Hello, I'm Dr. Robert Bastian of Bastian Voice Institute.
If you are having a problem swallowing, especially solid foods and
pills, and if that problem is slowly worsening over recent months or years, then this video
will give you some information about one of several potential explanations. It is a
problem with a muscle here in the throat that won't relax properly to let food through it and
into the esophagus. At Bastian Voice Institute we call this cricopharyngeal dysfunction. It is
also sometimes called upper esophageal sphincter achalasia. Now this is a disorder not well known
by many physicians for a legitimate reason; it is uncommon and they may have never heard of it
or encountered it. The problem this may have posed for you, however, is difficulty getting
a clear diagnosis and plan for treatment. Now, before we proceed further, let me note that this
discussion is intended to be informational. It's not for the purpose of a diagnosis. The hope is
that after watching you may be better equipped to discuss this problem with your own physician.
Now, over the months or years, the person will say, "The frequency of the lodgement of things wanting
to get stuck here has increased. It's happening more frequently and the number of foods that
cause the problem is expanding. First it was pills and meat, now, even bread sometimes will get stuck
here." So they'll say, "I've generally had to go for softer foods. I chew very carefully if
I'm eating meat. I cut it into very small pieces before I put it in my mouth." Some other people
will say, "I do a lot of throat clearing while I'm eating. I waken in the night with phlegm
in my throat. Sometimes I coughed during meal times," and so forth. And here's a key symptom for
some, not for all. Some will say, "I'll be sitting and watching TV and I cough or do that kind of
thing and spit, and there I find in the tissue something that I ate hours ago in the tissue."
All along the gastrointestinal tract are a series of sphincter muscles. The first sphincter is
technically the lips that can pinch together from all sides. The next sphincter is right here
at the cricoid cartilage, but it wraps around the food way, which is right behind the voice box. And
so, this muscle which is contracted—in you watching this right now, and in me. When we swallow something
over the tongue and down into the throat, it has to open up, let the food through, and then it clamps
shut again. It's like a gate that opens for a second and then closes right behind the food.
Well in some people, for reasons that are not always fully understood, that muscle stops
relaxing. It won't let go, the gate won't open. Now liquids and soft foods can still squeeze through,
because if it's partially relaxed they can get through a narrow opening, but solid foods less
and less. The problem progresses—always gets a little bit little bit worse over months
or years time and eventually, even soft foods and liquids have a hard time getting through.
The best single test is an x-ray. The video fluoroscopic swallowing study or VFSS,
often performed with the assistance of a speech pathologist. We can also see typical
findings during a video endoscopic swallowing study with a slender tube that goes through
the nose and down into the throat—performed at a place like Bastion Voice Institute. And
then sometimes, it is seen during esophagoscopy performed by a gastroenterologist.
Number one, you could choose to simply accept and live with the problem. you
would avoid certain foods, you wash with water a lot, you chew extra well, and that—
you just live with it. Option 2, you can try various dilation procedures often done by
a gastroenterologist to try to stretch the muscle and break its grip, and that
can often be done if there's not a big Zenker's in—which is the sack or the hernia.
Now in my experience this is a brief benefit at most and that benefit gets briefer as time
pass—and passes and as it's done more and more people get to the place where they say it just
doesn't help. Third option you can try, a newer treatment in the form of Botox injections into
the muscle, and I mention this option only for completeness sake as I don't personally view
it as a very good option for most people. Example: it has to be repeated every three to four months
and the benefit is highly variable. Option four: you can undergo traditional surgery through a
small incision in the side of the neck here, the procedure is called cricopharyngeal myotomy. The
muscle—let's pretend this is the muscle here—the muscle is divided from its outside surface
so that the ring is opened. So now, instead of the muscle contracting like this, when the muscle is
divided, when it when the muscle contracts, it contracts like that so the food can get
through. Now typically, traditional cricopharyngeal myotomy through a small neck incision here on the
side of the neck requires a general anesthetic, a brief hospital stay. Typically it's a single night
in the hospital. This is still a valid approach and is occasionally necessary. Now here's option
number five which I think for a lot of people is the attractive one. Option 5 is an endoscopic,
which means "through the mouth" approach that uses a laser to divide the muscle from its inside surface.
So instead of through the outside of the neck we're now inside the passive way dividing the
muscle from the inside to the outside, again, breaking the ring so that it can't obstruct
muscle—I mean food passage. Now there are always exceptions, but when this procedure is done, about
half of our patients are done as an outpatient, and the other half with a single night's stay.
Now if you identify with what I've described here, consult with your physician about the
possibility that your problem might be cricopharyngeus dysfunction, with or without a
Zenker's diverticulum. If that diagnosis is confirmed, then he or she can direct
you to the most experienced physicians and surgeons in your area, to develop an
appropriate plan. Thanks for spending time watching this video and I hope it helps!