Effects of body position and bolus consistency on the manometric parameters and coordination of the upper esophageal sphincter and pharynx

The development of a solid-state intraluminal sphincter transducer has alleviated many of the problems associated with manometric studies of the upper esophageal sphincter (UES) and pharynx (P). We used this technology to study the effect of position (upright vs. supine) on resting UES pressures and the pressure dynamics of the UES/P complex during both wet and dry swallows in 11 normal volunteers and the effects of foods of different consistencies on the UES/P swallow dynamics in 10 normal volunteers. The UES/P coordination parameters were defined as the 15 time intervals that can be measured between any 2 of 6 pertinent points: the beginning, peak, and end of the pharyngeal contraction and the beginning, nadir, and end of the UES relaxation. Data from both the circumferential transducer used to measure sphincter pressures and a standard microtransducer used to measure pharyngeal pressures were collected on-line by an Apple IIe microcomputer and analyzed by programs written in our laboratory. Significant changes in swallow coordination were measured between upright and supine swallows of the same bolus size, between wet and dry swallows in the same position, and among foods of varying consistencies. Resting UES pressure was unchanged by position and pharyngeal contraction pressure was unchanged by bolus size or consistency.     

Deterioration of esophageal motility with age: a manometric study of 79 healthy subjects

OBJECTIVE: Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus. METHODS: Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18-73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: < or = 25 yr, 26-35 yr, 36-45 yr, 46-55 yr, 56-65 yr, and > 65 yr. RESULTS: Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r = -0.943, p = 0.005), UES pressure (r = -0.943, p = 0.005), middle and lower peristaltic wave amplitude (r = -0.947, p = 0.004, and r = -0.844, p = 0.035, respectively), upper/middle peristaltic progression speed (r = -0.943, p = 0.005), and the proportion of simultaneous contractions (r = 0.926, p = 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups. CONCLUSIONS: The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.     

Manometric characteristics of the upper esophageal sphincter recorded with a microsleeve

OBJECTIVES: We compared manometric recordings of the upper esophageal sphincter (UES) recorded with a miniature sleeve to those obtained using standard manometry. METHODS: The UES pressure of eight volunteer subjects was measured by station pull-through (SPT), by rapid pull-through (RPT), and with a microsleeve sensor for 30 min, followed by 15 min of esophageal acid infusion. Deglutitive UES relaxation recorded with a microsleeve and solid state sensor were compared. RESULTS: The UES pressure recorded with the microsleeve (25+/-9 mm Hg) was significantly less than that by SPT (114+/-18 mm Hg) or RPT (152+/-19 mm Hg), and was unaffected by acid infusion. Periods of low UES pressure were observed during long interswallow intervals (11+/-4, range 6-18 mm Hg). Deglutitive relaxation duration and intrabolus pressure measured with the microsleeve were less than those recorded by the solid state transducer. CONCLUSIONS: "Normal" UES pressure is heavily dependent on measurement technique; pressures obtained with a miniature sleeve are a fraction of those obtained by SPT or RPT. During periods of relative comfort with minimal swallowing, UES tone is approximately 10 mm Hg, similar to that during sleep. Volume modulation of deglutitive UES relaxation is demonstrable with a microsleeve, albeit with less precision than with a solid-state transducer.     

Esophageal manometry: a comparison of findings in younger and older patients

Objective: We sought to determine the utility of esophageal manometry in an older patient population.
Methods: Consecutively performed manometry studies (470) were reviewed and two groups were chosen for the study, those ≥ 75 yr of age (66 patients) and those ≤ 50 years (122 patients). Symptoms, manometric findings (lower esophageal sphincter [LES], esophageal body, upper esophageal sphincter [UES]) and diagnoses were compared between the groups.
Results: Dysphagia was more common (60.6% vs 25.4%), and chest pain was less common (17.9 vs 26.2%) in older patients. In the entire group, there were no differences in LES parameters. Older patients with achalasia had lower LES residual pressures after deglutition (2.7 vs 12.0 mm Hg), but had similar resting pressures (31.4 vs 35.2 mm Hg) compared with younger achalasia patients. Duration and amplitude of peristalsis were similar in both groups, whereas peristaltic sequences were more likely to be simultaneous in the older group (15% vs 4%). The UES had a lower resting pressure in the older patients (49.6 vs 77.6 mm Hg) and a higher residual pressure (2.0 vs −2.7 mm Hg). The older patients were less likely to have normal motility (30.3% vs 44.3%) and were more likely to have achalasia (15.2% vs 4.1%) or diffuse esophageal spasm (16.6% vs 5.0%). When only patients with dysphagia were analyzed, achalasia was still more likely in the older group (20.0% vs 12.9%).
Conclusions: When older patients present with dysphagia, esophageal manometry frequently yields a diagnosis to help explain their symptoms.     

Upper esophageal sphincter function in patients with Zenker's diverticulum

Upper esophageal sphincter function (UES) was studied in 8 patients with Zenker's diverticulum. Radiologic and endoscopic studies revealed pharyngoesophageal diverticula of varying size. No tumor or stenosis was found. Esophageal manometry showed no significant difference between patients and 8 matched controls with respect to UES resting pressure, delay of maximal UES relaxation, and maximal pharyngeal contraction. All patients exhibited a drop of the UES pressure to esophageal resting pressure during swallowing. These results indicate that disturbances of UES function in established Zenker's diverticulum are a myth.     

Evaluation of the Upper Esophageal Sphincter (UES) Using Simultaneous High-Resolution Endoluminal Sonography (HRES) and Manometry

The aim of this study was to characterize the motion, morphology, and pressure of the upper esophageal sphincter (UES). The UES and its surrounding structures were evaluated in seven normal subjects and four human cadavers, using simultaneous high-resolution endoluminal sonography and manometry. The UES musculature on ultrasound is a C-shaped structure with an angle of 107 +/- 19 degrees. The mean peak resting UES pressure was 74 mm Hg, with a total cross-sectional area (CSA) of 0.87 +/- 0.33 cm2. During swallowing, the UES moved in an orad direction. Localizing the UES sonographically, the peak UES pressure in the cadavers was 19.7 +/- 10.0 mm Hg. The UES has a greater muscular CSA and resting pressure than the upper esophageal body. In the cadaver studies, the UES was imaged in conjunction with a significant increase in pressure, indicating that the pressure is due to passive mechanical conformational changes.     

The Effects of Age, Sex, and Smoking on Normal Pharyngoesophageal Motility

Previous reports of normal pharyngoesophageal motility have described normal ranges in small numbers of young adults. In this study, the results of upper esophageal sphincter (UES) manometry with a microtransducer assembly in 67 healthy volunteers aged 17-77 yr have been analyzed for possible effects of age, sex, and cigarette smoking. Older subjects were found to have only marginally lower UES tonic pressures, but markedly elevated pharyngeal contraction pressures. Increasing age was associated with a reduction in duration of upper esophageal contractions and, for bread swallows, an increase in pharyngoesophageal wave velocity which may represent compensatory mechanisms for airway protection. Male subjects showed greater UES axial asymmetry than females, perhaps due to sex differences in laryngeal anatomy, whereas females had greater UES wet swallow after-contraction pressures which may be relevant to the generation of globus sensation. All results were independent of cigarette smoking. We conclude that normal values obtained in small numbers of young adults form an inadequate basis for the interpretation of UES tonic and pharyngeal contraction pressures, which are reported to be abnormal in older patients with dysphagia, and that manometric investigation of dysphagic patients requires the analysis of multiple parameters of dynamic pharyngoesophageal function.     

Effect of head position on the dynamics of the upper esophageal sphincter and pharynx

Due to limitations in available technology it has been difficult to obtain data on upper esophageal sphincter (UES) and pharyngeal (P) function under varying physiologic conditions. We used a manometry system with solid-state intraluminal transducers, including a circumferential sphincter transducer, and computer analysis to measure pressure changes in UES and P during wet (5 ml H₂O) swallows as the head was moved through a 75 degree arc in nine normal volunteers. UES residual pressure increased markedly and duration of UES relaxation decreased with increasing head extension. Similar decreases were also seen with time between P peak and both UES nadir and UES end. There were no changes in either pharyngeal peak pressures or the duration of the pharyngeal contraction. Head extension produces major changes in UES relaxation and UES/P coordination. These effects may be clinically important when feeding neurologically impaired patients.     

Pharyngeal/upper esophageal sphincter pressure dynamics in humans

Extensive physiological studies of swallowing have been carried out in laboratory animals; however, similar studies in humans have been limited by available technology. In this study we describe the use of a solid-state circumferential sphincter transducer to define manometric characteristics of the human pharynx and upper esophageal sphincter (UES). Effects of pharmacologic agents and thermal stimulation are also described. We studied nine normal volunteers on three separate days. All studies were done in the upright position and consisted of a station pull-through of the UES and six wet swallows with the sphincter transducer in the most proximal segment of the UES and a posteriorly oriented single transducer 5 cm proximal in the pharynx. Baseline studies preceded all drug studies. Effects of bethanechol were studied on day 1, cold stimulation and benzonatate on day 2, edrophonium and atropine on day 3. The UES resting pressure showed large intrasubject day-to-day variations; however, mean values did not differ. There were no effects on UES relaxation or swallow coordination with any of the pharmacologic agents, although benzonatate produced multiple pharyngeal contractions.     

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 sphincters (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. The first author was financially supported by the Netherlands Digestive and Disease Foundation and the Netherlands Organization for Scientific Research (NWO).     

Lower-esophageal sphincter function does not determine resting upper-esophageal sphincter pressure

Records of 269 esophageal motility studies were reviewed to determine the relationship between lower-esophageal sphincter (LES) function and upper-esophageal sphincter (UES) pressure. Average and greatest UES pressures were similar in patients with LES pressures less than 10 mm Hg or greater than 20 mm Hg, and in patients with and without gastroesophageal reflux as determined by an intraesophageal pH electrode test. Although teliologically appealing, the belief that patients with weak lower-esophageal sphincters and gastroesophageal reflux have stronger upper-esophageal sphincters to guard against pharyngeal reflux and aspiration cannot be confirmed by current manometric techniques.     

Effect of age on differences in upper esophageal sphincter and pharynx pressures between patients with dysphagia and control subjects

OBJECTIVES: The aim of this study was to explore the effect of age and food consistency on manometric data of the swallow sequence in patients with dysphagia. METHODS: Manometric data from 41 patients (age range, 32-88 yr) and 41 age-matched control subjects was examined for differences between subgroups < 60 yr and > or = 60 yr of age, as well as for changes with food consistency. RESULTS: Only pharynx peak pressure showed an age-dependent decrease (144.1 +/- 21.4 mm Hg vs 95.8 +/- 15.1 mm Hg, p < 0.05) in patients. Significant higher upper esophageal sphincter residual pressure and delayed onset of upper esophageal sphincter relaxation were noted in patients aged <60 yr compared to age-matched controls, whereas only pharynx peak pressure was significantly lower in patients compared to controls aged > or = 60 yr. Food consistency did not have a consistent effect on manometric results in patients with dysphagia. CONCLUSIONS: This is the first study to systematically explore the influence of age and food consistency on manometric parameters in dysphagia patients. These results may provide useful insights when identifying actual manometric abnormalities in patients with dysphagia. They also suggest possible different underlying mechanisms of dysphagia in younger versus older patients.     

The Effects of Aspiration Status, Liquid Type, and Bolus Volume on Pharyngeal Peak Pressure in Healthy Older Adults

The reasons for aspiration in healthy adults remain unknown. Given that the pharyngeal phase of swallowing is a key component of the safe swallow, it was hypothesized that healthy older adults who aspirate are likely to generate less pharyngeal peak pressures when swallowing. Accordingly, pharyngeal and upper esophageal sphincter pressures were examined as a function of aspiration status (i.e., nonaspirator vs. aspirator), sensor location (upper vs. lower pharynx), liquid type (i.e., water vs. milk), and volume (i.e., 5 vs. 10?ml) in healthy older adults. Manometric measurements were acquired with a 2.1-mm catheter during flexible endoscopic evaluation. Participants (N?=?19, mean age?=?79.2?years) contributed 28 swallows; during 8 swallows, simultaneous manometric measurements of upper and lower pharyngeal and upper esophageal pressures were obtained. Pharyngeal manometric peak pressure was significantly less for aspirators (mean?=?82, SD?=?31?mmHg) than for nonaspirators (mean?=?112, SD?=?20?mmHg), and upper pharyngeal pressures (mean = 85, SD = 32?mmHg) generated less pressure than lower pharyngeal pressures (mean?=?116, SD?=?38?mmHg). Manometric measurements vary with respect to aspiration status and sensor location. Lower pharyngeal pressures in healthy older adults may predispose them to aspiration.     

Radial and longitudinal asymmetry of human pharyngeal pressures during swallowing

Radial asymmetry of upper esophageal sphincter resting pressure has been previously described; however, neither radial nor longitudinal asymmetry of pharyngeal pressures has been demonstrated. The authors used a specially designed intraluminal transducer catheter (Konigsberg; Konigsberg Instruments, Pasadena, CA) with four solid-state transducers separated by 3 cm and oriented circumferentially at 90 degrees intervals to measure pharyngeal pressures. Two wet swallows at each 1-cm interval along the length of the pharynx were measured in 12 normal volunteers (10 male, 2 female; mean age, 38 years). Pressure data were collected on-line by an Apple IIe microcomputer (Apple Computer Inc., Cupertino, CA) at 100 Hz and analyzed for both radial and longitudinal asymmetry. Significant (P less than 0.05) longitudinal asymmetry was shown in all positions except right lateral. Radial asymmetry was present for the first 4 cm only, with anterior and posterior pressures significantly (P less than 0.05) higher than lateral pressures. It was concluded that pharyngeal pressure responses show both axial and longitudinal asymmetry in the distal pharynx. Awareness of transducer position and orientation is essential in the evaluation of pharyngeal pressures.     

Manometric characteristics of cervical dysphagia in a patient with the Kearns-Sayre syndrome.

The manometric findings of deglutitive pharyngoesophageal function in a patient with the Kearns-Sayre syndrome and cervical dysphagia are described. These findings indicate that striated muscles of the pharynx, upper esophageal sphincter (UES), and proximal esophagus are involved. Near absence of pharyngeal peristalsis, abnormally low UES resting pressure, and absence of proximal esophageal peristalsis characterize the manometric findings in this patient. It is conceivable that in mild cases, a combination of various degrees of severity of the above findings may exist.     

Oropharyngeal swallowing in normal adults of different ages.

In an effort to evaluate the effect of normal aging on oropharyngeal events of swallowing, 80 normal volunteers, stratified by gender into four age groups, were studied. Liquid and semisolid swallows were performed and recorded simultaneously using videofluoroscopy and manometry. Several parameters, including total duration of oropharyngeal swallowing, were significantly longer in the oldest age group than in any other age group. A delay in initiation of maximal hyolaryngeal excursion primarily accounted for the longer durations with increased age. Significant durational changes also were found as a function of bolus consistency and presence or absence of the manometry tube. Females had a longer duration of upper esophageal sphincter (UES) opening. The amplitude of pharyngeal pressures, duration of peak pharyngeal pressures, and rate of propagation of the contractions were not significantly different for age, gender, or consistency of bolus. No significant differences were found between age groups or between genders in UES pressure. Normal aging affects some parameters of swallowing, while others are preserved.     

Effects of Bolus Volume on Pharyngeal Contact Pressure During Normal Swallowing

This cross-sectional study investigated the effect of bolus volume on contact pressure within the pharynx and upper esophageal sphincter (UES). Three solid-state manometric pressure sensors were placed transnasally into the pharynx and the proximal esophagus of 40 participants (gender equally represented and between the ages of 20 and 45 years). Participants completed five repetitions each of three swallowing conditions: 5-, 10-, and 20-ml water bolus swallows. Repeated-measures ANOVA revealed no significant differences in the amplitude of pharyngeal contact pressure between the three swallowing conditions (sensor 1: p = 0.627, sensor 2: p = 0.764). Similarly, for durational measures nonsignificant main effects were found at both sensor 1 (p = 0.436) and sensor 2 (p = 0.350). Significant differences were found in UES pressure between the three conditions of bolus swallows (p = 0.000), with negative pressure in the UES inversely proportionate to bolus volume. However, durational measures of UES relaxation pressure were not significantly different between all conditions (p = 0.473). This study demonstrates no significant pressure differences of amplitude and duration between swallowing conditions in the pharynx. At the level of the UES, smaller boluses generated greater negative pressure.     

Upper esophageal sphincter and esophageal motility in patients with chronic cough and reflux: assessment by high‐resolution manometry

The pathophysiology of chronic cough and its association with dsymotility and laryngopharyngeal reflux remains unclear. This study applied high‐resolution manometry (HRM) to obtain a detailed evaluation of pharyngeal and esophageal motility in chronic cough patients with and without a positive reflux–cough symptom association probability (SAP). Retrospective analysis of 66 consecutive patients referred for investigation of chronic cough was performed. Thirty‐four (52%) were eligible for inclusion (age 55 [19–77], 62% female). HRM (ManoScan 360, Given/Sierra Scientific Instruments, Mountain View, CA) with 10 water swallows was performed followed by a 24‐hour ambulatory pH monitoring. Of this group, 21 (62%) patients had negative reflux–cough SAP (group A) and 13 (38%) had positive SAP (group B). Results from 23 healthy controls were available for comparison (group C). Detailed analysis revealed considerable heterogeneity. A small number of patients had pathological upper esophageal sphincter (UES) function (n = 9) or esophageal dysmotility (n = 1). The overall baseline UES pressure was similar, but average UES residual pressure was higher in groups A and B than in control group C (?0.2 and ?0.8 mmHg vs. ?5.4 mmHg; P < 0.018 and P < 0.005). The percentage of primary peristaltic contractions was lower in group B than in groups A and C (56% vs. 79% and 87%; P = 0.03 and P < 0.002). Additionally, intrabolus pressure at the lower esophageal sphincter was higher in group B than in group C (15.5 vs. 8.9; P = 0.024). HRM revealed changes to UES and esophageal motility in patients with chronic cough that are associated with impaired bolus clearance. These changes were most marked in group B patients with a positive reflux–cough symptom association.     

Timing of Pharyngeal and Upper Esophageal Sphincter Pressures as a Function of Normal and Effortful Swallowing in Young Healthy Adults

The effect of effortful swallow on pharyngeal pressure and UES relaxation onsets and durations was examined. Eighteen adults, nine males and nine females (mean age = 27.9 yr), participated. Timing of pharyngeal pressure and onset and duration of UES relaxation were measured across ten trials of normal and ten trials of effortful swallows. Results revealed that manometric timing measurements are consistent across trials. The first and second statistical analyses investigated the pharyngeal pressure and UES relaxation onsets and durations, respectively. Both analyses identified a significant interaction of swallow type (i.e., effortful vs. normal) by manometric sensor location (p < 0.05). Across normal and effortful swallows, UES relaxation preceded pharyngeal pressure onsets, yet the rate of change (or degree of delay) varied across the sensors. Furthermore, the effortful swallow elicited longer pharyngeal pressure and UES relaxation durations, yet the pressure duration measured in the upper pharynx was significantly longer than that measured lower in the pharynx. These findings offer insight as to the potential positive and negative influence of the effortful swallow on pharyngeal timing.