Vol. 22, No.
8 August 2000
CE Refereed Peer Review
FOCAL POINT
★Cricopharyngeal achalasia (CPA)
in dogs can be treated effectively
with cricopharyngeal myotomy.
KEY FACTS
■ The common clinical signs
of CPA include dysphagia,
regurgitation, coughing,
aspiration pneumonia, and
poor growth in young dogs.
■ Clinical signs of dysphagia can
result from disruption of any part
of the oropharyngeal phase of
swallowing.
■ Contrast fluoroscopy is essential
for evaluating swallowing
function.
■ Improvement in swallowing
function is seen immediately
after cricopharyngeal myotomy.
■ Diagnosis of CPA depends on
careful evaluation of swallowing
function to exclude other
oropharyngeal disorders.
Cricopharyngeal
Achalasia in Dogs
University of London
Jane Ladlow, MA, VetMB
Robert J. Hardie, DVM
ABSTRACT: Cricopharyngeal achalasia occurs in young dogs, causing both swallowing and
respiratory signs. It occurs when the upper esophageal sphincter fails to open during swallow-
ing, thereby preventing food from entering the proximal esophagus. Careful evaluation of
swallowing function and exclusion of other causes of dysphagia are necessary for a diagnosis.
Cricopharyngeal myotomy is an effective treatment with few complications.
C
ricopharyngeal achalasia (CPA) is a disease of young dogs. It is caused by
failure of the upper esophageal sphincter to open during swallowing,
thereby preventing food from entering the proximal esophagus.1–3 Dys-
phagia, regurgitation, aspiration, coughing, and nasal reflux may occur during
eating as a result of food being retained in the pharynx after swallowing. Similar
clinical signs may be caused by other oropharyngeal or esophageal diseases. Di-
agnostic differentials should include cricopharyngeal asynchrony, pharyngeal
dysphagia, cleft palate, congenital hypoplasia of the soft palate, congenital steno-
sis of the esophagus, vascular ring anomaly, esophageal foreign body, esophageal
diverticulum, space-occupying masses, and megaesophagus.4–6 Determining the
diagnosis requires thorough history taking and physical examination as well as
careful evaluation of swallowing function. This article describes the relevant
anatomy, the phases of swallowing, diagnosis, surgical treatment, and a review of
reported cases; in addition, aspects of the disorder in dogs are compared with
those in humans.
ANATOMY
The cricopharyngeus and thyropharyngeus muscles compose the upper
esophageal sphincter that surrounds the caudal pharynx and proximal esopha-
gus.7 The cricopharyngeus muscle is the primary muscle controlling the passage
of food into the esophagus (Figure 1). At rest, the cricopharyngeus muscle is
contracted, thereby closing the proximal esophagus. Its function is to prevent air
from entering the esophagus during respiration and to preclude gastroesophageal
reflux from passing into the pharynx. During swallowing, the cricopharyngeus
muscle relaxes and opens to allow food into the esophagus.
Information regarding the anatomic structure of the cricopharyngeus muscle
is conflicting. Previous information indicated that the muscle was paired, with
Compendium August 2000 Small Animal/Exotics

each side originating from the tation, aspiration, and cough-

lateral surfaces of the cricoid
cartilage and inserting dorsal-
ly on the median raphe. 8
However, a more recent study
involving normal dogs indi-
cated that the cricopharyn-
geus muscle is not paired and
that individual muscle fibers
originating from one side of
the cricoid cartilage spread Figure 1—Lateral musculature of the laryngopharynx and be obtained to help determine
over the dorsal surface of the upper esophageal sphincter. (CH = ceratohyoideus; CP = the underlying cause (see Im-
esophagus and either termi- cricopharyngeus; E = esophagus; MH = myohyoideus; SH portant Questions to Ask When
nate within the body of the = sternohyoideus; SM = sternomastoideus; ST = ster- Taking the History of a Dog
muscle or insert on the oppo- nothyroideus; TP = thyropharyngeus)
site side of the cricoid carti-
lage.9
This study also identified differences between the
cricopharyngeus and thyropharyngeus muscles. The
cricopharyngeus muscle was found to be composed
predominately of type 1 fibers, whereas the thyropha-
ryngeus muscle was found to comprise predominately
type 2 fibers. A difference was also found in the distri-
bution of the motor end-plates within the muscles, and
the diameter of the muscle fibers was significantly
smaller in the cricopharyngeus muscle than in the thy-
ropharyngeus muscle.9 The blood supply to the crico-
pharyngeus muscle comes primarily from the branches
of the cranial thyroid artery, and the innervation is
from the glossopharyngeal nerve and the pharyngeal
branches of the vagus nerve.7
PHASES OF SWALLOWING
Swallowing is the coordinated process of moving a
bolus of food from the mouth to the stomach. The
process can be divided into oropharyngeal, esophageal,
and gastroesophageal phases. The oropharyngeal phase
of swallowing can be further divided into three separate
phases—oral, pharyngeal, and cricopharyngeal. In the
oral phase, prehension takes place and the bolus of food
is formed at the base of the tongue. In the pharyngeal
phase, the bolus is propelled to the caudal pharynx by
coordinated contractions of the rostral and caudal pha-
ryngeal muscles. In the cricopharyngeal phase, the
cricopharyngeal muscle relaxes and opens in coordina-
tion with the pharyngeal contraction, allowing the bo-
lus of food to pass into the proximal esophagus.10
Disruption to any part of the oropharyngeal phase of
swallowing can cause signs of dysphagia.4,6 In dogs with
CPA, failure of the cricopharyngeus muscle to relax
during pharyngeal contraction disrupts the cricopha-
ryngeal phase of swallowing. Consequently, food re-
mains in the pharynx, which causes gagging, regurgi-
ing. Repeated attempts to swal-
low eventually force some
food through the upper esopha-
geal sphincter, where it then
passes to the stomach.
DIAGNOSIS
For any dog with dyspha-
gia, a thorough history should
Suspected to Have Cricopha-
ryngeal Achalasia). Dogs with
CPA usually develop clinical signs (e.g., various degrees
of gagging, regurgitation, coughing, nasal reflux, and
possibly aspiration pneumonia) at the time of weaning.
The signs are usually static unless complicated by pneu-
monia. Prehension in these dogs is normal, and they
are able to form a bolus of food but are unable to swal-
low. Regurgitation occurs immediately after attempted
swallowing. Liquids are sometimes swallowed better
than solids are but may be associated with nasal reflux.
Owners may describe lack of weight gain or failure to
thrive despite a ravenous appetite.
Differentiating the various causes of dysphagia re-
quires a thorough oral examination and observation of
the dog while it eats. Watching the dog eat helps deter-
Important Questions to Ask When Taking
the History of a Dog Suspected to Have
Cricopharyngeal Achalasia
■ What was the dog’s age at the onset of clinical
signs?
■ Was onset acute or chronic?
■ Are the signs static or progressive?
■ When does regurgitation occur? What is the
condition of the regurgitated food?
■ Does the dog have any difficulty chewing or
swallowing or does food drop from its mouth?
■ Are liquids swallowed more easily than solids?
■ Is there any coughing, nasal reflux, or signs of
aspiration pneumonia?
■ How is the dog’s appetite?
■ Has there been any weight loss or other
concurrent problems?

CRICOPHARYNGEUS MUSCLE ■ OROPHARYNGEAL SWALLOWING PHASE ■ CLINICAL SIGNS

Small Animal/Exotics Compendium August 2000

mine which phase of swallow- line. Care must be taken to

ing is abnormal and aids in
further localizing the prob-
lem. Survey radiographs of
the pharyngeal area and tho-
rax are usually normal but
may reveal signs of aspiration
pneumonia caused by chronic
dysphagia. Contrast fluo-
roscopy is essential for evalu-
ating the phases of swallow- Figure 2—Preoperative fluoroscopic spot film showing sternohyoideus muscles and
ing and observing the passage contrast medium distending the caudal pharynx and aspi- subcutaneous tissue are closed
of food from the esophagus rating into the trachea in a dog with cricopharyngeal acha- with absorbable suture mate-
to the stomach. Barium sul- lasia. Only a very small amount of medium passed through rial in a simple continuous or
fate preparations are the most the upper esophageal sphincter during swallowing.
commonly used contrast me-
dia to examine swallowing.
Contrast media should be given in liquid or paste form
and mixed with food to obtain the maximum amount
of information on bolus formation and swallowing
function. For cases in which aspiration is likely, non-
ionic, water-soluble, iodine-based contrast medium
may be advisable to avoid potential complications with
inhaled barium.
Findings on endoscopic examination of the pharynx
and upper esophageal sphincter are normal, and there is
no obvious obstruction to the passage of an endoscope or
stomach tube in dogs with CPA. A presumptive diagno-
sis of CPA can be made if a dog is able to form a bolus
and move it to the caudal pharynx in the normal manner
but is unable to pass it into the esophagus because the
cricopharyngeus muscle fails to dilate during swallowing.
A diagnosis of CPA is confirmed by response to such
treatment as cricopharyngeal myotomy.6,11
SURGICAL TREATMENT
Surgical treatment for CPA involves transection of
the cricopharyngeus muscle to prevent further obstruc-
tion during swallowing.6,8 The procedure is performed
by using a ventral approach to the larynx and proximal
esophagus.1 A ventral midline incision should be made
cranial to the larynx to the midcervical region. The
sternohyoideus muscles are separated to expose the lar-
ynx. The larynx and proximal esophagus are identified
and rotated, avoiding injury to the recurrent laryngeal
nerve on the lateral aspect of the trachea. Rotation can
be maintained with a stay suture placed through the
lamina of the thyroid cartilage. An appropriately sized
tube placed down the esophagus aids identification of
the upper esophageal sphincter.
The cricopharyngeus muscle, which surrounds the
proximal esophagus immediately caudal to the thy-
ropharyngeus muscle, is transected on the dorsal mid-
ensure that all of the muscle
fibers are cut and no longer
constrict the esophagus. The
esophagus should be carefully
inspected for evidence of per-
foration before the stay suture
is removed and the esophagus
and trachea are returned to
their normal position. The
simple interrupted pattern.
The skin is closed routinely.
Postoperative care involves
providing necessary supportive care and analgesia and
monitoring the incision for complications. Once the
dog has recovered, swallowing function can be evaluat-
ed by feeding a small amount of soft food. Function
improves immediately after cricopharyngeal myotomy.1
Potential postoperative complications include recurrent
laryngeal paralysis, esophageal perforation, recurrence
of dysphagia, and pharyngocutaneous fistula.8
CASE REPORT
History
A 6.5-month-old female English cocker spaniel was
referred to the Royal Veterinary College at the Univer-
sity of London with a 5-month history of dysphagia,
regurgitation, and aspiration. The owner reported that
the first signs occurred at weaning when the dog regur-
gitated through the nares. The dog would occasionally
cough and become cyanotic when eating. Hand-feed-
ing small meals improved the dysphagia, although
episodes of regurgitation and coughing still occurred.
At the time of presentation, the dog was notably small-
er than its littermates.
Clinical Signs and Diagnosis
Physical examination revealed a dog of small stature
weighing 6.2 kg. Vital signs were normal, but increased
lower respiratory sounds were noted on thoracic auscul-
tation. Neurologic examination, which included testing
cranial nerve reflexes, was normal. Complete blood
count and serum biochemistry profiles were within
normal limits, except for an increased total leukocyte
count and mature neutrophilia. A lateral radiograph of
the thorax revealed an alveolar pattern in the ventral
lung lobes. Regurgitation was seen during feeding de-
spite normal prehension and swallowing efforts.
Swallowing function was examined using fluoroscopy

SURVEY RADIOGRAPHS ■ CONTRAST FLUOROSCOPY ■ CRICOPHARYNGEAL MYOTOMY

Compendium August 2000 Small Animal/Exotics

while the dog was fed a soft pH 9.8 and 4.3, esterase,
food–barium sulfate mixture. nicotinamide adenine dinu-
Fluoroscopy showed normal cleotide–tetrazolium reduc-
prehension and bolus forma- tase, acid phosphatase, alka-
tion with strong contractions line phosphatase, oil red O,
of the pharyngeal muscles, and staphylococcal protein-A
which pushed the bolus to- conjugated with horseradish
ward the upper esophageal peroxidase. The size of the
sphincter and distorted the myofibers varied moderately
pharynx. The sphincter did but seemed to be within the
not relax and open synchro- Figure 3—Interoperative photograph of the transected cri- normal range for the muscle.
nously with pharyngeal con- copharyngeus muscle and the underlying esophagus. Type 1 and 2 muscle fibers
traction, and thus food re- were present, and no specific
mained in the pharynx. Food abnormalities were noted
was aspirated into the trachea during enzyme reactions or
during inspiration and then with any of the staining
coughed up. A small amount methods.
of contrast medium passed
through the upper esophageal DOCUMENTATION
sphincter and into the stom- Cricopharyngeal achalasia
ach (Figure 2). The clinical ex- has been documented in only
amination and radiographic eight other dogs (Table
and fluoroscopic findings were I).2,3,5,6,11 Six of the eight dogs
consistent with CPA and sec- were treated surgically with
ondary aspiration pneumonia. Figure 4—Radiograph showing contrast medium in the cricopharyngeal myotomy,
The other diagnostic differen- upper esophagus after cricopharyngeal myotomy. Note and clinical signs were perma-
tial was severe pharyngeal–cri- the bolus of food in the region of the cricopharyngeal my- nently eliminated in five. In
copharyngeal asynchrony. otomy. There is no evidence of tracheal aspiration (com- the sixth dog, regurgitation
pare with Figure 2). recurred within 2 weeks, pre-
Surgical Procedure sumably because of fibrosis at
Cricopharyngeal myotomy the previous myotomy inci-
was performed using the ventral approach described sion, and further treatment was not pursued.2 Treat-
previously.1,6 The cricopharyngeus muscle was elevated ment and outcome were not recorded for the other two
off the esophagus and transected along the dorsal mid- dogs.
line. The transected muscle fibers contracted, leaving a
gap of approximately 1 cm between the cut edges (Fig- COMPARISON WITH THE DISORDER IN HUMANS
ure 3). A section of the cricopharyngeus muscle was re- Depending on the cause, CPA in humans is classified
moved for histopathologic examination. The esophagus as primary or secondary. Primary CPA includes congen-
was inspected for perforation and returned to its nor- ital or idiopathic cases that are not associated with other
mal position. The rest of the closure was routine. diseases. Secondary CPA is associated with other dis-
eases, including central neurologic disease; cerebrovascu-
Postoperative Results lar accidents; diffuse neuromuscular disorders; or such
Twelve hours after surgery, the dog was fed a small local lesions as pharyngoesophageal stenosis, esophageal
amount of soft food. It ate rapidly with no evidence of as- diverticulum, pharyngeal tumors, or external compres-
piration or regurgitation. Fluoroscopic examination the sive lesions.12,13
day after surgery demonstrated normal passage of food Confirming the diagnosis of CPA in humans is simi-
through the upper esophageal sphincter into the cranial lar to that in dogs. A thorough oral examination is per-
esophagus (Figure 4). At 1 and 3 months after surgery, the formed, and the patient is observed while eating. Diag-
owner reported that the dog was eating well, had no regur- nostic tests include laryngoscopic examination, contrast
gitation or aspiration, and coughed only occasionally. fluoroscopic examination of swallowing and esophageal
Histopathologic examination of the cricopharyngeus function, manometric studies of the upper and lower
muscle involved staining with hematoxylin and eosin, esophageal sphincters, and possibly endoscopic exami-
modified trichrome, periodic acid–Schiff, ATPase at nation of the esophagus.8,12

HISTOPATHOLOGY ■ PRIMARY VS. SECONDARY CPA ■ DIAGNOSTIC TESTS IN HUMANS

Small Animal/Exotics Compendium August 2000

TABLE I
Cases of Cricopharyngeal Achalasia Reported in the Literature
Authors Signalment Clinical Signs Diagnostic Test Treatment Outcome

Allen6 18-wk-old male Regurgitation Fluoroscopy Cricopharyngeal Clinically normal

miniature poodle myotomy 1 yr after surgery

Shaw and 10-wk-old female Regurgitation and Contrast Cricopharyngeal Clinically normal
Dodd11 mixed-breed aspiration pneumonia radiography myotomy 2 mo after surgery

Rosin and 5.5-mo-old male Dysphagia Fluoroscopy Cricopharyngeal Recurrence of

Hanlon2 terrier cross myotomy dysphagia 2 wk
after surgery;
euthanized at
owner’s request

5-mo-old male Dysphagia and Fluoroscopy Cricopharyngeal Clinically normal

cocker spaniel aspiration pneumonia myotomy 4 yr after surgery

4-mo-old female Dysphagia Fluoroscopy Conservative Occasional cough

miniature poodle therapy followed and nasal discharge;
by cricopharyngeal clinically normal
myotomy 2 yr after surgery

Pearson5 15-mo-old boxer Regurgitation Contrast Not reported Not reported

radiography

12-mo-old Regurgitation Contrast Not reported Not reported

foxhound radiography

Sokolovsky3 13-wk-old female Regurgitation Contrast Cricopharyngeal Clinically normal

mixed-breed radiography myotomy 3.5 mo after surgery

Treatment for CPA in humans is also similar to that in
dogs, although other nonsurgical approaches have been
described; spontaneous improvement has occurred in
some patients.8,12–15 Some infants with CPA may be fed
more efficiently by placing them in a semirecumbent po-
sition (i.e., by using a “chalasia chair”) to improve their
ability to swallow. More severely affected infants require
intermittent gavage feeding or a gastrostomy tube to
maintain adequate nutrition.12 Balloon dilation or bougi-
nage of the upper esophageal sphincter has been at-
tempted but has not proved to be effective in the long
term.8,16
The use of botulinum toxin for the diagnosis and
treatment of CPA has been reported.15 This technique
uses percutaneous electromyography to guide an injec-
tion of botulinum toxin into the cricopharyngeus mus-
cle. The botulinum toxin causes a graded muscle weak-
ness and temporarily relieves dysphagia. The technique
can be used as part of the diagnostic evaluation to de-
termine the extent to which the dysphagia is caused by
the cricopharyngeus muscle, to treat patients that are
unsuitable for surgery, or to provide temporary relief
while managing the primary disease.15
Cricopharyngeal myotomy remains the principal
treatment for humans with CPA. The procedure has
been performed through an external approach similar
to that described in dogs as well as an endoscopic ap-
proach that uses a rigid endoscope and carbon dioxide
laser to incise the cricopharyngeus muscle.8,12,14 The
overall prognosis for patients with CPA depends on the
primary cause, but significant long-term improvement
has been achieved with cricopharyngeal myotomy in
patients without other problems. 8,12
CONCLUSION
The signalment, history, and clinical signs for dogs
with CPA are uniformly similar. All reported cases have
occurred in young dogs, suggesting a congenital or pri-
mary abnormality. Careful evaluation of swallowing
function is necessary to differentiate among other oro-

GAVAGE FEEDING ■ BALLOON DILATION ■ BOTULINUM TOXIN

Compendium August 2000
pharyngeal disorders that cause similar signs. Cricopha-
ryngeal myotomy is an effective treatment with mini-
mal morbidity; however, other nonsurgical forms of
treatment may warrant further investigation.
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Small Animal/Exotics
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About the Authors
Ms. Ladlow and Dr. Hardie are affiliated with the Depart-
ment of Small Animal Medicine and Surgery, the Royal
Veterinary College, University of London, United King-
dom. Dr. Hardie is a Diplomate of the American College
of Veterinary Surgeons and the European College of Vet-
erinary Surgeons.