In considering the first possibility, it has long been appreciated that chronic obstructive pulmonary dis­eases have varied causes. Smoking has been consid­ered to be responsible in the large majority of patients; however, careful longitudinal studies have shown that only a minority of smokers developed airways obstruc­tion (although all develop mucous hypersecretion and, consequently, chronic bronchitis). Among other pre­disposing factors considered to play a part in the development of airways obstruction are hyperreactiv­ity of the airways and abnormalities of pulmonary defense mechanisms such as abnormal cilia or anti- protease deficiencies. In the present study, we have identified a potentially far more common association in 21 of 25 patients with frequent exacerbations of COPD. We assume that the cricopharyngeal dysfunc­tion leads to occult aspiration of small quantities of oropharyngeal contents. It is not unlikely that such repeated aspirations of oral secretions would be un­recognized and yet over a prolonged period could damage airway epithelium and promote parenchymal destruction. Presumed acute exacerbations of COPD common in this group of patients may have been related to larger aspirates.

Read the rest of this entry »

Patients with COPD are commonly subject to frequent exacerbations which are assumed to be related to infection or bronchial hyperreactivity. Herein we have identified an additional factor, crico­pharyngeal achalasia, in 21 of 25 patients. In 17 of these patients, it was judged to be severe, and in retrospect, all were found to have some degree of symptomatic dysphagia. Surgical correction in ten of them was associated with definite clinical improve­ment of pulmonary symptoms in eight.

Aspiration of gastric secretions into the tracheo­bronchial tree is already considered a potential cause of chronic pulmonary disease. Hiatal hernia with gastroesophageal reflux has been associated with pul­monary fibrosis and with severe asthma. Symptoms suggestive of aspiration (specifically, recumbent cough) have been reported in 10 to 50 percent of the patients with reflux, and occult aspiration has been docu­mented by radionuclide studies. The predominant reflux-permissive condition identified in these reports has been incompetence of the lower esophageal sphincter, with or without associated hiatal hernia; however, dysfunction of the upper esophageal sphinc­ter, (in large part, the cricopharyngeal) has received much less attention.

Read the rest of this entry »

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.

Read the rest of this entry »

A brief description of our index cases may l>e of help in describing this complication or abnormality.

Case 1

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.

Read the rest of this entry »

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 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.

Read the rest of this entry »