Upper Esophageal Sphincter Relaxation Duration Research Articles

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.

Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure.

Aspiration is a common complication after tracheostomy in patients with acquired brain injury (ABI), resulting from impaired swallowing function, and which may lead to aspiration pneumonia. The Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valve (PMV) has been used to enable voice and reduce aspiration; however, its mechanism is unclear. This study aimed to investigate the mechanisms underlying the beneficial effects of PMV intervention on the prevention of aspiration. A randomized, single-blinded, controlled study was designed in which 20 tracheostomized patients with aspiration following ABI were recruited and randomized into the PMV intervention and non-PMV intervention groups. Before and after the intervention, swallowing biomechanical characteristics were examined using video fluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). A three-dimensional (3D) upper airway anatomical reconstruction was made based on computed tomography scan data, followed by computational fluid dynamics (CFD) simulation analysis to detect subglottic pressure. The results showed that compared with the non-PMV intervention group, the velopharynx maximal pressure (VP-Max) and upper esophageal sphincter relaxation duration (UES-RD) increased significantly (P < 0.05), while the Penetration-Aspiration Scale (PAS) score decreased in the PMV intervention group (P < 0.05). Additionally, the subglottic pressure was successfully detected by CFD simulation analysis, and increased significantly after 2 weeks in the PMV intervention group compared to the non-PMV intervention group (P < 0.001), indicating that the subglottic pressure could be remodeled through PMV intervention. Our findings demonstrated that PMV could improve VP-Max, UES-RD, and reduce aspiration in tracheostomized patients, and the putative mechanism may involve the subglottic pressure. [http://www.chictr.org.cn], identifier [ChiCTR1800018686].

Variables influencing manometric parameters of deglutitive and non-deglutitive upper esophageal sphincter: A study of 89 asymptomatic participants.

High-resolution manometry overcomes limitations imposed by axial and radial asymmetry as well as swallow and respiration-induced movement of the upper esophageal sphincter (UES), allowing for its reliable use in evaluation of dysphagic and reflux patients. The aim of this study was to determine normative values and their variability across position, sex, age, height, weight, BMI, and volume for clinically relevant deglutitive and non-deglutitive UES parameters. We studied 89 asymptomatic volunteers age 19-90years, (45 female) during 3-10 repetitions of dry, 5 and 10ml water swallows at 30-s intervals using high-resolution manometry. Upper esophageal sphincter high-pressure zone was longer in men than women and in supine than upright position. UES basal contractile integral and mean basal pressure were higher in supine compared to upright; higher in men than women, inversely correlated with age, correlated positively with height and with weight in the supine position only. UES relaxation duration was longer in upright than in supine position but not affected by age, sex, height, weight, or BMI. It was longer with 5 and 10ml compared with dry swallows. UES minimum/nadir relaxation and mean relaxation pressures were lower in upright than supine position, increased with increase in age and were higher in men than women. Position, sex, age, height, weight, and volume affect some deglutitive and non-deglutitve UES manometric parameters. BMI does not affect the studied manometric parameters. These effects should be taken into consideration in clinical evaluation of UES.

Design and implementation of botulinum toxin on cricopharyngeal dysfunction guided by a combination of catheter balloon, ultrasound, and electromyography (BECURE) in patients with stroke: study protocol for a randomized, double-blinded, placebo-controlled trial

BackgroundCricopharyngeal dysfunction (CPD) occurs in various neurological disorders, especially stroke. The treatment approaches of CPD include swallowing training, cricopharyngeal dilation, botulinum toxin (BTX) injection, and cricopharyngeal myotomy. BTX injection into the cricopharyngeal muscle is effective and safe for some patients with dysphagia, with a success rate between 43 and 100% (mean = 76%). However, well-designed randomized controlled clinical trials are needed to verify its efficacy and safety for the treatment of CPD. The objective of this study is to explore the efficacy and safety of BTX for neurogenic cricopharyngeal achalasia, when administering an injection into the cricopharyngeal muscle guided by a novel precise positioning method, that combines ultrasound, catheter balloon, and electromyography (BECURE).MethodsBECURE is a single-center randomized, placebo controlled, double-blinded, superiority clinical trial. To detect a significant difference between the 2 groups, a sample size of 44 patients is estimated. The intervention is BTX versus placebo, with 1:1 randomization. The randomization sequence from 1 to 44 was generated using the Statistical Package for Social Sciences. The study is divided into two phases. In the first phase, patients will be injected with BTX or the placebo. In the second phase, patients who received a placebo injection and those who did not respond to the first BTX injection will receive an injection of BTX. The primary outcome is the score of the Functional Oral Intake Scale (FOIS). The secondary outcomes are as follows: upper esophageal sphincter (UES) residual pressure, UES resting pressure, duration of UES relaxation, velopharyngeal and laryngopharyngeal peak pressure, UES opening, pharyngeal construction ratio, residue of bolus in the epiglottis valley or piriform sinus, and penetration and aspiration.DiscussionDysphagia is a common complication of stroke. There is lack of high-quality evidence for the efficacy of BTX in treating neurogenic CPD. This study will clarify whether BTX injection into the cricopharyngeal muscle can be effective and safe for patients with stroke and CPD.Trial registrationChinese Clinical Trial Register (ChiCTR1900025562). Registered on September 1, 2019.

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.

Ability of High-Resolution Manometry to Determine Feeding Method and to Predict Aspiration Pneumonia in Patients With Dysphagia.

The introduction of high-resolution manometry (HRM) offered an improved method to objectively analyze the status of pharynx and esophagus. At present, HRM for patients with oropharyngeal dysphagia has been poorly studied. We aimed to determine feeding method and predict the development of aspiration pneumonia in patients with oropharyngeal dysphagia using HRM. We recruited 120 patients with dysphagia who underwent both HRM and videofluoroscopic swallow study. HRM was used to estimate pressure events from velopharynx (VP) to upper esophageal sphincter (UES). Feeding methods were determined to non-oral or oral feeding according to dysphagia severity. We prospectively followed patients to assess the development of aspiration pneumonia. VP maximal pressure and UES relaxation duration were independently associated with non-oral feeding. Non-oral feeding was determined based on optimal cutoff value of 105.0 mm Hg for VP maximal pressure (95.0% sensitivity and 70.0% specificity) and 0.45 s for UES relaxation duration (76.3% sensitivity and 57.5% specificity), respectively. During a mean follow-up of 18.8 months, 15.8% of patients developed aspiration pneumonia. On multivariate Cox regression analysis, VP maximal pressure (P<0.01) and UES relaxation duration (P<0.05) independently predicted the development of aspiration pneumonia. Cumulative incidence of aspiration pneumonia was significantly increased in patients with readings below optimal cutoff values for VP maximal pressure (P<0.01) and UES relaxation duration (P<0.01), individually. We first established the optimal thresholds for HRM parameters to determine feeding method and predict the development of aspiration pneumonia in patients with oropharyngeal dysphagia.

The effect of bolus consistency on swallowing function measured by high-resolution manometry in healthy volunteers.

This study evaluated the effects of three levels of bolus consistency (water, thick liquid, and paste) on the nature and duration of physiologic pressure while swallowing in healthy adults using high-resolution manometry (HRM). A case series of healthy adults. Thirty-four healthy young adults (mean age: 24.29 years) were instructed to swallow 3 mL and 10 mL of water, thick liquid, and paste material, respectively, during which the upper esophageal sphincter (UES) and pharyngeal pressures were measured by HRM. Variables that included maximum pharyngeal pressure, duration of pharyngeal pressure, pharyngeal pressure rise rate, UES residual pressure, duration of UES relaxation, and maximum preopening as well as postclosure UES pressure were analyzed across the three bolus consistencies by one-way repeated measures analysis of variance. Maximum pharyngeal pressure, duration of pharyngeal pressure, duration of UES relaxation, maximum preopening UES pressure, and maximum postclosure UES pressure were significantly increased while swallowing water when compared with the thick liquid and paste materials. No significant differences were observed in UES residual pressure and pharyngeal pressure rise rate among the three different consistencies. Variations in bolus consistency appear to have a significant effect on physiologic pressure and duration in healthy adults while swallowing water when compared with thicker materials. Identification of the differences across various bolus consistencies could provide further insight into the pathophysiology of both normal and pathological swallowing. 4. Laryngoscope, 127:173-178, 2017.

High-resolution manometry: reliability of automated analysis of upper esophageal sphincter relaxation parameters.

At present, automated analysis of high-resolution manometry (HRM) provides details of upper esophageal sphincter (UES) relaxation parameters. The aim of this study was to assess the accuracy of automatic analysis of UES relaxation parameters. One hundred and fifty three subjects (78 males, mean age 68.6 years, range 26-97) underwent HRM. UES relaxation parameters were interpreted twice, once visually (V) by two experts and once automatically (AS) using the ManoView ESO analysis software. Agreement between the two analysis methods was assessed using Bland-Altman plots and Lin's concordance correlation coefficient (CCC). The agreement between V and AS analyses of basal UES pressure (CCC 0.996; 95% confidence interval (CI) 0.994-0.997) and residual UES pressure (CCC 0.918; 95% CI 0.895-0.936) was good to excellent. Agreement for time to UES relaxation nadir (CCC 0.208; 95% CI 0.068-0.339) and UES relaxation duration (CCC 0.286; 95% CI 0.148-0.413) between V and AS analyses was poor. There was moderate agreement for recovery time of UES relaxation (CCC 0.522; 95% CI 0.397-0.627) and peak pharyngeal pressure (CCC 0.695; 95% CI 0.605-0.767) between V and AS analysis. AS analysis was unreliable, especially regarding the time variables of UES relaxation. Due to the difference in the clinical interpretation of pharyngoesophageal dysfunction between V and AS analysis, the use of visual analysis is justified.

A New Approach Is Needed to Analyze the Upper Esophageal Sphincter Because Currently Incorporated High-resolution Manometry Analysis Software Package Is Not Perfect.

TO THE EDITOR: I read with interest the review article by Wang et al1 regarding “High-resolution manometry (HRM) analysis of upper esophageal sphincter (UES) not addressed by the ‘Chicago classification’” disorders of the UES may include pharyngeal dysphagia and other cervical symptoms such as globus. Currently automated analysis of HRM provides the details of information such as mean basal UES pressure, mean residual UES pressure, UES relaxation time-to-nadir, UES relaxation duration, UES recovery time, and peak pharyngeal pressure. We have been evaluating whether HRM plays some roles in the assessment of the disorders of the UES with special interest for 4 years.2–4 To our experience, the information obtained by the software analysis often is not perfect as well as occasionally being wrong. Figure 1A shows erroneous locations of pharyngeal/UES wave markers, which are occurring despite of adequate setting thermal compensation and adjusting the spatial markers. Therefore it should be noted that it is very important to adjust the locations of the pharyngeal/UES wave markers correctly before the assessment of oropharyngeal dysphagia or globus. This problem frequently occurs in the setting of incomplete UES relaxation (Fig. 1B) and then gives misinformation regarding the duration of UES relaxation. However, it is very hard to correctly adjust UES wave markers under these circumstances. Given that, another new approach for quantitative assessment of UES relaxation should be considered. When we evaluate esophagogastric junction (EGJ) relaxation in the HRM examination, 4-second integrated relaxation pressure (IRP) is one of the best measures of EGJ relaxation, compared to nadir pressure and 3-second IRP.5 The opening time of UES is a lot shorter than that of EGJ. This suggests that IRP concept may be inappropriate in the assessment of UES relaxation. In HRM analysis, isobaric contours of 20 mmHg and 30 mmHg are currently used to assess distal contractile integral and distal segment contraction, respectively.5 These isobaric contours might be helpful for a more robust localization of these wave markers and then provide additional new concept regarding a measure of UES relaxation. To our experience, duration of UES relaxation on automated analysis seems to correlate well with the shortest horizontal distance from ending contour of pre-swallow UES peak to starting contour of post-swallow UES peak with 20 mmHg isobaric contour applied in this analysis (Fig. 2). This issue, however, should be further validated by larger study. In conclusion, we believe that the new approach should be introduced for better evaluation of disorders of the UES. Figure 1. Wrong location of pharyngeal/upper esophageal sphincter wave markers is noted. (A) Starting and ending points of UES relaxation wave makers are improperly located. (B) Starting, center and ending points of UES relaxation wave markers in third swallow ... Figure 2. Comparison of duration of the upper esophageal sphincter relaxation between automated analysis and new approach (using 20 mmHg isobaric contours).

Effect of bolus volume on pharyngeal swallowing assessed by high-resolution manometry

ObjectiveSolid-state high-resolution manometry (HRM) is fast becoming the gold standard for studying pharyngeal and esophageal motility. However, very few studies have ever evaluated the effect of bolus volume on the physiology of swallowing using HRM. We aimed to determine the effect of bolus volume on pressure, duration and velocity of the hypopharynx as well as the upper esophageal sphincter during pharyngeal swallowing using HRM. MethodsThirty-four healthy subjects completed nine swallows (3ml, 5ml and 10ml of water, thick liquid, and paste, respectively) in the natural sitting position. Pressure and duration measurements were acquired from the hypopharynx and upper esophageal sphincter (UES) using HRM. The UES residual pressure, UES relaxation duration, maximum preopening UES pressure, maximum postclosure UES pressure, maximum hypopharyngeal pressure, maximum hypopharyngeal pressure rise rate and hypopharyngeal pressure duration were analyzed across bolus volumes using repeated measures of one-way analysis of variance. ResultsA significant increase in UES residual pressure associated with increased bolus volume during water and paste swallowing was observed. Furthermore, UES relaxation duration was significantly increased with increasing in bolus volume for all three material swallows. No significant volume effects were found on the hypopharynx. ConclusionsIn summary, bolus volume has a significant effect on the residual pressure and relaxation duration, but no effect on maximum preopening pressure or maximum postclosure pressure of the UES. Maximum hypopharyngeal pressure, maximum hypopharyngeal pressure rise rate and pressure duration were also not affected by bolus volume. Consideration of these variables is paramount in understanding normal and pathological swallowing.

Esophageal dynamic and laryngopharyngeal reflux play a role in pathogenesis of vocal cord polyps

Through monitoring esophageal dynamic change, and detection of laryngopharyngeal reflux(LPR) and gastroesophageal reflux events,to discuss the relationship of vocal cord polyps with laryngopharyngeal reflux. Thirty-two patients with vocal cord polyps were diagnosed by electronic laryngoscopy in Nanfang Hospital between October 2011 to May 2012. This study applied high-resolution esophageal manometry (HRM) and ambulatory 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH) to obtain the upper esophageal sphincter(UES) and lower esophageal sphincter pressure, characteristics of sectional esophageal motility; laryngopharyngeal reflux (LPR)and gastroesophageal reflux events, as well as the reflux properties of substances. Sixteen healthy volunteers were recruited as normal controls. UES relaxation duration, duration of UES relaxation time, UES relaxation recovery time and mean length of LES were all shorter than those of the control group (t were 2.244, 2.624, 2.310 and -2.397, P < 0.05). There were 40.6% (13/32) LPR and 50.0% (16/32) gastroesophageal reflux found in vocal polyp patients. Median number (M [P25; P75]) of laryngopharyngeal acid reflux events were 0.5[0.0;3.5] and 0.0[0.0;0.0] in vocal polyp group and the controls, median mean time of laryngopharyngeal acid exposure 0.1[0.0;1.7] and 0.0[0.0;0.0] min, median clearance time of laryngopharyngeal acid were 3.5[0.0;53.5] and 0.0[0.0;0.0] s, median scores of DeMeester were 14.8[1.6;31.3] and 1.8[1.1;4.1] and median frequency of total liquid reflux episodes were 46.5[25.3;69.0] and 32.5[20.0;36.3], respectively. The median numbers of laryngopharyngeal acid reflux events, time of acid exposure, time of acid clearance, DeMeester scores and frequency of total liquid reflux episodes were increased or higher in vocal polyp group than those in the controls (z were 2.481, 2.767, 2.767, 2.344 and 1.980, P < 0.05). There are upper esophageal sphincter and Lower esophageal sphincter dismotility in vocal polyp patients with LPR. LPR events were dominated by acid reflux in upright position.Esophageal dynamic disfunction and LPR should be considered in the study of the pathogenesis of vocal cords polyps.

Are Manometric Parameters of the Upper Esophageal Sphincter and Pharynx Affected by Age and Gender?

The effects of age and gender on the upper esophageal sphincter's (UES) and pharyngeal manometric parameters were investigated in 84 healthy subjects (45 men, 39 women, mean age = 44 years, range = 18-91). Manometric recordings were performed with solid-state circumferential transducers. Subjects older than 60 years (n = 23) showed a significant lower UES resting pressure. In addition, during water swallows they had a higher UES residual pressure, shorter UES relaxation interval and UES relaxation duration, and a decreased UES relaxation rate. Furthermore, pharyngeal contraction had significant higher amplitude and longer duration in subjects older than 60 years during water swallows. Some of these findings were also observed during cookie and pudding swallows. Women had a higher UES resting pressure and a longer UES relaxation interval than men. The observed changes with increasing age indicate loss of basal tone and decreased compliance of the UES. Increased pharyngeal contraction amplitude and its prolonged duration in the elderly might be compensatory to this. These physiologic effects of age and gender on UES and pharyngeal parameters should be taken into account during analysis of manometric studies.