Manometry Of Upper Esophageal Sphincter Research Articles

Interpretation of a Manometric Trace of the Upper Esophageal Sphincter

TO THE EDITOR: While reporting the complexity behind the interpretation of the manometric trace of the upper esophageal sphincter (UES), Bhatia and Shah 1 wrote: “It is a technically demanding procedure due to the anatomy of the UES, as is the movement of the sphincter during swallowing.” We agree with the authors that some of the difficulties are due to the movement of the sphincter during swallowing. This is proved by the fact that for example the contraction of the sphincter is still referred to by many different terms, including “closing tone, closing phase, sphincter contraction and post-swallow UES contraction etc.” They nicely showed the limitations of manometry. They reported that “The parameters which are most evaluated are baseline UES pressure, UES relaxation time, nadir pressure during UES relaxation, UES co-ordination with pharyngeal contraction, amplitude of pharyngeal contraction and intrabolus pressure.” These are well-established factors associated with motility abnormalities of the UES. 2-4 So, to ask an old question, how should the UES manometry be interpreted? To give a contribution to the UES motility, we have recently reviewed our experience, and have stressed the fact that scientists are likely to focus only on the co-ordination between the pharynx and the UES and often disregard the co-ordination of the UES with the upper esophageal contraction (called crico-esophageal coordination). 5 We dissected the manometry of the UES into a two-phase waveform. The first of relaxation is normal when it occurs before the onset of the pharyngeal contraction while the second phase of contraction is normal when the peak of UES contraction precedes the peak of the UE contraction. The correlation between the UES and the upper esophagus has been demonstrated also using different methodologies such as histochemical analysis, 6 biomechanical markers and electromyographic study. The analysis of the crico-esophageal coordination permitted us to identify abnormalities in several patients suffering from high dysphagia that would have been remained undiagnosed. Crico-esophageal abnormalities have been found in patients with Zenker diverticulum, 7 tight Nissen 8 and achalasia of the LES. 9 A new classification of the pharyngo-esophageal motility disorders was proposed: pharyngeal (pre-sphincteric), sphincteric and esophageal (post-sphincteric) disorders. 10 To conclude, although we also agree with the authors’ final conclusion: “UES manometry is useful in the management of patients with dysphagia,” we believe that for a more precise understanding of the UES disorders the study of the crico-esophageal coordination should be added. Further investigative work may be required in the evaluation of the UES.

Tu1189 Effect of Neck Positions, Bolus Volume and Body Posture on High Resolution Pharyngo- UES Manometry

Introduction: Pharyngeal High Resolution Manometry (HRM) has been increasingly used in research studies. The utility of this technique for clinical purposes requires a better understanding of the effects of variables on the recorded pressure signature. Some of these variables such as neck position and volume of swallowed material may not have appreciable effect on esophageal pressure measurements but could affect the pharynx significantly. Therefore, our AIM was to determine the effect of the bolus volume, several neck positions, and posture on the pharyngeal and Upper Esophageal Sphincter (UES)pressure phenomenon using HRM technique. Methods: We studied 16 healthy young volunteers (8 F, age 20-30 years) with HRM in four neck positions (neck neutral, neck 15 extension, neck 30° and 45° flexion) and 2 body postures (sitting and supine), four volumes (dry and 5 ml, 10 ml and 20 ml). Each swallow volume was repeated three times. We measured amplitude (mmHg) duration (s) and velocity (cm/s). Results: A total of 1536 swallows were evaluated. Pharyngeal pressure phenomenon exhibited larger duration in the proximal pharynx compared to distal, while they exhibited higher amplitude in the distal pharynx compared to the proximal pharynx but not velopharyngeal region(P7-P6) (figure 1a and 1b). These parameters were not affected by posture, neck position or volume of swallowed liquid. Intrabolus hypopharyngeal pressure (IBP) increased with increased swallowed volume significantly (P,0.05). There was no effect by posture or neck position on the IBP. Resting UES pressure was not affected by the posture, however it showed significant change due to neck position P,0.05 (Table) ConclusionDuring pharyngeal HRM, neck position or posture has no appreciable effect on recorded pharyngeal peristalsis; however it affects the UES pressure significantly. This effect needs to be considered during pharyngeal HRM. Table. Effect of neck position on pharyngo-UES HRM variables

How to Perform and Interpret Upper Esophageal Sphincter Manometry

Manometry of the pharynx and the upper esophageal sphincter (UES) provides important information on the swallowing mechanism, especially about details on the pharyngeal contraction and relaxation of the UES. However, UES manometry is challenging because of the radial asymmetry of the sphincter, and upward movement of the UES during swallowing. In addition, the rapidity of contraction of the pharyngoesophageal segment requires high frequency recording for capturing these changes in pressure; this is best done with the use of solid state transducers and high-resolution manometry. UES manometry is not required for routine patient care, when esophageal manometry is being performed. The major usefulness of UES manometry in clinical practice is in the evaluation of patients with oropharyngeal dysphagia.

Manometric evidence for a phonation-induced UES contractile reflex

The mechanism against entry of gastric content into the pharynx during high-intensity vocalization such as seen among professional singers is not known. We hypothesized that phonation-induced upper esophageal sphincter (UES) contraction enhances the pressure barrier against entry of gastroesophageal contents into pharynx. To determine and compare the effect of phonation on luminal pressures of the esophagus and its sphincters, we studied 17 healthy volunteers (7 male, 10 female) by concurrent high-resolution manometry and voice analysis. We tested high- and low-pitch vowel sounds. Findings were verified in six subjects by UES manometry using a water-perfused sleeve device. Eight of the volunteers (2 male, 6 female) had concurrent video fluoroscopy with high-resolution manometry and voice recording. Fluoroscopic images were analyzed for laryngeal movement. To define the sex-based effect, subgroup analysis was performed. All tested phonation frequencies and intensities induced a significant increase in UES pressure (UESP) compared with prephonation pressure. The magnitude of the UESP increase was significantly higher than that of the distal esophagus, the lower esophageal sphincter (LES), and the stomach. Concurrent videofluoroscopy did not show posterior laryngeal movement during phonation, eliminating a purely mechanical cause for phonation-induced UESP increase. Subgroup analysis demonstrated phonation-induced UESP increases in males that were significantly greater than those of females. Phonation induces a significant increase in UESP, suggesting the existence of a phonation-induced UES contractile reflex. UESP increase due to this reflex is significantly higher than that of the distal esophagus, LES, and stomach. The phonation-induced UESP increase is influenced by sex.

AGA technical review on the clinical use of esophageal manometry

AGA technical review on the clinical use of esophageal manometry

Safety and feasibility of evaluating airway protective reflexes during sleep: New technique and preliminary results

Background The airway is vulnerable to aspiration during sleep. The integrity of aerodigestive-protective reflexes during sleep has not been studied previously because of a lack of adequate techniques. Objective To determine the safety and the feasibility of a new technique to elicit pharyngoglottal closure reflex (PGCR), pharyngo–upper-esophageal sphincter (UES) pressure contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS) during sleep. Setting Outpatient sleep laboratory. Design and Intervention PGCR, PUCR, and RPS were elicited in 3 subjects by injecting colored water into the pharynx through a specially designed UES manometry catheter to which a thin videoendoscope was taped. This assembly was passed transnasally and positioned to obtain UES-pressure recordings and adequate endoscopic glottic views. Sleep was monitored by polysomnography, and all modalities were synchronized by using a timer. Subjects were evaluated while awake and during stage I sleep. Results All subjects were monitored for 3 hours of natural sleep, during which several periods of stage I sleep were observed. While awake, PGCR, PUCR, and RPS were elicited in all subjects. During sleep, PGCR was present in all, PUCR in 2, and RPS in 2 (1 after arousal) subjects. Threshold volumes for reflex elicitation were not significantly different between the awake state and stage I sleep. None of the subjects exhibited laryngeal penetration or aspiration. Limitations Small numbers of subjects were studied only in stage I sleep. Conclusions When using the above technique, it is safe and feasible to study aerodigestive reflexes during sleep. Preliminary data suggest that PGCR, PUCR, and RPS can be elicited during sleep.

Clinical, endoscopical and manometric evaluation of swallowing in patients with acquired autoimmune myasthenia gravis

Dysphagia, or difficulty swallowing, is a common problem following myasthenia gravis (MG) and may lead to aspiration of saliva, food or liquids. We herein present 22 MG patients, with complaint of dysphagia, evaluated by phonoaudiological evaluation, nasofibrolaryngoscopical analysis and manometry of upper esophageal sphincter. The main objective was to evaluate the phases of the swallowing process and anatomical and functional aspects of oropharyngeal musculature. The age of patients varied from 19 to 74 years; being 19 female and 3 male. The main data were: (1) statistically significant relation between the phonoaudiological clinical evaluation and nasofibrolaryngoscopical one; (2) stomatognatical system disorders present in 100%; (3) swallowing and chewing disorders present in 100%, when clinically evaluated, and in 81,8% when evaluated by the nasofibrolaryngoscopy; (4) statistically significant relation between penetration/aspiration and antecedents of pneumonia; (5) stomatognatical muscles very altered, difficulty controlling the bolus, collection of food in the pharynx or larynx and presence of penetration and/or aspiration showed significant correlation with weakness of a pharyngeal muscles. These findings justify the necessity to evaluate clinically the swallowing phases in MG patients, with the main purpose to prevent both aspiration and dehidration from inadequate oral intake.

Pharyngeal and upper esophageal sphincter manometry in the evaluation of dysphagia.

The use of esophageal manometry seems to be increasing, but the utility of pharyngeal and upper esophageal sphincter (UES) manometry is not widely recognized. This article is intended to clarify this subject. Initially, we review the anatomy and physiology of this area. Most studies indicate that the manometry of the UES and pharynx provides useful information primarily in patients that have symptoms of oropharyngeal dysfunction. Oropharyngeal dysphagia has high morbidity, mortality, and cost. It occurs in one third of all stroke patients and is common in the chronic care setting; up to 60% of nursing home occupants have feeding difficulties, of whom a substantial portion have dysphagia. For patients with oropharyngeal dysphagia, as for those with esophageal dysphagia, barium swallow study and manometry are complimentary. Their combined use permits us to enhance the understanding of the pathophysiologic process that causes the patient's symptoms. Abnormalities have been noted in a variety of diseases, such as Parkinson's disease, oculopharyngeal muscular dystrophy, achalasia, and scleroderma. Thus, it is possible to determine the primary pathology that is causing the patient's dysphagia by analyzing the manometry results. Pharyngeal and UES manometry also has a value in evaluating patients who are candidates for myotomy or dilatation, as it can help identify patients with a prospective good outcome.