Ann Otol 88 :1979
CRICOPHARYNGEUS MYOTOMY AS THE ONLY TREATMENT FOR ZENKER DIVERTICULUM LIONEL ZUCKERBRAUN,
MD
M. S. BARNA, MD Los
ANGELES, CALIFORNIA
Cricopharyngeal dysfunction, one of the most common causes of pharyngeal dysphagia, exhibits a variety of manifestations, one of which is Zenker diverticulum. This paper examines the physiology of swallowing, pathophysiology of its aberrations, and various methods of treating Zenker diverticulum. It is our purpose to emphasize cricopharyngeus (CP) myotomr as the only needed treatment for this diverticulum. Even in its advanced stages, excision 0 the diverticulum is a needless surgical exercise. Seven cases of Zenker diverticulum are reported in elderly patients; one of them had an excision of the diverticulum prior to presentation. Some were either completely obstructed or aspirating on esophagram, Cricopharyngeus myotomy, the only treatment provided, proved to be safe and effective without morbidity or fatalities. Pa'tients' ability to eat orally was restored on the night of or the morning after surgery. No Levin tube is necessary and there is no risk of suture line leakage after the conventional diverticulectomy and CP myotomy. Hospital stay is greatly reduced and there is no risk of structure formation. In contrast to endoscopic division of CP muscle, there is no risk of mediastinitis because there is no break through the mucosa.
In 1925 Jackson and Shallow' described the treatment of pharyngoesophageal diverticulum by dilatation of the cricopharyngeus muscle. Since then, CP muscle or pharyngoesophageal sphincter dysfunction has drawn attention as the cause of these diverticula. Various disorders have been ascribed to this region. Spasm,2,3 premature contraction of the muscle,' delayed relaxation of the muscle," failure of relaxation or achalasia,2,s and the phenomenon of second swallow against a closed sphincter," all have been described or implicated in the etiology of Zenker diverticulum. Better understanding of the physiologic role of this anatomic region in the act of deglutition has been greatly aided by the introduction of manometric studies and cine-esophagrams, Many fonns of surgical therapy have been used in the past. The most conservative of these surgical procedures is simple inversion and suspension of the sac. A two stage operation, suspension followed later bv excision of the sac, has been described by Lahey and Warren." Dohlman and Mattsson" popularized endoscopic diverticulotomy, a procedure
dividing the common wall between the esophagus and the diverticulum below the sac orifice. This procedure, essentially a CP myotomy from within, invariably has led to controversy against excision of the diverticulum. Nevertheless, in order to avoid recurrence, those who favored diverticulectomy have stressed the necessity of dividing the muscle as well.lO,n Cricopharyngeal myotomy as the sole treatment for only small diverticula has been successfully employed. 12-14 This approach has been an evolution of better understanding of the pathogenesis of these diverticula. We have learned that its application to advanced cases is also successful. Furthermore, CP myotomy has been extended successfully for treatment of other causes of upper esophageal dysphagia of neural and/or muscular origin.1 5 , l S In conservation surgery of the larynx, CP myotomy has been advocated and has shown significant reduction of the upper esophageal sphincter. It appears, however, that functionally there is no difference postoperatively between those who did and those who did not have myotomy."
From the Denartment of Surgery/Head and Neck Surgery, UCLA School of Medicine, Los Angeles. California. Prp-sP-Jlted at the meetlJl~ of the American Broncho-Esophagologlcal Association, Los Angeles. California. April 2-3, 1979.
798
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZENKER DIVERTICULUM
ANATOMY
The CP muscle is a sling connecting the two lateral borders of the cricoid cartilage and passing across the posterior wall of the pharynx. Its analogue on the other extremity of the alimentary tract is the puborectalis sling attached anteriorly to the inner aspect of the pubis and encircling the beginning of the anal canal. Both have no median raphe. Cricopharyngeal tonic contraction prevents involuntary air entry into the esophagus during respiration. In the same manner, the puborectalis controls the involuntary descent of rectal contents. The CP muscle blends inferiorly into the circular and longitudinal fibers of the inferior constrictor which insert into the median raphe. The prominent pharyngeal branch of the vagus that controls the CP muscle in dogs has no counterpart in the human. The pharyngeal plexus, which is formed by contributions from the vagus and glossopharyngeal nerves, innervates all the pharyngeal muscles, including the CP muscle in man. Sympathetic fibers arise from the superior cervical ganglion and join the plexus. Certain animal studies and clinical experience are noteworthy to cast some light on the problem of CP muscle innervation. In an attempt to relieve dysphagia and increase the blood supply to the pharyngeal mucosa, Rogers" performed bilateral superior cervical ganglionectomy in a 50-year-old female suffering from Plummer-Vinson syndrome (iron deficiency anemia, atrophic mucous membranes and spasmodic dysphagia). The result was bilateral Horner syndrome and complete relief of dysphagia. Horner syndrome seems to have discouraged further operations of this type, but the relief of dysphagia is nonetheless significant. Kirchner" has shown that unilateral section of the vagus above the ganglion nodusum in dogs produced little disability, although the degree of CP muscle relaxation during swallowing was diminished. Bilateral section of the vagus nerve led to total failure of relaxation during swallowing with marked dysphagia. However, the resting crico-
799
pharyngeal pressures remained the same in both situations. Stimulation of the cut distal ends of the vagus resulted in a sudden and sharp drop of pressure at the CP muscle. Vagal stimulation after CP myotomy produced no pressure changes at the cricopharyngeus. Superior cervical sympathetic ganglion as well as direct muscle stimulation produced an increase in pressure. It was concluded, therefore, that the vagus is responsible for relaxation of the CP muscle on swallowing, that the interruption of one vagus is not crippling, and that the sympathetic supply is antagonistic. Conley,"? on reviewing swallowing dysfunction after radical head and neck resections, noted that bilateral resection of both vagi high in the neck has led to marked dysphagia whereas unilateral section of vagus or recurrent laryngeal in the mid or lower neck led to little disability. Loss of both superior laryngeal nerves led to marked dysphagia secondary to sensory loss in the larynx. Cineradiographic study of patients with unilateral and bilateral recurrent nerve paralysis failed to show cricopharyngeal dysfunction." It is safe to conclude that motor innervation of the CP muscle is vagal in origin. The glossopharyngeal nerve seems entirely sensory since intracranial section leads to no motor dysfunction. The sympathetic supply is antagonistic to vagal action. leading to increased sphincter tone. This autonomic innervation is similar to that of other sphincters of the alimentary tract. PHYSIOLOGY AND PATHOPHYSIOLOGY
The complex and coordinated act of swallowing starts with an oral phase, which is voluntary, and an involuntary pharyngoesophageal phase. Immediately before or simultaneously with the onset of contraction of the superior constrictor, the CP muscle relaxes with a sudden drop of pressure within the sphincter zone. This relaxation lasts for less than one second during which time the inferior constrictor is contracting. The CP muscle contracts again at the end of the inferior constrictor contraction for a period lasting two to four seconds (Fig. 1).22 This highly coordi-
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
800
ZUCKERBRAUN-BAHNA
1
30 em. H
em. (rom INCISORS
II
-
23
20
pressure
PHARYNX
/
ESOPHAGUS
__---.,....L-...--/
Pneumog raji
»>
myofraph
Swallow ( J
'
~
Iseeond
\~"'--'---
~-
....
•• .- - - - - " ' "
Fig. 1. Pressures recorded simultaneously during a swallow. Note the order of propagation of the muscular contractions and the sphincteric relaxation in anticipation of pharyngeal contraction. Reprinted with permission of publisher and Code CF, Schlegel
IF.'"
nated physiologic event of deglutition suggests a reflex arc through the modified submucous plexus and a myenteric plexus located in the external surface of the pharyngeal muscles. The integrity of the bulbar nuclei in the floor of the fourth ventricle, peripheral nerves contributing to the pharyngeal plexus with its sympathetic and parasympathetic contribution, and the musculature of the pharynx are essential for the pharyngeal phase of deglutition. Derangement at any level of th's apparatus causes upper dysphagia. In patients afflicted with pharyngoesophageal diverticulum, Ellis and coworkers'" reported immediate sphincter relaxation on deglutition with sphincter contraction occurring prior to completion of the contraction in the pharynx. Lichter'" has reported similar results, while others have found no incoordination of the swallow mechanism." The exact etiology of muscular incoordination is not known; a relation between peptic esophagitis (with or without hiatal hernia) and cricopharyngeal dysfunction is, however, believed to be responsible. METHODS AND MATERIALS Seven patients, four males and three females,
have been operated upon since 1975. Their average age was 69 years, with a range of 52 to 83 years. Symptoms of dysphagia from threeday to ten-year duration ranged from mild sensation of food sticking in the throat to total esophageal obstruction. Two patients had histories of aspiration pneumonitis, one patient had a massive aspiration that required a tra-
Fig. 2. A and B) Two different prooperative views of diverticulum. C) Postcricopharyngeus myotomy view; portable swallow.
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ZENKER DIVERTICULUM
Fig. 3. Preoperative barium swallow. Note that the remarkable degree of aspiration and esophageal obstruction produced a tracheogram rather than an esophagram, A) Anteroposterior view; B) Lateral view. cheostomy. Manometric and esophageal motility studies were not done. Radiologic Findings. Six patients had typical pharyngoesophageal divertic~la ranging in size from 3 em to 5 x 8 em (FIgS. 2-4). One patient, who had undergone a diverticul~ctomy nine months previously, showed only evidence of hypertrophic CP muscle with proximal pharyngeal dilation; one patient had associated hiatal hernia, and another had a second lower esophageal diverticulum. A preliminary postoperative Gas~ografin@ swallow, prior to starting oral feedmg~, was done for three patients. There was no evidence of leaks. Technique. A 10 cm incision is made along the anterior border of the sternomastoid muscle the esophagoscope having been taped in pla'ce prior to draping of the patien~. Leftsided incision is used; however, the side has no bearing except for the surgeon's preference. Retraction of the carotid sheath is allowed by dividing the omohyoid muscle, middle thyroid, and posterior facial veins while traction sutures in the thyroid facilitate medial rotation of the larynx and trachea. The diverticulum and upper esophageal sphincter are identified. After the recurrent laryngeal nerve is identified, myotomy is carried out using a scalpel. Transillumination with the esophagoscope light has been found helpful in dividing all. mu~cle fibers seen across the mucosa. The diverticulum is left untouched; nasogastric tube and wound drainage are not utilized. CASE REPORTS
Case 1. The patient was a 77-year-old male
801
Fig. 4. Same patient as in Fig. 3. Esophagrams A) three months and B) three years after cricopharyngeal myotomy. Note the smaller diverticulum in A with poor filling and failure of filling in
B.
presenting with the shortest duration of symptoms. He underwent coronary bypass; three days postoyeratively he was unable to resume normal ora intake and finally suffered a major aspiration requiring emergency tracheostomy. Barium swallow demonstrated a large pharyngoesophageal diverticulum (Fig. 2A, B). He was placed on intravenous hyperalimentation. After one week, when his pulmonary status permitted another anesthesia, he underwent CP myotomy. Oral feedings were resumed on the night of surgery after a preliminary Castrografin swallow done at bedside (Fig. 2C). He is now eight months postrnyotomy and has no dysphagia. On retrospective questioning of this patient, he admitted having had mild, nontroublesome dysphagia, mainly at supper, for several years which he had failed to mention to his cardiovascular surgeon. Case 2. An 83-year-old female presented with a ten-year history of dysphagia which recently had become disabling. She sought medical advice because of choking and coughing with every meal and a reported ten-pound weight loss over the preceding four weeks. Barium swallow (Fig. 3) showed remarkable aspiration with almost total esophageal obstruction and a large Zenker diverticulum. Esophagoscopy revealed trapped pieces of meat which were removed followed by CP myotomy. Oral feedings were resumed on the first postoperative day. Follow-up esophagrams three months after surgery (Fig. 4A) suggested contraction of the diverticulum. Three years later (Fig. 4B ), there was evidence of a smaller pouch. The disappearance of her symptoms was significant after the myotomy. Case 3. A 52-year-old male had a resection of a pharyngoesophageal diverticulum in 1974. His symptoms were not relieved after surgery and became progressively worse. When evaluated nine months postoperativly, there was no
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZUCKERBRAUN-BAHNA
802
indication in his records of having a CP myotomy. Esophagram showed remarkable narrowing at the level of the CP muscle, with proximal distension of the pharynx above the CP muscle level. Esophagoscopy was unproductive. Because of the previous left-sided approach, he underwent CP myotomy through a right-sided incision. Dysphagia was dramatically relieved from the first postoperative day. Follow-up esophagram six weeks after myotomy demonstrated relief of the prior constriction. This case emphasizes the point that, in treating a pharyngoesophageal pouch, CP myotomy should be the surgeon's target rather than the pouch itself. DISCUSSION
Cricopharyngeal myotomy, whether it is done endoscopically or by external approach, addresses itself to the etiology of Zenker diverticulum. The diverticulum, once the obstruction is relieved, starts to contract and involutes. Excision of the diverticulum is a needless surgical exercise unless there is reason to suspect an ulceration or malignancy in the pouch. Several advantages are obtained by limiting surgery to the myotomy: 1) a shorter operating time, particularly valuable for the elderly; 2) ability to resume oral feeding immediately upon recovery from anesthesia; 3) elimination of the need for Levin tube; 4) elimination of the risk of suture line leakage and stricture formation secondary to tight closure; 5) elimination of the need for prophylactic antibiotics, or wound drainage, since the likelihood of postoperative wound infection is
practically nil, provided no mucosal tears occur; 6) reduced hospital stay; and 7) in contrast to endoscopic division of CP muscle (Dohlman procedure ), there is no risk of mediastinitis. Certainly an advantage is the possibility of performing the surgery under local anesthesia, although none of our patients accepted this method of anesthesia. By simply asking the patient to swallow, one would expect to observe the disordered motility of the CP region.> Also, it will facilitate identification and division of the whole length of the muscle. Myotomy produces dramatic relief of dysphagia, although radiologic evidence of a smaller diverticulum persists. We are after the dysphagia relief and not the x-ray picture; hence, excision of the diverticulum is a needless effort unless intradiverticular pathology is suspected. SUMMARY
Anatomy, innervation, physiology and pathophysiology of the CP muscle are discussed. Seven cases of variable sizes of pharyngoesophageal diverticulum, treated only with cricopharyngeal myotomy are discussed. The validity of this method is supported by restoration of normal swallowing, clinically and radiologically. The advantages of this approach and the possible use of local anesthesia are discussed.
REFERENCES 1. Jackson C, Shallow TA: Diverticula of oesophagus, pulsion, traction, malignant, and congenital. Ann Surg 83: 1-19, 1926 2. Belsey B: Function of disease of the esophagus. J Thorac Cardiovasc Surg 52: 164188, 1966 3. Negus VE: The etiology of pharyngeal diverticula. Bull Johns Hopkins Hosp 101:209, 1957 4. Ardran GM, Kemp FH: The radiography of the lower lateral food channels. J Laryngol Otol 75:358-370, 1961 5. Cross FS: Esophageal diverticula: Related neuromuscular problems. Ann Otol Rhinol Laryngol 77 :914-926, 1968 6. Dohlman G, Mattsson 0: The role of the cricopharyngeal muscle in cases of hypopharyngeal diverticula: A cineroentgenographic study. Am J Roentgenol 81:561-569, 1959 7. Wilson C: Pharyngeal diverticula, their cause and treatment. J Laryngol Otol 76:151180, 1962
8. Lahey FH, Warren KW: Esophageal diverticula. Surg Gynecol Obstet 98: 1-28, 1954 9. Dohlman G, Mattsson 0: The endoscopic operation for hypopharyngeal diverticula. Arch Otolaryngol 71:744-752, 1960 10. Warren KW: Some technical considerations in the management of pharyngo-esophageal diverticulum. Surg Clin North Am 40: 633-643, 1960 11. Gammelgaard A: Esophageal diverticula. Acta Chir Scand 109:181-183, 1955 12. Sutherland HD: Cricopharyngeal achalasia. J Thorac Cardiovasc Surg 43:114-126, 1962 13. Wilkins SA: Indications for section of the cricopharyngeus muscle. Am J Surg 108: 533-538, 1964 14. Hiebert CA: Surgery for the cricopharyngeal dysfunction under local anesthesia. Am J Surg 131:423-427, 1976 15. Blakeley WR, Garety EJ, Smith DE:
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZENKER DIVERTICULUM
Section of the cricopharyngeus muscle for dysphagia. Arch Surg 96:745-762, 1968 16. Calcaterra TC, Kadell BM, Ward PH: Dysphagia secondary to cricopharyngeal muscle dysfunction. Arch Otolaryngol 101:726729, 1975 17. Berlin BP, Furstein JT, Tedesca F, et al: Manometric studies of the upper esophageal sphincter. Ann Otol Rhinol Laryngol 86:598602, 1977 18. Rogers L: The treatment of spasmodic dysphagia by sympathetic denervation. Br J Surg 22:829-832, 1935 19. Kirchner JA: The motor activity of the cricopharyngeus muscle. Laryngoscope 68: 1119-1159, 1958 20. Conley JJ: Swallowing dysfunctions associated with radical surgery of the head and neck. Arch Surg 80:602-612, 1960
803
21. Lund WS: A study of the cricopharyngeal sphincter in man and in the dog. Ann R ColI Surg Engl 37 :225-246, 1965 22. Code CF, Schlegel JF: Motor action of the esophagus and its sphincters, in Handbook of Physiology - Alimentary Canal. Bethesda, Md, American Physiologic Society, 1967, vol 4, pp 1821-1839 23. Ellis FH, Schlegel JF, Lynch VP, et al: Cricopharyngeal myotomy for pharyngoesophageal diverticulum. Ann Surg 170:340-349, 1969 24. Lichter I: Motor disorder in pharyngoesophageal pouch. J Thorac Cardiovasc Surg 76:272-275, 1978 25. Kodicek JM, Creamer B: A study of pharyngeal pouches. J Laryngol Otol 175: 406-411, 1961
ACKNOWLEDGMENT - The authors thank Ms. Tatiana Astroza for her help in typing this manuscript. REPRINTS - M. S. Bahna, MD, Division of Head and Neck Surgery, UCLA School of Medicine, Los Angeles, CA 90024.
SYMPOSIUM ON THE NUTRITION OF THE CANCER PATIENT Symposium on the Nutrition of the Cancer Patient sponsored by the National Cancer Institute, Jan. 10-11, 1980 at the National Institutes of Health, Bldg. 10, Masur Auditorium, Bethesda, Maryland. For information write: Jean Cook, Capital Systems Group, 6110 Executive Blvd., Rockville, MD 20852 or call (301) 881-9400.
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CRICOPHARYNGEUS MYOTOMY AS THE ONLY TREATMENT FOR ZENKER DIVERTICULUM LIONEL ZUCKERBRAUN,
MD
M. S. BARNA, MD Los
ANGELES, CALIFORNIA
Cricopharyngeal dysfunction, one of the most common causes of pharyngeal dysphagia, exhibits a variety of manifestations, one of which is Zenker diverticulum. This paper examines the physiology of swallowing, pathophysiology of its aberrations, and various methods of treating Zenker diverticulum. It is our purpose to emphasize cricopharyngeus (CP) myotomr as the only needed treatment for this diverticulum. Even in its advanced stages, excision 0 the diverticulum is a needless surgical exercise. Seven cases of Zenker diverticulum are reported in elderly patients; one of them had an excision of the diverticulum prior to presentation. Some were either completely obstructed or aspirating on esophagram, Cricopharyngeus myotomy, the only treatment provided, proved to be safe and effective without morbidity or fatalities. Pa'tients' ability to eat orally was restored on the night of or the morning after surgery. No Levin tube is necessary and there is no risk of suture line leakage after the conventional diverticulectomy and CP myotomy. Hospital stay is greatly reduced and there is no risk of structure formation. In contrast to endoscopic division of CP muscle, there is no risk of mediastinitis because there is no break through the mucosa.
In 1925 Jackson and Shallow' described the treatment of pharyngoesophageal diverticulum by dilatation of the cricopharyngeus muscle. Since then, CP muscle or pharyngoesophageal sphincter dysfunction has drawn attention as the cause of these diverticula. Various disorders have been ascribed to this region. Spasm,2,3 premature contraction of the muscle,' delayed relaxation of the muscle," failure of relaxation or achalasia,2,s and the phenomenon of second swallow against a closed sphincter," all have been described or implicated in the etiology of Zenker diverticulum. Better understanding of the physiologic role of this anatomic region in the act of deglutition has been greatly aided by the introduction of manometric studies and cine-esophagrams, Many fonns of surgical therapy have been used in the past. The most conservative of these surgical procedures is simple inversion and suspension of the sac. A two stage operation, suspension followed later bv excision of the sac, has been described by Lahey and Warren." Dohlman and Mattsson" popularized endoscopic diverticulotomy, a procedure
dividing the common wall between the esophagus and the diverticulum below the sac orifice. This procedure, essentially a CP myotomy from within, invariably has led to controversy against excision of the diverticulum. Nevertheless, in order to avoid recurrence, those who favored diverticulectomy have stressed the necessity of dividing the muscle as well.lO,n Cricopharyngeal myotomy as the sole treatment for only small diverticula has been successfully employed. 12-14 This approach has been an evolution of better understanding of the pathogenesis of these diverticula. We have learned that its application to advanced cases is also successful. Furthermore, CP myotomy has been extended successfully for treatment of other causes of upper esophageal dysphagia of neural and/or muscular origin.1 5 , l S In conservation surgery of the larynx, CP myotomy has been advocated and has shown significant reduction of the upper esophageal sphincter. It appears, however, that functionally there is no difference postoperatively between those who did and those who did not have myotomy."
From the Denartment of Surgery/Head and Neck Surgery, UCLA School of Medicine, Los Angeles. California. Prp-sP-Jlted at the meetlJl~ of the American Broncho-Esophagologlcal Association, Los Angeles. California. April 2-3, 1979.
798
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZENKER DIVERTICULUM
ANATOMY
The CP muscle is a sling connecting the two lateral borders of the cricoid cartilage and passing across the posterior wall of the pharynx. Its analogue on the other extremity of the alimentary tract is the puborectalis sling attached anteriorly to the inner aspect of the pubis and encircling the beginning of the anal canal. Both have no median raphe. Cricopharyngeal tonic contraction prevents involuntary air entry into the esophagus during respiration. In the same manner, the puborectalis controls the involuntary descent of rectal contents. The CP muscle blends inferiorly into the circular and longitudinal fibers of the inferior constrictor which insert into the median raphe. The prominent pharyngeal branch of the vagus that controls the CP muscle in dogs has no counterpart in the human. The pharyngeal plexus, which is formed by contributions from the vagus and glossopharyngeal nerves, innervates all the pharyngeal muscles, including the CP muscle in man. Sympathetic fibers arise from the superior cervical ganglion and join the plexus. Certain animal studies and clinical experience are noteworthy to cast some light on the problem of CP muscle innervation. In an attempt to relieve dysphagia and increase the blood supply to the pharyngeal mucosa, Rogers" performed bilateral superior cervical ganglionectomy in a 50-year-old female suffering from Plummer-Vinson syndrome (iron deficiency anemia, atrophic mucous membranes and spasmodic dysphagia). The result was bilateral Horner syndrome and complete relief of dysphagia. Horner syndrome seems to have discouraged further operations of this type, but the relief of dysphagia is nonetheless significant. Kirchner" has shown that unilateral section of the vagus above the ganglion nodusum in dogs produced little disability, although the degree of CP muscle relaxation during swallowing was diminished. Bilateral section of the vagus nerve led to total failure of relaxation during swallowing with marked dysphagia. However, the resting crico-
799
pharyngeal pressures remained the same in both situations. Stimulation of the cut distal ends of the vagus resulted in a sudden and sharp drop of pressure at the CP muscle. Vagal stimulation after CP myotomy produced no pressure changes at the cricopharyngeus. Superior cervical sympathetic ganglion as well as direct muscle stimulation produced an increase in pressure. It was concluded, therefore, that the vagus is responsible for relaxation of the CP muscle on swallowing, that the interruption of one vagus is not crippling, and that the sympathetic supply is antagonistic. Conley,"? on reviewing swallowing dysfunction after radical head and neck resections, noted that bilateral resection of both vagi high in the neck has led to marked dysphagia whereas unilateral section of vagus or recurrent laryngeal in the mid or lower neck led to little disability. Loss of both superior laryngeal nerves led to marked dysphagia secondary to sensory loss in the larynx. Cineradiographic study of patients with unilateral and bilateral recurrent nerve paralysis failed to show cricopharyngeal dysfunction." It is safe to conclude that motor innervation of the CP muscle is vagal in origin. The glossopharyngeal nerve seems entirely sensory since intracranial section leads to no motor dysfunction. The sympathetic supply is antagonistic to vagal action. leading to increased sphincter tone. This autonomic innervation is similar to that of other sphincters of the alimentary tract. PHYSIOLOGY AND PATHOPHYSIOLOGY
The complex and coordinated act of swallowing starts with an oral phase, which is voluntary, and an involuntary pharyngoesophageal phase. Immediately before or simultaneously with the onset of contraction of the superior constrictor, the CP muscle relaxes with a sudden drop of pressure within the sphincter zone. This relaxation lasts for less than one second during which time the inferior constrictor is contracting. The CP muscle contracts again at the end of the inferior constrictor contraction for a period lasting two to four seconds (Fig. 1).22 This highly coordi-
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
800
ZUCKERBRAUN-BAHNA
1
30 em. H
em. (rom INCISORS
II
-
23
20
pressure
PHARYNX
/
ESOPHAGUS
__---.,....L-...--/
Pneumog raji
»>
myofraph
Swallow ( J
'
~
Iseeond
\~"'--'---
~-
....
•• .- - - - - " ' "
Fig. 1. Pressures recorded simultaneously during a swallow. Note the order of propagation of the muscular contractions and the sphincteric relaxation in anticipation of pharyngeal contraction. Reprinted with permission of publisher and Code CF, Schlegel
IF.'"
nated physiologic event of deglutition suggests a reflex arc through the modified submucous plexus and a myenteric plexus located in the external surface of the pharyngeal muscles. The integrity of the bulbar nuclei in the floor of the fourth ventricle, peripheral nerves contributing to the pharyngeal plexus with its sympathetic and parasympathetic contribution, and the musculature of the pharynx are essential for the pharyngeal phase of deglutition. Derangement at any level of th's apparatus causes upper dysphagia. In patients afflicted with pharyngoesophageal diverticulum, Ellis and coworkers'" reported immediate sphincter relaxation on deglutition with sphincter contraction occurring prior to completion of the contraction in the pharynx. Lichter'" has reported similar results, while others have found no incoordination of the swallow mechanism." The exact etiology of muscular incoordination is not known; a relation between peptic esophagitis (with or without hiatal hernia) and cricopharyngeal dysfunction is, however, believed to be responsible. METHODS AND MATERIALS Seven patients, four males and three females,
have been operated upon since 1975. Their average age was 69 years, with a range of 52 to 83 years. Symptoms of dysphagia from threeday to ten-year duration ranged from mild sensation of food sticking in the throat to total esophageal obstruction. Two patients had histories of aspiration pneumonitis, one patient had a massive aspiration that required a tra-
Fig. 2. A and B) Two different prooperative views of diverticulum. C) Postcricopharyngeus myotomy view; portable swallow.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZENKER DIVERTICULUM
Fig. 3. Preoperative barium swallow. Note that the remarkable degree of aspiration and esophageal obstruction produced a tracheogram rather than an esophagram, A) Anteroposterior view; B) Lateral view. cheostomy. Manometric and esophageal motility studies were not done. Radiologic Findings. Six patients had typical pharyngoesophageal divertic~la ranging in size from 3 em to 5 x 8 em (FIgS. 2-4). One patient, who had undergone a diverticul~ctomy nine months previously, showed only evidence of hypertrophic CP muscle with proximal pharyngeal dilation; one patient had associated hiatal hernia, and another had a second lower esophageal diverticulum. A preliminary postoperative Gas~ografin@ swallow, prior to starting oral feedmg~, was done for three patients. There was no evidence of leaks. Technique. A 10 cm incision is made along the anterior border of the sternomastoid muscle the esophagoscope having been taped in pla'ce prior to draping of the patien~. Leftsided incision is used; however, the side has no bearing except for the surgeon's preference. Retraction of the carotid sheath is allowed by dividing the omohyoid muscle, middle thyroid, and posterior facial veins while traction sutures in the thyroid facilitate medial rotation of the larynx and trachea. The diverticulum and upper esophageal sphincter are identified. After the recurrent laryngeal nerve is identified, myotomy is carried out using a scalpel. Transillumination with the esophagoscope light has been found helpful in dividing all. mu~cle fibers seen across the mucosa. The diverticulum is left untouched; nasogastric tube and wound drainage are not utilized. CASE REPORTS
Case 1. The patient was a 77-year-old male
801
Fig. 4. Same patient as in Fig. 3. Esophagrams A) three months and B) three years after cricopharyngeal myotomy. Note the smaller diverticulum in A with poor filling and failure of filling in
B.
presenting with the shortest duration of symptoms. He underwent coronary bypass; three days postoyeratively he was unable to resume normal ora intake and finally suffered a major aspiration requiring emergency tracheostomy. Barium swallow demonstrated a large pharyngoesophageal diverticulum (Fig. 2A, B). He was placed on intravenous hyperalimentation. After one week, when his pulmonary status permitted another anesthesia, he underwent CP myotomy. Oral feedings were resumed on the night of surgery after a preliminary Castrografin swallow done at bedside (Fig. 2C). He is now eight months postrnyotomy and has no dysphagia. On retrospective questioning of this patient, he admitted having had mild, nontroublesome dysphagia, mainly at supper, for several years which he had failed to mention to his cardiovascular surgeon. Case 2. An 83-year-old female presented with a ten-year history of dysphagia which recently had become disabling. She sought medical advice because of choking and coughing with every meal and a reported ten-pound weight loss over the preceding four weeks. Barium swallow (Fig. 3) showed remarkable aspiration with almost total esophageal obstruction and a large Zenker diverticulum. Esophagoscopy revealed trapped pieces of meat which were removed followed by CP myotomy. Oral feedings were resumed on the first postoperative day. Follow-up esophagrams three months after surgery (Fig. 4A) suggested contraction of the diverticulum. Three years later (Fig. 4B ), there was evidence of a smaller pouch. The disappearance of her symptoms was significant after the myotomy. Case 3. A 52-year-old male had a resection of a pharyngoesophageal diverticulum in 1974. His symptoms were not relieved after surgery and became progressively worse. When evaluated nine months postoperativly, there was no
Downloaded from aor.sagepub.com at The University of Iowa Libraries on June 14, 2015
ZUCKERBRAUN-BAHNA
802
indication in his records of having a CP myotomy. Esophagram showed remarkable narrowing at the level of the CP muscle, with proximal distension of the pharynx above the CP muscle level. Esophagoscopy was unproductive. Because of the previous left-sided approach, he underwent CP myotomy through a right-sided incision. Dysphagia was dramatically relieved from the first postoperative day. Follow-up esophagram six weeks after myotomy demonstrated relief of the prior constriction. This case emphasizes the point that, in treating a pharyngoesophageal pouch, CP myotomy should be the surgeon's target rather than the pouch itself. DISCUSSION
Cricopharyngeal myotomy, whether it is done endoscopically or by external approach, addresses itself to the etiology of Zenker diverticulum. The diverticulum, once the obstruction is relieved, starts to contract and involutes. Excision of the diverticulum is a needless surgical exercise unless there is reason to suspect an ulceration or malignancy in the pouch. Several advantages are obtained by limiting surgery to the myotomy: 1) a shorter operating time, particularly valuable for the elderly; 2) ability to resume oral feeding immediately upon recovery from anesthesia; 3) elimination of the need for Levin tube; 4) elimination of the risk of suture line leakage and stricture formation secondary to tight closure; 5) elimination of the need for prophylactic antibiotics, or wound drainage, since the likelihood of postoperative wound infection is
practically nil, provided no mucosal tears occur; 6) reduced hospital stay; and 7) in contrast to endoscopic division of CP muscle (Dohlman procedure ), there is no risk of mediastinitis. Certainly an advantage is the possibility of performing the surgery under local anesthesia, although none of our patients accepted this method of anesthesia. By simply asking the patient to swallow, one would expect to observe the disordered motility of the CP region.> Also, it will facilitate identification and division of the whole length of the muscle. Myotomy produces dramatic relief of dysphagia, although radiologic evidence of a smaller diverticulum persists. We are after the dysphagia relief and not the x-ray picture; hence, excision of the diverticulum is a needless effort unless intradiverticular pathology is suspected. SUMMARY
Anatomy, innervation, physiology and pathophysiology of the CP muscle are discussed. Seven cases of variable sizes of pharyngoesophageal diverticulum, treated only with cricopharyngeal myotomy are discussed. The validity of this method is supported by restoration of normal swallowing, clinically and radiologically. The advantages of this approach and the possible use of local anesthesia are discussed.
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ZENKER DIVERTICULUM
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21. Lund WS: A study of the cricopharyngeal sphincter in man and in the dog. Ann R ColI Surg Engl 37 :225-246, 1965 22. Code CF, Schlegel JF: Motor action of the esophagus and its sphincters, in Handbook of Physiology - Alimentary Canal. Bethesda, Md, American Physiologic Society, 1967, vol 4, pp 1821-1839 23. Ellis FH, Schlegel JF, Lynch VP, et al: Cricopharyngeal myotomy for pharyngoesophageal diverticulum. Ann Surg 170:340-349, 1969 24. Lichter I: Motor disorder in pharyngoesophageal pouch. J Thorac Cardiovasc Surg 76:272-275, 1978 25. Kodicek JM, Creamer B: A study of pharyngeal pouches. J Laryngol Otol 175: 406-411, 1961
ACKNOWLEDGMENT - The authors thank Ms. Tatiana Astroza for her help in typing this manuscript. REPRINTS - M. S. Bahna, MD, Division of Head and Neck Surgery, UCLA School of Medicine, Los Angeles, CA 90024.
SYMPOSIUM ON THE NUTRITION OF THE CANCER PATIENT Symposium on the Nutrition of the Cancer Patient sponsored by the National Cancer Institute, Jan. 10-11, 1980 at the National Institutes of Health, Bldg. 10, Masur Auditorium, Bethesda, Maryland. For information write: Jean Cook, Capital Systems Group, 6110 Executive Blvd., Rockville, MD 20852 or call (301) 881-9400.
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