food, and histories of aspiration or aspiration pneumonia. Decisions regarding recommendations for cricopharyngeal myotomy were made by a head-and-neck surgeon (L.Z.) according to standard clinical criteria and were based on historical data, frequent exacerbations of COPD with coughing and respiratory distress at times requiring hospitalization, and radiographic observations of severe upper esophageal obstruction due to cricopharyngeal spasm. In addition, videoftuoroscopic studies of swallowing were performed in 128 unmatched adult patients aged 27 to 85 years, without known pulmonary disease. They were referred fur upper gastrointestinal examinations for various medical problems other than dysphagia. &dWgraphic Methods Preliminary roentgenograms of the chest and soft tissue of the neck were obtained in all patients. The radiologic pharyngoesophageal examination included either cineradiography or videoftuoroscopic recording with capability of playback analysis in slow-motion and freeze-frame modes. These studies are mandatory for an adequate evaluation, since the transit time of the bolus through the pharynx is quite rapid. Liquid barium swallows were supplemented by solid or semisolid materials such as barium-impregnated marshmallows or pieces of bagel coated with barium. Prior to administering contrast material, the motion of the sol\ palate was viewed ftuoroscopically in the lateral projection, and the CHEST I 97 I 2 I FEBRUARY. 1990
347
fimdion of the vocal rds was observed in the frontal projection. Upri~ht lateral and anteroposterior views were obtained with r laryn~eal penetration. Examinations of tlu• month. upper rwck, and lower neck were then performed, followt•d hy lateral dt·cuhihrs and prone ohlitJUe views of the pharynx and cervical and thoracic esopha~us. Radio~raphic spot films of the t • sopha~us wert' obtained. Additionally, examination was performed to search fC>r ~astroesopha~eal reflux. More sensitive techniques for dia~nosis of ~·L~Iroesopha~eal reflux (q~. nuclear scintiscan or t • sopha~eal motility studies) were not employed hecause of the additional inpharyn~eal muscle occurs. Failure of the muscle to swallowin~ is observed as a defect or posterior rt•lax durin~ indentation into tlw barium mlumn (Fi~ I). In thost• patients with crit.1>pharyn~eal achalasia , the dysfunction obS
