Management of Post-Cricoid Web in a 50-Year-Old Female
Endoscopic dilatation is the primary treatment for symptomatic post-cricoid web in this patient, using wire-guided or fluoroscopically-guided techniques to safely disrupt the web and restore swallowing function. 1, 2
Initial Assessment and Preparation
Before proceeding with dilatation, careful evaluation is essential:
- Endoscopy and contrast radiology should be performed to assess the exact location, extent, and characteristics of the web, as post-cricoid pathology increases perforation risk and requires an experienced endoscopist 1
- Barium swallow provides useful anatomical detail when the stricture is tight or prevents endoscope passage 1
- Tissue diagnosis through biopsies should be obtained to exclude malignancy, particularly in a 50-year-old female where post-cricoid carcinoma must be ruled out 1, 3
Primary Treatment: Endoscopic Dilatation
The definitive management is wire-guided or endoscopically-controlled dilatation, which offers enhanced safety for this anatomically challenging location 2:
- Use fluoroscopic guidance during the procedure to minimize complications, especially given the increased perforation risk in the post-cricoid region 1, 2
- Carbon dioxide insufflation should be preferred over air to minimize luminal distension and reduce post-procedural pain 2
- The procedure aims to restore oral nutrition and reduce aspiration risk 1
Treatment Schedule and Follow-Up
- Weekly or two-weekly dilatation sessions should continue until symptomatic improvement is achieved 2
- Monitor patients for at least 2 hours in the recovery room post-procedure 2
- Ensure the patient tolerates water before discharge 2
- Provide clear written instructions regarding fluids, diet, medications, and emergency contact information 2
Alternative Treatment Option
Cricopharyngeal myotomy may be considered if dilatation fails or for structural abnormalities causing persistent dysphagia 2:
- This surgical approach is particularly relevant when the web is associated with cricopharyngeal dysfunction 2
- However, dilatation should be attempted first as it is less invasive 2
Critical Safety Considerations
Active esophageal perforation is an absolute contraindication to dilatation 1:
- Suspect perforation if the patient develops persistent pain, breathlessness, fever, or tachycardia after the procedure 2
- The post-cricoid region carries greater perforation risk due to pharyngeal and cervical anatomy 1
- Coagulopathy should be corrected and anticoagulants withdrawn prior to dilatation 1
Important Clinical Pitfalls
- Do not overlook malignancy: Post-cricoid webs in middle-aged women can be associated with Plummer-Vinson syndrome or may mask early carcinoma, making tissue diagnosis mandatory 1, 3
- Experienced endoscopist required: The guidelines explicitly state that proximal dysphagia pathology like post-cricoid webs should only be managed by experienced operators due to increased perforation risk 1
- Avoid forceful manipulation: Gentle technique is essential as this region is prone to bleeding and edema 1