Stepwise Surgical Management of Severe Dysphagia in Multiple System Atrophy: A Case Report

Introduction: Multiple system atrophy (MSA) is a rapidly progressive neurodegenerative disorder in which dysphagia emerges early and worsens over time. Although swallowing improvement procedures such as laryngeal suspension or cricopharyngeal myotomy can temporarily restore oral intake, surgical strategies for severe dysphagia in patients with prior swallowing surgery and reduced physiological reserve remain poorly described. Case Report: A 70-year-old man with MSA had previously undergone laryngeal suspension and tracheostomy, allowing continued oral intake. Over the following months, he experienced progressive deterioration, including dysphonia, copious secretions requiring frequent suctioning, and recurrent aspiration pneumonia and transient ventilatory dependence. Clinical assessment revealed diminished laryngeal sensation, severe saliva pooling, silent aspiration on laryngoscopy and videofluoroscopy, and impaired upper esophageal sphincter (UES) relaxation on high-resolution manometry. Given his frailty, extended spectrum beta-lactamase colonization, and a desire to resume limited oral intake, a minimally invasive yet effective approach was required. Subglottic laryngeal closure with bilateral cricopharyngeal myotomy was performed through a small operative field, achieving complete aspiration prevention and improved UES opening. Conclusion This case highlights the importance of individualized, stage-specific surgical planning for advanced MSA-related dysphagia. Careful integration of physiological findings, systemic tolerance, and patient-centered goals can optimize outcomes, even in patients with prior swallowing surgery.