A method for continuous monitoring of upper esophageal sphincter pressure

We tested a manometric assembly employing a sleeve sensor that is able to monitor anterior or posterior pressure in the human upper esophageal sphincter (UES) for prolonged intervals. When compared to rapid pull-through measurement of UES pressure obtained with conventional manometric assemblies, the sleeve sensor measured significantly lower UES pressures with less variability between subjects, thereby suggesting that the rapid pull-through maneuver stimulates the UES to contract. Concurrent recordings of UES pressure with a sleeve sensor and a side-hole sensor during a slow station pull-through yielded almost equal pressure values at the peak of the high-pressure zone (station zero), but the side-hole site recorded significantly lower pressures than the sleeve at stations 0.5 cm or more from the peak of the high-pressure zone. During 10 min of recording at station zero, the sleeve sensor recorded greater pressures than the side-hole sensor. This finding demonstrated the suceptibility of the side-hole sensor to axial movement relative to peak UES pressure. When stationary, both the sleeve sensor and the side-hole sensor recorded significantly lower UES pressure after 1-2 min of recording, again suggesting that movement of the recording assembly stimulates the UES to contract. Sleeve recordings of swallow-induced UES relaxations showed that UES relaxations induced by water swallows were slightly longer than those induced by dry swallows. Augmentations of UES pressure induced by balloon distension of the esophageal body were also recorded. We conclude that the sleeve sensor is a suitable method for investigating the normal physiology and pathophysiology of the UES in human subjects.     

Aging-related alterations in human upper esophageal sphincter function

Recent improvements in manometric catheters have made measurement of pharyngeal (P) and upper esophageal sphincter (UES) swallowing mechanics more reliable. Few studies have attempted to evaluate the effect of normal aging on P and UES mechanics. Pharyngeal and upper esophageal sphincter dynamics were studied in 10 healthy elderly adults (age greater than 60; range 62-79 yr) and 10 younger adults (age less than 60; range 24-59 yr). A solid-state intraluminal transducer system was used with a proximal unidirectional Konigsberg microtransducer and a circumferential (sphincter) transducer located 5 cm distally. Mean resting UES pressure was significantly (p less than 0.05) lower in the elderly than in the younger subjects (52 +/- 5 vs 72 +/- 6 (SE)) mm Hg. A significant inverse relation (R = -0.54; p less than 0.02) was found between age and resting UES pressure. Time from peak of pharyngeal contraction to UES nadir was significantly (p less than 0.05) shortened in the healthy elderly vs younger controls (10 +/- 30 vs 90 +/- 20 ms) during dry swallows. Our studies indicate that aging is associated with lower resting UES pressure and delayed UES relaxation, relative to the pharyngeal peak.     

Relationship of Intraluminal pH and Pressure within the Lower Esophageal Sphincter

To determine the relationship between lower esophageal sphincter (LES) intraluminal pressure and its intraluminal pH, we studied six healthy volunteers. We recorded intraluminal pressure and pH concurrently using rapid pull-through, slow pull-through, and station pull-through, as well as, rapid push-through and slow push-through techniques. The results showed that LES length was 35 +/- 4 (SE) mm by RPT and 30 +/- 3 mm by SPT. The pressure was maximal in the proximal half of the LES. On rapid pull-throughs, the intraluminal pH rose from about 1.5 to reach a value of about 2.5 at the peak of the high pressure zone. With continued withdrawal into the esophageal body, the recorded pH rose minimally to about 3-4. On push-throughs, the pH recorded along the LES was the same as that of the esophageal body. After the electrode cleared the LES, the pH abruptly fell to gastric pH. During station pull-through with the electrode 0.5-1.5 cm proximal to the distal LES margin, transient pH drops were observed with swallows. With rapid swallows, however, the pH drop did not occur until after the last swallow. This finding suggests that the pH drops with swallows were due to axial LES movement rather than gastroesophageal acid reflux. We conclude that 1) the relationship of the gastroesophageal pH transition zone and LES high pressure zone is better defined by a sphincter push-through than a pull-through; 2) the transition between gastric and esophageal pH occurs either at or slightly distal to the distal LES margin; and 3) swallow-induced axial LES movement may cause spurious recording of acid reflux when the pH probe is positioned within the distal half of the LES.     

Evaluation of esophageal motility in laryngectomized patients

Laryngectomy for treatment of laryngeal-pharyngeal carcinomas may impair the sensation in the larynx and epiglottis, with consequent impairment of esophageal motility. Our aim in the present study was to investigate the esophageal motility of laryngectomized patients. Esophageal manometry was performed on 17 patients submitted to laryngectomy 2 to 71 months (median 29 months) before the examination. Eleven were rehabilitated with esophageal voice and six could not speak. Ten swallows of a 5 ml bolus of water were recorded at the lower esophageal sphincter and at 5, 10 and 15 cm above it. The lower esophageal sphincter pressure was measured by the rapid pull-through method and the upper esophageal sphincter pressure by the station pull-through method. The results were compared with those obtained for a control group of 40 healthy volunteers. The amplitude of contractions was lower and the number of nonperistaltic contractions was higher in laryngectomized patients than in volunteers (P < 0.05). The duration of lower esophageal sphincter relaxation (7.4 +/- 1.5 s) was shorter in laryngectomized patients than in volunteers (8.8 +/- 1.6 s, P < 0.05). The upper esophageal sphincter pressure was lower (34.9 +/- 29.1 mm Hg) in laryngectomized patients than in volunteers (61.2 +/- 20.8 mm Hg, P < 0.05). There was no difference between groups in contraction duration or velocity, in the numbers of multipeaked or failed contractions, lower esophageal sphincter pressure or in the number of swallows followed by complete lower esophageal sphincter relaxation. In conclusion, laryngectomy causes esophageal motility impairment characterized by low contraction amplitude, nonperistaltic contraction and shorter lower esophageal sphincter relaxation duration.     

Esophageal manometry

Pressure transients in the pharyngoesophagus vary widely, from about 2500 mm Hg/sec in the pharynx to 150 mm Hg/sec in the lower esophageal sphincter (LES). Perfused side-hole and Dent-sleeve manometry have limitations with respect to their inability to record pharyngeal pressure transients and their relative inability to record abrupt pressure increases in the upper esophageal sphincter (UES), although falling pressure changes, ie, relaxations, of more than 1000 mm Hg/sec can be detected easily by the Dent sleeve. Hence, accurate pharyngeal and UES recordings require pressure sensors that are able to record pressure transients faster than 2500 mm Hg/sec. Microtransducers meet this requirement. Except for their relatively high costs of acquisition, microtransducers have a lot of advantages in comparison with the perfused side-hole methods: the small outer diameter and flexibility enable easy intubation; baseline pressures are not affected by subject position; and plumbing necessary for infusion is eliminated. After presoaking in water, calibration is stable and the baseline drift is acceptable. They have an excellent linearity and a negligible hysteresis. Their durability is satisfactory. The microtransducer assemblies can be designed in almost any configuration and even circumferentially sensitive microtransducers for acute sphincter measurements have been developed. For long-interval recordings of the UES and the LES, however, microtransducers are not suitable: for these the Dent sleeve is required. Recently, microtransducers have been used more frequently because they are indispensable in the 24-hr ambulatory esophageal manometry technology.     

Reproducibility of the Rapid Pull-Through Technique for Categorizing Lower Esophageal Sphincter Pressure

Duplicate measurements of basal lower esophageal sphincter (LES) pressure using a triple-lumen catheter and the rapid pull-through technique (RPT) were performed in 250 consecutive patients to determine their reproducibility for categorizing LES pressures as normal, hypertensive, or hypotensive. For all subjects, mean LES pressure did not differ for the two measurements (25.3 +/- 1.0 vs. 26.2 +/- 1.0 mm Hg, p greater than 0.5), but the correlation coefficient was only modest (r = 0.73). Reproducibility of categorization was 92% (230 of 250 subjects), and was best for subjects with normal (170/179, 95%) or hypotensive (24/26, 92%) values (for hypertensives: 36/45, 80%). Interstudy variability was least for the hypotensive group (1.8 +/- 0.2 mm Hg) and greatest for the hypertensive group (16.4 +/- 1.9 mm Hg). Likewise, the range of individual values from the triple-lumen catheter was least for the hypotensive subjects (4.7 +/- 0.7 mm Hg) and greatest for those with hypertensive LES pressure (32.5 +/- 2.6 mm Hg). These data show that, despite its interstudy variability, the RPT reproducibly categorizes basal LES pressure in greater than 90% of cases. The technique appears least reliable in determining hypertensive LES pressure, where diaphragmatic contraction may most significantly contribute to measurement variability.     

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.     

Comparison of Lower Esophageal Sphincter Manometrics and Gastroesophageal Reflux Measured by 24-Hour pH Recording

We compared lower esophageal sphincter (LES) pressures to parameters of acid reflux measured during 24-h pH monitoring in 81 patients being evaluated for possible reflux disease. Mid-respiratory LES pressures were significantly higher (p less than 0.05) in patients with normal amounts of reflux than in those with abnormal reflux. This difference did not occur with LES pressure measured by end-expiratory station pull-through (SPT) or rapid pull-through (RPT). There was no significant difference in total length or intra-abdominal portion of LES between the two groups. However, the product of LES pressure and total LES length was greater (p less than 0.05) for patients with normal reflux than for these with abnormal reflux. No difference was noted in the percentage of abnormal contractions in the distal esophagus between groups. These studies support the following conclusions: 1) LES pressure may be a more important protective mechanism against reflux than LES length. 2) Mid-respiratory SPT technique appears to identify the LES antireflux barrier better than either end-expiratory SPT or RPT techniques. 3) Acid exposure time seems to be a better measure of gastroesophageal reflux than the number of reflux episodes.     

Upper esophageal sphincter pressure recording: Is an oval manometry catheter necessary?

A comparison was made between recording by a round and oval catheter of upper esophageal sphincter (UES) pressures in 20 normal volunteers. Each catheter had four radial side openings at 90°. The round catheter was 4 mm in diameter, which was identical to the smaller (antero posterior) dimension of the oval catheter. Studies were performed using a pneumohydraulic perfusion system with a random sequence of studies regarding the type of catheter and technique; station pull-through, or rapid pull-through. All pressures were evaluated by on-line computer analysis. There was no significant difference in mean, maximum, or minimum UES pressure recorded by the round or oval catheter. Consistently higher pressures were obtained during rapid pull-through with both the oval and round catheters. We conclude that UES pressures recorded in normal subjects vary with pull-through technique and that comparable UES pressures can be obtained with either an oval or round catheter configuration having at least four side openings at 90° intervals.     

Normal pharyngoesophageal motility

Upper esophageal manometry is technically problematic. Published normal values are, therefore, few and wide ranging, reflecting catheter and recording-system variables, while the reproducibility of measurements and the influence of food consistency have been little studied. In this investigation, 50 healthy volunteers were studied with (1) a 2.8-mm-diameter six-sensor catheter-mounted transducer assembly and (2) a 3.2×7.2-mm sleeve device linked to a computerized recorder with a pressure-sample rate of 32/sec. The study protocol included water, bread, and semisolid swallows. Upper esophageal sphincter (UES) tonic pressures measured with the catheter-mounted assembly were lower and more reproducible than pressures measured with the sleeve system. Compared with water, bread swallows showed greater pharnygeal and sphincter after-contraction pressures, while semisolid swallows had less complete sphincter relaxation. Duration of pharyngoesophageal contractions was greater with bread or semisolid than water. The observations have established normal values for measurements of UES function and, in addition, have shown that (1) catheter variables significantly influence the measurement of upper sphincter tonic pressure, (2) pressures recorded with the catheter-mounted transducer are most reproducible, and (3) pharyngoesophageal motility patterns vary significantly according to the substance swallowed.This study was supported by the Scottish Home and Health Department grant K/MRS/50/C922.     

Effect of phenylalanine-vasopressin on the lower esophageal sphincter. Possible implications in the treatment of bleeding esophageal varices]

Vasopressin and its analogs are used inthe treatment of bleeding esophageal varices. Since gastrointestinal reflux may have a deleterious effect on variceal hemorrhage, the effect of 2,3-phenylalanine-8-lysine-vasopressin upon the lower esophageal sphincter (LES) was studies by rapid pull-through manometry in 24 persons. PLV infusion up to a dosis of 2.7 mU/kg/h raised LES pressure from 15.1 +/- 1.3 (SEM) to 17.9 +/- 2.0 mm Hg. Higher doses lowered LES pressure progressively to 12.1 +/- 0.7 mmHg at 54 mU/kg/h. The serum gastrin level did neither correlate with basal LES pressure not with LES pressure changes during PLV infusion. Therefore, PLV does not appear to act indirectly through serum gastrin. Because of the danger of systemic side effects and of the undesirable in LES pressure with the usual high doses of vasoactive substances, a continuous infusion of lower doses of vasopressin analogs appears to be advantageous.     

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.     

Double-blind investigation of the effects of propranolol and placebo on the pressure of esophageal varices in patients with portal hypertension

This study was aimed at investigating the effects of propranolol on esophageal variceal pressure in patients with portal hypertension. Variceal pressure was measured at endoscopy using a miniature pressure-sensitive gauge in 20 patients with portal hypertension. Measurements were obtained under baseline conditions and 20 min after double-blind administration of propranolol (0.15 mg/kg; n = 10) or an identical amount of placebo (normal saline, 0.3 ml/kg; n = 10). Under baseline conditions, variceal pressure was similar in propranolol and placebo groups (14.1 +/- 5 mm Hg vs. 14.9 +/- 6.6 mm Hg, respectively; not significant). Placebo had no significant effect on variceal pressure (baseline = 14.9 +/- 6.6 mm Hg; placebo = 15.5 +/- 6.6 mm Hg; not significant), and values after placebo administration were closely correlated with baseline values (r = 0.98; y = 1.1 + 0.97 x; p less than 0.0001). In contrast, propranolol caused a significant decrease in the pressure of esophageal varices (from 14.1 +/- 5 mm Hg to 11.3 +/- 4.4 mm Hg; p less than 0.0002). No significant changes in the size of esophageal varices were observed after propranolol or placebo administration. This study shows (a) the endoscopic pressure-gauge technique has a low variability and may be used to assess acute drug-induced changes in variceal pressure; and (b) propranolol causes significant decreases in variceal pressure in patients with portal hypertension and esophageal varices.     

Upper esophageal sphincter function during belching

We studied the mechanism of belching with specific attention to the upper esophageal sphincter (UES) in 14 normal volunteers. Belching occurred by the following sequence of events: lower esophageal sphincter relaxation; gastroesophageal gas reflux, recorded manometrically as a gastroesophageal common cavity phenomenon; UES relaxation; esophagopharyngeal gas reflux; and restoration of intraesophageal pressure to baseline by a peristaltic contraction. Upper esophageal sphincter relaxations comparable to those associated with belches were induced by abrupt esophageal distention with air boluses. In contrast, fluid boluses injected into the midesophageal body either had no effect on UES pressure or increased UES pressure. Thus, the UES responded to esophageal body distention in two distinct ways: abrupt relaxation in response to air boluses and pressure augmentation in response to fluid boluses. Mucosal anesthesia did not alter the UES response to esophageal boluses of gas or liquid thereby making it unlikely that these substances are differentiated by a mucosal receptor. Rapid distention of the proximal esophagus with a cylindrical balloon (15 cm long) elicited UES relaxation. These findings suggest that the rapidity and spatial pattern of esophageal distention, rather than discrimination of the type of material causing the distention, determines whether or not UES relaxation occurs.     

Cholecystokinin is not a major hormonal regulator of lower esophageal sphincter pressure

Although injection of cholecystokinin can reduce resting lower esophageal sphincter pressure, the physiological significance of this finding has not been established. The purpose of this double-blind crossover study was to determine the effect of physiological plasma levels of cholecystokinin on resting lower esophageal sphincter pressure. Eighteen normal male volunteers were studied on two separate days. Following a 20-minute baseline period, subjects received infusions of saline or synthetic cholecystokinin-8 at increasing rates. Basal plasma cholecystokinin levels averaged 1.3 +/- 0.2 pmol/L (mean +/- SE) and increased to levels of 7.4 +/- 0.9 pmol/L, 12.1 +/- 2.4 pmol/L, and 23.1 +/- 3.8 pmol/L during cholecystokinin infusion rates of 21, 42, and 84 pmol/min, respectively. Lower esophageal sphincter pressure was recorded continuously with a sleeved catheter. Basal lower esophageal sphincter pressure averaged 19.9 mm Hg and did not change with the first infusion, which produced physiological peak postprandial plasma levels of cholecystokinin. Lower esophageal sphincter pressure declined only during the infusions that produced plasma cholecystokinin levels two to four times greater than normal peak postprandial levels. Since infusion of cholecystokinin to levels that reproduce physiological blood levels does not significantly decrease lower esophageal sphincter pressure, it was concluded that cholecystokinin is not a major hormonal regulator of lower esophageal sphincter relaxation.     

Correlation between clinical severity score and the lower esophageal sphincter relaxation pressure in idiopathic achalasia

OBJECTIVES: Achalasia is an esophageal motor disorder characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES). The meaningful correlation between LES relaxation pressure and the severity of clinical symptoms is uncertain. The aim of this study was to elucidate the correlation between the clinical scoring and the LES relaxation pressure. METHODS: Over a 4-yr period from 1997 to 2001, all newly diagnosed patients with idiopathic achalasia were consecutively enrolled in a study. Diagnosis was established based on clinical, radiographic, endoscopic, and manometric criteria. The severity of five cardinal symptoms was scored on a scale of 0-3, and each patient received a total symptom score of 1-15. Manometry was subsequently performed, and the mean of five complete pull-through measurements was recorded as the resting LES relaxation pressure. RESULTS: A total of 115 patients (67 male and 48 female) with a mean age of 37.7 yr (range 12-90 yr) were included in the study. The mean total symptom score was 9.32 (range 3.00-14.00) and mean LES relaxation pressure before therapy was 56.29 mm Hg (range 8.00-107.80 mm Hg). Linear regression analysis showed a significant association between the total symptom score and LES relaxation pressure (p < 0.002, r = 0.290). Among the main symptoms, active and passive regurgitation showed significant correlation with LES relaxation pressure when compared to other individual symptoms using Pearson's correlation coefficient (p < 0.001 and 0.002, respectively). CONCLUSIONS: Our study showed that a clinical symptom score can be an appropriate predictor of the LES relaxation pressure in patients with idiopathic achalasia before therapy. Further studies are needed to evaluate similar correlations after therapeutic intervention.     

Human anal motility while fasting, after feeding, and during sleep

The aim of this study was to determine whether the human anal sphincter responds dynamically to changing physiological states. In 19 healthy human subjects, intraluminal anal canal pressure was measured with a 5-cm perfused sleeve sensor during the day while fasting (3 hours) and after feeding (3 hours) and at night during sleep (8 hours). Daytime mean anal canal pressures (+/- SEM) while fasting (50 +/- 3 mm Hg) were similar to those after feeding (49 +/- 3 mm Hg) and to those at night during sleep (49 +/- 3 mm Hg). Marked minute-to-minute variations in mean pressure occurred in all three periods, however, as did large phasic increases and decreases in pressure (greater than 20 mm Hg) and small phasic changes in pressure less than 20 mm Hg (anal slow waves). The minute-to-minute variations in mean pressure were greater during the awake fed state (4 +/- 1 mm Hg/min) than at night during sleep (2 +/- 1 mm Hg/min; P less than 0.03), as were the number of large phasic waves per minute (increases in pressure: awake, fed = 0.5 +/- 1 waves/min, night = 0.3 +/- 0.1 waves/min, P less than 0.05; decreases in pressure: awake, fed = 0.4 +/- 0.1 waves/min, night = 0.2 +/- 0.1 waves/min, P less than 0.05). Anal small waves had a similar frequency of about 17 waves/min in all three states. In conclusion, the anal sphincter maintains a continuous pressure barrier to rectal outflow both during the day and at night during sleep. However, marked minute-to-minute variations in mean pressure and large phasic increases and decreases in pressure do occur. Both are fewer at night during sleep.     

Lower esophageal sphincter relaxation characteristics using a sleeve sensor in clinical manometry

Objective: We undertook this study to determine the characteristics of swallow-induced lower esophageal sphincter (LES) relaxation in the setting of clinical manometry using a standardized methodology.
Methods: We reviewed 170 manometric recordings performed using a perfused manometric assembly with a sleeve sensor and a computer polygraph. Patients were categorized as patient controls, gastroesophageal reflux disease (GERD), diffuse esophageal spasm (DES), or achalasia. Tracing were semiautomatically analyzed for basal LES pressure, LES pressure during deglutitive relaxation (relaxation LES pressure), duration of LES relaxation, timing of LES relaxation, and the success rate of primary peristalsis.
Results: Forty-six patient controls, 93 with GERD, five with DES, and 26 with achalasia were identified. GERD and achalasia patients had lower or higher basal LES pressures than patient controls, respectively. Compared with patient controls, achalasia patients had higher relaxation LES pressures, lower percent LES relaxation, and shorter durations of LES relaxation. The best single measure for distinguishing achalasia was the relaxation LES pressure; using the 95th percentile value of patient controls (12 mm Hg) as the upper limit of normal, its sensitivity and positive predictive value for the diagnosis of achalasia were 92% and 88%, respectively. Coupled with the finding of aperistalsis, a relaxation LES pressure ≥10 mm Hg achieved 100% sensitivity and positive predictive value among these patients.
Conclusion: Sleeve sensor recording is a practical method for clinical manometry that reliably records LES relaxation characteristics and is amenable to both a standardized manometry protocol and a semiautomated analysis routine. Relaxation LES pressure has a high diagnostic value for achalasia.     

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.     

Absence of an Upper Esophageal Sphincter Response to Acid Reflux

Manometric studies of the upper esophageal sphincter (UES) were done on 17 volunteer subjects and 16 patients with endoscopically evident esophagitis. Subjects entered one or both of two protocols designed to assess the effect of esophageal acid exposure on UES pressure. In protocol 1, continuous 3-h postprandial recordings were obtained; a modified sleeve sensor was used to measure UES pressure, and an intraluminal pH electrode was used to detect occurrences of spontaneous gastroesophageal acid reflux. In protocol 2, UES pressure was continuously monitored during a 10-min control period, followed by a 25-min period of esophageal perfusion with 0.1 N HCl. Our findings were that: 1) basal UES pressure measured during the 3-h recording was similar in the normal volunteers and in the group of patients with esophagitis, 2) episodes of spontaneous gastroesophageal acid reflux were not associated with a change in UES pressure in either the normal volunteers or in the patients with esophagitis, and 3) esophageal perfusion with HCl did not affect the UES pressure in either group, although severe heartburn occurred in most of the esophagitis patients. We conclude that the upper esophageal sphincter exhibits normal basal pressure in patients with esophagitis and that esophageal acid exposure, either spontaneous or experimental, does not affect UES pressure in normal volunteers or in patients with esophagitis.