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Letters to the Editor
June 2000

The Failure of Cricopharyngeal Myotomy to Improve Postoperative Dysphagia: Is Videofluoroscopic Diagnosis Adequate?—Reply

Arch Otolaryngol Head Neck Surg. 2000;126(6):804-805. doi:

In reply

My colleagues and I would like to thank Drs Spiegel and Albright for their interest in our work and offer the following comments in response. Although videofluoroscopy is not the only evaluative tool available to investigate dysphagia, it does, unlike operator-dependent manometry, lend itself to a multi-institutional trial design. Also, to be accurate, pharyngeal manometry requires concurrent videofluoroscopy.1 Pharyngeal manometry alone only measures pressures generated or reduced at the upper esophageal sphincter; it does not allow assessment of swallow function, and the clinician cannot tell if the bolus even reaches the upper esophageal sphincter. Our study did not attempt to address the cause of the failure, but rather the question concerning whether cricopharyngeal myotomy, when performed on a multi-institutional basis, is successful in improving posttherapy dysphagia in the head and neck cancer population. It still represents, to the best of our knowledge, the only prospective randomized trial that has attempted to answer this question. We were unable to demonstrate any substantial improvement with the procedure when tested in this fashion. Although we recognize that not all enrolled patients had complete follow-up, the dropout rate in the 2 randomized groups was similar. Moreover, the observed differences in swallowing function between the 2 arms was small, indicating that there was no difference in efficacy between the groups. The observation that significant rehabilitative progress occurs after 6 months has not been rigorously evaluated for the myotomy procedure to date. However, other studies that have been performed following recovery after similar operations on patients with head and neck cancer (supraglottic laryngectomies and posterior composite resections) have demonstrated no significant improvement in swallowing ability at 6 or 12 months after surgery compared with 3 months after surgery.2,3 Unfortunately, our literature is full of reports that have subsequently been discarded claiming the efficacy of a therapy based on a relatively small number of patients in uncontrolled trials. We hope that in the future there will be a prospective randomized evaluation of the success of cricopharyngeal myotomy for other proposed indications.

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