Upper Esophageal Sphincter Dysfunction: Identifying False Statements
Statement A, which claims that UES dysfunction is diagnosed by characteristic manometric findings of UES spasm, is FALSE. UES dysfunction is not primarily diagnosed by manometric findings of spasm, as this is not the characteristic diagnostic pattern for this condition.
Correct Understanding of UES Dysfunction
- UES dysfunction involves abnormalities in the high-pressure zone between the pharynx and cervical esophagus, which normally functions to prevent reflux into airways and air entry into the digestive tract 1
- The UES is composed of the cricopharyngeus muscle (CP) in the lower third and the thyropharyngeus (TP) muscle in the upper two-thirds, with the anterior wall formed by the cricoid cartilage and arytenoid muscles 1
Diagnostic Approaches for UES Dysfunction
- Modified barium swallow is the most common and reliable method for diagnosing UES dysfunction, not manometry alone 2
- Manometry can be used but has limitations due to catheter motion during swallowing, making it a secondary diagnostic tool rather than the primary diagnostic method 2
- High-resolution esophageal manometry (HREM) may show UES abnormalities including impaired relaxation, hypertensive, or hypotensive resting pressure, but these findings alone are not diagnostic of "UES spasm" 3
Accurate Statements About UES Dysfunction
- Statement B is correct: Typical symptoms of UES dysfunction include cervical dysphagia, expectoration of saliva, and hoarseness 2
- Statement C is correct: The classic finding on barium esophagogram is indeed a posterior cricopharyngeal bar 2
- Statement D is correct: Medical or surgical therapy of gastroesophageal reflux may be curative in some cases, particularly when UES dysfunction is secondary to reflux 4
- Statement E is correct: A cervical esophagomyotomy for UES dysfunction should be limited to 2-3 cm in length to avoid damaging normal muscle 2
Treatment Options for UES Dysfunction
- External upper esophageal sphincter compression devices have shown promise in managing UES dysfunction, with studies showing symptom improvement when added to PPI therapy 5
- Cricopharyngeal myotomy (CPM) can be performed through external technique, endoscopic approach, balloon dilatation, or botulinum toxin injection, with each approach having specific indications 2
- For patients with UES dysfunction related to gastroesophageal reflux disease (GERD), PPI therapy for 8-12 weeks may be beneficial, especially when combined with UES-specific interventions 5
Clinical Considerations and Pitfalls
- UES abnormalities are frequently found in patients with impaired lower esophageal sphincter (LES) relaxation, including achalasia and esophagogastric junction outflow obstruction 3
- Patients with UES dysfunction and achalasia have worse treatment outcomes compared to those with achalasia alone, suggesting the importance of identifying and addressing UES abnormalities 3
- Before performing any surgical intervention for UES dysfunction, massive reflux should be controlled and the patient should be medically stable 2
In summary, statement A is false because UES dysfunction is not diagnosed primarily by manometric findings of UES spasm, but rather through a combination of clinical history, physical examination, and primarily barium swallow studies, with manometry serving as a supplementary diagnostic tool.