Manometric characteristics of the pharynx,upper esophageal sphincter,esophagus, and lower esophageal sphincter in patients with oculopharyngeal muscular dystrophy

Improved techniques in esophageal manometry have made this test an attractive option for investigating pharyngeal or esophageal disorders in patients with dysphagia. We studied esophageal as well as upper esophageal sphincter/pharyngeal (UES/P) pressure dynamics in 11 patients with an established diagnosis of oculopharyngeal muscular dystrophy with modern solidstate manometric techniques and then compared manometric and clinical findings. Esophageal manometric abnormalities were found in 10/11 patients, with the most common being simultaneous contractions and incomplete lower esophageal relaxation. 9/11 patients showed abnormal UES/P manometrics, with the most common abnormalities found in the pharynx. The presence of manometric abnormalities closely paralleled clinical assessment of degree of disease severity. Modern manometric techniques offer an opportunity for a quantitative assessment of swallow abnormalities.     

Influence of the catheter diameter on the investigation of the esophageal motility through solid‐state high‐resolution manometry

Past studies have shown that catheter diameter is one of the device‐dependent problems which influence the manometric results in the conventional water perfusion esophageal manometry. High‐resolution solid‐state manometry which abandons water perfusion is thought as an improved manometry method benefited from more pressure sensors, and it is gradually widely used in many present esophageal motility studies. There was no research to evaluate the influence of catheter diameter on the solid‐state high‐resolution manometry results. The aim of this study was to investigate whether solid‐state high‐resolution catheters of different diameter provide different data and results. Nine asymptomatic volunteers and 18 gastroesophageal reflux disease patients accepted high‐resolution manometry examinations with two solid‐state catheters of different outer diameter (4.2 mm and 2.7 mm). Every examination contained 5 minutes resting pressure, 10 water swallows and 10 bread swallows. Some important parameters of the esophageal sphincters and esophageal body peristalsis were analyzed. They included the locations and resting pressure of sphincters, the distal contractile integral, the 4‐second integrated relaxation pressure etc. Then, these parameters and the diagnosis of each swallow based on them provided by the two different diameter catheters were compared. (i) The 4.2 mm thick catheter provided higher upper esophageal sphincter resting pressure than the 2.7 mm thick catheter (59.4 ± 21.1 mmHg vs. 49.7 ± 21.4 mmHg); (ii) the 2.7 mm thick catheter provided higher 4‐second integrated relaxation pressure than the 4.2 mm thick catheter (10.9 ± 4.5 mmHg vs. 8.5 ± 3.8 mmHg) in water swallows; (iii) the mean distal contractile integral of the water and bread swallows in the large diameter catheter were higher than in the small diameter catheter (989.2 ± 650.0 mmHg/cm/s vs. 806.3 ± 563.7 mmHg/cm/s in water swallows, 1762.5 ± 1440.6 mmHg/cm/s vs. 1275.7 ± 982.0 mmHg/cm/s in bread swallows); (iv) on the lower esophageal sphincter resting pressure, most parameters in bread swallows provided by the two catheters were of no statistical significance; (v) the 2.7 mm thick catheter detected more hypotensive peristalsis swallows than the other catheter in water swallows; and (vi) the final diagnosis of about half of the subjects provided by the two catheters were different. The 2.7 mm thick solid‐state high‐resolution manometry catheter provides somewhat different data from the usually used 4.2 mm thick catheter. It is needed to set up different and independent series of normative value for the solid‐state high‐resolution manometry catheters of different outer diameter. The normative value and diagnostic criterion got from one catheter is not universal and acceptable for researches with catheter of different diameter.     

A new evaluation of the upper esophageal sphincter using the functional lumen imaging probe: a preliminary report

Objective and reliable evaluation of upper esophageal sphincter (UES) opening during swallowing based on videofluoroscopy and pharyngeal manometry challenges dysphagia clinicians. The functional lumen imaging probe (FLIP) is a portable tool based on impedance planimetry originally designed to measure esophogastric junction compliance. It is hypothesized that FLIP can evaluate UES distensibility, and can provide UES diameter and pressure measurements at rest, during swallowing, and during voluntary maneuvers. Eleven healthy adult subjects consented to FLIP evaluation. The probe was inserted transorally, and the balloon was positioned across the UES. Two 20‐mL ramp distensions were completed. Changes in UES diameter and intraballoon pressure were measured during dry and 5‐mL liquid swallows, and during voluntary swallow postures and maneuvers employed in clinical practice. The protocol was completed by 10 of 11 healthy subjects. Mean intraballoon pressure increased throughout 5‐mL (5.8 mmHg; ?4.5–18.6 mmHg), 10‐mL (8.7 mmHg; 2.3–28.5 mmHg), 15‐mL (17.3 mmHg; 9.5–34.8 mmHg), and 20‐mL (31.2 mmHg; 16–46.3 mmHg) balloon volumes. Mean resting UES diameter (4.9 mm) increased during dry swallows (9.2 mm) and 5‐mL liquid swallows (7.7 mm). Mean UES diameter increased during 5‐mL liquid swallows with head turn to right (8.1 mm) and left (8.3 mm), chin tuck (8.4 mm), effortful swallow (8.5 mm), Mendelsohn maneuver (8.1 mm), and supraglottic swallow (7.8 mm). FLIP was safely inserted and distended in the UES, and provided useful quantitative data regarding UES distensibility and UES diameter changes during swallowing maneuvers. Further research is being conducted to explore the role of FLIP in UES evaluation.     

Simultaneous videoradiography and pharyngeal solid state manometry (videomanometry) in 25 nondysphagic volunteers

Recent technological advances in manometry, including solid state transducers and computerized analysis, allows for reliable interpretation of intraluminal pharyngeal pressures. Simultaneous videoradiography (barium swallow) provides fluoroscopic control of the manometric sensors (videomanometry), thereby eliminating the uncertainty of sensor dislocation during laryngeal elevation. This is the first study describing normal manometric parameters in videomanometry during barium swallow. Seven manometric parameters and six videoradiographic parameters were analyzed. We included 25 nondysphagic volunteers with normal videoradiographic parameters in the study. The examination was performed in an upright physiologic position during 10-ml barium and dry swallows. Mean resting pressure in the upper esophageal sphincter was 89.6±32.6 (±2 SD) mmHg. Mean residual pressure during relaxation of the upper esophageal sphincter was 7.2±8.0 (±2 SD) mmHg during barium swallow and 3.8±6.2 (±2 SD) mmHg during dry swallow. The mean duration of upper esophageal sphincter relaxation was 601±248 (±2 SD) msec. The mean peristaltic contraction of the upper esophageal sphincter was 253.8±142.8 (±2 SD) mmHg. Fourteen (56%) of the 25 had a measurable intrabolus pressure (mean 33.2±17.3 mmHg) at the level of the inferior pharyngeal constrictor. A specific finding was discovered when the epiglottis tilts down hitting the manometric sensor. This epiglottic tilt was identified in 7 subjects (28%) and caused pressures of around 600 mmHg. A standardized manometric technique is important in videomanometry, and normal values as described in this study are essential in clinical use.     

Dilatation therapy for dysphagia in patients with upper esophageal sphincter dysfunction--manometric and symptomatic response.

Inability to maintain oral nutrition due to oropharyngeal dysphagia is common in patients with a variety of neurological and neuromuscular disorders and severely affects quality of life. Cricopharyngeal dilatation has been used as empiric therapy in these patients, but little data exist on symptom response and there is no data on the effect on the manometric characteristics of the upper esophageal sphincter (UES) and pharynx. We studied 10 patients with oropharyngeal dysphagia and either elevated upper esophageal sphincter resting pressure, or a high residual pressure or attenuated duration of relaxation on swallowing. Dilatation therapy was performed with an 18-20 mm Savary dilator and manometry was repeated after an average period of 4 weeks. Nine out of 10 patients had improvement in dysphagia and have maintained oral nutrition for a mean follow-up of 13 months. UES residual pressure decreased in nine out of 10 patients and the group median value decreased significantly from 10.8 mmHg pretreatment to 5.7 mmHg after therapy (P < 0.05). UES resting pressure decreased in eight out of 10 patients and the group median value decreased from 82 to 43 mmHg (P < 0.05). Duration of relaxation did not change significantly. Videoradiography was normal in five out of nine responders to therapy. For selected patients with oropharyngeal dysphagia and manometric signs of UES dysfunction, dilatation therapy may give excellent symptomatic relief, apparently by reducing UES resting pressure and/or increasing the duration and completeness of relaxation.     

Effect of Tracheotomy Tube Occlusion on Upper Esophageal Sphincter and Pharyngeal Pressures in Aspirating and Nonaspirating Patients

The biomechanics of the pharyngeal swallow in patients with a tracheotomy tube were investigated with manometry. Upper esophageal sphincter (UES) and pharyngeal pressure recordings were made with and without occlusion of the tracheotomy tube. Criteria for selection were ability to tolerate tracheotomy tube occlusion for both 5 minutes prior to and during the first manometric analysis, absence of surgery to the upper aerodigestive tract other than tracheotomy, and no history of oropharyngeal cancer or stroke. Aspiration was determined objectively by fiberoptic endoscopic evaluation of swallowing (FEES) immediately prior to manometric recording. Eleven adult individuals with tracheotomy participated; 7 swallowed successfully and 4 exhibited aspiration on FEES. The results indicated no significant effect of tracheotomy tube occlusion on UES or pharngeal pressures in either aspirating or nonaspirating patients. It was concluded that the biomechanics of the swallow as determined by UES and pharyngeal manometric pressure measurements were not changed significantly by tracheotomy tube occlusion in aspirating or nonaspirating patients. These results support previous observations that subjects either aspirated or swallowed successfully regardless of tracheotomy tube occlusion status.     

Dysphagia after pharyngolaryngeal cancer surgery. Part I: Pathophysiology of postsurgical deglutition

Eighty-one patients were examined after laryngopharyngeal cancer surgery with a sequential computer manometry system using 4-channel-pressure probes. The general swallowing coordination is neither a matter of the oropharyngeal pressure thrust nor of the pharyngeal transit time, but mainly depends on swallowing initiation. The points of interest are both the pharyngeal inlet and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter (UES). Resections of the base of the tongue lead to a decrease of volume available for pressure generation, thus reducing the tongue driving force. The swallowing reflex is uncoordinated resulting in dyskinesia of the UES. Compensation may be achieved with a stronger oropharyngeal thrust and/or repeated swallows. Distal resections alter the pharyngoesophageal segment so that a functional obstruction results, combined with lower pressure amplitudes in the hypopharynx, reducing the pressure gradient necessary for bolus flow. This increasing resistance can be overcome by higher propulsive forces in the base of the tongue region. In case of additional lingual defects, deglutition is subject to decompensation, highlighting the major role of the tongue as a pressure generator for bolus passage.     

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.     

Incomplete Upper Esophageal Sphincter Relaxation: Association with Achalasia but Not Other Esophageal Motility Disorders

Incomplete upper esophageal sphincter (UES) relaxation is not well understood. We compared clinical and manometric characteristics of patients with normal and abnormal UES relaxation. Consecutive patients (n = 208) underwent manometric evaluation of the lower esophageal sphincter (LES), esophageal body, and UES/pharynx. The patients were divided into those with abnormal UES relaxation (residual pressure >6.7 mmHg) (n = 21) and normal relaxation (n = 187). Clinical and manometric profiles were compared. Sex, age, and presenting complaint did not correlate with UES relaxation. Normal esophageal peristaltic sequences were more frequently present in the normal UES group (73.6%) compared with the abnormal (55.8%) (p < 0.01). The UES relaxation was shorter in the group with abnormal relaxation (410.0 ms vs. 510.2 ms, p < 0.001). All other manometric parameters were not different between the two groups. When individual manometric diagnoses were analyzed, only achalasia was noted to be more common in the abnormal UES group (23.8% vs. 9.1%, p < 0.05), and a trend was noted toward diffuse esophageal spasm being more common (14.3% vs. 9.6%, not significant). We conclude that incomplete UES relaxation is a rare manometric finding, associated with achalasia and not specifically associated with any other motility disturbance. This finding may represent a secondary response to the poor esophageal emptying seen in achalasia.     

Facioscapulohumeral Muscular Dystrophy: A Radiologic and Manometric Study of the Pharynx and Esophagus

Facioscapulohumeral muscular dystrophy (FSHD) is not a recognized neuromuscular cause of dysphagia. However, a study of pharyngoesophageal function in FSHD has not been performed or reported. The aim of this study was to ascertain by relatively noninvasive techniques whether the dystrophic muscle disease that underlies FSHD involves the pharyngeal and/or the esophageal striated and smooth muscles. We used conventional cineradiography and intraluminal esophageal manometry on separate occasions to study pharyngeal and esophageal function in 20 patients with FSHD at various stages of disease, with or without complaints of deglutition. Age- and sex-matched control data were used for comparison of the manometric component of the study. Twelve men and eight women with FSHD were studied. The mean patient age was 38.1 years (41.9 years for controls), and the age range was 19-61 years (22-55 years for controls). The mean disease duration was 16.7 years (range = 4-39 years).Five patients admitted to having intermittent oropharyngeal dysphagia (difficulty to initiate swallowing, cough after swallowing, sensation of food stuck in throat, or nasal regurgitation), and three patients admitted to intermittent esophageal dysphagia (difficulty swallowing both liquids and solids). Chest roentgengrams showed a hiatal hernia in four patients, but no active cardiopulmonary disease. Abnormal instrumental results were documented in eight patients: Cineradiography detected ineffectual pharyngeal contractions (2 patients), pharyngeal diverticula but normal pharyngeal motility (2 patients), and decreased cricopharyngeal and upper esophageal relaxation (2 patients). The mean manometric pressure of the patient group was not significantly different from the control data. However, manometry detected motility abnormalities that were not reflected in the mean data and included increased lower esophageal sphincter resting pressure with normal or abnormal relaxation (2 patients) and inconsistent, high-amplitude, long-duration, primary peristaltic contractions (1 patient). Patients with FSHD did not spontaneously volunteer intermittent complaints of deglutition. This study did not definitely establish that the cause of abnormal pharyngeal and cervical esophageal function was related to the dystrophic process that underlies FSHD. Any esophageal dysmotility was nonspecific and insignificant and was caused by an undetermined, probably neuropathic, process unrelated to the muscular dystrophy.     

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).     

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.     

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.     

The use of intraluminal manometry to assess upper esophageal sphincter function

The UES is a striated muscular structure that exhibits substantial variation in tone in response to a wide variety of stimuli as well as during deglutition. It is an asymmetric structure subject to substantial axial movement. Hence the findings on UES manometry are highly dependent upon the manometry equipment used, positioning of this equipment in relation to the UES, and external stimuli. There is considerable intrasubject and intersubject variation in some parameters from UES pressure recordings. These factors must be taken into account in the clinical use of UES manometry.     

Effect of Age and Bolus Variables on the Coordination of the Glottis and Upper Esophageal Sphincter during Swallowing

We studied 1) the effect of age and bolus variables on a) the coordination of deglutitive vocal cord adduction and upper esophageal sphincter (UES) relaxation and b) the duration of deglutitive vocal cord adduction; 2) the effect of the presence of a manometric catheter across the UES on the deglutitive glottal function; and 3) the temporal relationship between deglutitive vocal cord closure and swallow-induced apnea. We studied 10 young (23 ± 2 yr) and 10 healthy elderly (73 ± 2 yr) volunteers by concurrent videoendoscopy, UES manometry, respirography, and submental surface electromyography. In both groups the onset of vocal cord adduction preceded the onset of UES relaxation, deglutitive apnea, and submental electromyogram swallowing signal. In both groups, bolus volume and temperature did not have any significant effect on the duration of deglutitive vocal cord adduction. In both young and elderly volunteers, water swallows, compared with dry swallows, significantly shortened the interval between the onset of deglutitive vocal cord adduction and the onset of UES relaxation.
In conclusion, coordination between deglutitive glottal and UES function, as well as the duration of deglutitive vocal cord adduction, is preserved in the elderly. Bolus volume and temperature do not have a modulatory effect on the duration of vocal cord closure, but water swallow shortens the interval between the onset of glottal closure and UES relaxation. This shortened interval may contribute to the safety of the airway during swallowing of liquid volumes.     

Factors influencing lower esophageal sphincter relaxation after deglutition

AIM:To study the relationship between upper esophageal sphincter (UES) relaxation,peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects.METHODS:Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES,the esophageal body and the LES.Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation,LES pressure at time of UES relaxation,duratio...     

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.     

Continuous monitoring of the upper esophageal sphincter with the Dent device, during acid perfusion or distension with balloon of the esophageal body]

The aim of the present study was to evaluate pressure changes of the UES under conditions that simulate the effects of gastroesophageal reflux (GER), that are, balloon esophageal distension and acid perfusion 0.1 N. Studies were performed in eight healthy subjects and fourteen patients with reflux esophagitis (RE), divided in two groups according to symptoms, 6 patients with heartburn and 8 patients with heartburn and regurgitation. We have employed the Dent sleeve to monitor UES pressure. The catheter was located with the help of a side-hole manometric catheter placed in the opposite side of the Dent sleeve; thereafter, it was anchorated. Perfusion of acid at 5 and 10 cm below the UES induces a pressure increase statistically significant, (paired data). This pressure increase is shown when mean values of the 5 minutes are considered as well for every minute. On the after hand, esophageal balloon distension did not produce pressure increases in any of the groups.     

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.