Cricopharyngeal Dysfunction

How the upper esophageal sphincter works

The cricopharyngeus muscle forms most of the upper esophageal sphincter, at about the level of the Adam's apple. It stays contracted at rest, which keeps air out of the esophagus and stops food and acid from flowing back into the throat. During a swallow, it relaxes and the throat pulls it open for less than a second to let food through.

In cricopharyngeal dysfunction, the muscle:

• does not relax completely
• relaxes too late or closes too early
• becomes stiff and scarred (fibrosed), so it cannot stretch open

On X-ray this can appear as a cricopharyngeal bar, a shelf-like bulge at the back of the throat.

Causes and risk factors

• Age-related changes: fibrosis and loss of elasticity of the muscle
• Neurological conditions: stroke, Parkinson's disease, ALS, multiple sclerosis
• Muscle diseases: inclusion body myositis, oculopharyngeal muscular dystrophy
• Gastroesophageal reflux: acid may trigger the muscle to tighten
• Head and neck surgery or radiation
• Often no clear cause is found

Symptoms

• a feeling that food, especially solids and pills, sticks at the base of the throat
• needing to swallow several times per mouthful
• coughing, choking or throat clearing during or after meals
• regurgitating undigested food
• a lump-in-throat sensation
• hoarseness or a "wet" voice after eating
• weight loss and avoiding certain foods
• repeated chest infections from food or liquid entering the airway

Zenker's diverticulum

Pushing food against a tight cricopharyngeus raises pressure in the throat. Over years, the throat lining can bulge through a weak area just above the muscle, forming a pouch called Zenker's diverticulum. Food collects in the pouch, causing bad breath, gurgling in the neck, regurgitation of old food, and a higher risk of aspiration. Treating the cricopharyngeus is part of treating the pouch.

Diagnosis

Cricopharyngeal dysfunction is one cause of dysphagia, so tests aim to locate the problem and rule out other causes:

• Barium swallow: X-ray images while swallowing barium, showing a cricopharyngeal bar or pouch
• Videofluoroscopic swallow study (modified barium swallow): done with a speech-language pathologist to watch the whole swallow and check for aspiration
• Flexible endoscopic evaluation of swallowing (FEES) through the nose
• Upper endoscopy: to exclude tumors, strictures and other esophageal disease
• High-resolution manometry: measures pressure and relaxation of the sphincter
• Electromyography: in selected cases, to assess muscle activity
• Neurological evaluation when a nerve or muscle disease is suspected

Treatment

Swallowing therapy

A speech-language pathologist teaches exercises and techniques:

• the Shaker (head lift) exercise, which strengthens the muscles that pull the sphincter open
• the Mendelsohn maneuver, prolonging the upward movement of the larynx during a swallow
• postural changes such as turning the head
• diet changes: softer, moist foods, smaller bites, liquids alternated with solids, and crushing pills when appropriate

Medical procedures

• Dilation: stretching the sphincter with a balloon or bougie during endoscopy. Relief can be temporary and may need repeating.
• Botulinum toxin (Botox) injection: relaxes the muscle for about 3 to 6 months; also useful as a test before surgery.
• Treat reflux if present.

Surgery

• Cricopharyngeal myotomy: cutting the muscle so it can no longer tighten. It can be done endoscopically through the mouth or through a small neck incision. It gives long-lasting relief in many people with a cricopharyngeal bar or Zenker's diverticulum.
• Diverticulum treatment: endoscopic division of the wall between the pouch and esophagus, or open removal.

Complications

• aspiration pneumonia
• weight loss and malnutrition
• dehydration
• Zenker's diverticulum
• reduced quality of life and social eating

Frequently asked questions

What does cricopharyngeal dysfunction feel like?

It feels as though food or pills get stuck at the base of the throat, around the level of the Adam's apple. People often need to swallow several times, cough or clear their throat, and sometimes bring food back up.

What causes cricopharyngeal spasm?

The muscle may fail to relax because of age-related stiffening, nerve or muscle diseases, stroke, reflux, or previous neck surgery or radiation. In many people no specific cause is found.

Can cricopharyngeal dysfunction be cured?

Many people get lasting relief. Swallowing therapy helps mild cases. Dilation and Botox injections often help for months. Cricopharyngeal myotomy, cutting the muscle, gives long-term improvement for many people with a stiff muscle or Zenker's diverticulum.

Is cricopharyngeal dysfunction serious?

It can be, mainly because food or liquid entering the airway can cause pneumonia, and swallowing difficulty can lead to weight loss. Anyone with persistent swallowing problems should be evaluated to find the cause and rule out other conditions.