Function Of Upper Esophageal Sphincter Research Articles

Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia.

To investigate the relationship between upper esophageal sphincter abnormalities achalasia treatment We performed a retrospective study of 41 consecutive patients referred for high resolution esophageal manometry with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of Upper esophageal sphincter (UES) abnormality, and clinical and manometric profiles were compared. Correlation between UES abnormality and sub-type (i.e., hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness, psychiatric illness, surgical history, dominant presenting symptom, treatment type, age and gender were also evaluated. Among all 41 patients, 24 (58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profiles. Among those with UES abnormalities, the majority were either hypertensive (41.67%) or had impaired relaxation (37.5%) as compared to hypotensive (20.83%), although this did not reach statistical significance (P = 0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority (78.57%) had good treatment response, as compared to 21.43% with poor treatment response (P = 0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality (P = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality (P = 0.017). The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function.

Upper Esophageal Sphincter Abnormalities Are Strongly Predictive of Treatment Response in Patients with Achalasia

Purpose: The introduction of high resolution esophageal manometry (HRM) has allowed the ability to assess the upper esophageal sphincter (UES). However, UES abnormalities are often interpreted as incidental findings with no defined significance. We hypothesized that UES abnormalities have clinical significance and may predict treatment response in patients with achalasia. Methods: We performed a retrospective study of 41 consecutive patients referred for HRM with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of UES abnormality, and clinical and manometric profiles were compared. Correlation between UES abnormality and sub-type (i.e. hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness, psychiatric illness, surgical history, dominant presenting symptom, treatment type, age, and gender were also evaluated. Results: Among all 41 patients, 24 (58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profi les. Among those with UES abnormalities, the majority were either hypertensive (41.67%) or had impaired relaxation (37.5%), as compared to hypotensive (20.83%), although this did not reach statistical significance (p=0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority (78.57%) had good treatment response, as compared to 21.43% with poor treatment response (p=0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality (p = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality (p=0.017). Conclusion: The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function, irrespective of the type of treatment received or achalasia sub-type. Future prospective studies are needed to determine whether specific UES abnormalities have additional prognostic value and to further delineate the underlying mechanism between UES dysfunction with achalasia in order to optimize therapeutic treatment modalities.

Balloon dilation of the esophago‐gastric junction affects lower and upper esophageal sphincter function in achalasia

Pneumatic dilation of the lower esophageal sphincter (LES) in achalasia has an unappreciated effect on upper esophageal sphincter (UES) function. We studied UES pressure patterns at baseline and alterations in UES parameters resulting from therapy. High-resolution manometry (HRM) tracings from 50 achalasia patients, seen at a tertiary center between January 2009 and July 2011, were reviewed. Manometric parameters studied were (i) LES: resting pressure (restP), 4-second integrated relaxation pressure (IRP4); (ii) UES: resting pressure (restP), minimal relaxation pressure (MRP), peak pressure (PP), relaxation interval (RI), intrabolus pressure (IBP), and deglutitive sphincter resistance (DSR). Mixed models analyses with LES and UES parameters as dependent variables and treatment stage as within-subject independent variable of interest were used. Correlations between treatment-induced changes in LES, UES, and esophageal body (EB) parameters were performed. Pre- and posttreatment HRM tracings were available from 50 patients (mean age 52.7± 18.6years, 29 men). Upper esophageal sphincter parameters MRP (17.9±1.2 vs 15.2±0.9mmHg; p=0.02) and IBP (31.5±1.5 vs 27.4±1.2mmHg; p=0.009) were significantly reduced after initial balloon dilation and this effect was significant in type II achalasia (p=0.002 and p=0.0006). Peak pressure, RI, and DSR were not. The therapeutic effect on LES IRP4 correlated significantly with the change in UES MRP, statistically mediated by the change in EB deglutitive pressure (p=0.004 and p=0.0002). We present the first HRM study demonstrating that pneumatic dilation of the LES affects intraesophageal and UES pressures in patients with achalasia.

SIG 13 Perspectives Vol. 21, No. 2, June 2012

SIG 13 Perspectives Vol. 21, No. 2, June 2012

Evaluation of Upper Esophageal Sphincter Function

Under normal circumstances, the upper esophageal sphincter (UES) serves as an important gatekeeper, regulating antegrade and retrograde bolus movement through the upper aerodigestive tract. Dysfunction of the UES can result in multiple distressing symptoms and serious complications; accurate diagnosis is critical to appropriate management. The complex anatomy and physiology of the UES precludes any single available testing modality from completely assessing all aspects of UES dysfunction. This article provides an overview of the basic anatomy and physiology of the UES and reviews the advantages and shortcomings of the current techniques for evaluating its function.

Development of pharyngo‐esophageal physiology during swallowing in the preterm infant

Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants. Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31-32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows. During swallowing, we observed an age-related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age-related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants. Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.

Pharmacotherapeutic Approaches for Swallowing Disorders

Recently, swallowing disorders have increasingly become a critical clinical issue. The aims of treatment for dysphagic patients are focused on the recovery of oral alimentation and prevention of aspiration pneumonia. Rehabilitation and surgical interventions have been the basic treatment strategies. In addition, pharmacologic treatment options have been developed over the last two decades. Substance P plays an important role as a neurotransmitter for inducing the swallowing or cough reflex. Angiotensin converting enzyme inhibitors, dopamine agonists, and capsaicin facilitate local accumulation of substance P, therefore, they upregulate the impaired swallowing reflex. Many recent reports have described that these pharmacotherapeutic approaches could reduce the risk of pneumonia. Our clinical study showed that capsaicin administration for a month improved decreased pharyngeal contraction and upper esophageal sphincter function. Also, anti-platelet therapy with cilostazol, traditional Chinese medicine (Hange-Koboku To), and olfactory stimulation with black pepper oil and menthol were reported to prevent pneumonia, especially in the elderly. However, many of these reports lack sufficient evidence, and additional studies are warranted. Botulinum toxin injection into the cricopharyngeal muscle has a direct effect on various types of dysphagia by blocking sustained contraction of the upper esophageal sphincter. It can be an alternative treatment instead of cricopharyngeal myotomy. Influenza or pneumococcal vaccination were reported to be beneficial and recommended for elderly disabled patients at high-risk for pneumonia, but its efficacy is still the subject of discussion. In conclusion, although pharmacologic treatment for dysphagia is a novel research topic, it has a great possibility as an efficient therapeutic option for numerous patients with swallowing disorders. Further studies are necessary.

Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report

Globus sensation is a bothersome and difficult symptom to treat. The aims of this study were to evaluate the acceptability and utility of hypnotically-assisted relaxation (HAR) in decreasing the perception of globus sensation and the effect of HAR on interdeglutitive upper esophageal sphincter (UES) pressure. Sixteen subjects with persistent globus sensation unresponsive to therapy for reflux disease and with normal esophageal/laryngeal imaging studies were invited to participate in a 7-session clinical protocol. Before and after HAR, subjects completed standard questionnaires including the esophageal symptoms questionnaire. High-resolution manometric assessment of respiratory augmentation and average resting UES pressure were assessed before and after HAR. Ten of the 16 subjects agreed to participate in the protocol. All participants were women with median age 51.5 (range 30-72 years). The participants found HAR acceptable and completed the entire 7-session trial. Globus symptom severity varied widely pre-treatment (median=52.5, range 16-72), and 9 of 10 subjects reported a reduction in globus symptomatology following treatment (median=14.0, range 3-19; P=.007). Only 1 subject exhibited abnormal respiratory augmentation of UES pressure (>27 mm Hg) prior to treatment and was normal following treatment (9.9 mm Hg). Resting UES pressure was normal in all subjects (<118 mm Hg). Group respiratory augmentation and average resting UES pressure were unaffected by HAR (P=.48, .89). This case series suggests that HAR can provide a substantial improvement in globus sensation irrespective of cause. UES function was unaffected. We suggest that HAR therapy is an acceptable and useful intervention for patients with globus sensation.

Swallowing Disturbance Pattern Relates to Brain Lesion Location in Acute Stroke Patients

The relationship of brain lesion location and swallowing disturbance pattern has been poorly studied in acute stroke patients. Sixty patients with first-ever acute ischemic stroke at clearly assessed location and clinical signs of dysphagia were studied. Swallowing-related parameters rated clinically and fiberendoscopically were attention deficit, buccofacial apraxia, orofacial paresis, gag reflex, delay of pharyngeal swallow, pharyngeal contraction, larynx elevation, function of upper esophageal sphincter (UES), and aspiration severity. Attention deficit was independently predicted only by parietotemporal infarction, buccofacial apraxia by left-sided parietotemporal infarction, orofacial paresis by infarction encompassing upper motor neuron of cranial nerves, and impaired UES opening by lateral medullary infarction. Other swallowing parameters were not related to lesion topology. On posthoc analysis, pneumonia within 21 days after stroke was predicted only by insular lesion. Distinct acute brain lesion locations result in characteristic swallowing disturbance patterns. Dysphagic patients with insular stroke appear to have even higher risk of pneumonia suggesting a further associated factor promoting infection in these subjects.

AGA technical review on the clinical use of esophageal manometry

AGA technical review on the clinical use of esophageal manometry

Upper esophageal sphincter function during gastroesophageal reflux events revisited.

Upper esophageal sphincter (UES) function during gastroesophageal reflux events is not completely elucidated because previous studies addressing this issue yielded conflicting results. We reexamined the UES pressure response to intraluminal esophageal pressure and pH changes induced by reflux events. We studied 14 healthy, asymptomatic volunteers (age 49 +/- 6 yr) and 7 gastroesophageal reflux disease patients (age 48 +/- 5 yr). UES pressure, intraesophageal pressure, and pH were monitored at the distal, middle, and proximal esophagus concurrently in the supine position 1 h before and 2 h after a 1,000-calorie meal. A total of 321 reflux events were identified by the development of abrupt reflux-induced intraesophageal pressure increase (IPI); 285 events occurred in patients and 36 in control subjects. In control subjects 33 of 36 and in patients 252 of 285 IPI events were associated with a pH drop. Among patients and control subjects, 99% and 100%, respectively, of all IPI events irrespective of pH drop were associated with abrupt increase in UES pressure (34 +/- 2 and 27 +/- 6 mmHg, respectively). The average percentage of maximum UES pressure increase over prereflux values ranged between 66% and 96% (control subjects) and 34% and 122% (patients). IPIs induced by both acidic and nonacidic reflux events evoke strong UES contractile responses.

Functional anatomy and physiology of the upper esophageal sphincter

Upper esophageal sphincter (UES) refers to the high-pressure zone located in between the pharynx and the cervical esophagus. The physiological role of this sphincter is to protect against reflux of food into the airways as well as prevent entry of air into the digestive tract. UES is a musculocartilaginous structure with its anterior wall being formed by the full extent of the posterior surface of the cricoid cartilage and arytenoid and interarytenoid muscles in the upper part. Posteriorly and laterally the cricopharyngeus (CP) muscle is a definitive component of the UES. CP has many unique characteristics: it is tonically active, has a high degree of elasticity, does not develop maximal tension at basal length, and is composed of a mixture of slow- and fast-twitch fibers, with the former predominating. These features enable the cricopharyngeus to maintain a resting tone and yet be able to stretch open by distracting forces, such as a swallowed bolus and hyoid and laryngeal excursion. CP, however, constitutes only the lower one third of the entire high-pressure zone. The thyropharyngeus (TP) muscle accounts for the remaining upper two thirds of the UES. The UES pressure is not entirely the result of myogenic activity, as a component of the pressure is the result of passive elasticity of the tissues. The opening of the UES involves relaxation of CP and TP muscles and forward movement of the larynx by the contraction of hyoid muscles. The UES function is controlled by a variety of reflexes that involve afferent inputs to the motorneurons innervating the sphincter. These physiological reflexes elicit either contraction or opening of the UES. Inability of the sphincter to open leads to difficulty in swallowing. Opening of the sphincter without associated CP relaxation leads to the clinical syndrome of cricopharyngeal bar.

Upper esophageal sphincter function in patients with gastroesophageal reflux before and after laparoscopic funduplication

Department of Gastroenterology, Tel-Aviv Souraski Medical Center, and Sackler Medical School, Tel-Aviv University, Israel, Maccabi Sick Fund

Lower esophageal sphincter dysfunction often precludes safe gastric feeding in stroke patients.

To determine the relationship between stroke and lower esophageal dysfunction with vomiting and to identify an optimal nutrition protocol based on our findings. The lower and upper esophageal sphincter functions were assessed in 35 patients who had an acute stroke to determine whether gastric or jejunal enteral feeding was the optimal route. Stroke was due to unilateral ischemia in 20 patients, unilateral intracerebral hemorrhage in 8 patients, and global ischemia in 7 patients. Our study consisted of 18 men and 17 women with an average age of 64 years. Using standard esophageal manometric definitions, the lower esophageal sphincter function was below normal in 24 patients: 3 had global anoxia, 5 had unilateral hemorrhage, and 16 had unilateral ischemia. The upper esophageal sphincter function was low in 30 patients: 6 had global anoxia, 7 had unilateral hemorrhage, and 17 had unilateral ischemia. Based on lower esophageal sphincter pressure, 7 patients underwent tube gastrostomy and 13 patients underwent tube jejunostomy placement. All tolerated enteral alimentation well. Prior to lower esophageal sphincter assessment, 4 patients had percutaneous endoscopy gastrostomy feedings that led to aspiration pneumonitis and consultation for tracheostomy; 2 terminally ill patients were referred to the ethics service, and 2 were converted to feeding via jejunostomy tube at the time of tracheostomy and did well. Vomiting with aspiration due to lower esophageal sphincter dysfunction is common after acute strokes. Esophageal manometry serves as a guide to find the optimal feeding route.

Upper esophageal sphincter function during gastro-esophageal reflux events

Upper esophageal sphincter function during gastro-esophageal reflux events

Influence of altered tongue contour and position on deglutitive pharyngeal and UES function.

The potential influence of altered lingual position and contour during the bolus loading phase of the swallow in mediating the swallowed bolus volume-dependent regulation of upper esophageal sphincter (UES) relaxation and opening was studied in 15 healthy volunteers using simultaneous videoradiography and manometry. A maxillary dental splint modulated tongue deformity during the early oral phase of deglutition. We examined the effect of the splint and swallowed bolus density on bolus volume-dependent changes in the timing of events in the swallow sequence and on hypopharyngeal intrabolus and midpharyngeal pressures. Peak mid-pharyngeal pressure (P = 0.001) and hypopharyngeal intrabolus pressure (P = 0.04) were significantly reduced by the splint. The normal volume-dependent earlier onset of sphincter relaxation and opening was preserved with the splint in situ. The splint significantly delayed the onset of hyoid motion and UES relaxation and opening without influencing transit times or total swallow duration. Alterations in tongue contour and position reduce intrabolus pressure and pharyngeal contraction without influencing normal bolus volume-dependent regulation of timing of UES relaxation and opening.

Upper Esophageal Sphincter Function During Antegrade and Retrograde Transit

The striated musculature of the UES, along with the cricoid and thyroid cartilages, the hyoid bone, their ligaments, and the supra- and infrahyoid musculature form a functional unit that selectively controls the opening and closing of the esophageal inlet. At rest, upper esophageal tone acts as a barrier against both entry of air into the esophagus and regurgitation of materials coming from the proximal esophagus. However, reflexive responses of the sphincter offer no substantial protection against regurgitation of stomach contents that cause substantial esophageal distension. Although esophageal distention can experimentally induce sphincter contraction, this potential protective reflex against esophago-pharyngeal reflux has not been observed during spontaneous gastroesophageal reflux episodes. Furthermore, owing to the effects of gaseous distention, regurgitation may be more likely when acid and gaseous contents gastroesophageal reflux together. Modulation of the timing and the extent of sphincter opening during swallowing is intimately correlated with the volume and physical properties of the bolus, along with coordinated activity of the tongue, pharyngeal constrictors, and hyoid musculature, which suggests continuous sensory feedback throughout the pharyngeal swallow.

Function of upper esophageal sphincter during swallowing: the grabbing effect.

This study investigated deglutitive axial force developed within the pharynx, upper esophageal sphincter (UES), and cervical esophagus. Position and deglutitive excursion of the UES were determined using combined manometry and videofluoroscopy in eight healthy volunteers. Deglutitive clearing force was quantified with a force transducer to which nylon balls of 6- or 8-mm diameter were tethered and positioned within the oropharynx, hypopharynx, UES, and cervical esophagus. Axial force recordings were synchronized with videofluoroscopic imaging. Clearing force was dependent on both sphere diameter (P < 0.05) and location, with greater force exhibited in the hypopharynx and UES compared with the oropharynx and esophagus (P < 0.05). Within the UES, the onset of traction force coincided with passage of the pharyngeal clearing wave but persisted well beyond this. On videofluoroscopy, the persistent force was associated with the aboral motion of the ball caught within the UES. Force abated with gradual slippage of the UES around the ball. The force attributable to the combination of UES contraction and laryngeal descent was named the grabbing effect. The grabbing effect functions to transfer luminal contents distal to the laryngeal inlet at the end of the pharyngeal swallow, presumably acting to prevent regurgitation and/or aspiration of swallowed material.

Influence of mucosal receptors on deglutitive regulation of pharyngeal and upper esophageal sphincter function.

The potential influence of mucosal sensory receptors on the regulation of oral-pharyngeal swallow events was studied in 15 healthy volunteers using simultaneous videoradiography and manometry. We determined the effects of selective pharyngeal and oral plus pharyngeal anesthesia on the following temporal and manometric measures in response to liquid and viscous swallows: regional transit and clearance times; motion of hyoid and larynx; upper esophageal sphincter relaxation, opening, and closure; and pharyngeal contraction wave characteristics. Under the influence of mucosal anesthesia no subjects demonstrated aspiration during deglutition. Neither regional transit and clearance times nor pharyngosphincteric coordination was influenced significantly by pharyngeal mucosal anesthesia or oral plus pharyngeal anesthesia. Although midpharyngeal and distal pharyngeal contraction amplitudes were not influenced by mucosal anesthesia, midpharyngeal contraction wave duration was reduced significantly by both pharyngeal (P = 0.02) and oral plus pharyngeal anesthesia (P = 0.0005). We conclude that 1) neither elicitation of the pharyngeal swallow response nor temporal regulation among swallow events is dependent on mucosal sensory receptors and 2) duration of the pharyngeal contraction is influenced by sensory input from the oral-pharyngeal mucosa.

Videoradiographic, manometric, and electromyographic analysis of canine upper esophageal sphincter

We assessed upper esophageal sphincter (UES) function in dogs by concurrent recording of cricopharyngeal electromyographic (EMG) activity, intraluminal pressure, and dimensional changes of the pharyngoesophageal junction at rest and during swallowing. Radial and axial pressure profiles of the UES were determined by continuous pull-through manometry. EMG activity of the cricopharyngeus and thyropharyngeus muscles were correlated with UES pressure under static conditions. We also quantified the temporal relationships among EMG activity of the cricopharyngeus, UES pressure, and pharyngoesophageal junction dimensional changes during swallowing of 2, 4, and 6 ml of barium. When the dogs were prone, the anterior and posterior UES pressures were about twice the lateral pressures and the axial length of the UES was approximately 4 cm. All radial pressures equalized to approximately 20 mmHg when the dogs lay on their sides. The peak pressure zone of the UES corresponded closely with the level of the cricopharyngeal electrode, and resting UES pressure correlated closely with cricopharyngeal but not thyropharyngeal EMG activity. During swallowing, the cricopharyngeus relaxed approximately 200 ms before UES opening and 100 ms before UES relaxation. Superior movement of the hyoid and the larynx was associated temporally with UES relaxation, while anterior movement was associated with UES opening. Increases in bolus volume significantly increased maximal sagittal UES diameter during UES opening but did not alter temporal changes in UES function.(ABSTRACT TRUNCATED AT 250 WORDS)