OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &

NECK OPERATIVE SURGERY

CRICOPHARYNGEAL MYOTOMY: SURGICAL TECHNIQUE Johan Fagan

Cricopharyngeal myotomy may be indica-

ted for cricopharyngeal spasm causing dys-
phagia or aspiration and is done in patients
undergoing external resection of a pharyn-
geal pouch / Zenker’s diverticulum (ZD).

Cricopharyngeal dysfunction / achalasia

may be primary or secondary. Primary
achalasia refers to persistent spasm or
failure of the cricopharyngeus to relax,
where the pathology is confined to the
muscle and there is no underlying neurolo-
gic or systemic cause. It may be idiopathic
or be associated with intrinsic disorders of
the muscle e.g. polymyositis, muscular
dystrophy, and hypothyroidism. Cricopha- Figure 1: Note cricopharyngeal bar
ryngeal spasm may be secondary to neuro-
logic disorders e.g. poliomyelitis, oculo-
pharyngeal dysphagia, stroke, and amyo-
trophic lateral sclerosis (ALS), or diabetic
neuropathy, myasthenia gravis, and peri-
pheral neuropathies.

The diagnosis is made on history and

contrast swallow (videofluoroscopy). The
contrast swallow typically shows a
prominent bulge in the posterior wall of the
proximal oesophagus due to contraction of
the cricopharyngeus muscle (Figure 1).
Figure 2 shows spasm of the crico-
pharyngeus muscle causing dysphagia and
regurgitation.

The myotomy is commonly done via an Figure 2: Spasm of cricopharyngeus muscle

external approach, although an endoscopic causing dysphagia
approach using CO2 laser can also be em-
ployed. Alternative treatments include With endoscopic diverticulotomy, the cri-
dilatations and Botulinum toxin injections. copharyngeus muscle is divided when cut-
ting through the wall between the ZD and
Cricopharyngeal myotomy is also done in the oesophagus (Figure 3-5). See chapter on
patients undergoing external resection of a Zenker’s Diverticulum. Cricopharyngeal
pharyngeal pouch, as elevated cricopha- myotomy may also be done in isolation for
ryngeus muscle tone is considered a cause very small ZDs (Figure 6).
of a ZD.
Figure 3: Contrast swallow before and
after endoscopic diverticolotomy: Crico-
pharyngeus (yellow arrows) and the party
wall between the ZD and the oesophagus
are divided
Figure 6: ZD would be very difficult to treat
with a stapler and is best done with CO2
laser cricopharyngeal myotomy, as it is too
O shallow for the stapling technique
CP
Surgical anatomy

ZD

Figure 4: Cricopharyngeal bar (CP) con-

taining the cricopharyngeus muscle, which
separates oesophagus (O) from ZD

Inferior Constrictor

Cricopharyngeus

Recurrent laryngeal n

Oesophagus

Figure 7: Red arrow shows where ZD ex-

trudes through Killian’s dehiscence (blue)
between the inferior constrictor and the
Figure 5: Party wall has been divided. Note cricopharyngeus muscles
that both the cricopharyngeus muscle and
mucosa have been divided to the inferior Figure 7 illustrates how the cricopharyn-
aspect of the sac geus muscle fans out from its origin from
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the cricoid cartilage to surround the proxi- buccopharyngeal fascia is situated imme-
mal end of the oesophagus. Note Killian’s diately behind the cricopharyngeus muscle;
dehiscence through which a ZD typically hence great care must be taken to preserve
herniates between the cricopharyngeus and this fascial layer when endoscopically divi-
inferior constrictor muscles. Note also the ding the cricopharyngeus muscle. Despite
proximity of the recurrent laryngeal nerve, initial fears that this fascia could not be
which should be protected from injury with preserved during endoscopic cricopharyn-
external surgical approaches. geal myotomy, Chang et al demonstrated in
a cadaveric study that the buccopharyngeal
Figure 8 illustrates the buccopharyngeal fascial layer remained histologically intact
fascial layer that contains the pharynx and with CO2 laser cricopharyngeal myotomy.1
oesophagus, and a ZD.
Special investigations

Diagnosis of cricopharyngeal spasm and a

ZD is confirmed with a contrast swallow or
videofluoroscopy (Figures 1-2). Laryngos-
copy is done to rule out other causes of
dysphagia. Preoperative evaluation must in-
clude assessment of the function of the
lower oesophageal sphincter, as cricopha-
ryngeal myotomy in patients with an in-
competent lower sphincter places them at
risk of developing severe gastroesophageal
and laryngopharyngeal reflux.

External cricopharyngeal myotomy

External cricopharyngeal myotomy is a

quick and relatively simple procedure.

Figure 8: Barium swallow of ZD. Note how • Perform direct laryngoscopy and rigid
the buccopharyngeal fascia contains the oesophagoscopy to exclude other patho-
pharynx, oesophagus and diverticulum logy causing dysphagia such as tumours
(green line) and strictures
• Stent the oesophagus with a piece of
The anatomic relationship between the ZD suction tubing (Figure 9) / endotra-
and the surrounding buccopharyngeal fas- cheal tube / Maloney dilator; this helps
cial layer is key to understanding how the the surgeon to palpate and identify the
upper digestive tract remains separated oesophagus during dissection
from the retropharyngeal space when inci- • Extend the neck and turn the head to the
sing the anterior wall of the diverticulum, or right side
with isolated endoscopic cricopharyngeal • Palpate and identify the cricoid cartila-
myotomy. Disrupting this fascial layer can ge; this denotes the level of cricopha-
theoretically increase the likelihood of ryngeus
developing mediastinitis. When endoscopi-
cally dividing a hypertrophic cricopharyn-
geus muscle in the absence of a ZD, the

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 • Dissect along the anterior border of the
sternocleidomastoid muscle
• Identify and divide the omohyoid mus-
cle as it crosses the internal jugular vein
• Dissect along the medial aspect of the
internal jugular vein and common caro-
tid artery, and the lateral aspect of the
thyroid gland, larynx and trachea
• Identify, ligate and divide the middle
Figure 9: Suction tubing used to stent thyroid vein
oesophagus • Continue the dissection until the prever-
tebral fascia is reached, and strip supe-
• Make a liberal transverse cervical skin riorly and inferiorly with a finger to ex-
incision to the left of the midline at the pose the larynx, oesophagus, thyroid
level of the cricoid (Figure 10). A gland (medially) and contents of the
transverse incision is cosmetically pre- carotid sheath (laterally) (Figure 12)
ferable to a vertical incision
• Incise platysma muscle
• Elevate subplatysmal flaps (Figure 11)

L SCM
IJV
CA

TG
Figure 10: Transverse skin incision
Figure 12: Retracting the sternocleidomas-
toid (SCM) exposes the thyroid gland (TG),
larynx (L), internal jugular vein (IJV) and
common carotid artery (CA)

• The superior laryngeal nerve defines the

superior boundary of the dissection
SCM • Palpate the cricothyroid joint
• Place a double pronged hook or sharp
rake under the posterior edge of the
AJV thyroid cartilage or the thyroid gland
and rotate the laryngotracheal complex
to bring the oesophagus, cricopharyn-
Figure 11: Liberal exposure achieved with
geus and inferior pharyngeal constrictor
transverse incision and subplatysmal flaps;
muscles into view (Figure 13)
AJV: Anterior jugular vein; SCM: Sterno-
cleidomastoid
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 IC

CP

TR O

Figure 14: Cricopharyngeal myotomy, with

oesophageal mucosa stretched over suction
tubing coming into view
Figure 13: The rake is retracting the
thyroid gland to expose the 1st tracheal ring
(TR), Oesophagus (O), cricopharyngeus
(CP), and inferior constrictor (IC)

• With this laryngotracheal rotation the

RLN is safe, provided one dissects close
to the posterior midline of the crico-
pharyngeus muscle
• Palpate and identify the cricoid cartilage
• Palpate and identify the firm tubing /
dilator within the oesophagus
• The cricopharyngeus muscle is easily
palpated and visualized, stretched over
the oesophageal stent
• Cut vertically with a 15# scalpel blade
through the cricopharyngeus muscle
until the underlying oesophageal muco-
sa comes into view (Figures 14, 15)
• Ensure haemostasis
• Insert a suction drain, and close the neck
in a layered fashion (Figure 16) Figure 15: Completion of cricopharyngeal
• Introduce oral fluids the same day if the myotomy with muscle elevated from mucosa
mucosa has not been breached

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 o Distract the blades further to better
visualise the cricopharyngeus bar
o Suspend the scope with a scope
holder

Figure 16: Closed wound and suction drain

Endoscopic cricopharyngeal myotomy

Figure 17: Weerda bivalve diverticulo-
• Administer broad spectrum antibiotics scope
perioperatively
• General anaesthesia is done with orotra-
cheal intubation (nasotracheal intuba-
tion hampers access)
• Protect the upper teeth with a gum guard
• Perform laryngoscopy
• Perform rigid oesophagoscopy
o Inspect the oesophagus to rule out
other pathology that may be causing
symptoms such as tumours or stric-
tures
o Dilating the oesophageal opening
with the scope facilitates subsequent
passage of the diverticuloscope Figure 18: Benjamin diverticuloscope
• Insert a Weerda or Benjamin diverticu-
loscope (Figures 17, 10) • Visualise the cricopharyngeus bar using
o Extend the neck posteriorly as far as an operating microscope with an inte-
the cervical spine allows grated CO2 laser microsled
o Lubricate the scope • Set the CO2 laser at 5-10W, CW mode
o Advance the scope with blades and with a slightly defocused spot size
slightly apart until the oesophageal to improve haemostasis
opening appears • Use CO2 laser to transect the mucosa
o It is not always possible to insert the overlying the muscle in the midline
scope due to anatomical limitations (Figure 19)
o Pass the anterior blade of the scope • Meticulously completely transect the
into the oesophagus and keep the cricopharyngeus muscle without disrup-
posterior blade against the posterior ting the posterior layer of perioeso-
wall of the hypopharynx phageal fascia (Figure 20)
o Identify the transverse bar denoting
the upper edge of cricopharyngeus
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 • The patient should remain on liquids
and soft foods for at least a week

Reference

1. Chang CWD, Liou SS, Netterville JL.

Anatomic Study of Laser-Assisted
Endoscopic Cricopharyngeus Myoto-
Figure 19: Transmucosal laser cricopha- my. Ann Otol Rhinol Laryngol 2005;
ryngeal myotomy: incising mucosa and 114(12):897-901
muscle
Suggested chapters in Open Access Atlas

• CO2 laser transoral microsurgery

(TLM)
https://vula.uct.ac.za/access/content/gr
oup/ba5fb1bd-be95-48e5-81be-
586fbaeba29d/CO2%20laser%20transo
ral%20microsurgery%20_TLM_.pdf

• Surgery for pharyngeal pouch /

Figure 20: Transmucosal laser cricopha-
Zenker’s diverticulum
ryngeal myotomy: completed myotomy
https://vula.uct.ac.za/access/content/gr
oup/ba5fb1bd-be95-48e5-81be-
• Instruct the anaesthetist to avoid venti- 586fbaeba29d/Surgery%20for%20phar
lating the patient with a face mask yngeal%20pouch%20_Zenker_s%20di
when reversing the anaesthesia, as it verticulum_.pdf
may cause air to track through the defect
into the tissues of the neck, causing Author & Editor
surgical emphysema and potentially in-
creasing the risk of a postoperative leak Johan Fagan MBChB, FCS (ORL), MMed
and sepsis Professor and Chairman
• Observe the patient overnight Division of Otolaryngology
• Following CO2 laser, a small number of University of Cape Town
patients develop some subcutaneous Cape Town, South Africa
emphysema; this almost never results in johannes.fagan@uct.ac.za
mediastinitis
• Monitor for signs and symptoms that
THE OPEN ACCESS ATLAS OF
signal mediastinitis e.g. radiating back
or chest pain, fever, and tachycardia OTOLARYNGOLOGY, HEAD &
despite adequate pain control, as early NECK OPERATIVE SURGERY
intervention for this rare but potentially www.entdev.uct.ac.za
fatal complication is mandatory
• Commence a clear liquid diet the mor-
ning following surgery
• Discharge the patient if he/she tolerates The Open Access Atlas of Otolaryngology, Head & Neck
Operative Surgery by Johan Fagan (Editor)
a clear liquid diet without concerning johannes.fagan@uct.ac.za is licensed under a Creative
signs or symptoms Commons Attribution - Non-Commercial 3.0 Unported
License

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