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 pharyngoesoph- ageal 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, videofluoroscopic studies of swallowing were performed in 128 unmatched adult patients aged 27 to 85 years, without known pulmonary disease. They were referred for upper gastrointestinal examinations for various medical problems other than dysphagia.
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Preliminary roentgenograms of the chest and soft tissue of the neck were obtained in all patients. The radiologic pharyngoesoph- ageal examination included either cineradiography or videofluoroscopic 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 marsh- mallows or pieces of bagel coated with barium.
Prior to administering contrast material, the motion of the soft palate was viewed fluoroscopically in the lateral projection, and the function of the vocal cords was observed in the frontal projection. Upright lateral and anteroposterior views were obtained with contrast swallow. The first lateral swallow was viewed at the level of the larynx to check for laryngeal penetration. Examinations of the mouth, upper neck, and lower neck were then performed, followed by lateral decubitus and prone oblique views of the pharynx and cervical and thoracic esophagus. Radiographic spot films of the esophagus were obtained. Additionally, examination was performed to search for gastroesophageal reflux. More sensitive techniques for diagnosis of gastroesophageal reflux (eg, nuclear scintiscan or esophageal motility studies) were not employed because of the additional inconvenience and cost to the patients.
Figure 1. Lateral view of barium swallow, showing severe cricopharyngeal dysfunction. There is a prominent cricopharyngeal inden¬tation or bar (arrow) on posterior esophagus (see text) (case 1).
The cineradiograins or videoradiograms were carefully examined for anatomic and functional abnormalities of deglutition.7 Normally, the upper esophageal segment is opened by relaxation of the cricopharyngeal muscle. At the completion of the swallow, contraction of the cricopharyngeal muscle occurs. Failure of the muscle to relax during swallowing is observed as a defect or posterior indentation into the barium column (Fig 1). Apcalis Oral Jelly
In those patients with cricopharyngeal achalasia, the dysfunction observed on radiologic studies was categorized according to the degree of upper esophageal obstruction and the presence or absence of airways penetration of barium. Less than 30 percent obstruction was termed 1 +; from 30 to 50 percent was 2 +; greater than 50 percent was 3 +; and greater than 50 percent combined with Zenker’s diverticulum or airways penetration or leakage was 4 + .