Cricopharyngeal Dysfunction in Chronic Obstructive Pulmonary Disease: RESULTS

4 Apr
2011

We studied 25 patients with cricopharyngeal dys­function who had moderate to severe COPD and FEWy less than 70 percent of predicted (Table 1). All of these patients had been referred for frequent exacerbations of respiratory distress.

Twenty-one of the patients had dysfunction of the cricopharyngeous muscle shown by videotape record­ings of the swallowing sequence. All patients studied except one were over the age of 50 years. There was an apparent association between age and severity of cricopharyngeal achalasia (Fig 3). All patients with severe cricopharyngeal achalasia (3-1- to 4 +) were 65 years old or older, and the majority were women.

The observed FEV, did not correlate significantly with the severity of cricopharyngeal achalasia, but two thirds of the patients with the most severe abnormal­ities also had severe cricopharyngeal achalasia. Of the 17 patients with severe cricopharyngeal achalasia, ten had an FEV, of 1.0 L or less, while four who were similarly affected had an FEV, of 1.6 to 1.8 L at the time of the studies. Further studies utilizing random­ization techniques and evaluating reversibility of air­ways obstruction would be necessary to clarify the precise relationship between FEV, and cricopharyn­geal achalasia in patients with COPD.
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All but three subjects had received theophylline and inhaled p2-adrenergic medications; however, the three patients who had received no previous broncho- dilator medications also had severe cricopharyngeal achalasia on radiologic examinations; two of these patients had severe reductions of FEV,. One subject (no. 16) had only mild symptoms of airways obstruction and a normal FEV, at the time of examination. Four of the subjects with cricopharyngeal achalasia had received prior corticosteroids, two by inhalation only. Two of the four patients without cricopharyngeal achalasia had been receiving oral corticosteroids. Six­teen of the subjects had a history of smoking, but we observed no correlation between this and cricopharyn­geal achalasia.

Radiographic examinations for hiatal hernia were reported in 16 patients with cricopharyngeal dyspha­gia and were positive in 12. Although there was no definite association between hiatal hernia and crico­pharyngeal dysfunction, ten of 13 patients with severe (3 + to 4 -I-) radiologic swallowing disorders had radi­ographic evidence of hiatal hernia when so examined.

FIGURE 3. Severity of cricophary ngeal achalasia compared with age (see text for discussion).

Thirteen patients with severe cricopharyngeal dys­function (3+ or 4 +) were studied radiologically for gastroesophageal reflux; four of these were positive.

Among four patients with lesser transluminal narrow­ing (1 + or 2 +), one had reflux on examination. The incidence of gastroesophageal reflux in those studied for this was therefore 29 percent (5/17). Two patients had gastroesophageal reflux in the presence of severe COPD and studies negative for swallowing dysfunc­tion. Definitive studies for reflux, including esopha­geal pH measurements by esophageal probe or acid perfusion studies, were not performed.
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With informed consent, ten of the subjects had cricopharyngeal myotomies performed under local anesthesia. All of the subjects had severe cricopha­ryngeal dysfunction on video pharyngoesophageal study. The intent of the procedure was to improve deglutition and to relieve the frequent episodes of pulmonary distress believed to be secondary to aspi­ration. All subjects did observe marked improvement of deglutition, including two who were not aware of preoperative difficulties. Postoperative radiologic ex­aminations revealed normal to minimally disturbed cricopharyngeal function. Eight of the subjects re­ported marked relief in episodes of cough, sputum production, wheezing, and dyspnea, as well as im­proved sleep. Objective data to support the subjective improvement in their symptoms exists only in the form of fewer admissions to the hospital and visits to the emergency room. One subject who had observed relief of her swallowing problem failed to notice any changes in respiratory status. Another subject died of unrelated causes shortly after cricopharyngeal myot­omy. Pulmonary function studies after myotomy in six patients failed to show any consistent improvement in the subjects’ chronic airways obstruction.

Table 1—Characteristics of Patients with COPD Studied for Swallowing Disorders

C-P Achalasia

Patient,

Severity

FEV,*

Clinical

Smoking

Age, Sex

(Radiograph
icallv)

(%
Pred)

Dysphagia

Pack-yrs

1,79,F

4 +

0.4 (20)

+

37

2,73,M

4 +

0.4 (22)

+

50

3,68,F

4 +

0.5 (24)

+

60

4,75,
M

4 +

0.7 (25)

60

5,79,
M

4 +

0.9 (30)

+

10

6,78,
M

4 +

0.9 (31)

+

0

7,77,F

4 +

0.8 (39)

+

ot

8,84,F

4 +

0.8 (44)

+

0

9,75,F

4 +

0.8 (46)

+

0

10,69,
F

4 +

1.2 (51)

+

30

11,80,M

4 +

1.2 (57)

+

60

12,79,F

4 +

1.3 (61)

+

0

13,80,F

4 +

1.0 (62)

+

0

14,68,F

4 +

1.2 (63)

+

0

15,78,
F

4 +

1.6 (79)

0

16,65,F

4 +

1.8 (90)

+

0

17,63,F

3 +

1.1 (41)

+

0

18,54,F

2 +

0.5 (23)

+

100

19,69,M

2 +

1.1 (39)

40

20,61,M

1 +

1.5 (57)

15

21,37,F

1 +

2.2 (69)

0

22,79,M

0

0.6 (17)

30

23,68,
M

0

0.9 (33)

0

24,55,
M

0

1.6 (56)

20

25,57,F

0

1.4 (62)

+

10

In 128 patients referred for upper CI radiologic evaluation for multiple conditions, videotaping of deglutition was performed. Among these patients, cricopharyngeal dysfunction was observed in 14 (11 percent). None of these had obstructions greater than 2. These data are similar to other reports. Eight of these patients were female. The frequency of cricopharyngeal dysfunction in the subjects 65 years old or older was 21 percent. Pulmonary function data are not available from these 128 individuals.

 

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