Treatment of Patulous Upper Esophageal Sphincter
For patulous upper esophageal sphincter (UES), treatment options are extremely limited as this is a rare condition with minimal evidence; management should focus on conservative measures including dietary modifications (thickened liquids to prevent aspiration) and swallowing therapy, with consideration of surgical intervention only in severe cases with intractable aspiration.
Understanding the Condition
Patulous UES is an exceptionally rare finding with virtually no documented treatment protocols in the literature 1. Unlike the more common UES dysfunction characterized by failure to relax or open (which presents with dysphagia), a patulous sphincter remains abnormally open, potentially allowing:
- Aspiration of gastric contents
- Airway protection compromise
- Oropharyngeal dysphagia symptoms
Critical distinction: The available guidelines address UES dysfunction characterized by impaired opening/relaxation 2, which is the opposite pathophysiology from a patulous sphincter. Therefore, standard treatments like dilatation, botulinum toxin injection, or myotomy are contraindicated as they would worsen a patulous sphincter.
Treatment Approach
Conservative Management (First-Line)
Dietary modifications:
- Thickened liquids to reduce aspiration risk (nectar-thick or honey-thick consistencies have demonstrated dramatic reductions in aspiration) 3
- Testing various food consistencies during instrumental swallowing evaluation to determine safe textures 3
- Avoid thin liquids which pose highest aspiration risk
Swallowing therapy:
- Muscle strengthening exercises may help improve sphincter tone and coordination 3
- The Shaker exercise (sustained and repetitive head lifts in supine position, three times daily) showed significant improvement in UES function in 27 patients with abnormal UES relaxation, with 93% returning to regular or soft mechanical diet 3
- While this evidence is for UES opening dysfunction, strengthening surrounding musculature may provide some benefit
Monitoring and Assessment
- Fiberoptic endoscopic evaluation of swallowing (FEES) or videofluoroscopic swallow evaluation to assess aspiration risk 3
- Nutritional assessment to ensure adequate intake 3
- Chest radiograph to evaluate for aspiration pneumonia 3
Surgical Intervention (Last Resort)
Only for intractable aspiration 3:
- Surgical options exist for severe cases but carry significant morbidity
- Procedures like laryngotracheal separation or supracricoid partial laryngectomy have been used for intractable aspiration
- These are highly invasive with permanent effects on voice and swallowing
- Should only be considered after all conservative measures have failed
Critical Caveats
Do NOT use standard UES dysfunction treatments:
- No dilatation - this is for strictures/failure to open 2
- No botulinum toxin - this relaxes the sphincter further 4, 5
- No myotomy - this surgically opens the sphincter 5, 6
Common pitfall: Endoscopists may be unfamiliar with this rare finding and attempt standard dysphagia treatments that would be harmful 1.
Prognosis and Follow-up
Given the lack of evidence for patulous UES specifically, close monitoring is essential:
- Regular assessment for aspiration pneumonia
- Nutritional status monitoring
- Quality of life assessment regarding dietary restrictions
- Consider referral to specialized swallowing centers for complex cases 2
The rarity of this condition means treatment must be highly individualized based on symptom severity, aspiration risk, and impact on quality of life, with conservative management prioritized to avoid iatrogenic harm.