A brief description of our index cases may l>e of help in describing this complication or abnormality.
An 80-year-old physician was admitted urgently to the Brotman Medical Center. One year previously, he had observed the onset of wheezing and severe dyspnea treated with bronchodilator drugs and large doses of corticosteroids (48 mg of methylprednisolone daily at the time of admission). On the evening of admission, the patient was awakened from sleep with severe coughing and wheezing that was unresponsive to therapy. While in the emergency room and later in a medical intensive care unit, he was given the customary large doses of intravenous steroids, aininophylline, antibiotics, and chest physiotherapy, with some improvement. After conversion to oral steroids, frequent exacerbations of dyspnea, coughing, and wheezing were recorded. Bedside observations suggested that symptoms became worse after eating or even swallowing saliva. Swallowing and upper gastrointestinal contrast studies, including videotaping of deglutition, revealed severe cricopharyngeal achalasia, as demonstrated in Figure 1. Retention of barium in the hypopharvnx with tracheal aspiration was also seen on the videotape. Following cricopharyngeal myotomy, performed under local anesthesia, there was marked improvement in his clinical state. The underlying COPD was still present, but he was able to work full time and did not require corticosteroids.
An 80-year-old female patient with a long history of severe COPD had been making frequent visits to an emergency room with exacerbations typified by episodes of coughing, sputum production, wheezing, and severe shortness of breath. When questioned about swallowing, the patient and a family member described a long history of eating and drinking very small portions and of being an unusually slow eater. A v ideotape of her swallowing revealed severe cricopharyngeal achalasia (4 +); she also had dramatic relief following cricopharyngeal myotomy. With minimal swallowing retraining, there was marked improvement in her eating habits, elimination of the frequent visits to the emergency room, and reduction in the frequency of exacerbations of respiratory distress.
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A 75-year-old woman had severe COPD and complaints of swallowing difficulties. As shown in Figure 2, there was a prominent cricopharyngeal bar and a large Zenker’s diverticulum. Following a myotomy, there was marked improvement in her swallowing ability; reduction in size of the Zenker’s diverticulum, and relief from exacerbations of respiratory distress.
FIGURE 2. Severe cricopharyngeal dysfunction in a 75-year-old woman with severe COPD. There is esophageal compression due to dysfunction of a cricopharyngeal muscle and also the large Zenker’s diverticulum (arrow), both of which may also be due to gastroesophageal reflux (case 3).