The Laryngoscope VC 2009 The American Laryngological, Rhinological and Otological Society, Inc.

Endoscopic CO2 Laser Cricopharyngeal Myotomy

Michael Pitman, MD; Philip Weissbrod, MD

tion of the procedure via intraoperative photographs, Objectives: Over the past 10 years, endoscopic illustrations, and an online video demonstration. cricopharyngeal myotomy laser surgery has been pro- posed as an alternative to transcervical cricopharyngeal myotomy. We will describe the technique and review METHODS/RESULTS the literature so that it may gain credence as a viable The ECPM technique involves postcricoid placement of a option for the treatment of cricopharyngeal achalasia. diverticuloscope. A nasogastric tube may be placed in the esoph- Methods: A literature review of endoscopic and agus to help identify the esophageal introitus and guide transcervical cricopharyngeal myotomy will be per- placement of the diverticuloscope (Fig. 1). Visualization of the formed. The technical aspects of endoscopic cricophar- cricopharyngeus (CP) is aided by pressure of the scope on yngeal myotomy will be presented and accompanied the surrounding tissues. The anterior flange of the diverticulo- by intraoperative photographs, illustrations, and an scope approaches the esophageal introitus, and the posterior online video demonstration. flange abuts the posterior pharyngeal wall highlighting the CP Results: Endoscopic cricopharyngeal myotomy is (Fig. 2). The mucosa-covered CP is easily identified as the a well-tolerated procedure with low morbidity and mound of tissue just proximal to the esophageal introitus good outcomes. It can be performed by surgeons who (Fig. 3). Once the CP is well exposed and the scope is sus- are comfortable with transoral laryngopharyngeal pended, the nasogastric tube is removed. The CP is palpated to laser surgery. obtain a sense of its mass and depth. A transmucosal vertical Conclusions: Endoscopic cricopharyngeal myot- midline incision is then made with a CO laser set in continu- omy is a viable alternative to classic transcervical cri- 2 ous wave mode at a power of 4 to 6 watts mechanically pulsed copharyngeal myotomy with equivalent outcomes and at 0.1 seconds on and 0.3 seconds off (Figs. 4 and 5). As one comparable if not less morbidity. gains experience, the majority of the procedure is performed in Key Words: Dysphagia, cricopharyngeal, myo- a nonpulsed fashion for increased efficiency. The overlying mu- tomy, laser surgery, endoscopy. cosa is surprisingly thick. There is a plane between the mucosa Laryngoscope, 119:45–53, 2009 and CP, which allows retraction of the incised mucosa and improves exposure of the underlying muscle (Fig. 6). The muco- INTRODUCTION sal incision should completely transect the overlying mucosa, Endoscopic cricopharyngeal myotomy (ECPM) was exposing a substantial amount of the CP prior to incising the CP in a vertical midline fashion. As the muscle is transected with first described in 1994.1 Since that time, a number of the laser, there is lateral retraction of visible muscle fibers published series have demonstrated that it is a safe and (Fig. 7). As a result, the muscle is very easy to discern from the effective procedure with decreased anesthesia time and overlying mucosa. The excellent visualization and pulsed laser morbidity compared with the more traditional transcer- mode makes it easy to ensure transection of every fiber of the CP vical cricopharyngeal myotomy (TCPM). Despite the without damage to the underlying buccopharyngeal fascia (BPF). obvious benefits of ECPM, the procedure has yet to be If nonpulsed mode is being used to expedite the procedure, popularized due to apprehension of learning this new then mechanical pulsing is initiated as the BPF is approached, technique and for fears of mediastinitis.2,3 Here, we before it is exposed. The pulsing utilizes the properties of thermal hope to elucidate the benefits and safety of this approach relaxation to minimize unintended peripheral damage due to the through a literature review and a detailed demonstra- laser. In addition, it allows more precise control of the laser. Con- sidering the importance of the inferior pharyngeal constrictor (IPC) in the function of the upper esophageal sphincter (UES), From the Department of Otolaryngology, The New York Eye and Ear 4 Infirmary, New York, New York, U.S.A. some promote including transection of its inferior aspect. After Editor’s Note: This Manuscript was received April 22, 2008, and complete transection of the CP, repositioning the diverticuloscope accepted for publication July 10, 2008. proximally allows for this to be performed. If hemostasis beyond

Additional Supporting Information may be found in the online ver- the capabilities of a CO2 laser is needed during the procedure, a sion of this article. neuropledget soaked with 1:10,000 of epinephrine will stop most Send correspondence to Michael Pitman, MD, New York Eye and bleeding while suction cautery is occasionally necessary. Ear Infirmary, 310 East 14th Street, 6th Floor, New York, NY 10003. Following transection of the muscle fibers of the CP, the E-mail: [email protected] intact BPF is nearly always visible as a contiguous translucent DOI: 10.1002/lary.20032 sheet overlying the areolar tissue of the retropharyngeal space

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 45 Fig. 1. Placement of the nasogastric tube helps localize the esophageal entroitus and the cricopharyngeal muscle.

(RPS) (patient B in Fig. 8). However, this layer is not consist- especially in the absence of BPF or if the fascia has been inad- ent. Figure 9, which was extracted from the surgical video, is vertently violated. Some authors recommend sealing the an example of a patient (patient A) where the BPF is extremely surgical site with fibrin glue.5 This does not appear to be neces- thin to nonexistent. The areolar tissue of the retropharyngeal sary unless the BPF has been violated. space is immediately encountered after CP transection. Despite As with TCPM, there is a wide array of postoperative proto- the presence or absence of BPF, the RPS should not be dis- cols as to timing of postoperative swallow studies, length of turbed and the alar fascia should never be violated. Disruption hospital stay, time to oral feeding, and advancement of diet. No of these tissue barriers will substantially increase the risk of convincing studies exist that evaluate the optimal protocol. We mediastinitis. At the completion of the procedure, the mucosa, place patients on Ampicillan/Sulbactam and perform a gastro- completely transected CP, BPF, and underlying areolar tissue of graffin swallow on the morning of postoperative day 1. If no leak the RPS are easily discernible (Fig. 10). is noted, then patients begin a clear liquid diet. If the diet is toler- As seen in Figures 8 and 9, the RPS is not empty but filled ated and no complications arise, the patient will be discharged with areolar tissue. As a result, as demonstrated by patient A’s home that evening on Amoxicillin/Clavulinic acid elixir for 5 early postoperative gastrograffin swallow, gross pharyngeal con- days. The patients will advance to full liquids on postoperative tents should be confined to the area directly involved in the day 3 and then maintain a soft diet from postoperative days 6 to surgery even when the buccopharyngeal fascia is not present or 14. A postoperative esophagram is obtained at 6 weeks (Fig. 13). has been minimally disrupted (Fig. 11). As is seen in this figure, although gross pharyngeal contents are contained, air may still track through the RPS. It should be noted that as with patient DISCUSSION B, when the BPF is present and undamaged, there is no leak- The symptoms of CP achalasia are well known but age of air into the RPS (Fig. 12). Hence, we recommend relatively nonspecific. Patients may complain of progres- avoiding positive pressure ventilation at the end of the surgery, sive dysphagia to solids and occasionally liquids. There

Fig. 2. Placement of the diverticuloscope and surrounding anatomy.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 46 Fig. 3. The cricopharyngeus (CP) mound is just proximal to the esophageal introitus. may also may be a globus sensation or in severe cases composed of an outer layer of fast-twitch type I myosin gross aspiration due to bolus overflow from the hypo- heavy chain (MHC) muscle fibers and an inner layer of pharynx when it is prevented from passing the upper slow-twitch type II MHC muscle fibers.9,10 The type II esophageal sphincter. When symptoms are severe, fibers are felt to be most responsible for sustained mus- patients often become afraid of eating or physically can- cle contraction and are the predominant fiber type in not eat enough to obtain sufficient calories. Weight loss both these muscles, more so in the CP. Considering the ensues as well as the morbidity that accompanies the re- slinglike insertion of the CP and its predominance of sultant malnutrition. type II fibers, it is hypothesized that the CP is most re- The UES is comprised posteriorly of the CP as well sponsible for the resting sphincteric closure of the UES. as contributions from the IPC. Anteriorly, the UES is Dysfunction of the CP is from anatomic, neurologic, made up of the cricoid and arytenoid cartilages. The iatrogenic, inflammatory, neoplastic, or idiopathic causes, UES corresponds to a 2–4 cm high pressure zone inferior and can lead to significant globus sensation, dysphagia, to the laryngeal opening extending to the inferior border aspiration, a Zenker’s diverticulum, and associated mor- of the cricoid cartilage.6 Opening of the UES is success- bidities. There is no gold standard diagnostic test for ful by both the relaxation of the CP and the dysfunction of the CP. Most commonly, a diagnosis is anterosuperior displacement of the laryngeal framework based on findings of postcricoid pooling on flexible from the contraction of the suprahyoid musculature. The laryngoscopic examination and abnormalities on video- above processes in conjunction with adequate tongue fluoroscopy; however, videofluoroscopy is largely and pharyngeal propulsion of food bolus are essential to subjective and postcricoid pooling is nonspecific. On fluo- a successful swallow.7,8 roscopy, CP dysfunction is assumed if there is obstruction The CP is crescent shaped with attachments to the of the bolus or if >50% of the lumen is obstructed by a cri- lateral ends of the cricoid cartilage, while the ICP copharyngeal bar (Fig. 13). Manometry has also been inserts onto a midline raphe. Both the CP and IPC are used to diagnose CP dysfunction. Elevated resting UES

Fig. 4. Initial mucosal incision.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 47 the office transorally under endoscopic guidance, or trans- cervically via EMG guidance. These injections can be both diagnostic and temporarily therapeutic.5 If the injection is helpful, then it is likely that a myotomy will also be help- ful. If the injection does not lead to improvement, the significance is unclear. Zaninotto et al.15 had a 72.7% suc- cess rate with CP myotomy for patients who did not respond to botox injection. It is important to note that one death from aspiration due to botox injection of the CP has been reported.13 This was likely secondary to increased dysphagia from paresis of the inferior constrictor muscle due to diffusion of the botox. Based on the above studies, treatment is indicated for patients with defective CP relaxation and adequate oral and pharyngeal propulsion and laryngeal elevation. Fig. 5. Surgeon’s view with surrounding anatomy. Practically speaking, though not optimal, most decisions are based on flexible laryngoscopic examination as well as videofluoroscopy. More controversial are patients with pressure has been suggested as an indicator of UES dys- normal anatomic and functional studies but clinically function. Unfortunately, this study is complicated by evident dysphagia. It remains unclear which of these multiple technical and physiologic issues. The resting patients would benefit from myotomy. Unfortunately, our pressure of the UES changes with multiple physiologic diagnostic armamentarium does not allow us to accu- factors as well as with different catheters used. Research rately diagnose all patients, so some are treated on has also revealed substantial inter- and intra-subject vari- clinical suspicion with mixed success. This should only ability. As a result, no consensus exists on the normal be done with much trepidation and patient education. range of resting UES pressure.11,12 The traditional surgical treatment for UES dysfunc- Probably the best evaluation of UES function is tion involves cricopharyngeal myotomy using a with intrabolus manofluorography. Manometry is per- transcervical approach.16–18 An open approach, while formed under videofluoroscopy to verify the position of effective, carries surgical morbidity including possible the manometric sensors and allow quantitative analysis pharyngocutanous fistula, recurrent laryngeal nerve pa- of intrabolus pressures in the pharyngoesophageal seg- ralysis, hematoma, seroma, and wound infection.19,20 In ment. Using this technique and calculating a mid- 1994, endoscopic cricopharyngeal myotomy was devel- intrabolus pressure gradient appears to be a useful and oped by utilizing direct laryngoscopy with laser incision 1,21 reproducible measurement to identify UES dysfunction, of the CP with a KTP laser. Soon after, CO2 laser although further study is necessary.13 Unfortunately, was employed and has become the laser of choice due to this technique is not widely available. its ability to coagulate small vessels and minimize unin- Other diagnostic techniques include electromyogra- tended spread of thermal damage.22,23 phy aimed at capturing dyskinesia of the CP and IPC14 or In reviewing the literature, it is apparent that com- botox injection of the CP. Botox injections can be adminis- plications from either ECPM or TCPM are few. tered under general anesthesia via direct laryngoscopy, in Assessing complications from TCPM alone proves

Fig. 6. A plane between the mucosa and underlying cricopharyngeus (CP) allows retraction of the mucosa to better visualize the muscle and confirm the incision depth.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 48 Fig. 7. The cricopharyngeus (CP) muscle fibers retract laterally with each laser pulse. They are easily discernible from the mucosa and underlying fascia. difficult because few series address only TCPM while crisis, and stroke (0.7%). The authors of this study cite a excluding patients with a Zenker’s diverticulum. Studies 75% improvement in oropharyngeal dysphagia symptoms that focus on ECPM are few in number and all have rel- for patients undergoing TCPM; however, there is no refer- atively small sample sizes (Table I). Even in these ence to any objective or subjective measure. Similarly, in a studies, the etiology underlying CP dysfunction and series of 54 patients who underwent TCPM, Mckenna and presence or absence of concomitant oropharyngeal dys- Dedo16 cite normal postoperative swallowing in 45% and phagia varies dramatically. As a result, there are improved swallowing in an additional 30%, in a group multiple confounding factors that make interstudy com- that had a surgical complication rate of just 3.7%. parision difficult. Additionally, for both ECPM and Ross et al.,20 in a series of 33 TCPM, divided their TCPM studies, preoperative diagnostic criteria differ sig- patients into three categories including head and neck nificantly depending on institution, and postoperative surgical patients (n 13), neurosurgical patients (n measures are equally as diverse. 9), and patients with¼ primary neurogenic disorders (n ¼ Brigand et al.19 examined a large series of patients 11). Outcomes were measured by tolerance of oral intake¼ with dysphagia. One subset included individuals who and dysphagia symptoms. They were stratified as excel- underwent TCPM for dysphagia secondary to muscular lent (resumption of full diet and disappearance of dystrophy. They performed TCPM on 139 patients and aspiration), good (maintenance on some form of oral recorded 28 complications in 16 patients (11.5%) in addi- feeding with minimal dysphagia), or poor (persistent tion to four mortalities (2.9%), which were all related to aspiration of food and secretions). The best results were pulmonary infections. Complications included 12 mucosal seen in the primary neurogenic group with 8/11 patients breaks (8.6%), eight pulmonary infections (5.8%), two categorized as excellent surgical outcome, 1/11 as good hematomas (1.4%), and one wound infection, fistula, buc- surgical outcome, and 2/11 as poor surgical outcome. The cal floor infection, pulmonary embolism, hypertensive worst-performing group was the neurosurgical group

Fig. 8. Intact buccopharyngeal fascia after complete transection of the cricopharyngeus muscle.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 49 Fig. 9. In patient A, the buccopharyngeal fascia (BPF) was extremely thin to nonexistent, and the areolar tissue of the retropharyngeal space (RPS) is immediately encountered upon complete transection of the cricopharyngeus (CP). with 6/9 patients having a poor surgical outcome, 1/9 one pharyngocutaneous fistula. There were no inciden- good, and 2/9 excellent. Four (12%) complications were ces of mediastinitis. noted including one wound infection, one aspiration Other series of ECPM report few complications and pneumonia, one transient vocal fold paresis, and one good functional outcomes. Takes et al.,24 in a series of 10 mortality secondary to staphylococcal pneumonia. patients, reported no major complications, free air in Dauer et al.3 compared the Mayo experience of soft tissue on X-ray in four patients, and subcutaneous TCPM (n 8) vs. ECPM (n 14) from 1996 to 2003. emphysema in one patient. If postoperative day 1 X-ray Preoperative¼ evaluation of swallowing¼ was measured showed no free air, an oral diet was started. In the pres- with the ‘‘Functional Outcome Swallowing Scale.’’ While ence of free air on day 1, oral intake was started on preoperative and postoperative swallowing was worse postoperative day 3. As measured by a questionnaire at in the TCPM group, mean improvement was equal three months, all subjects improved postoperatively, but between groups. Mean hospital stay was shorter for the not all were symptom free. One patient required a revi- endoscopic group (1.2 vs. 4.4 days) as was median oper- sion procedure secondary to fibrosis at the surgical site. ative time (29 vs. 87 minutes). However, this was at Brondbo,4 in a series of 17 patients, reported no com- least partially attributed to the need for additional pro- plications related to ECPM, and subjective swallowing cedures for the TCPM group (laryngo hyoid suspension improved in all but one patient. A soft diet was resumed 3/8 and muscle biopsy 1/8). Complications in the ECPM on postoperative day 3. Similarly, Lawson et al.,14 in a se- group included two patients with fever of unknown ori- ries of 29 patients, reported no complications and near gin and one self-limited episode of chest pain as universal improvements in subjective evaluation of dys- opposed to the TCPM group, which included one indi- phagia and aspiration as well as objective variables as vidual with chest pain, one prolonged intubation, and measured by flexible laryngoscopic evaluation and

Fig. 10. At the completion of the procedure, the mucosa, completely transected cricopharyngeus (CP), buccopharyngeal fascia (BPF), and underlying areolar tissue of the retropharyngeal space (RPS) are easily discernible.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 50 Fig. 11. Patient A gastrograffin swallow postoperative day 1. Note Fig. 12. Patient B gastrograffin swallow postoperative day 1. Note the containment of contrast by retropharyngeal space (RPS) with the containment of contrast by the buccopharyngeal fascia (BPF) minimal tracking of air through the space. in the surgical area. Due to intact BPF, there is no evidence of air entry into the RPS. videofluoroscopy. A liquid or soft diet was started on post- operative day 3 following video-fluoroscopy. the AF is the danger space (DS), which is defined poste- Critics of endoscopic myotomy commonly cite risk of riorly by the prevertebral fascia (PVF). This is a mediastinitis secondary to breach of the BPF; however, potential space, which runs from the skull base superi- this complication has not been documented in recent se- orly to the diaphragm inferiorly. Posterior to the PVF is ries.3,4,20,21 A brief discussion of facial planes and the prevertebral space. Anterior to the vertebral bodies, potential spaces is important in understanding the this is a potential space that runs from the skull base to potential concerns regarding violation of fascial planes. the coccyx inferiorly. Laterally, the prevertebral muscles The fascial plane surrounding the esophagus, CP, and are adherent to the transverse processes.25,26 Violation IPC is the BPF, the visceral layer of the middle layer of of these facial layers clearly can predispose patients to the deep cervical fascia. Its superior limit is the skull having pharyngeal contents travel extraluminally and base and inferiorly is continuous with the fibrous peri- cause infection. cardium of the mediastinum. Posterior to the BPF is the In investigation of ECPM and fascial planes, ECPM RPS, which is filled with areolar tissue and defined pos- was performed with CO2 laser on cadaveric specimens. teriorly by the AF. The AF is part of the deep layer of Postoperative dissection revealed an intact BPF layer, the deep cervical fascia, which fuses with the BPF in the which correlates to preservation of the fascial layer protect- superior mediastinum at the level of T1/T2. Posterior to ing spread into the RPS.27 In addition, as demonstrated in

Fig. 13. (a) Patient A preoperative barium swallow with cricopharyngeal bar. (b) Patient A six-week postoperative gastrograffin swallow. Note the recurrence of the asymptomatic small anterior esophageal web that has recurred despite the dilation immediately prior to the myotomy.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 51 aygsoe19 aur 09Pta n esbo:Edsoi CO Endoscopic Weissbrod: and Pitman 52 2009 January 119: Laryngoscope

TABLE I. Review of Published ECPM Literature.

Series Brondbo4 Dauer3 Halvorson21 Heberhold22 Lawson14 Lim23 Takes24 No. of patients 17 14 18 32 29 44 10 Preoperative VFS, manometry MFG MBS VFS, manometry VFS, EMG, MBS, fiberoptic VFS, fiberoptic diagnostic workup 15/17 gastroesophageal endoscopy, endoscopy endoscopy manometry 5/44

CO2 laser settings 1.5–3.0 W 3–5 W KTP 5–20 W 10 W 10–12 W 4 W Operative time NR 29 minutes NR NR NR NR NR Length of NR 1.2 days NR Typically 2 days Typically 3 days NR 4.8 days hospital stay Postoperative NGT for 3 days Puree on POD 1 Clear liquids Clear liquids as Parenteral for 3 days; Puree starting NGT; PO on POD intake on POD 1; tolerated soft diet POD >4 hours post-op 1 after neck advanced 3–10 after VFS after barium and chest X-ray as tolerated swallow; regular diet POD 10-14 Complications 0 3 minor: 2 fever NR 2 major: 1 prolonged 0 2 major: 2 esophageal 0 of unknown origin, intubation, 1 suspicion perforations 1 chest pain of mediastinitus with negative w/u Perioperative NR 1 week NR Yes 8 days Yes 24 hours antibiotics Perioperative NR NR NR NR Daily CXR for 3 days, Barium swallow Chest and lateral radiologic evaluation VFS POD 3 POD 0 neck X-ray POD 1 Postoperative NR NR NR VFS at week 1 VFS at week 2 or 3 VFS at 6–8 months VFS at week

2 radiologic evaluation 2 and 3 months ae rcpayga Myotomy Cricopharyngeal Laser Other 7 patients also had 4 patients also had Zenker’s diverticulum Zenker’s diverticulum

VFS videofluoroscopy; MFG manofluorography; MBS modified barium swallow; EMG electromyography; KTP potassium-titanyl-phosphate laser; NR not reported; NGT nasogastric tube; POD postoperative¼ day; PO orally;¼ CXR chest radiograph.¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ this paper, even when the BPF is minimally violated, gross 8. McConnel FM, Cerenenko D, Mendelsohn MS. Manofluoro- pharyngeal contents are contained by the undisturbed are- graphic analysis of swallowing. Otolaryngol Clin N Am olar tissue of the retropharyngeal space. 1988;21:625–635. 9. Mu L, Sanders I. Muscle fiber-type distribution pattern in CP myotomy is not the only treatment option for the human criocopharyngeus muscle. Dysphagia 2002;17: patients with UES dysfunction. Alternate therapeutic 87–96. options include intramuscular botox injections15,28,29 and 10. Mu L, Sanders I. Nuromuscular organization of the human various forms of dilation including bougie or balloon dila- upper esophageal sphincter. Ann Otol Rhinol Laryngol 30 1998;107:370–377. tion. The above options are associated with recurrence 11. Kahrilas PJ, Clouse RE, Hogan WJ. American Gastroen- of symptoms and need for repeated procedures. Surgical terological Association technical review on the clinical intervention appears to be a more reliable and lasting use of esophageal manometry. Gastroenterology 1994; intervention for treating UES dysfunction. 107:1865–1884. 12. Dire C, Shi G, Manka M, Kahrilas PJ. Manometric charac- teristics of the upper esophageal sphincter recorded with CONCLUSIONS a microsleeve. Am J Gastroenterol 2001;96:1383–1389. When considering surgical treatment for CP dysfunc- 13. Bammer T, Salassa JR, Klingler PJ. Comparison of methods tion, ECPM is a safe, reliable, and possibly a more for determining cricopharyngeal intrabolus pressure in attractive option than TCPM. Either approach for myot- normal patients as possible indicator for cricopharyngeal myotomy. Otolaryngol Head Neck Surg 2002;127:299– omy has relatively low risk of postoperative complication 308. and good functional outcome. The endoscopic approach is 14. Eidan J, Shochina M, Gohen B, Gay I. Electromyography of favorable considering the reduced surgical time, reduced the inferior constrictor and cricopharyngeal muscles during recovery time, lack of external scar, and lower risk of com- swallowing. Ann Otol Rhinol Laryngol 1990;99:466–469. 15. Zaninotto G, Marchese Ragona R, Briani C, et al. The role plication during reoperation after previous TCPM. of botulinum toxin injection and upper esophageal As with any new procedure, the acceptance and pop- sphincter myotomy in treating oropharyngeal dysphagia. ularization of the procedure must overcome certain J Gastrointest Surg 2004;8:997–1006. hurdles. First, the procedure must be advantageous when 16. McKenna JA, Dedo HH. Cricopharyngeal myotomy: indica- compared with the gold standard. The new procedure tions and technique. Ann Otol Rhinol Laryngol 1992;101: 216–221. should be proven to be safe and efficacious with similar 17. Goyal RK, Martin SB, Shapiro J, Spechier SJ. The role of outcomes from multiple surgeons. The results must per- cricopharyngeus muscle in pharyngoesophageal disor- sist over long-term follow-up. The technique has to be ders. Dysphagia 1993;8:252–258. described such that it can be duplicated using the skills 18. Kaplan S. Paralysis of deglutination, a post-poliomyelitis complication treated by section of the cricopharyngeus already in the armamentarium of a surgeon who wishes muscle. Ann Surg 1951;133:572–573. to conduct the surgery. Endoscopic cricopharyngeal myot- 19. Brigand C, Ferraro P, Martin J,Duranceau.Risk factors in omy has fulfilled all the above criteria except for the patients undergoing cricopharyngeal myotomy. Br J Surg description of the surgery. Thus far, descriptions have 2007;94:978–983. consisted of minimal text or still photo description. We 20. Ross ER, Green R, Auslander MO, Biller HF. Cricopharyng- eal mytomy: management of cervical dysphagia. Otolar- anticipate that the above review, comprehensive surgical yngol Head Neck Surg 1982;90:434–441. description, intraoperative photographs, illustrations, 21. Halvorson DJ. The treatment of cricopharyngeal dysmotility and supplementary online video demonstration will pro- with transmucosal cricopharyngeal myotomy using the vide the necessary information to encourage surgeons to potassium-titanly-phosphate laser. Endoscopy 1998;30: 46–50. consider ECPM as a viable alternative to TCPM. 22. Heberhold C, Walther EK. Endoscopic laser myotomy in cri- copharyngeal achalasia. Adv Otorhinolaryngol 1995;49: 144–147. BIBLIOGRAPHY 23. Lim RY. Endoscopic CO2 laser cricopharyngeal myotomy. J 1. Halvorson DJ, Kuhn FA. Transmucosal cricopharyngeal my- Clin Laser Med Surg 1995;13:241–247. otomy with the potassium-titanyl-phosphate laser in the 24. Takes RP, van den Hoogen FJA, Marres HAM. Endoscopic treatment of cricopharyngeal dysmotility. Ann Otol Rhi- myotomy of the cricopharyngeal muscle with CO2 laser nol Laryngol 1994;103:173–177. surgery. Head Neck 2005;27:703–709. 2. Kelly JH. Managagment of upper esophageal sphincter dis- 25. Grodinsky M, Holyoke E. The fasciae and fascial spaces of orders: indications and complications of myotomy. Am J the head, neck and adjacent regions. Am J Anat 1938: Med 2000;108:43s–46s. 63:367–408. 3. Dauer E, Salassa J, Iuga L, Kasperbauer J. Endoscopic 26. Paonessa DF, Goldstein JC. Anatomy and physiology of laser vs open approach for cricopharyngeal myotomy. Oto- head and neck infections. Otolaryngol Clin N Am 1976; laryngol Head Neck Surg 2006;134:830–835. 9:561–580. 4. Brondbo K. Treatment of cricopharyngeal dysfunction by 27. Chang CWD, Liou SS, Netterville JL. Anatomic study of endoscopic laser myotomy. Acta Otolaryngol 2000;Suppl laser-assisted endoscopic cricopharyngeus myotomy. Ann 543:222–224. Otol Rhinol Laryngol 2005;114:897–901. 5. Lawson G, Remacle M. Endoscopic cricopharyngeal myot- 28. Moerman MBJ. Cricopharyngeal botox injection: indication omy: indications and techniques. Curr Opin Otolaryngol and technique. Curr Opin Otolaryngol Head Neck Surg Head Neck Surg 2006;14:437–441. 2006;14:431–436. 6. Sivarao DV, Goyal RK. Functional anatomy and physiology 29. Parameswaran MS, Sloiman AMS. Endoscopic botulinum of the upper esophageal sphincter. Am J Med 2000;108: toxin injection for cricopharyngeal dysphagia. Ann Otol 27s–37s. Rhinol Laryngol 2002;111:871–874. 7. Cook IJ, Dodds WJ, Dantas RO, et al. Opening mechanisms 30. Wang AY, Kadkade R, Kahrilas PJ, Hirano I. Effectiveness of the human upper esophageal sphincter. Am J Physiol of esophageal dilation for symptomatic cricopharyngeal 1989;20:748–759. bar. Gastrointest Endosc 2005;61:148–152.

Laryngoscope 119: January 2009 Pitman and Weissbrod: Endoscopic CO2 Laser Cricopharyngeal Myotomy 53