Manometric Measurements Research Articles

Intracranial pressure, its components and cerebrospinal fluid pressure-volume compensation.

Clinical measurement of intracranial pressure (ICP) is often performed to aid diagnosis of hydrocephalus. This review discusses analysis of ICP and its components' for the investigation of cerebrospinal fluid (CSF) dynamics. The role of pulse, slow and respiratory waveforms of ICP in diagnosis, prognostication and management of hydrocephalus is presented. Two methods related to ICP measurement are listed: an overnight monitoring of ICP and a constant-rate infusion study. Due to the dynamic nature of ICP, a 'snapshot' manometric measurement of ICP is of limited use as it might lead to unreliable results. Therefore, monitoring of ICP over longer time combined with analysis of its waveforms provides more detailed information on the state of pressure-volume compensation. The infusion study implements ICP signal processing and CSF circulation model analysis in order to assess the cerebrospinal dynamics variables, such as CSF outflow resistance, compliance of CSF space, pressure amplitude, reference pressure, and CSF formation. These parameters act as an aid tool in diagnosis and prognostication of hydrocephalus and can be helpful in the assessment of a shunt malfunction.

Acromegaly can be associated with impairment of LES relaxation in the oesophagus.

Although prolonged small intestine and colonic transit time has been demonstrated in acromegaly patients, the influence of acromegaly on oesophagus motility and the pathological mechanisms involved are still not clarified. We aimed to investigate manometric measurements to ascertain whether oesophagus motility is affected in active acromegaly patients. The study was performed in an institutional referral centre at a tertiary care hospital. Twenty-three acromegaly patients (mean age 43.2 ± 13.2 years) and 25 sex- and age-matched healthy control subjects (mean age 48.6 ± 7.9 years) were recruited to a case-control study. Oesophageal manometry was performed using MMS (Medical Measurement Systems, Netherlands) Solar GI - Air Charged Intelligent Gastrointestinal Conventional Manometry. In manometric measurements the lower oesophageal sphincter pressure was 18 ± 7 mmHg in acromegaly patients and 15.6 ± 4.4 mm Hg in controls, and there was no significant difference (p = 0.17). The percentage of relaxation was 64.8% and 81.8%, respectively, and it was significantly lower in acromegaly patients than in controls (p < 0.001). Additionally, the duration of relaxation was found to be 4 ± 1.9 seconds and 5 ± 1.7 seconds in patients and controls, respectively (p = 0.049). Our study has demonstrated a significant reduction in the percentage and duration of lower oesophageal sphincter relaxation in oesophagus motility even in acromegaly patients without any gastrointestinal symptoms. Further clinical and pathophysiological studies are required to clarify the underlying mechanisms of gastrointestinal motility disorders in acromegaly.

Interpreting manometric signals for propulsion in the gut

Propulsion of intestinal contents involves coordinated contractions and relaxations of the muscle controlled by polarised enteric neural reflex pathways. Due to the inaccessibility of the small and large bowel, obtaining detailed manometric measurements in the gut or visualizing the movement of digesta is difficult in vivo. Computational modelling that incorporates the complex interactions between gut content and wall contractility has the potential to explain the mechanisms behind propulsive motor patterns and aid the interpretation of manometric measurements. We present here a biomechanical computational model of coupled wall flexure and flow dynamics in a virtual segment of intestine. The model uses the smoothed particle hydrodynamics method which permits coupling of the fluid/solid motion and wall deformation in a natural way. Peristaltic waves of contraction and relaxation, similar to those observed in physiological experiments, were applied to the gut wall of the model. A catheter containing manometric sensors was also incorporated into the model to derive representative pressure readings. The sensitivity of the model to input parameters including wall stiffness, viscosity of content and degree of muscular contraction is also presented. The results show that there is a rapid rise in pressure of fluid content trapped between the catheter and the contracting wall. The peristaltic wave travels along the length of the virtual segment of intestine passing over each sensor. The bolus, formed by the peristaltic contraction, grows in size and longitudinal extent until the bolus size reaches steady state. The wall force and the peak fluid pressure both scale proportionally with the change in muscle length, indicating that manometric data provide a reliable means for measuring the strength of contractions. Changes in stiffness of the wall and viscosity of contents result in predictable changes in the parameters of peristalsis. The model can be thus applied to manometry measurements in real experimental conditions.

Synchrotron Diffraction Studies of Hydrogen Absorption/Desorption on CaH2 + MgB2 Reactive Hydride Composite Mixed With Fluorinated Compounds

The reactive hydride composites 9CaH2 + CaF2 + 10MgB2, 10Ca(BH4)2 + 9MgH2 + MgF2, and 9Ca(BH4)2 + Ca(BF4)2 + 10MgH2 were prepared by ball milling. Their properties toward hydrogen absorption/desorption were tested by means of manometric measurements. The highest hydrogen storage capacity was obtained for 9CaH2 + CaF2 + 10MgB2 (7.6 wt %) at the first cycle. The effects of CaF2, MgF2, or Ca(BF4)2 on the dehydrogenation reaction were studied by means of in situ synchrotron radiation powder X-ray diffraction (in situ SR-PXD) and differential scanning calorimetry (DSC). The high resolution SR-PXD technique was used to confirm the formation of hydrogenated products and side products in the 9CaH2 + CaF2 + 10MgB2 reactive hydride composites. These studies indicate the formation of a complex mixture of phases.

Application of Process Analytical Technology for Monitoring Freeze-Drying of an Amorphous Protein Formulation: Use of Complementary Tools for Real-Time Product Temperature Measurements and Endpoint Detection

Process analytical technology (PAT) and quality by design have gained importance in all areas of pharmaceutical development and manufacturing. One important method for monitoring of critical product attributes and process optimization in laboratory scale freeze-drying is manometric temperature measurement (MTM). A drawback of this innovative technology is that problems are encountered when processing high-concentrated amorphous materials, particularly protein formulations. In this study, a model solution of bovine serum albumin and sucrose was lyophilized at both conservative and aggressive primary drying conditions. Different temperature sensors were employed to monitor product temperatures. The residual moisture content at primary drying endpoints as indicated by temperature sensors and batch PAT methods was quantified from extracted sample vials. The data from temperature probes were then used to recalculate critical product parameters, and the results were compared with MTM data. The drying endpoints indicated by the temperature sensors were not suitable for endpoint indication, in contrast to the batch methods endpoints. The accuracy of MTM Pice data was found to be influenced by water reabsorption. Recalculation of Rp and Pice values based on data from temperature sensors and weighed vials was possible. Overall, extensive information about critical product parameters could be obtained using data from complementary PAT tools.

Uncertainty in pore size distribution derived from adsorption isotherms: II. Adsorption integral approach

Uncertainty in the amount adsorbed in manometric adsorption isotherm measurements is well established. Here, we extend uncertainty methodologies from adsorption isotherm data uncertainty and apply them to calculate pore size distributions based on adsorption integral methods. The analyses consider as variables: uncertainty in adsorption isotherm data, regularization parameter, molecular potential model, and the number of single pore isotherms calculated with an associated quadrature interval. We demonstrate how the calculated pore size distribution is quite insensitive to the uncertainty in experimental data, but in contrast, the uncertainty in the experimental data affects the calculated value of the optimized regularization parameter which, in turn, leads to considerable variation in the calculated pore size distribution. The calculated pore size distribution is also shown to be highly dependent on the potential model selected and on the number of single pore isotherms applied to the inversion process. We conclude and suggest a quantitative comparison between calculated pore size distributions should be discouraged unless the uncertainty in the experimental data is relatively small and, default values for regularization parameters, potential models, the number of single pore isotherms and their distribution are exactly the same for each pore size distribution evaluation.

Akalazya-Bir olgu sunumu nedeniyle

Achalasia is a rare esophageal motility disorder, with dysphagia to solids and liquids being the most common symptom. It can be confused with distal esophageal and gastric cardia malignancies. When this disorder is suspected, the first investigation should be barium esophagography, while the definite diagnosis is made by esophageal manometric measurements and upper gastrointestinal tract endoscopic series. Pneumatic dilation is the most effective and safest medical treatment approach. The present case is reported due to failure to diagnose the condition in spite of a ten year history.

Finite Element Method (FEM) Modeling of Freeze-drying: Monitoring Pharmaceutical Product Robustness During Lyophilization.

Lyophilization is an approach commonly undertaken to formulate drugs that are unstable to be commercialized as ready to use (RTU) solutions. One of the important aspects of commercializing a lyophilized product is to transfer the process parameters that are developed in lab scale lyophilizer to commercial scale without a loss in product quality. This process is often accomplished by costly engineering runs or through an iterative process at the commercial scale. Here, we are highlighting a combination of computational and experimental approach to predict commercial process parameters for the primary drying phase of lyophilization. Heat and mass transfer coefficients are determined experimentally either by manometric temperature measurement (MTM) or sublimation tests and used as inputs for the finite element model (FEM)-based software called PASSAGE, which computes various primary drying parameters such as primary drying time and product temperature. The heat and mass transfer coefficients will vary at different lyophilization scales; hence, we present an approach to use appropriate factors while scaling-up from lab scale to commercial scale. As a result, one can predict commercial scale primary drying time based on these parameters. Additionally, the model-based approach presented in this study provides a process to monitor pharmaceutical product robustness and accidental process deviations during Lyophilization to support commercial supply chain continuity. The approach presented here provides a robust lyophilization scale-up strategy; and because of the simple and minimalistic approach, it will also be less capital intensive path with minimal use of expensive drug substance/active material.

Manometric measurement of the outflow facility in the living human eye and its dependence on intraocular pressure.

The intraocular pressure (IOP) is determined by a dynamic equilibrium between the production and outflow of the aqueous humour. The relationship between IOP and the outflow rate through the conventional and unconventional pathway is quantified by the outflow facility coefficient (C). The purpose of this study is to employ a direct (manometric) tonographic technique and determine C as well as its inverse, resistance (R), as a function of IOP in the living human eye. Nineteen cataract patients were enrolled in the study. An intraoperative manometric device was used to measure IOP. After cannulation of the anterior chamber, the IOP was increased by infusion of controlled amounts of saline solution. At 40 mmHg, the infusion stopped, and a pressure sensor recorded the IOP. The measured pressure-volume relationship was considered in order to convert pressure changes to corresponding ocular volume changes. An appropriate mathematical model was applied to calculate C and (its inverse), R. The average C was 0.0672 ± 0.0296 μl/min/mmHg at 40 mmHg and 0.2652 ± 0.1164 μl/min/mmHg at 20 mmHg. There was a strong dependence of coefficient C on IOP in all subjects (p < 0.001). The corresponding values for R were 17.9 ± 11.17 min mmHg/μl at 40 mmHg and 4.51 ± 2.69 min mmHg/μl at 20 mmHg. This study provides measurement of outflow facility and its dependence with pressure in healthy living human eyes. This relation is shown to be non-linear, using a direct manometric method.

The Correlation Between Manometric and Videofluoroscopic Measurements of the Swallowing Function in Brainstem Stroke Patients With Dysphagia

The objective of the current study was to examine the correlation between high-resolution manometric and videofluoroscopic measurements of the swallowing function. In such cases in which manometric analysis is not feasible, it would be ideal if information regarding pressure during swallowing could be inferred from a videofluoroscopic swallowing study (VFSS) evaluation alone. The swallowing function was examined using simultaneous VFSS and high-resolution manometry (HRM) in 24 brainstem stroke survivors with dysphagia. The pharyngeal constriction ratio (PCR) and upper esophageal sphincter (UES) maximum opening diameter were measured using VFSS digital analysis. The pharyngeal maximum pressure and UES residual pressure were measured using HRM. The correlation coefficients between the PCR and pharyngeal maximum pressure and between the UES maximum opening diameter and UES residual pressure were calculated. The Spearman analyses were used to calculate the correlation coefficients between manometric and fluoroscopic parameters. The increase in the pharyngeal maximum pressure wave amplitude was significantly correlated with a decrease in the PCR (r=-0.849, P<0.001). The increase in the UES opening diameter was significantly correlated with a decrease in the UES residual pressure (r=-0.705, P<0.001). High space-time correlations between the pressure and kinematics of swallowing-related structures were obtained using simultaneous manometric and videofluoroscopic measurements. Certain VFSS measures are significantly correlated with measures of pressure assessed using HRM. The measures may be used as indicators of possible pressure deficits of swallowing.

Comparison of the thermochemical and mechanochemical transformations in the 2NaNH2–MgH2 system

We focus on the chemical transformations involved in the 2NaNH2 + MgH2 system subjected to thermal and mechanical inputs. Transformations occurring on the powder mixture during thermochemical and mechanochemical processes are described by ex-situ X-ray powder diffraction (XRPD), FT-IR spectroscopy, differential scanning calorimetry and manometric measurements. In the thermally activated samples, the reaction take place through the fast formation of Mg(NH2)2 and NaH via metathesis reaction between NaNH2 and MgH2 at 125 °C. FT-IR analysis confirms the presence of unreacted NaNH2 and a new Na-amide phase that could be ascribable to tetramide, Na2Mg(NH2)4. At higher temperature, the formation of new imide-amide phase is detected, stables up to 300 °C. On the other hand when the initial mixture is subjected to mechanochemical processing for longer milling time (50 h), only Mg(NH2)2 and NaH are produced. The hydrogen desorption reaction of the as-milled Mg(NH2)2–NaH mixture starts at 100 °C together with the formation of the NaMg(NH2)(NH) imide-amide phase, equally to the initial mixture.

Left lateral position and common gynecologic examining position in anal manometry measurements for evaluation of urogynecologic patients

The aim of this study is to compare the anometrical parameters obtained in the left lateral position, which is the conventional position of anal manometry, with the same measurements taken in the common gynecologic examining position (45° sitting position in a birthing chair with maximum hip flexion). Twenty-one patients with lower urinary tract symptoms (LUTS) were enrolled into this prospective cohort study. Basal mean resting pressure (BMRP), maximum squeeze pressure (MSP), rectal sensation, rectal compliance, and recto-anal inhibitory reflex (RAIR) were compared between the gynecologic examining position and left lateral position. There was no statistically difference between the anal manometric measurements of the left lateral and gynecologic examining positions (paired t-test, p>.05). It can be concluded that it seems to be unnecessary to change the examination chair and/or patient position in urogynecological patients who need an anorectal assessment.

Acinarization (parenchymal blush) observed during secretin-enhanced MRCP: clinical implications.

T2 hyperintensity of pancreatic acini during secretin-enhanced MRCP is called "acinarization." We sought to determine the clinical significance of this finding. Patients were selected if the radiology report included the phrases "acin*" (where * represented a wild card search) or "blush" using the institution's customized lexicon-search software. Sixty-seven consecutive patients without acinarization on secretin-enhanced MRCP who also underwent ERCP were enrolled as the control group. The intensity of acinarization was classified into three groups: grade 0, no visible acinarization; grade 1, barely visible parenchymal hyperintensity; or grade 2, easily visible parenchymal hyperintensity. ERCP findings of ductal abnormalities and basal pancreatic sphincter manometry were recorded. There were higher frequencies of divisum (p = 0.001) and of a clinical history of recurrent acute pancreatitis (p < 0.001) and higher basal pancreatic sphincter of Oddi manometric pressure measurements (p = 0.008) in the acinarization group. There was no difference in the frequency of ERCP-defined chronic pancreatitis (p = 0.10) between the groups. In patients with acinarization, a higher mean sphincter pressure was seen in patients with more intense acinarization than in those with faint acinarization, but this difference was not significant (p = 0.22). Ampullary tumors were found in four patients with acinarization. Acinarization probably occurs in patients with a propensity for increased pancreatic ductal pressure (i.e., patients with divisum, elevated basal pancreatic sphincter pressure, ampullary tumor) and adequate exocrine function (absence of severe chronic pancreatitis).

Efficacy of biofeedback-assisted pelvic floor muscle training in females with pelvic floor dysfunction

BackgroundStress urinary incontinence (SUI), fecal incontinence (FI) and/or pelvic floor dyssynergia, with pelvic organ prolapse (POP) are described as pelvic floor dysfunction (PFD). Pelvic floor muscle training (PFMT) is the first-line therapy in the treatment of PFD either alone or combined with biofeedback assisted pelvic floor muscle training (BF-assisted PFMT). Clinical practice regarding BF-assisted PFMT is controversial. AimsTo evaluate the efficacy of BF-assisted PFMT in females with mild to moderate PFD after a maximum duration of up to twelve weeks. Materials and subjects52 females with PFD were classified into 2 groups: Group 1(26 females with (SUI)) and Group 2 (26 females with (FI)) with or without stages I and II (POP). Females older than 20 years old and pelvic floor muscles grade 3–4 were included. Each group was divided in two equal groups (13 patients each): intervention group: performed BF-assisted PFMT and home exercise program (HEP) and control group: performed (HEP). All females were evaluated before and after the end of PFMT program by assessment questionnaires, PFM strength measurements using PFMs grading according to modified oxford score (MOS) and PFM contraction manometric measurements. ResultsParticipation rate was 90%. A Significant improvement was detected in 19 females (79.2%) in the intervention group compared to 7 females (31.8%) in the control group. Initial clinical and electrophysiological assessments were predictive for female improvement. ConclusionBiofeedback-assisted PFMT is an effective therapy compared to PFMT alone for well-motivated females with mild to moderate PFD.

Cryptococcal Meningitis Management in Tanzania With Strict Schedule of Serial Lumber Punctures Using Intravenous Tubing Sets

Cryptococcal meningitis (CM) has a mortality rate of ∼70% among HIV-infected adults in low-income countries. Controlling intracranial pressure (ICP) is essential in CM, but it is difficult in low-income countries because manometers and practical ICP management protocols are lacking. As part of a continuous quality improvement project, our Tanzanian hospital initiated a new protocol for ICP management for CM. All adult inpatients with CM are included in a prospective patient registry. At the time of analysis, this registry included data from 2 years before the initiation of this new ICP management protocol and for a 9-month period after. ICP was measured at baseline and at days 3, 7, and 14 by both manometer and intravenous (IV) tubing set. All patients were given IV fluconazole according to Tanzanian treatment guidelines and were followed until 30 days after admission. Among adult inpatients with CM, 32 of 35 patients (91%) had elevated ICP on admission. Cerebrospinal fluid pressure measurements using the improvised IV tubing set demonstrated excellent agreement (r = 0.96) with manometer measurements. Compared with historical controls, the new ICP management protocol was associated with a significant reduction in 30-day mortality (16/35 [46%] vs. 48/64 [75%] in historical controls; hazard ratio = 2.1 [95% CI: 1.1 to 3.8]; P = 0.018]. Increased ICP is almost universal among HIV-infected adults admitted with CM in Tanzania. Intensive ICP management with a strict schedule of serial lumbar punctures reduced in-hospital mortality compared with historical controls. ICP measurement with IV tubing sets may be a good alternative in resource-limited health facilities where manometers are not available.

Videofluoroscopic and manometric evaluation of pharyngeal and upper esophageal sphincter function during swallowing.

Background/AimsThe purpose of this study was to determine important manometric metrics for the analysis of pharyngeal and upper esophageal sphincter (UES) function and to investigate the effect of viscosity and other confounding factors on manometric results.MethodsManometric studies were performed on 26 asymptomatic volunteers (12 men and 14 women; age, 19–81 years). The manometric protocol included 5 water swallows (5 mL), 5 barium swallows (5 mL) and 5 yogurt swallows (5 mL). Evaluation of high-resolution manometry parameters including basal pressure of the UES, mesopharyngeal contractile integral (mesopharyngeal CI, mmHg · cm · sec), CI of the hypopharynx and UES (hypopharyngeal CI), relaxation interval of UES, median intrabolus pressure and nadir pressure at UES was performed using MATLAB.ResultsMesopharyngeal CIs for barium and yogurt swallows were significantly lower than those for water swallows (both P < 0.05). Hypopharyngeal CIs for water swallows were significantly lower than those for barium swallows (P = 0.004), and median bolus pressure at UES for barium swallows was significantly higher than that for water and yogurt swallows (both P < 0.05). Furthermore, hypopharyngeal CI and median intrabolus pressure at UES were significantly related to age for 3 swallows (all P < 0.01 and P < 0.05, respectively). A significant negative correlation was also noted between nadir pressure at UES and age for water and yogurt swallows (all P < 0.05).ConclusionsManometric measurement of the pharynx and UES varies with respect to viscosity. Moreover, age could be a confounding variable in the interpretation of pharyngeal manometry.

Intragastric manometric measurements of patients with hiatal hernia: A prospective controlled study

Objective: Hiatal hernia is a disorder in which abdominal contents, especially gastroesophageal junction and proximal stomach are displaced through an incompetent esophageal hiatus into mediastinum. Aim of this study is to investigate the relationship betweeen intragastric pressure and incompetent cardioesophageal sphincter and hiatal hernia. Methods: The sample is composed of 81 individuals; 51.9% of which are male (n: 42) and 48.1% of which are female (n: 39) with median age of 42.00. Two groups have been constituted: A control group of healthy volunteers (G1) and a patient group with hiatal hernia (G2). After gastroscopy, all patients and controls underwent gastric and esophageal manometry using a water perfused catheter Results: Mean intragastric pressure was 1,308 mmHg for G1 and, -0,105 mmHg for G2. Mean lower esophageal pressure were 13,143 mmHg and 11,65 mmHg, and upper esophageal pressure were 35,273 mmHg and 27,211 mmHg for G1 and G2, respectively. 24 hour pH metry test revealed 26.8% physiologic gastroesophageal reflux and 73.2% pathologic gastroesophageal reflux in G2. There were statistically significant difference between two groups for mean intragastric pressure (p <0.001) and mean lower esophageal pressure (p <0.05). Conclusion: This study shows that hiatal hernia results in significantly lower intragastric pressures.

Effects of viscosity and volume on the patterns of esophageal motility in healthy adults using high-resolution manometry

The purpose of this study was to determine the effects of age, sex, body mass index (BMI), viscosity, and volume on esophageal motility using high-resolution manometry (HRM). Manometric studies were performed on 60 asymptomatic volunteers (27 men and 33 women, age: 19-56 years) while in a supine position. Manometric protocol included 10 water swallows (5 cc), 10 jelly swallows (5 cc), and 1 water swallow (20 cc). Evaluation of HRM parameters including length of proximal pressure trough (PPT length), distal latency (DL), contractile front velocity (CFV), distal contractile integral (DCI), and 4-second integrated relaxation pressure (IRP) was performed using MATLAB. Significant differences were noted in median IRP between water 5 cc (median 7.2 mmHg [range 5.5-9.6]), jelly 5 cc (median 6.0 mmHg [range 3.8-8.0]), and water 20 cc {(Median 4.8 mmHg [range 3.3-7.4]), P < 0.01}. DL were significantly different between water 5 cc, jelly 5 cc, and water 20 cc (P < 0.01), and in terms of PPT, proportions of small (2 cm ≤ < 5 cm) and large (5 cm≤) break for jelly 5 cc were significantly higher than those for the water 5 cc swallow (P < 0.05). Furthermore, DCI increased with age for water 5 cc, and a significant negative correlation was noticed between proportions of small break and BMI for water 5 cc. Manometric measurements vary depending on age, BMI, viscosity, and volume. These findings need to be taken into account in the interpretation of manometry results.

The effect of lateral internal sphincterotomy on resting anal sphincter pressures*

Anal fissures are one of the most common proctologic disorders. This study aimed to investigate alterations in anal sphincteric resting pressures after lateral internal sphincterotomy, which was performed for chronic anal fissure treatment. Fifty-six (68.3%) male and 26 (31.7%) female patients were included in this study. Patients complicated with fistula-in-ano, abscess, cancer, inflammatory bowel disease, dermatitis, poor general condition, allergy to any of the standard medications, previous history of anal trauma, previous anal surgery, or diagnosis of a neurological disease and patients who did not give consent to the trial were excluded from the study. Two groups were formed: a control group with 41 healthy volunteers and a study group with 41 chronic anal fissure patients. Preoperative and postoperative manometric anal measurements were compared. Preoperative mean resting anal sphincter pressure was 51.29 mmHg for the control group and was 59.99 mmHg for the patient group. Although resting anal sphincteric pressures of the patient group remained within the physiological range, when compared with the control group there was a statistically significant difference. Postoperative mean resting anal sphincteric pressures of the patient group was 32.43 mmHg. Lateral internal sphincterotomy decreases resting anal sphincter pressures effectively in chronic anal fissure patients.

Implementation of High-resolution Manometry in the Clinical Practice of Speech Language Pathology

Visual imaging modalities, videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow, for assessment of oropharyngeal dysphagia have been part of the speech language pathologist's (SLPs) armamentarium for the diagnosis and treatment of dysphagia for decades. Recently, the addition of high-resolution manometry (HRM) has enabled the SLP to evaluate pharyngeal pressures and upper esophageal sphincter relaxation. Taken together, the use of visual imaging modalities with HRM can improve interpretation of swallowing physiology and facilitate more effective treatment planning. The goal of this article is to describe a clinical paradigm using HRM as an adjunct to VFSS, by the SLP, in the assessment of complex dysphagia. Moreover, in three cases described, the value of manometric measurements in elucidating swallowing imaging studies and documenting physiologic change in response to treatment is highlighted. As technology in this area is evolving, so will the clinical use of HRM by the SLP. Limitations of current HRM systems and applications are discussed.