Upper Esophageal Sphincter Dysfunction Research Articles

The Relationship between Upper Esophageal Sphincter Manometry Function and Esophageal Motility Disorders.

High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function. Cross-sectional study. Referral centre. HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3). 2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001). Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Manometric Abnormalities in Patients With and Without Chronic Cough

PurposeThis study examines the relationship between chronic cough and vagal hypersensitivity by measuring baseline esophageal motility, with interest in the upper esophageal sphincter (UES). Materials and methodsPatients undergoing workup for dysphagia were assigned to a chronic cough or control group based on self-reported symptoms. Differences in demographics, medical comorbidities, and high resolution esophageal manometry findings were obtained retrospectively. Results62.5% of our cohort had chronic cough (30/48). There were no significant differences between the two groups with respect to sex, age, and race/ethnicity. Laryngopharyngeal reflux (LPR) was the only statistically significant predictor of CC (OR 74.04, p = 0.010). Cough patients had upper esophageal sphincter relaxation duration (734 ms) significantly longer than the non-cough patients (582 ms; p = 0.03), though both groups had similar upper esophageal mean basal pressure, mean residual pressure, relaxation time-to-nadir, and recovery time. No significant difference was found in the median intrabolus pressure and UES motility mean peak pressure between groups. ConclusionSubtle differences in high-resolution manometry between patients with and without cough suggest, in line with previous studies, baseline alterations of upper esophageal function may manifest in patients with chronic cough through an undetermined mechanism that may include underlying vagal hypersensitivity. These findings encourage further manometric study examining the relationship between UES dysfunction and chronic cough.

Heterogeneous Presentations and Serologies in Myasthenia Gravis Patients Presenting with Dysphagia.

Myasthenia gravis (MG) is an autoimmune disease that affects the neuromuscular junction. MG patients may present de novo with primary otolaryngology complaints, including swallowing dysfunction. This study describes a range of unique presentations and rare diagnostic serologies, which have not previously been fully described. A retrospective review was performed of all patients presenting with primary symptom of dysphagia and subsequently diagnosed with MG. Data collected included demographics, clinical presentation, swallow studies, serology, imaging, treatment, and response. Five patients met the inclusion criteria. Four endorsed dysphagia as primary complaint and one endorsed dysphagia and dysphonia. All patients underwent in-office swallow evaluations that showed vallecular or pyriform sinus residue. Three patients completed modified barium swallow studies that showed pharyngeal weakness and epiglottic dysfunction in all, and upper esophageal sphincter dysfunction in two. One patient with additional symptom of dyspnea was admitted and found to be in myasthenic crisis. Upon serologic evaluation, three patients were positive for acetylcholine receptor (AChR) antibodies only, one for muscle-specific-kinase (MuSK) antibodies only, and one for low density lipoprotein receptor-related protein 4 (LRP4) antibodies only. All patients received neurology evaluation and were treated with steroids, pyridostigmine, plasma exchange, or rituximab. In three patients with over 1 year follow-up, symptoms were significantly improved or resolved. MG is an important differential diagnosis in patients with unexplained pharyngeal dysphagia. While workup can include AChR antibody screening, in seronegative patients with persistent symptoms, additional testing for MuSK and LRP4 may lead to diagnosis and effective treatment. 4 Laryngoscope, 134:4903-4910, 2024.

Ultrasonographic Evaluation of Upper Esophageal Sphincter for Dysphagia During the Acute Postoperative Phase of Anterior Cervical Surgery.

A retrospective study. To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES). There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES. We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter 2 weeks postoperatively /US parameter at baseline ) and the existence of significant correlations with change in the EAT-10 score (=EAT-10 2 weeks postoperatively -EAT-10 at baseline ). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups. A total of 46 patients (mean age, 61.3y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group. Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia.

Upper Esophageal Sphincter Dysfunction in Children with Type 1 Laryngeal Cleft after Failed Primary Cleft Repair.

Changes in pharyngeal and upper-esophageal-sphincter (UES) motor dynamics contribute to swallowing dysfunction. Children with type 1 laryngeal clefts can present with swallowing dysfunction and associated symptoms which may persist even after the initial endoscopic intervention. This study sought to characterize pharyngeal and esophageal motor function in children with type 1 laryngeal clefts who had persistent presenting symptoms after their initial therapeutic intervention. We retrospectively analyzed high-resolution esophageal manometry studies of children ≤ 18 years old with type 1 laryngeal clefts who had an esophageal manometry study performed for persistent symptoms after an initial repair. A total of 16 children were found to have significantly increased UES resting pressure, UES pre- and post-swallow maximum pressures, and duration of UES contraction during swallows in comparison to nine age-matched controls of children without pharyngeal anatomical abnormalities. There was no difference between UES residual pressures or pharyngeal dynamics between the two groups. UES resting and residual pressures did not correlate with VFFS in penetration and aspiration scores of children with type 1 laryngeal clefts status post repair. Our study is the first to identify specific changes in UES motor function in patients with type 1 laryngeal cleft post initial repair.

The Manometric Representation of the Upper Esophageal Sphincter During the Resting State: A Descriptive Study.

The upper esophageal sphincter (UES) is the high-pressure zone marking the transition between the hypopharynx and esophagus. There is limited research surrounding the resting UES using pharyngeal high-resolution manometry (HRM) and existing normative data varies widely. This study describes the manometric representation of the resting UES using a clinically accessible method of measurement. Data were obtained from 87 subjects in a normative database of pharyngeal HRM with simultaneous videofluoroscopy. The resting UES manometric region was identified and ten measurement segments of this region were taken throughout the duration of the study using the Smart Mouse function within the manometry software. Intraclass correlation coefficients (ICC) were used to analyze within-subject reliability across measurements. Linear mixed-effects regression models were used to analyze how subject characteristics and manometric conditions influence resting UES pressure. There was excellent within-subject reliability between resting UES mean pressures (ICC = 0.96). In bivariate analysis, there were significant effects of age, number of sensors contained within the resting UES, and preceding swallow volume on mean resting UES pressure. For every 1 unit increase in age, there was a 0.19 unit decrease in resting UES pressure (p = 0.008). For every 1 unit increase in number of sensors contained within the resting UES, there was a 3.71 unit increase in resting UES pressure (p < 0.001). This study presents normative data for the resting UES, using a comprehensive and clinically accessible protocol that can provide standard comparison for the study of populations with swallowing disorders, particularly UES dysfunction, and provides support for UES-directed interventions.

Botulinum Toxin Injection for the Treatment of Upper Esophageal Sphincter Dysfunction

Dysphagia associated with upper esophageal sphincter (UES) dysfunction remarkably affects the quality of life of patients. UES injection of botulinum toxin is an effective treatment for dysphagia. In comparison with skeletal muscles of the limb and trunk, the UES is a special therapeutic target of botulinum toxin injection, owing to its several anatomical, physiological, and pathophysiological features. This review focuses on (1) the anatomy and function of the UES and the pathophysiology of UES dysfunction in dysphagia and why the entire UES rather than the cricopharyngeal muscle before/during botulinum toxin injection should be examined and targeted; (2) the therapeutic mechanisms of botulinum toxin for UES dysfunction, including the choice of injection sites, dose, and volume; (3) the strengths and weaknesses of guiding techniques, including electromyography, ultrasound, computed tomography, and balloon catheter dilation for botulinum toxin injection of the UES.

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson's disease.

Background and study aims Oropharyngeal dysphagia (OPD) is prevalent in patients with Parkinson’s disease (PD). Upper esophageal sphincter (UES) dysfunction is an important pathophysiological factor for OPD in PD. The cricopharyngeus (CP) is the main component of UES. We assessed the preliminary efficacy of cricopharyngeal peroral endoscopic myotomy (C-POEM) as a treatment for dysphagia due to UES dysfunction in PD. Patients and methods Consecutive dysphagic PD patients with UES dysfunction underwent C-POEM. Swallow metrics derived using high-resolution pharyngeal impedance manometry (HRPIM) including raised UES integrated relaxation pressure (IRP), raised hypopharyngeal intrabolus pressure (IBP), reduced UES opening caliber and relaxation time defined UES dysfunction. Sydney Swallow Questionnaire (SSQ) and Swallowing Quality of Life Questionnaire (SWAL-QOL) at before and 1 month after C-POEM measured symptomatic improvement in swallow function. HRPIM was repeated at 1-month follow-up. Results C-POEM was performed without complications in all (n = 8) patients. At 1 month, there was an improvement in both the mean SSQ (from 621.5 to 341.8, mean difference –277.3, 95 %CI [–497.8, –56.7], P = 0.02) and SWAL-QOL (from 54.9 to 68.3, mean difference 9.1, 95 %CI [0.7, 17.5], P = 0.037) scores. Repeat HRPIM confirmed a decrease in both the mean UES IRP (13.7 mm Hg to 3.6 mm Hg, mean difference –10.1 mm Hg, 95 %CI [–16.3, –3.9], P = 0.007) and the mean hypopharyngeal IBP (23.5 mm Hg to 10.4 mm Hg, mean difference –11.3 mm Hg, 95 %CI [–17.2, –5.4], P = 0.003). Conclusions In dysphagic PD patients with UES dysfunction, C-POEM is feasible and enhances UES relaxation and reduces sphincteric resistance to flow during the swallow, thereby improving dysphagia symptoms.

The upper esophageal sphincter in the high-resolution manometry era.

The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM). This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era. We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation). This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

The Prevalence of Esophageal Disorders Among Voice Patients With Laryngopharyngeal Reflux—A Retrospective Study

The goal of this study was to determine the prevalence of esophageal disorders among voice patients with intractable laryngopharyngeal reflux (LPR) who have undergone 24 pH impedance and esophageal manometry. A retrospective chart review was performed of patients with LPR-associated dysphonia in the absence of subjective dysphagia who presented between January 1, 2007 and June 30, 2019 and underwent 24 pH impedance and esophageal manometry studies after inadequate response to lifestyle modifications, high dose of Proton Pump Inhibitor (PPIs), H2 blockers, alkaline water, and Gaviscon (GlaxoSmithKline, Warren, NJ, USA). The comorbidities, medications, Strobovideolaryngoscopy findings, 24 pH impedance, and esophageal manometry results were analyzed. The study included 109 patients ages 19 to 80 years old, with a mean age of 51.5 (SD 16.8). About 24.8% of the 109 subjects were found to have peristaltic wave abnormalities indicating esophageal dysmotility (11% with esophageal stasis). Lower esophageal sphincter pressures were normotensive in 56.9% of patients, hypertensive in 24.8%, and hypotensive in 18.4% of patients. In addition, the upper esophageal sphincter pressures were normotensive in 57.8% of patients, hypertensive in 36.7%, and hypotensive in 2.8% of patients. About 12.6% had both lower esophageal sphincter and upper esophageal sphincter dysfunction (hypertensive or hypotensive). The average total reflux events in patients exhibiting dysmotility on manometry 101.81, which was significantly higher compared with the mean total of 61.28 in the group of patients without dysmotility (P= 0.0396). In addition, there was a significantly higher prevalence of total events that were weakly acidic in the group with dysmotility compared with the group without (all patients performed the study on reflux medications, mean of total weakly acidic events 70.2 in dysmotility group vs 44.2 in normal motility group, P= 0.0427).Finally, the average number of total supine reflux events and the total acidic supine events were both significantly higher in the dysmotility group compared with the group without motility problems (P = 0.0199 and P = 0.0213, respectively). Esophageal dysmotility may be a significant cofactor in voice patients with refractory LPR on appropriate reflux medications and lifestyle modifications. Further research is advised.

Relationship Between Tongue Pressure and Pharyngeal Function Assessed Using High-Resolution Manometry in Older Dysphagia Patients with Sarcopenia: A Pilot Study.

Tongue pressure is often used to evaluate swallowing muscle strength in dysphagia patients with sarcopenia. However, the amount of tongue pressure that reflects pharyngeal swallowing function is unclear. The aims of this descriptive study were (1) to assess the association between tongue pressure and swallowing function using high-resolution manometry (HRM), (2) to evaluate whether manometric parameters were related to maximum tongue pressure (MTP) and other sarcopenia-related factors, and (3) to evaluate the manometric characteristics of pharyngeal swallowing in sarcopenic dysphagia. Sixteen patients with dysphagia (13 men; mean age 85.0 ± 6.6) who were diagnosed with sarcopenia and sixteen healthy subjects (10 men; mean age 33.6 ± 7.2) were included. Evaluation of HRM parameters including velopharyngeal contractile integral (VPCI), mesohypopharyngeal contractile integral (MHPCI), upper esophageal sphincter (UES) relaxation duration, and UES nadir pressure was performed. HRM parameters of patients were compared with MTP, sarcopenia factors, and manometric parameters of healthy subjects. The VPCI showed no statistically significant differences between patient and healthy groups. In the patient group, the MHPCI was significantly lower (126.1 ± 76.6 vs 193.2 ± 34.1mmHgcms; p = 0.003), UES nadir pressure was significantly higher (10.5 ± 27.5 vs -11.2 ± 6.7mmHg; p < 0.001), and UES relaxation duration (318.0 ± 152.4 vs 520.6 ± 60.0ms; p = 0.007) was significantly shorter than those in the healthy group. HRM parameters were not significantly correlated with MTP and sarcopenia factors. Older dysphagia patients with sarcopenia had weaker pharyngeal contractility and UES dysfunction. Manometric evaluation of pharyngeal function may not be significantly associated with MTP and sarcopenia-related factors. Further study is needed to clinically apply tongue pressure for evaluating sarcopenic dysphagia.

1780 Combined Esophageal Achalasia and Cricopharyngeal Achalasia in a Patient With Type 1 Myotonic Dystrophy

INTRODUCTION: Type 1 myotonic dystrophy (MD) is a rare inherited disease that presents with skeletal muscle weakness and myotonia. Involvement of smooth muscles is also common and mainly manifests in the gastrointestinal tract. We report a case of type 1 MD who presented with dysphagia and was found to have unique esophageal manometry findings. CASE DESCRIPTION/METHODS: A 57-year-old Caucasian male patient presented with progressive dysphagia to solids and liquids for the last few months. The patient had a history of type 1 myotonic muscular dystrophy diagnosed at the age of 34. Past medical history was also significant for gastroesophageal reflux disease, diaphragmatic paralysis, and obstructive sleep apnea. Last upper endoscopy showed a small hiatal hernia and a normal esophagus, stomach, and duodenum. His only home medication was omeprazole. Past surgical history was insignificant. Both his father and brother died in their 50s because of unclear respiratory problems. He was a former smoker and did not drink alcohol. Review of systems was unremarkable. On physical exam, the patient was alert, oriented, and in no acute distress. Vital signs were within normal limits. Cardiovascular, lung, abdominal, and skin exams were unremarkable. Neurological exam was significant for bilateral facial muscle weakness and mild ptosis. His other cranial nerves were intact. He had atrophy and weakness of the distal upper and lower extremities. Deep tendon reflexes were absent. Sensory, cerebellar, and gait exams were unremarkable. Upper endoscopy showed mild hyperemia of the stomach, but a normal esophagus and no hiatal hernia. Esophageal biopsies were normal and showed no evidence of eosinophilic esophagitis. After two weeks of being off omeprazole, the patient underwent a 24-hour esophageal pH testing which showed no significant acid reflux. Esophageal manometry revealed elevated lower esophageal sphincter (LES) pressure, elevated upper esophageal sphincter (UES) pressure, and very week peristalsis of the esophageal body. DISCUSSION: Esophageal involvement is common in type 1 MD manifesting with dysfunction of UES, esophageal body, and LES. Manometry usually describes a reduced resting tone of the UES and LES. Our patient had elevated LES pressure and week peristalsis of the esophageal body consistent with esophageal achalasia. He also had an elevated UES pressure consistent with cricopharyngeal achalasia. This is the opposite of what is expected in type 1 MD.

378 Resting Upper Esophageal Sphincter Pressure Is Elevated in Proton Pump Inhibitor-Refractory Chronic Cough Patients and May Be a Marker for Laryngeal Hypersensitivity

INTRODUCTION: Chronic cough is difficult to treat when unresponsive to proton-pump inhibitor (PPI) and sinus therapy. In this setting it is presumed to be neurogenic in etiology. Despite the role of the upper esophageal sphincter (UES) as a barrier to laryngopharyngeal reflux disease, it has not been well characterized in chronic cough patients. We aim to assess UES tonicity in patients with PPI-refractory chronic cough and otherwise intact esophageal motor function. METHODS: Patients with a Chicago Classification diagnosis of normal esophageal motility on high-resolution esophageal manometry (HRM) on studies performed for the indication of chronic cough were retrospectively studied. All studies were performed at a GI motility lab at a tertiary care center from January 2013 to August 2018. Patients with prior cervical spinal surgery, foregut surgery, gastroparesis, severe pulmonary disease or manometric hiatal hernia were excluded. All HRM were performed with a solid-state assembly with a 4.2 mm outer diameter catheter. Upper esophageal resting pressure and residual pressure (mmHg) were recorded from HRM studies and compared to a control group of patients with normal esophageal motility on studies performed for an indication of non-cardiac chest pain. Available pH-metry tests in chronic cough patients were also reviewed for acid exposure time. RESULTS: Fourteen patients with chronic cough (mean age 63 ± 25, 71% female) and twenty patients with non-cardiac chest pain (mean age 55 ± 14, 60% female) were included. Median resting UES pressure (mmHg) was higher in the chronic cough group (80) vs the chest pain group (50.8) with a p value of 0.004 (Figure 1). There was no difference in residual UES pressure (3.5 in chronic cough vs 3.15 in chest pain). A total of 12 pH studies were performed in chronic cough patients; 9 of these were on PPI. Median distal acid exposure time % was 1.35 [IQR 0.5-6]. CONCLUSION: UES hypertonicity found in PPI-refractory chronic cough patients may be a marker of laryngeal hypersensitivity. A second possibility is that primary UES dysfunction is the cause of cough in this subgroup.

3105 Zenker's Diverticulum: Unusual Cause of Acute Oesophageal Impaction

INTRODUCTION: Dysphagia amongst the elderly results from increasing dysfunction of the upper esophageal sphincter (UES), which is vulnerable to effects of aging. Prevalence of dysphagia in geriatric population, especially above 80 is higher than overall prevalence in the general population. Zenker's diverticulum (ZD) is the hallmark pathology for UES dysfunction. These false diverticula are herniation of mucosa and submucosa through the Killian's Triangle. Albeit progressive dysphagia is the most common presentation, symptoms can range from globus sensation to obstruction. ZD may rarely present as complete esophageal obstruction. CASE DESCRIPTION/METHODS: An 89 years old female with hypertension, osteoarthritis and polycythemia vera presented with complaint of “having a pill stuck in my throat.” Unable to tolerate her breakfast and spitting up sputum. Similar symptoms in the past for which she changed her diet to soft bread. Initially, it worked however dysphagia gradually worsened to the extent of having to butter her pills to ease swallowing. Denies GERD. Vital signs within normal limits, physical exam revealed enlarged multinodular goiter with retropharyngeal extension however negative Pemberton's sign. Boyce sign was positive on sipping some water. Euthyroid and no other abnormalities. Urgent upper endoscopy was recommended however patient refused but agreed the next day. Endoscopy was remarkable for pill lodged in upper esophagus, upper esophageal ring and impacted food in ZD compressing esophagus. The ring was split using the endoscope and pill pushed down which was then propelled by peristalsis to the stomach. Content of ZD was retrieved with Roth net. Remaining endoscopy exam was unremarkable. ENT evaluation was recommended for ZD and goiter however patient declined intervention. DISCUSSION: ZD often presents as solid food and pill dysphagia, rarely as acute esophageal obstruction as seen in this case. A number of factors in addition to external esophageal compression by the enlarging ZD likely contributed to her presentation, including pressure from enlarged thyroid. ZD compounds the pharyngeal weakness that leads to its development, trapping the patient in a vicious cycle of worsening dysphagia that eventually results in obstruction. Furthermore, an association between esophageal webs and ZD has been demonstrated. Combination of these factors resulted in the complete obstruction in our patient. Dysphagia in old age, always have ZD in mind.

Swallowing exercise for upper esophageal sphincter dysfunction in stroke patient with dysphagia: A systematic review

Dysphagia is common in patients with stroke. Patients may experience deficits in oral, pharyngeal and upper esophageal sphincter (UES) function, including insufficiency in chewing and mastication, weak pharyngeal constriction, UES and pharyngeal incoordination, and abnormal UES relaxation. The UES is usually closed except during swallowing phase. The suprahyoid muscles make the larynx move upward and forward to open the UES. Many studies have reported the swallowing exercise for the UES dysfunction, this systematic review aims to appraise the evidence of the swallowing exercise to facilitate the suprahyoid muscle and open the UES for stroke patients with dysphagia. A systematic search of Pubmed, Embase, Medline, Web of Science, The Cochrane Library, and ProQuest databases was conducted from January 2007 to December 2017. The following four areas of research were reviewed: –(1) studies including specific swallowing exercise for improving suprahyoid muscles activity; –(2) studies examining the efficacy of each swallowing exercise with a device in healthy adults; –(3) studies examining the efficacy of specific swallowing exercise with a device as a dysphagia treatment in stoke patients with dysphagia; –(4) studies comparing the difference between those swallowing exercise in healthy adults and stroke patients. A narrative analysis of the results was conducted. Five types of swallowing exercise including Shaker Exercise, Chin tuck against resistance, Jaw open Exercise, Modified Jaw open Exercise and Head extension Exercise may facilitate the suprahyoid muscle and the opening of the UES. With the strengthened suprahyoid muscles, the amount of upward and forward movement was increased to facilitate the opening of UES and decrease the time of pharynx passage. Though many studies have reported the swallowing exercise is efficacious for suprahyoid muscles, the Modified Jaw Opening Exercise holds more potential in training the suprahyoid muscle among the five swallowing exercise for stroke patients with dysphagia.

Open vs. endoscopic cricopharyngeal myotomy; Is there a difference?

IntroductionThe upper esophageal sphincter (UES) is composed largely of the cricopharyngeus muscle (CP) and acts as the gatekeeper to the esophagus. There are multiple methods of treating UES dysfunction, but myotomy has been shown to be the most definitive means. We aim to evaluate the difference between open and endoscopic CP myotomy (CPM). MethodsA retrospective review of all patients undergoing endoscopic and open CPM was undertaken. We recorded demographic, clinical, operative, hospital, and postoperative data for both groups from January 2010–March 2015. The endoscopic and open CPM groups were directly compared. ResultsOur cohort consisted of 38 open and 41 endoscopic CPM patients. There were 22 males and 16 females in the open group and 9 males and 32 females in the endoscopic group. The primary diagnosis for both groups was cricopharyngeal hyperfunction. We found a significant improvement in surgical time and symptomatic outcomes in the endoscopic group (p=0.008 and p=0.010).There was no difference in UES preop pressure, hospital stay, complication rate, time to oral intake, or length of follow-up between cohorts. ConclusionEndoscopic CPM is a safe and effective alternative to the open approach. Patients undergoing endoscopic CPM have shorter operative times and improved outcomes when compared to the open approach.

Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction.

AIMTo evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement.METHODSAll balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES).RESULTSFour hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission.CONCLUSIONUES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

Disorders Involving the Pharynx and Upper Esophagus

A wide variety of disorders can affect the pharynx and upper esophagus, such as inherited or acquired structural abnormalities, malignancies, and inflammation secondary to a number of etiologies including bacterial, yeast and viral infections, irradiation, and gastroesophageal reflux disorder. Laryngoceles and peritonsillar abscess can also lead to pain and dysfunction. However, this review will focus on the main motility disorders that affect the pharynx and upper esophagus, namely oropharyngeal dysphagia, disorders associated with globus pharyngeus, and Zenker’s diverticulum. Figures show the anatomy of the three stages of normal swallow, various findings on functional endoscopic evaluation of swallowing, electromyography of the cricopharyngeal sphincter and submental muscles, and Zenker’s diverticulum. Tables list causes of oropharyngeal dysphagia, neuromuscular control of the pharyngeal phase (with identified cranial and cervical spinal nerve roots), pathophysiology of oropharyngeal dysplasia, diagnostic tests for oropharyngeal dysplasia, behavioral treatments to improve swallow and reduce aspiration, and potential overlapping causes of impaired upper esophageal sphincter relaxation. This review contains 4 highly rendered figures, 6 tables, and 40 references Key words: Oropharyngeal dysphagia; Globus; Upper esophageal sphincter dysfunction; Swallowing disorder; Dysphagia; Zenker’s diverticulum; Swallow assessment; Globus pharyngeus

Maximum upper esophageal sphincter (UES) admittance: a non-specific marker of UES dysfunction.

Assessment of upper esophageal sphincter (UES) motility is challenging, as functionally, UES relaxation and opening are distinct. We studied novel parameters, UES admittance (inverse of nadir impedance), and 0.2-s integrated relaxation pressure (IRP), in patients with cricopharyngeal bar (CPB) and motor neuron disease (MND), as predictors of UES dysfunction. Sixty-six healthy subjects (n = 50 controls 20-80 years; n = 16 elderly >80 years), 11 patients with CPB (51-83 years) and 16 with MND (58-91 years) were studied using pharyngeal high-resolution impedance manometry. Subjects received 5 × 5 mL liquid (L) and viscous (V) boluses. Admittance and IRP were compared by age and between groups. A p < 0.05 was considered significant. In healthy subjects, admittance was reduced (L: p = 0.005 and V: p = 0.04) and the IRP higher with liquids (p = 0.02) in older age. Admittance was reduced in MND compared to both healthy groups (Young: p < 0.0001 for both, Elderly L: p < 0.0001 and V: p = 0.009) and CPB with liquid (p = 0.001). Only liquid showed a higher IRP in MND patients compared to controls (p = 0.03), but was similar to healthy elderly and CPB patients. Only admittance differentiated younger controls from CPB (L: p = 0.0002 and V: p < 0.0001), with no differences in either parameter between CPB and elderly subjects. The effects of aging and pathology were better discriminated by UES maximum admittance, demonstrating greater statistical confidence across bolus consistencies as compared to 0.2-s IRP. Maximum admittance may be a clinically useful determinate of UES dysfunction.

Upper esophageal sphincter abnormalities: frequent finding on high-resolution esophageal manometry and associated with poorer treatment response in achalasia.

Abnormalities of the upper esophageal sphincter (UES) on high-resolution esophageal manometry (HREM) have been observed in both symptomatic and asymptomatic individuals and are often interpreted as incidental findings of unclear clinical significance. Our primary aims were: (1) to assess the frequency of UES abnormalities in consecutive patients referred for HREM studies; and (2) to characterize the demographics, clinical symptoms, and manometric profiles associated with UES abnormalities as compared with those with normal UES function. We performed a retrospective study of 200 consecutive patients referred for HREM. Patients were divided into those with normal and abnormal UES function, including impaired relaxation (residual pressure >12 mm Hg), hypertensive (>104 mm Hg), and hypotensive (<34 mm Hg) resting pressure. Clinical and manometric profiles were compared. A total of 32.5% of patients had UES abnormalities, the majority of which were hypertensive (55.4%). Patients with achalasia were significantly more likely to have UES abnormalities as compared with normal UES function (57.2% vs. 42.9%, P=0.04), with the most frequent abnormality being a hypertensive UES (50%). In addition, patients with impaired lower esophageal sphincter (LES) relaxation (esophagogastric junction outflow obstruction or achalasia) were more likely to have an UES abnormality present as compared with those with normal LES relaxation (53.1% vs. 28.6%, P=0.01). When we assessed for treatment response among patients with achalasia, we found that subjects with evidence of UES dysfunction had significantly worse treatment outcomes as compared with those without UES abnormalities present (20% improved vs. 100%, P=0.015). This remained true even after adjusting for type of treatment received (surgical myotomy, per-oral endoscopic mytotomy, botulinum toxin injection, pneumatic dilatation, medical therapy, P=0.67) and achalasia subtype (P=1.00). UES abnormalities are a frequent finding on HREM studies, especially in patients with impaired LES relaxation, including both achalasia and esophagogastric junction outflow obstruction. Interestingly, the most common UES abnormality associated with achalasia was a hypertensive resting UES, despite the fact that achalasia is thought to spare striated muscle. Among patients with achalasia, we found a significant association between the lack of treatment response and the presence of UES dysfunction. The routine evaluation of UES function in patients referred for manometry may enhance our understanding of esophageal motility disorders and may yield important prognostic information, particularly in subjects with achalasia. Future prospective studies are needed to further delineate the underlying mechanism between UES dysfunction with achalasia and other esophageal motility disorders to predict treatment response and guide therapeutic treatment modalities.