Stepwise surgical management of severe dysphagia in multiple system atrophy.

Multiple system atrophy (MSA) is a rapidly progressive neurodegenerative disorder in which dysphagia progressively worsens over time. We report a 70-year-old man with MSA who had previously undergone laryngeal suspension and tracheostomy, allowing continued oral intake while preserving phonation. However, disease progression led to recurrent aspiration pneumonia, severe secretion retention, and transient ventilatory dependence. Reassessment revealed severe saliva pooling, silent aspiration, impaired laryngeal sensation, and upper esophageal sphincter (UES) dysfunction on high-resolution manometry. Given the patient's frailty, colonization with extended-spectrum beta-lactamase-producing organisms, and strong desire to resume oral intake, subglottic laryngeal closure combined with bilateral cricopharyngeal myotomy was performed through a minimally invasive surgical field. Postoperatively, aspiration was successfully prevented, UES opening improved, and partial oral intake was resumed without recurrent aspiration pneumonia. This case highlights the importance of individualized and stage-specific surgical decision-making for severe dysphagia in progressive neurodegenerative disease.