2021 Volume 25 Issue 3 Pages 245-251
Case: The patient was a man in his 80s.
History of present illness: The patient experienced difficulty swallowing and felt that he was choking while having a meal. After a month, he visited his local clinic, and was diagnosed with dysphagia of unknown cause. Two months after the diagnosis, he was referred to our hospital to do swallowing exercises.
Intervention and clinical course: Initial videofluoroscopic examination of swallowing (VFSS) revealed significant cricopharyngeal dysfunction. In order to widen the upper esophageal sphincter, esophageal dilation with a balloon was performed for 3 months. VFSS performed after the exercises showed improved cricopharyngeal dysfunction, and the exercises were discontinued. However, the patient returned with dysphagia 3 weeks later due to exacerbation of dysphagia, and swallowing exercises were resumed. Since the symptoms were similar, the patient performed the Mendelsohn maneuver as a swallowing exercise for 2 months in order to widen the narrowed upper esophageal sphincter. Interferential current stimulation was used concurrently to facilitate the swallowing reflex during the Mendelsohn maneuver. VFSS performed after the exercise showed that the cricopharyngeal dysfunction was improved. However, cricopharyngeal bar (CB) was identified as a bolus moved through the esophagus. VFSS with a liquid swallow demonstrated a change of the duration of esophageal opening from 0.20 s prior to the swallowing exercises to 0.33 s after balloon dilation and 0.43 s after the Mendelsohn maneuver. After the balloon dilation, the bolus remained in the oropharynx as the upper esophageal sphincter opened. After the Mendelsohn maneuver, improved timing of opening of the upper esophageal sphincter was demonstrated, and the bolus moved through the esophagus as the upper esophageal sphincter opened. The frequency of these exercises was reduced from twice a week to once a week. After 3 months, the symptoms of dysphagia remained well-controlled.
Discussion: In the present case, idiopathic cricopharyngeal dysphagia was suspected due to the presence of CB. Both the opening of the upper esophageal sphincter and its timing are important in improving cricopharyngeal dysfunction. By managing the patient while monitoring the progress of the swallowing exercises, we were able to prolong the duration of esophageal opening and improve the coordination of the organs involved in the process of swallowing.
