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[DYSPHAGIA] cricopharyngeal spasms
- Subject: [DYSPHAGIA] cricopharyngeal spasms
- From: QuinnD@rvh.on.ca (Quinn, Darin)
- Date: Mon, 12 Mar 2001 11:55:18 -0500
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It's an interesting subject as many of the radiologists here dismiss the
prescence of a CP bar as a normal variation, particularly when the
oral/pharyngeal swallow mechanism appears to be working normally (even
though these patients come in with real complaints of globus, etc.). What
do you think about the relationship between CP bar and GER? (as noted in
Brady, A.P.; Stevenson, G.W.; Somers, S.; Hough, D.M.; Di Giandomenico, E.
(1995) Abdom Imaging 20:225-229.)
> ----------
> From: I Campbell-Taylor[SMTP:icampbelltaylor@sympatico.ca]
> Sent: March 11, 2001 12:50 PM
> To: Phyllis Palmer; Larry/Pam Seibert
> Cc: dysphagia@medonline.com
> Subject: Re: [DYSPHAGIA] cricopharyngeal spasms
>
> One of the most comprehensive articles on the subject is:
>
> Biomechanics of cricopharyngeal bars.
> Dantas RO; Cook IJ; Dodds WJ; Kern MK; Lang IM; Brasseur JG
> Gastroenterology, 99:1269-74 1990
> Patients with a prominent cricopharyngeal bar visible on radiography are
> generally considered to have spasm of the cricopharyngeus, which is the
> major muscle component of the upper esophageal sphincter. This condition
> has
> been termed "cricopharyngeal achalasia". The aim of this study was to
> determine the pathogenesis of cricopharyngeal bars. Concurrent
> videofluoroscopic and manometric examinations of the pharynx and upper
> esophageal sphincter were performed in a cohort of six patients with
> prominent cricopharyngeal bars and in eight control volunteers. In each
> subject, swallows of 2-30-mL barium boluses were recorded. The patients
> with
> cricopharyngeal bars showed (a) normal peristaltic contraction in the
> pharynx, (b) normal axial upper esophageal sphincter pressure and
> relaxation, (c) normal flow rate across the upper esophageal sphincter,
> and
> (d) normal duration of upper esophageal sphincter opening for different
> bolus volumes. The major abnormalities in the patients with
> cricopharyngeal
> bars were (a) reduced maximal dimensions of the upper esophageal sphincter
> during the transsphincteric flow of barium and (b) increased intrabolus
> pressure upstream to the upper esophageal sphincter. Thus, the increase in
> intrabolus pressure preserved normal transsphincteric flow rates even
> though
> the upper esophageal sphincter did not open normally. Overall, the
> constellation of findings in the patients studied suggests that the
> underlying pathogenesis of their cricopharyngeal bar was reduced muscle
> compliance wherein the relaxed cricopharyngeus did not distend normally
> during swallowing.
>
> This would seem to imply that resistance within the muscles of the CP
> (slow
> twitch fiber muscles, mainly) prevent the mechanical stretching required
> by
> the hyoid attachments and/or did not distend following applied pressure of
> the bolus.
> Comments?
> Irene.
>
> ----- Original Message -----
> From: Phyllis Palmer <ppalmer@medonline.com>
> To: Larry/Pam Seibert <lpseibert@home.com>
> Cc: <dysphagia@medonline.com>
> Sent: Sunday, March 11, 2001 12:22 AM
> Subject: Re: [DYSPHAGIA] cricopharyngeal spasms
>
>
> > Pam,
> >
> > Opening of the UES is accomplished by passive stretch due to
> hyolaryngeal
> > elevation, widening from intrabolus pressure, and relaxation of the CP
> > muscle. I would want to know more about what he saw at teh level of the
> > UES and what led him to diagnose a spasm. Did he do EMG durign
> swallowing
> > to not CP relaxation patterns? While I am sure the answer is no, I say
> > this because I am not certain that you can tell the CP is spasming from
> > susopending a scope in the pharynx (at least I can't)...you guys who do
> > lots of scoping, what is your experience with being able to identify
> > dysfunction of the CP muscle within the UES.
> >
> > If the problem is related to CP relaxation then some docs may consider
> > botox or bougie before they consider myotomy. If the issue is relatred
> to
> > either of the other 2 components of the UES opening, you have some rx
> > techniques you can try,
> >
> > Woudl love to hear how others deal with prominent CP muscles...or what
> > folks do when they see a CP bar on video?
> >
> > Phyllis
> >
> >
> > On Thu, 8 Mar 2001, Larry/Pam Seibert wrote:
> >
> > > Am scheduled to see a quadraplegic tomorrow who is on a cuffless trach
> > > and was recently scoped because he started having trouble swallowing
> > > solids. He complained that there was difficulty at the level of the
> > > trach. He was on a regular diet for years prior to this.
> > >
> > > When scoped the physician ordered 2 months of speech therapy to
> > > strengthen the swallow before considering a myotomy. A spasm was
> noted
> > > at the level of the cricophayngus.
> > >
> > > I haven't done much of this before and would appreciate anyone's
> advice
> > > on such a case.
> > >
> > > Pam
> > >
> > > ---------------------------------------------------------------------
> > > To UNSUBSCRIBE from this list, please send an e-mail message to
> > > majordomo@medonline.com with the following text as a message:
> > > unsubscribe dysphagia
> > > ---------------------------------------------------------------------
> > >
> >
> > --
> > __________________________________________________________
> > Phyllis M. Palmer, Ph.D. Speech Language Pathologist
> > www. dysphagia.com
> > __________________________________________________________
> >
> > ---------------------------------------------------------------------
> > To UNSUBSCRIBE from this list, please send an e-mail message to
> > majordomo@medonline.com with the following text as a message:
> > unsubscribe dysphagia
> > ---------------------------------------------------------------------
>
> ---------------------------------------------------------------------
> To UNSUBSCRIBE from this list, please send an e-mail message to
> majordomo@medonline.com with the following text as a message:
> unsubscribe dysphagia
> ---------------------------------------------------------------------
>
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<TITLE>RE: [DYSPHAGIA] cricopharyngeal spasms</TITLE>
</HEAD>
<BODY>
<P><FONT COLOR=3D"#0000FF" SIZE=3D2 FACE=3D"Arial">It's an interesting =
subject as many of the radiologists here dismiss the prescence of a CP =
bar as a normal variation, particularly when the oral/pharyngeal =
swallow mechanism appears to be working normally (even though these =
patients come in with real complaints of globus, etc.). What do =
you think about the relationship between CP bar and GER? (as =
noted in Brady, A.P.; Stevenson, G.W.; Somers, S.; Hough, D.M.; Di =
Giandomenico, E. (1995) Abdom Imaging 20:225-229.)</FONT></P>
<BR>
<UL>
<P><FONT SIZE=3D2 FACE=3D"MS Sans Serif">----------</FONT>
<BR><B><FONT SIZE=3D2 FACE=3D"MS Sans Serif">From:</FONT></B> =
<FONT SIZE=3D2 FACE=3D"MS Sans Serif">I =
Campbell-Taylor[SMTP:icampbelltaylor@sympatico.ca]</FONT>
<BR><B><FONT SIZE=3D2 FACE=3D"MS Sans Serif">Sent:</FONT></B> =
<FONT SIZE=3D2 FACE=3D"MS Sans Serif">March 11, 2001 12:50 PM</FONT>
<BR><B><FONT SIZE=3D2 FACE=3D"MS Sans Serif">To:</FONT></B> =
<FONT SIZE=3D2 FACE=3D"MS Sans Serif">Phyllis =
Palmer; Larry/Pam Seibert</FONT>
<BR><B><FONT SIZE=3D2 FACE=3D"MS Sans Serif">Cc:</FONT></B> =
<FONT SIZE=3D2 FACE=3D"MS Sans =
Serif">dysphagia@medonline.com</FONT>
<BR><B><FONT SIZE=3D2 FACE=3D"MS Sans Serif">Subject:</FONT></B> =
<FONT SIZE=3D2 FACE=3D"MS Sans =
Serif">Re: [DYSPHAGIA] cricopharyngeal spasms</FONT>
</P>
<P><FONT SIZE=3D2 FACE=3D"Arial">One of the most comprehensive articles =
on the subject is:</FONT>
</P>
<P><FONT SIZE=3D2 FACE=3D"Arial">Biomechanics of cricopharyngeal =
bars.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Dantas RO; Cook IJ; Dodds WJ; Kern =
MK; Lang IM; Brasseur JG</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Gastroenterology, 99:1269-74 =
1990</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Patients with a prominent =
cricopharyngeal bar visible on radiography are</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">generally considered to have spasm of =
the cricopharyngeus, which is the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">major muscle component of the upper =
esophageal sphincter. This condition has</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">been termed "cricopharyngeal =
achalasia". The aim of this study was to</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">determine the pathogenesis of =
cricopharyngeal bars. Concurrent</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">videofluoroscopic and manometric =
examinations of the pharynx and upper</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">esophageal sphincter were performed =
in a cohort of six patients with</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">prominent cricopharyngeal bars and in =
eight control volunteers. In each</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">subject, swallows of 2-30-mL barium =
boluses were recorded. The patients with</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">cricopharyngeal bars showed (a) =
normal peristaltic contraction in the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">pharynx, (b) normal axial upper =
esophageal sphincter pressure and</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">relaxation, (c) normal flow rate =
across the upper esophageal sphincter, and</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">(d) normal duration of upper =
esophageal sphincter opening for different</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">bolus volumes. The major =
abnormalities in the patients with cricopharyngeal</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">bars were (a) reduced maximal =
dimensions of the upper esophageal sphincter</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">during the transsphincteric flow of =
barium and (b) increased intrabolus</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">pressure upstream to the upper =
esophageal sphincter. Thus, the increase in</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">intrabolus pressure preserved normal =
transsphincteric flow rates even though</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">the upper esophageal sphincter did =
not open normally. Overall, the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">constellation of findings in the =
patients studied suggests that the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">underlying pathogenesis of their =
cricopharyngeal bar was reduced muscle</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">compliance wherein the relaxed =
cricopharyngeus did not distend normally</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">during swallowing.</FONT>
</P>
<P><FONT SIZE=3D2 FACE=3D"Arial">This would seem to imply that =
resistance within the muscles of the CP (slow</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">twitch fiber muscles, mainly) prevent =
the mechanical stretching required by</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">the hyoid attachments and/or did not =
distend following applied pressure of</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">the bolus.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Comments?</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Irene.</FONT>
</P>
<P><FONT SIZE=3D2 FACE=3D"Arial">----- Original Message -----</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">From: Phyllis Palmer =
<ppalmer@medonline.com></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">To: Larry/Pam Seibert =
<lpseibert@home.com></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Cc: =
<dysphagia@medonline.com></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Sent: Sunday, March 11, 2001 12:22 =
AM</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">Subject: Re: [DYSPHAGIA] =
cricopharyngeal spasms</FONT>
</P>
<BR>
<P><FONT SIZE=3D2 FACE=3D"Arial">> Pam,</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> Opening of the UES is =
accomplished by passive stretch due to hyolaryngeal</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> elevation, widening from =
intrabolus pressure, and relaxation of the CP</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> muscle. I would want to know =
more about what he saw at teh level of the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> UES and what led him to diagnose =
a spasm. Did he do EMG durign swallowing</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> to not CP relaxation patterns? =
While I am sure the answer is no, I say</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> this because I am not certain =
that you can tell the CP is spasming from</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> susopending a scope in the =
pharynx (at least I can't)...you guys who do</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> lots of scoping, what is your =
experience with being able to identify</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> dysfunction of the CP muscle =
within the UES.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> If the problem is related to CP =
relaxation then some docs may consider</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> botox or bougie before they =
consider myotomy. If the issue is relatred to</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> either of the other 2 components =
of the UES opening, you have some rx</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> techniques you can try,</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> Woudl love to hear how others =
deal with prominent CP muscles...or what</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> folks do when they see a CP bar =
on video?</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> Phyllis</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> On Thu, 8 Mar 2001, Larry/Pam =
Seibert wrote:</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > Am scheduled to see a =
quadraplegic tomorrow who is on a cuffless trach</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > and was recently scoped =
because he started having trouble swallowing</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > solids. He complained =
that there was difficulty at the level of the</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > trach. He was on a =
regular diet for years prior to this.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> ></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > When scoped the physician =
ordered 2 months of speech therapy to</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > strengthen the swallow =
before considering a myotomy. A spasm was noted</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > at the level of the =
cricophayngus.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> ></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > I haven't done much of this =
before and would appreciate anyone's advice</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > on such a case.</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> ></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > Pam</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> ></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > =
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<BR><FONT SIZE=3D2 FACE=3D"Arial">> > majordomo@medonline.com =
with the following text as a message:</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > unsubscribe =
dysphagia</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> > =
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<BR><FONT SIZE=3D2 FACE=3D"Arial">> ></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> --</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> =
__________________________________________________________</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> Phyllis M. Palmer, =
Ph.D. Speech Language =
Pathologist</FONT>
<BR><FONT SIZE=3D2 =
FACE=3D"Arial">>  =
; www. dysphagia.com</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> =
__________________________________________________________</FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">></FONT>
<BR><FONT SIZE=3D2 FACE=3D"Arial">> =
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