咽喉反流性疾病患者食管上括约肌压力高分辨测量的诊断价值

目的分析咽喉反流性疾病（LPRD）患者食管上括约肌（UES）压力高分辨测量（HRM）的应用价值。方法对71例咽部异感患者及28例健康志愿者进行UES压力HRM，根据反流症状指数（RSI）量表评分将71例患者分为咽喉反流组（A组，31例，RSI>13分）及非咽喉反流组（B组，40例，RSI≤13分），健康志愿者为C组（28例）。A、B、C组性别构成、平均年龄及平均体质指数（BMI）经比较差异无统计学意义（P均>0.05），具有可比性。结果3组生活质量评价量表（SF 36）评分A组患者（91.44±4.17）分显著低于B组的（99.51±5.86）分及C组的（114.03±5.29）分（P均<0.05）；平均UES静息压A组为（104.50±33.84）mmHg，B组为（76.34±20.08） mmHg，C组为（46.92±11.56）mmHg, A组与B、C组比较差异均具有统计学意义（P均<0.05）；残余压A组为（26.31±8.27）mmHg，B组为（15.40±7.19）mmHg, C组为（10.25±4.74）mmHg, A组与B、C组比较差异均具有统计学意义（P均<0.05）。A、B、C组平均远端收缩积分（DCI）及平均远端潜伏期（DL），经比较差异无统计学意义（P均>0.05）。结论LPRD患者生活质量评分较低，其症状的出现可能与UES静息压及残余压增高有关，UES静息压及残余压测量可为LPRD的诊断及其预后判断提供一定的参考价值。     

喉咽反流性疾病的发病机制和诊治

喉咽反流性疾病(laryngopharyngeal reflux disease,LPRD)是一种比较常见的疾病,是胃内容物异常反流至食管上括约肌(upper esophageal sphincter,UES)以上的咽喉部而引起的一系列症状和体征的总称。临床表现主要为咽喉异物感、咽喉痛、慢性咳嗽、声嘶、发音障碍及吞咽不畅等,体征主要有咽部黏膜充血、增厚,咽后壁淋巴滤泡增生,杓间区黏膜增生、肥厚,声带弥漫性充血水肿,严     

内镜下CO2激光环咽肌切开术的适应证

1简介环咽肌（cricopharyngeus,CP）是由咽下缩肌下缘的横行纤维组成,是食管上括约肌（the upper esophageal sphincter,UES）的主要组成部分。静息状态下,CP适当收缩,而吞咽时则适当放松。由于神经源性功能障碍或纤维化导致吞咽时CP不能适当放松时,功能障碍便发生了。CP功能障碍的症状包括吞咽困难、吞咽疼痛、呼吸困难、咳嗽和鼻腔反流。严重时会发生吸入和体重下降现象。     

胃食管反流对咽喉反流病患者的食管动力学影响

目的应用高分辨率食管测压的方法,通过与正常人群的比较,探讨胃食管反流对咽喉反流病(laryngopharyngeal reflux disease,LPRD)患者的食管动力学影响。方法将初筛为LPRD的患者进行诊断性治疗,治疗前后均行高分辨率食管测压检测。按胃食管反流病(gastroesophageal reflux disease,GERD)问卷评分标准,分为单纯LPRD组和LPRD伴GERD组。无咽喉不适的健康人群设为对照组。结果确诊为LPRD的患者56例,单纯LPRD组24例,LPRD伴GERD组32例,正常对照组20例。LPRD患者的年龄、性别构成比、BMI指数等较对照组差异均无统计学意义(P>0.05),吸烟、饮酒及睡前3小时进食的患者构成比较对照组有统计学差异(P<0.05)。单纯LPRD食管动力参数较对照组均无统计学差异(P>0.05)。LPRD伴GERD组的UESP、LESP、DCI、DL较对照组均有统计学意义(P<0.05)。结论单纯咽喉反流病无明显食管动力异常,而胃食管反流病能导致咽喉反流病的食管动力障碍,一定程度上提示了单纯咽喉反流病与胃食管反流病存在不同的发病机制。     

咽喉反流

咽喉反流（1aryngopharyngeal reflux，LPR）其定义为胃内容物反流至上食管括约肌（upperesophageal sphincter，UES）以上的咽喉部。病理性咽喉反流可表现为慢性咽喉炎、哮喘及不明原因的胸痛。与耳鼻咽喉科相关的症状包括慢性声嘶、咽异物感、频繁清嗓、慢性咳嗽、吞咽困难及痰液增多等。咽喉反流与消化科常见的胃食管反流（gastroesophageal reflux，GER．）存在着较多差异，本文重点介绍咽喉反流的发生机制、诊断及其与咽喉部病变和阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome，OSAHS）的关系。     

咽喉反流

咽喉反流(laryngopharyngeal reflux,LPR)其定义为胃内容物反流至上食管括约肌(upper esophageal sphincter,UES)以上的咽喉部。病理性咽喉反流可表现为慢性咽喉炎、哮喘及不明原因的胸痛。与耳鼻咽喉科相关的症状包括慢性声嘶、咽异物感、频繁清嗓、慢性咳嗽、吞咽困难及痰液增多等。咽喉反流与消化科常见的胃食管反流(gastroesophageal reflux,GER)存在着较多差异,本文重点介绍咽喉反流的发生机制、诊断及其与咽喉部病变和阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)的关系。     

埃索美拉唑联合伊托必利治疗咽喉反流性疾病及食管动力学分析

目的　通过埃索美拉唑联合伊托必利诊断性治疗,观察咽喉反流性疾病（laryngopharyngeal reflux disease,LPRD）患者在治疗前后反流症状体征的变化及食管动力学特点。方法　将疑似LPRD患者进行诊断性治疗,治疗前后均行反流体征评分量表（reflux finding score,RFS）和反流症状指数量表（reflux symptom index,RSI）的评分及高分辨率食管测压（high resolusion manometry,HRM）检测。按胃食管反流病（gastroesophageal ref lux disease,GERD）问卷评分标准,分为单纯LPRD组和LPRD伴GERD组。结果　确诊为LPRD患者38例,单纯LPRD组12例,LPRD伴GERD组26例。两组中患者年龄、性别构成比、BMI等差异均无统计学意义。单纯LPRD组RSI评分在治疗前后差异有统计学意义（Z =-3.009,P＜0.05）,RFS评分在治疗前后差异无统计学意义（Z =-0.976,P＞0.05）,LPRD伴GERD组RSI和RFS评分在治疗前后差异均有统计学意义（P＜0.05）。单纯LPRD组治疗前后食管动力变化差异无统计学意义,LPRD伴GERD组食管动力参数UESP、LESP、DCI和DL在治疗前后的变化均有统计学意义。结论  单纯LPRD患者反流体征较症状的明显改善需要更长的治疗时间。埃索美拉唑联合伊托必利能改善LPRD伴GERD的食管动力,单纯的LPRD治疗前后食管动力无明显变化,一定程度上提示了单纯LPRD与GERD存在不同的发病机制。     

健康教育对提高咽喉反流疾病治愈率的临床意义

据不完全统计,耳鼻咽喉科门诊就诊的患者中有10％的人存在咽喉反流症状和体征^[1]。而咽喉科疾病包括嗓音疾病中大约有半数患者,咽喉反流是主要病因或是重要的病因协同因素。咽喉反流疾病（Iaryngopharyngeal reflux,LPR）是指胃内容物反流至上食管括约肌以上的咽喉部。大多数患者初期临床表现不明显,只有咽部异物感、慢性清嗓及发音疲劳等。     

以咽部异物感为主诉的胃食管反流病的诊治

胃食管反流病(gastroesophageal reflux dis-ease,GERD)的诊断和治疗一般属于消化内科的范畴,耳鼻咽喉科医生很少涉及,对因GERD引起的咽部异物感的患者易漏诊误治,现将86例以咽部异物感为主诉的GERD     

阻塞性睡眠呼吸暂停低通气综合征与夜间咽喉反流的相关性研究

目的 探讨阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)与夜间咽喉反流(laryngopharyngeal reflux,LPR)的关系.方法 分析19例OSAHS患者整夜同步多道睡眠监测+咽喉pH监测+食管压力测量数据,研究呼吸紊乱指标、整夜咽喉pH平均值及食管压力指标相关性,并描述每次LPR事件出现时的睡眠周期、体位、食管压力变化以及与呼吸事件的关系.结果 ①19例OSAHS患者中LPR阳性者6例,共记录LPR事件63次;②LPR阳性患者OSAHS严重程度与咽喉pH平均值呈负相关,但未发现反流事件与呼吸事件之间存在明确时间上的一一对应的关系;③LPR阳性组与阴性组患者的食管压(t=3.211,P=0.007)和上食管括约肌压力(t=2.234,P=0.046)差异均有统计学意义;④所有患者整夜咽喉pH平均值与食管压力平均值呈正相关(r=0.592,P=0.033).结论 OSAHS患者严重程度与夜间咽喉部pH值密切相关.OSAHS患者夜间易发生胃食管反流,造成近端食管胃酸暴露增加,进一步增加发生LPR的概率.LPR阳性的OSAHS患者睡眠时静息上食管括约肌压力下降更为明显,可能也是导致反流的另一危险因素.     

Effect of pharyngeal stimulation on the motor function of the esophagus and its sphincters

OBJECTIVE/HYPOTHESIS: Sensory impulses from the pharynx induce contraction of the upper esophageal sphincter (UES), relaxation of the lower esophageal sphincter (LES), and inhibition of peristalsis. To determine 1) the magnitude of UES contractile response to threshold volume of fluid that induces LES relaxation and 2) the effect of rapid pharyngeal air stimulation on LES resting pressure and its concurrent influence on the UES and progression of esophageal peristalsis. METHODS: Eleven healthy volunteers (age, 31 +/- 2 y) were studied by concurrent UES, esophagealbody, and LES manometry. RESULTS: At a threshold volume of 0.3 +/- 0.05 mL, injections of water into the pharynx directed posteriorly, resulted in complete LES relaxation. Duration of these relaxations averaged 19 +/- 1 seconds. In 10 of 11 subjects, these relaxations were accompanied by a simultaneous increase in UES resting tone that averaged 142% +/- 27% above preinjection values. Pharyngeal stimulation by rapid air injection resulted in complete LES relaxation in 8 of the 11 subjects (threshold volume, 14 +/- 6 mL). Five of 8 developed a concurrent mild increase in resting UES pressure (17% +/- 6% above preinjection values) (P < .05). Pharyngeal water injection inhibited the progression of the peristaltic pressure wave at all tested sites and in all subjects, but pharyngeal air injection in only 2 of the 11 studied subjects. CONCLUSIONS: The inhibitory effect of pharyngeal water injection on LES resting pressure is accompanied by a substantial contractile effect on the UES. Although stimulation of the pharynx by rapid air injection may induce LES relaxation, its inhibitory effect on esophageal peristalsis and stimulatory effect on UES pressure are negligible compared with that of water injection.     

Pharyngoesophageal dysmotility in globus sensation

Ambulatory esophageal pH monitoring, radiologic examination, endoscopy, and manometry were undertaken in 142 patients with globus. The results demonstrate that abnormal gastroesophageal reflux occurred in 23% of patients, implying that, while reflux may be responsible for globus in some patients, it is not the cause of globus sensation in the majority of individuals with this symptom. Comparing patients with globus and control subjects, there were no differences in lower esophageal sphincter pressures, esophageal body motility, or tonic upper esophageal sphincter pressures, but patients with globus exhibited higher pharyngeal and upper esophageal sphincter after-contraction pressures during deglutition. The physiological significance of this pharyngeal and upper esophageal dysmotility is not clear and it may be no more than a secondary phenomenon. Alternatively, it may contribute to the generation of globus, perhaps in combination with other physical and psychological triggers.     

Swallowing disorders in paralysis of the lower cranial nerves: a functional analysis.

Deficits of the lower cranial nerves (nerves IX, X, XI, and XII) occurring after treatment of skull base tumors may cause disabling swallowing disorders. To assess the mechanisms of swallowing disorders involved in such cases, we performed functional examinations: a videoendoscopic swallowing study and simultaneous manometry and videofluoroscopy in 7 patients. This study shows that the main mechanism of the swallowing disorders was a disturbance of the pharyngeal stage, including a decrease of pharyngeal propulsion, reduced laryngeal closure, and cricopharyngeal dysfunction, which led to aspiration. Decreased pharyngeal propulsion was found in 6 patients, with a very high correlation between fiberoscopy and simultaneous manometry-fluoroscopy. The responsibility of the upper esophageal sphincter in swallowing disorders was more difficult to assess. The role of the upper esophageal sphincter and pharyngeal propulsion in the onset of the problem is discussed in regard to the cricopharyngeal myotomy.     

Loss of secondary esophageal peristalsis is not a contributory pathogenetic factor in posterior laryngitis

Secondary esophageal peristalsis helps prevent the entry of gastric acid into the pharynx by clearing the refluxed gastric contents back into the stomach. Because the loss of this mechanism may contribute to the pathogenesis of reflux-induced laryngeal disorders, our aim was to study the frequency of stimulation and parameters of secondary esophageal peristalsis in patients with posterior laryngitis (PL). We studied 14 patients (45 +/- 5 years) with PL documented by videolaryngoscopy and 11 healthy controls (46 +/- 6 years). The upper esophageal sphincter (UES) pressure was monitored by a sleeve assembly incorporating an injection port 5 cm distal to the sleeve. The esophageal body and lower esophageal sphincter (LES) pressures were measured by an LES sleeve assembly. Primary esophageal peristalsis was induced by 5-mL water swallows. Secondary esophageal peristalsis was induced by abrupt injection of volumes of air, incrementally increased by 5 mL, into the esophagus. Secondary esophageal peristalsis could not be elicited by injection of any volume (up to 60 mL) in 3 PL patients and 2 controls. These 5 subjects had normal primary peristalsis. The threshold volume of air required to stimulate secondary esophageal peristalsis in PL patients (median, 15 mL) was similar to that of controls (median, 10 mL). The parameters of the secondary esophageal peristaltic pressure wave were similar in both groups, and in both groups, they were similar to those of primary peristalsis. The UES response to the injection of the threshold volume that induced secondary esophageal peristalsis in PL patients was contraction in 58% of the trials, partial relaxation in 3%, and no response in 39%. The findings were similar to those in the controls. The LES response to injection of the threshold volume was complete relaxation in both the PL patients and the controls. We conclude that the integrity of secondary esophageal peristalsis is preserved in PL patients.     

Factors influencing pharynx' and pharyngoesophageal sphincter's morphology and their function after total laryngectomy

The usefulness of the videolaryngoscopy in patients after total laryngectomy/laryngopharyngectomy was discussed. They serve for: a) evaluation of the pharynx and of the pharyngoesophageal sphincter (pes) morphology, b) prognosis of the esophageal speech developing. In the study videolaryngoscopy was done in 82 patients (7 female and 75 male). In 62 of them total laryngectomy was done (among them in 50/62--with standard pharynx suture, in 9/62--with the pes plasty, and 3/62--with simple pes myotomy). In 20 case of laryngopharyngectomies--4/20 standard pharynx suture was done, 12/20 were reconstructed with tongue flap, 3/20--with pes plasty, and in 1/20 simple myotomy was performed. The investigations were carried out between 1 to 36 months after total laryngectomy and 24 month after laryngopharyngectomy. The analysis of the videolaryngoscopy imagings revealed that the pharynx and pes morphology after laryngectomy/laryngopharyngectomy (shape, thickness of the mucose, weakened wall peristalsis, secretion retention, lack or presence of the pes relaxation at the time of examination) correlates with the rest pressure in the pes area, measured by Seeman's method and with the occurrence of the esophageal speech mastering. The most significant changes in morphology and function of the pharynx (irregular shape, weakened wall peristalsis, retention of secretion) as well as the highest pressure in the area (5.1 +/- 3.33 kPa-38 +/- 25 mm Hg) was found after pharyngolaryngectomy. The shape of the pharynx in all the patients after laryngectomy with plasty or simple myotomy of the pes was regular, with thin and smooth mucosa while the rest pressure was low (3.0 +/- 1.18 kPa(-)+/- 22.5 +/- 8.8 mm Hg). In the analyzed material at the rest pressure in the sphincter area from 0.7 to 4kPa (from 5 to 30 mm Hg), 93% (41/44) of the patients have mastered the esophageal speech. It was stressed that videolaryngoscopy is entirely sufficient for the approximate assessment of the rest pressure in the pes area and prognosis of the esophageal speech development process.     

上食管括约肌在咽喉反流性疾病中的作用

咽喉反流性疾病(laryngopharyngeal reflux disease,LPRD)是指一组因胃内容物异常反流至食管上括约肌以上的咽喉部而引起的一系列临床症候群.人体具有多个抗反流相关屏障,包括下食管括约肌、膈肌脚、膈食管韧带等构成的高压带,食管体部的蠕动和酸廓清能力,上食管括约肌,咽喉部黏膜的自然抵抗力等.上食管括约肌在咽喉反流中发挥着屏障作用,然而上食管括约肌功能障碍是否是导致咽喉反流的原因至今还未明确.本文就国内外的一些相关研究进行讨论.     

Ambulatory 24‐Hour Double‐Probe pH Monitoring: The Importance of Manometry

Objective Historically, manometry has been used for sphincter localization before ambulatory 24‐hour double‐probe pH monitoring to ensure accurate placement of the probes. Recently, direct‐vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard. Methods Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry. Results Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects. Conclusion For double‐probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid‐exposure times. Thus, manometry is needed to ensure valid double‐probe pH monitoring data.     

The hypopharyngeal diverticulum. A simultaneous cineradiographic and manometric examination

The upper esophageal sphincter (UES) was studied in 10 patients with symptomatic hypopharyngeal diverticulum during rest and at deglutition using simultaneous cineradiography and manometry by means of triple pressure microtransducers. In all 10, cineradiographic examinations were performed. Occurrence of double pressure peaks was examined in 8/10. In 7/10, the length and resting pressure of the UES could be determined. In 5/10, the UES pressure could be recorded when the bolus was in the pharynx and in 6/10 when it reached the UES. The pressure below the neck of the diverticulum at the time when the bolus reached the diverticular entrance, was of the same magnitude or exceeded the resting pressure of the UES in 4 patients and was approximately 0 kPa in 2 patients. In 3 patients the UES contraction was elicited as soon as the bolus entered the pharynx and remained so till it had passed the UES. In 3 patients the contrast bolus was seen to pass simultaneously into the diverticulum and into the esophagus, even though the sphincter was contracted. It is plausible that the pharyngeal wall gives way when a bolus is forced against the contracted UES by the high peristaltic pressure forming a pulsion diverticulum as postulated already by Zenker in 1878. Double pressure peaks were registered in the UES at rest in 6 patients indicating a split between the muscle bundles in the sphincter.     

Swallowing and pharyngo-esophageal manometry in obstructive sleep apnea

IntroductionUpper airway nerve and muscle damage associated with obstructive sleep apnea may impair the strength and dynamics of pharyngeal and esophageal contractions during swallowing.ObjectiveTo evaluate the presence of alterations in pharyngoesophageal manometry in patients with obstructive sleep apnea with and without oropharyngeal dysphagia.MethodsThis study prospectively evaluated 22 patients with obstructive sleep apnea without spontaneous complaints of dysphagia, using a questionnaire, fiberoptic endoscopic evaluation of swallowing, and pharyngoesophageal manometry, including measurement of the upper and lower esophageal sphincter pressures and mean pharyngeal pressures at three levels during swallowing.ResultsThe dysphagia group consisted of 17 patients (77.3%) in whom swallowing abnormalities were detected on fiberoptic endoscopic evaluation of swallowing (n = 15; 68.2%) and/or in the questionnaire (n = 7; 31.8%). The five remaining cases comprised a control group without oropharyngeal dysphagia. In all cases of abnormalities on fiberoptic endoscopic evaluation of swallowing, there was premature bolus leakage into the pharynx. There was no statistically significant difference between the groups regarding any of the pharyngoesophageal manometry measurements, age, or severity of obstructive sleep apnea.ConclusionPharyngoesophageal manometry detected no statistically significant difference between the groups with and without oropharyngeal dysphagia.     

Hochauflösungsmanometrie der pharyngealen Schluckdynamik

Background

To transport a bolus from the mouth into the stomach, regular contraction of the pharyngeal muscles and a coordinated function of the upper esophageal sphincter (UES) are necessary. The muscle contraction generates intraluminal pressure, which pushes the bolus continuously forward. In contrast to imaging studies, manometric methods enable assessment of intraluminal pressure buildup and the function of the muscles involved. These methods were initially established for the esophagus and have been used increasingly in the pharynx for 7–8 years. Pharyngeal high-resolution manometry (pHRM) allows pressure measurements in high spatial and temporal resolution, and assessment of pharyngeal swallowing dynamics.

Objective

An overview is given of the implementation, evaluation, and interpretation of the pHRM data, as well as of the current state of research.

Materials and methods

PubMed and Scopus were searched for the keywords “high-resolution manometry” and “pharynx” or “upper esophageal sphincter”. Original articles, reviews, and book chapters on the subject pHRM were included.

Results

Swallowing pressure conditions in the pharynx and the UES can be assessed by pHRM. The spatiotemporal pressure plot gives an overview of changes in pharyngeal motor function. Determination of swallowing parameters enables a sophisticated evaluation of swallowing; a comparison with normal values permits delimitation of pathologies.

Conclusion

Although several swallowing parameters still need to be further evaluated for clinical routine, a pHRM study should nowadays always be carried out for a comprehensive evaluation of the swallowing process.