What is the management approach for a patient with cricopharyngeal spasm?

Management of Cricopharyngeal Spasm

For cricopharyngeal spasm causing dysphagia, cricopharyngeal myotomy is the definitive treatment for structural abnormalities, while botulinum toxin injection serves as an effective diagnostic and therapeutic option for patients with muscle hypertonicity, poor surgical candidates, or those requiring temporary relief. 1

Initial Diagnostic Approach

• Obtain videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to confirm cricopharyngeal dysfunction and assess for aspiration risk, as these are essential for documenting upper esophageal sphincter hyperfunction and hypopharyngeal retention. 1

• Perform esophageal manometry to objectively measure cricopharyngeal muscle tone and differentiate true spasm from other causes of dysphagia, as this helps guide treatment selection. 2

• Exclude structural abnormalities and recurrent malignancy through endoscopic evaluation before proceeding with any intervention, particularly in patients with prior cancer treatment. 1

Treatment Algorithm

Conservative Management First-Line

• Refer to speech-language pathologist for swallowing evaluation and therapy, as this should be the initial approach for patients with oral-pharyngeal dysphagia. 1

• Consider dietary modifications including texture modification and food fortification to mitigate symptoms while definitive treatment is planned. 1

Botulinum Toxin Injection for Selected Patients

• Inject 100-180 MU botulinum toxin A endoscopically into the cricopharyngeus muscle for patients with confirmed cricopharyngeal spasm, particularly those who are poor surgical candidates or require diagnostic confirmation. 3, 4, 2

• Expect symptom improvement lasting 2-14 months (mean 3.8 months), with 11 of 12 patients showing improvement in one series. 4

• Use botulinum toxin as a diagnostic tool to confirm that cricopharyngeal dysfunction is the primary cause of dysphagia before committing to surgical myotomy. 3, 5

• Avoid toxin diffusion into the hypopharynx by precise injection technique, as this can diminish pharyngeal contractility and worsen dysphagia. 2

Surgical Intervention for Definitive Treatment

• Perform cricopharyngeal myotomy for patients with structural abnormalities including pharyngeal or cricopharyngeal strictures, posterior pharyngeal diverticulum, and cervical webs, as this is the most common and effective surgical treatment. 1

• Reserve myotomy for structural causes, NOT neurologic insults, as outcomes are disappointing in diffuse neurological disorders. 1, 6

• Consider dilatation for benign stenoses or webs based on expert opinion, though this is not recommended for cricopharyngeal bars, prominent cervical osteophytes, or lateral pharyngeal diverticula. 1

Critical Clinical Pitfalls

• Do NOT perform dilatation of potentially malignant strictures until recurrent cancer has been excluded or approved by multidisciplinary team. 1

• Avoid high esophageal stents that impinge on cricopharyngeus, as these are poorly tolerated and should be avoided. 1

• Do NOT recommend myotomy for neurologic causes of dysphagia, as the operation is specifically indicated for structural abnormalities causing upper esophageal sphincter hyperfunction. 1

• Monitor for aspiration pneumonia risk, which occurred in 21.7% of patients after conservative surgical procedures in one series. 1

Nutritional Support During Treatment

• Provide specialist dietary assessment to ensure appropriate texture modification and food fortification while awaiting definitive treatment. 1

• Consider enteral feeding tubes when other measures fail to maintain weight and hydration, particularly in patients with intractable symptoms. 1

• Temporary gastrostomy may be required in patients undergoing surgical intervention, with permanent gastrostomy rates around 1.4%. 1

Special Considerations

• Patients with intractable aspiration despite conservative measures may require more radical surgical intervention including laryngeal suspension or diversion procedures, though these eliminate speech function. 1

• Botulinum toxin has limited effect in patients with reflux disease and only slight cricopharyngeus dysfunction, so proper patient selection is essential. 6

• Repeat injections are feasible for patients who respond well initially, as the therapeutic effect is temporary and can be safely repeated. 4, 2