Complex evaluation of pain after tonsillectomy

CONCLUSION: Postoperative odynophagia should be assessed by a variety of methods including visual analogue scale (VAS) pain scores (subjective), clinical data (objective qualitative) and surface electromyography (sEMG; objective quantitative). sEMG might be used for quantitative evaluation of odynophagia when aggravation or hysteria-conversion reaction is suspected. Tonsillectomy affects muscle activity significantly by involving additional muscles in deglutition. OBJECTIVES: Complex evaluation of post tonsillectomy odynophagia was used for objective assessment of complaints of operated patients. PATIENTS AND METHODS: Parameters evaluated for 50 randomly chosen operated adults included VAS pain score, clinical data, and the EMG data such as the timing, electric amplitude and graphic patterns of muscular activity during deglutition. We investigated masseter (MS), infrahyoid (INF) and submental-submandibular (SUB) muscles. The results were compared with a normative database. The patients were first tested 12 h after surgery and were monitored for 30 days. The sEMG data were compared with VAS pain score with regard to changes in clinical condition of the patients. RESULTS: Signs of clinical recovery after tonsillectomy did not always correspond with the VAS pain score evolution. sEMG was more in concord with clinical recovery than VAS. Electric activity of MS and LSM was significantly higher among the patients in comparison with a normative database (p<0.005).     

Complex evaluation of pain after tonsillectomy

Conclusion. Postoperative odynophagia should be assessed by a variety of methods including visual analogue scale (VAS) pain scores (subjective), clinical data (objective qualitative) and surface electromyography (sEMG; objective quantitative). sEMG might be used for quantitative evaluation of odynophagia when aggravation or hysteria-conversion reaction is suspected. Tonsillectomy affects muscle activity significantly by involving additional muscles in deglutition. Objectives. Complex evaluation of post tonsillectomy odynophagia was used for objective assessment of complaints of operated patients. Patients and methods. Parameters evaluated for 50 randomly chosen operated adults included VAS pain score, clinical data, and the EMG data such as the timing, electric amplitude and graphic patterns of muscular activity during deglutition. We investigated masseter (MS), infrahyoid (INF) and submental-submandibular (SUB) muscles. The results were compared with a normative database. The patients were first tested 12 h after surgery and were monitored for 30 days. The sEMG data were compared with VAS pain score with regard to changes in clinical condition of the patients. Results. Signs of clinical recovery after tonsillectomy did not always correspond with the VAS pain score evolution. sEMG was more in concord with clinical recovery than VAS. Electric activity of MS and LSM was significantly higher among the patients in comparison with a normative database (p<0.005).     

The influence of tonsillitis on oral and throat muscles in children

OBJECTIVES: Surface electromyography (sEMG) studies were performed on 80 children with acute tonsillitis (AT) and 110 children with recurrent tonsillitis (RT), age 4-12 years, to trace sEMG changes of duration and amplitude of muscle activity during swallowing and continuous drinking. STUDY DESIGN: Prospective observational study of randomly chosen patients compared to normative database. METHODS: Timing and amplitude (in muV) of activity of masseter, submental and infrahyoid muscles were evaluated during voluntary single swallows of saliva ("dry" swallow), water swallows, swallows of excessive amount of water (up to 15 ml), and continuous drinking of 50 ml of water. These parameters were measured for two age groups for both conditions: 4-8 and 9-12 years old. The previously established normative database was taken for control. RESULTS: AT presents prolonged duration of swallowing and electric hyperactivity of infrahyoid muscles but this activity returns to normal after recovery. RT affects masseter and infrahyoid muscles even during periods of remission but do not affect duration of swallowing activity. CONCLUSION: AT and RT in children age 4-12 years affects muscle activity during swallowing significantly by involving additional muscles (mainly infrahyoid) in this process. AT presents temporary electric hyperactivity of infrahyoid muscles. RT affects masseter and infrahyoid muscles even during periods of remission (pathologic changes are fixed). Abnormally high electric activity of masseter and infrahyoid muscles in patients with RT might serve as an additional indicator for tonsillectomy. Surface EMG of swallowing is a simple, non-invasive and reliable method for diagnostic and preoperative evaluation of dysphagia complaints associated with tonsillitis.     

Recurrent aspiration pneumonia precipitated by obstructive sleep apnea

ObjectiveThe clearance of the pharynx by deglutition and the respiratory phase patterns associated with deglutition are important in protecting airways and lungs against aspiration. The deglutition and respiratory phase patterns during sleep in patients (without swallowing disorders while awake) with obstructive sleep apnea (OSA) precipitating recurrent intractable aspiration pneumonia were investigated.MethodsAfter videoendoscopic and videofluorographic examinations of swallowing showed subjects had no swallowing disorders while awake, two adults with recurrent intractable aspiration pneumonia precipitated by severe OSA were examined via time-matched digital recordings of polysomnography and surface electromyography of the muscles (thyrohyoid and suprahyoid muscles) related to swallowing and compared with the same patients before and under CPAP therapy.ResultsCPAP therapy cured recurrent intractable aspiration pneumonia. Swallows following and/or followed by inspiration (uncoordinated deglutition with respiration), which were frequently observed before CPAP therapy, were markedly reduced under CPAP therapy. On the other hand, swallows following and/or followed by expiration (coordinated deglutition with respiration) markedly increased under CPAP therapy. Deglutition was related to the sleep stage. The deeper the sleep stage, the lower the deglutition frequency. Before and under CPAP therapy, swallowing was infrequent and absent for long periods. However, respiratory phase patterns associated with sleep-related deglutition in patients with OSA under CPAP therapy markedly improved.ConclusionsIn patients (without swallowing disorders while awake) with OSA precipitating recurrent intractable aspiration pneumonia, the high rate of uncoordinated deglutition with respiration (swallows following and/or followed by inspiration) during sleep were markedly reduced and the rate of coordinated deglutition with respiration (swallows following and/or followed by expiration) was markedly increased under CPAP therapy.Sleep-related deglutition and respiratory phase patterns are likely to adversely influence aspiration pneumonia in patients with OSA. CPAP therapy improved not only apnea-hypopnea during sleep and sleep quality but also sleep-related deglutition, especially respiratory phase patterns associated with deglutition in patients with OSA. CPAP therapy may decrease the risk of aspiration and greatly improve aspiration-related diseases such as aspiration pneumonia.     

Fibrin sealant reduces pain after tonsillectomy: prospective randomized study

OBJECTIVES: Postsurgical pain in adults following tonsillectomy with fibrin sealant or electrocoagulation was assessed by surface electromyography (sEMG), a dysphagia severity rating scale (DSRS), and a visual analog scale (VAS) pain METHODS: For group 1 (n = 40), hemostasis was achieved by fibrin sealant spraying to the tonsillar fossae. For group 2 (n = 40), hemostasis was achieved by bipolar or needle point electrocautery. The timing of single swallowing and continuous drinking and the mean electrical activity of the masseter, infrahyoid, and submental-submandibular muscles were compared with a normative database during 30 days and with DSRS and VAS scores. RESULTS: Electrical activity of the masseter and infrahyoid muscles was significantly higher in both groups in comparison with the normative database (p < .05 to p < .005), whereas timing was less affected. The combined sEMG, DSRS, and VAS assessment showed that tonsillectomy ended with sealant causes less pain than electrocoagulation (p < .05). The DSRS score data were in strong positive correlation with the sEMG records, whereas the VAS pain score was less informative. CONCLUSIONS: The combined sEMG and pain score data indicate that the electrocautery hemostatic technique is more painful and traumatic than the sealant technique. Surface electromyography of swallowing is a simple, reliable evaluation method for postsurgical odynophagia complaints and might be used as an objective tool for pain assessment.     

Electromyography in evaluation of pain after different types of tonsillectomy: prospective randomized study

BACKGROUND: Combined surface electromyography (sEMG) and visual analogue scale (VAS) pain assessment was performed on randomly assigned adults following tonsillectomy to research the effect of fibrin sealant (Group 1, n = 25), CO(2) laser (Group 2, n = 18) and electrocoagulation (Group 3, n = 40) on postsurgical pain. METHODS: Timing and amplitude of sEMG activity of masseter, infrahyoid and submandibular muscles were measured during swallowing simultaneously with VAS assessment and compared to normative database. RESULTS: Postsurgical electric activity of masseter and infrahyoid was significantly higher in comparison with normative database. sEMG and VAS data showed that tonsillectomy ended with fibrin sealant caused less pain than laser or electrocoagulation techniques with no correlation between the VAS score and duration of swallows. CONCLUSION: Tonsillectomy affects muscle activity significantly by involving additional muscles (infrahyoid) in swallowing. Combined sEMG and VAS data indicated electrocautery as the most painful, laser as less painful, and fibrin sealant as the least painful technique.     

Oral vs. pharyngeal dysphagia: surface electromyography randomized study

Background

A clear differential diagnosis between oral and pharyngeal dysphagia remains an unsolved problem. Disorders of the oral cavity are frequently overlooked when dysphagia/odybophagia complaints are assessed. Surface electromyographic (sEMG) studies were performed on randomly assigned patients with oral and pharyngeal pathology to evaluate their dysphagia complaints for the sake of differential diagnosis.

Methods

Parameters evaluated during swallowing for patients after dental surgery (1: n = 62), oral infections (2: n = 49), acute tonsillitis (3: n = 66) and healthy controls (4: n = 50) included timing and amplitude of sEMG activity of masseter, infrahyoid and submental muscles.

Results

The duration of swallows and drinking periods was significantly increased in dental patients and was normal in patients with tonsillitis. The electric activity of masseter was significantly lower in Groups 1 and 2 in comparison with the patients with tonsillitis and controls. The submental and infrahyoid activity was normal in dental patients but infrahyoid activity in patients with tonsillitis was high.

Conclusion

Dysphagia following dental surgery or oral infections does not affect pharynx and submental muscles and has clear sEMG signs: increased duration of a single swallow, longer drinking time, low activity of the masseter, and normal range of submental activity. Patients with tonsillitis present hyperactivity of infrahyoid muscles. These data could be used for evaluation of symptoms when differential dental/ENT diagnosis is needed.     

Surface electromyographic studies of swallowing in normal children, age 4-12 years

OBJECTIVES: Surface electromyographic (sEMG) studies were performed on 100 normal children, age 4-12 years, to establish normative database for duration and amplitude of muscle activity during swallowing and continuous drinking. STUDY DESIGN: Prospective observational study of healthy volunteers. METHODS: Parameters evaluated during swallowing include the timing and amplitude (in microV) of activity of m. orbicularis oris, masseter, submental and infrahyoid (laryngeal strap muscles (LSM)) groups covered by platisma. Four tests were examined: voluntary single swallows of saliva ("dry" swallow), voluntary single water swallows as normal, voluntary single swallows of excessive amount of water (up to 15ml), continuous drinking of 50ml of water (duration and number of swallows). Duration of muscle activity during swallowing (mean plus standard deviation (S.D.)) was measured for two age groups: 4-8 and 9-12 years old. The group of 40 adults, age 18-30 years, was taken as a control group. RESULTS: Normative data for duration and amplitude of muscle activity during single swallowing and continuous drinking are established for healthy children. The duration of muscle activity during swallows and drinking in all tests showed decrease with the age, and this tendency is statistically significant (one-dimensional analysis of variance, SPSS, chi(2) criterion, 95% confidence interval). There was no statistically significant difference in amplitude (range) measurements between children and adults (P=0.05). There was no statistically significant difference between male and female children duration of muscle activity during single swallowing and continuous drinking in all age groups (P>/=0.05). CONCLUSION: Surface EMG of swallowing is a simple and reliable noninvasive method for screening evaluation of swallowing with low level of discomfort of the examination. The normative timing of events data can be used for evaluation of complaints and symptoms, as well as for comparison purposes in pre- and postoperative stages and in electromyography (EMG) monitoring during ENT or neurological treatment. These parameters represent normal deglutition, and can be used to identify abnormalities in pediatric patients, and provide a basis for comparison of swallowing performance, both within and between patients.     

Deglutition and respiratory patterns during sleep in the aged

Conclusion: Deglutition was extremely infrequent and displayed unique patterns during sleep in the aged.

Objectives: The deglutition and respiratory phase patterns during sleep in the healthy aged were investigated in this study.

Methods: Ten aged adults (average age =?71 years) were examined via time-matched digital recordings of polysomnography and surface electromyography of the muscles (thyrohyoid and suprahyoid muscles) related to swallowing.

Results: During sleep, swallowing was extremely infrequent and absent for long periods in the aged. The median number of swallows per hour during total sleep time was 0.6, and the median longest deglutition-free period was 134.8?minutes. Most deglutition occurred in association with spontaneous electroencephalographic arousal both in REM and non-REM sleep. Deglutition was related to the sleep stage. The deeper the sleep stage, the lower the mean deglutition frequency. There was no deglutition during deep sleep. Overall muscle tone is inhibited during REM sleep. However, deglutition also occurred in association with spontaneous EEG arousal. The deeper the sleep stage, the lower the mean arousal frequency, and the lower the mean ratio of arousal with deglutition to arousal. Approximately one-third of swallows occurred after inspiration and were followed by inspiration.     

Progressive dysphagia with peculiar laryngeal movement induced by tardive dystonia

Recently, patients receiving the long-term administration of typical antipsychotics have been recognized to be at risk of developing intractable tardive dystonia. A 44-year-old man was referred to our hospital because of progressive dysphagia for about 5 years. He had received several typical antipsychotic medications since at age of 24 years for the treatment of chronic schizophrenia. The patient had been suffering from an abnormal sensation in his throat and progressive dysphagia for five years, and nasal escape on deglutition for one year. A videotape recorder esophago pharyngography revealed that his larynx was positioned low, at the level of the 6th cervical vertebra, before swallowing, and was not elevated but rather descended to the level of the 7th vertebra upon swallowing. When the larynx was in this lower position, a small amount of swallowed material was transported to the esophagus. The remaining material in the pyriform sinus overflowed into the laryngeal cavity and lower airway after swallowing. However, the patient was able to eat with ease when he was with a girl friend, eating in a restaurant, and was hungry. The peculiar downward movement of the larynx was not observed during speech production, only during deglutition. Based on these findings, we suspected that his peculiar swallowing disorder might have been induced by tardive dystonia arising from the long-term administration of typical antipsychotics.     

Pill swallowing by adults with dysphagia

OBJECTIVE: To evaluate differences in swallowing physiology and safety in patients with dysphagia between conventional tablets and a new method of tablet transportation, orally disintegrating technology (ODT) (RapiTab; Schwarz Pharma Inc, Milwaukee, Wis). DESIGN: The study observed a single group, crossover design. SETTING: Outpatient clinic within an academic teaching hospital. PARTICIPANTS: A total of 36 adult dysphagic patients referred to the clinic. INTERVENTIONS: All subjects underwent simultaneous nasopharyngeal endoscopic evaluation, surface electromyographic (sEMG) measurement, and respiratory monitoring during swallowing. Subjects were evaluated swallowing the ODT and a conventional tablet formulation. Tablets were randomly and blindly presented to each subject. Subjects completed a preference survey subsequent to swallowing both tablets. RESULTS: Significant differences included greater sEMG amplitude and longer apneic duration when swallowing a conventional tablet compared with the ODT (P<.001). Patients with dysphagia demonstrated significantly longer total swallow durations (P<.001), a higher number of swallows per tablet (P<.002), and the need for fluid to assist in the clearance of the conventional tablet (P<.001). No significant difference was noted between the 2 tablet preparations in amount of residue or airway compromise during or following the swallow. On a postevaluation survey, patients reported that they preferred the ODT preparation for most of the parameters assessed. CONCLUSIONS: Patients with dysphagia frequently complain of trouble swallowing medication. In this study, an ODT formulation provided a method of delivery that required less effort to swallow, did not result in increased levels of airway compromise, and was preferred by dysphagic patients. The ODT medication delivery technology may provide benefit to adults with dysphagia in convenience, compliance, and accuracy of dosing.     

Oropharyngeal swallowing variability

OBJECTIVES/HYPOTHESIS: The pharyngeal phase of deglutition is considered to occur in a reflexive, preprogrammed fashion. Previous studies have determined a general sequence of events based on the mean timing of bolus transit and swallowing gestures. However, individual variability has not been studied. The purpose of the present study was to evaluate the amount of sequence variability that normally occurs during the oropharyngeal phase of deglutition. STUDY DESIGN: Prospective analysis of conservative subjects. METHODS: Dynamic swallow studies from 60 normal volunteers were evaluated, and event sequence variability was determined around two event sequences during swallowing of three bolus sizes. RESULTS: There was found to be substantial variability in event sequences for all events analyzed. Variability was greater during a smaller bolus swallow. CONCLUSIONS: The evaluation of variability within the study group of individuals reveals the complexity of the swallowing mechanism and underscores the importance of not relying on general guidelines in evaluating the coordination of swallowing gestures in a given individual with dysphagia complaints.     

Swallowing disorders in the elderly

Changes that occur as a natural part of senescence in the complex action of deglutition predispose us to dysphagia and aspiration. As the "baby-boomers" begin to age, the onset of swallowing difficulties will begin to manifest in a greater number of our population. Recent advances in the evaluation of normal and abnormal swallowing make possible more precise anatomical and physiological diagnoses. Coupled with an understanding of swallowing physiology, such detailed evaluation allows greater opportunity to safely manage dysphagia with directed therapy and appropriate surgical intervention. The current study is a discussion of the changes that occur in deglutition with normal aging, contemporary evaluation of swallowing function, and some of the common causes of dysphagia in elderly patients.     

Endoscopic cricopharyngeal myotomy: indications and technique

PURPOSE OF REVIEW: Cricopharyngeal muscle myotomy to treat swallowing disorders has a definite role in the management of cervical dysphagia. Several reports emphasize the benefits of the endoscopic approach compared with the transcervical technique. This review examines recent surgical management of cricopharyngeus dysmotility. RECENT FINDINGS: Several investigations have provided pertinent information on selecting patients for cricopharyngeal myotomy. Manofluorography appears to be more accurate in detecting intrabolus pressure anomalies during swallowing. Isolated cricopharyngeus dyscoordination, however, is not easily identified using this method. Electromyographic activity of the inferior pharyngeal constrictor and cricopharyngeus recorded by transcutaneous electrodes at rest and during deglutition has shown different dysfunction patterns. Ambulatory 24 h double probe pH monitoring and the triple sensor combination pH test demonstrate clinical correlation between pH results and symptoms in patients suffering from dysphagia related to laryngopharyngeal reflux. Transoral cricopharyngeal myotomy for the treatment of cricopharyngeus dysmotility is now established as a safe and effective method. The development of new devices has enhanced the procedure's efficacy and the overall success rate without major complications. SUMMARY: Diagnosis of cricopharyngeus dysfunction is based on anamnesis and videoradiograph findings. In doubtful cases manofluorography and electromyography should be performed. Endoscopic cricopharyngeal myotomy is a safe and effective treatment option for patients with cricopharyngeus dysphasia.     

Factors that affect swallowing-related apnea times in humans

The dynamics of deglutition were studied in relation to potential changes due to aging. Swallowing-related apnea time (SAT) was measured during “dry” and “wet” swallowing in 84 adults without dysphagia to examine if age-related variation of SAT corresponded to changes in deglutition dynamics due to aging and to determine possible significance. Swallowing movements were recorded using a transducer for measuring swallowing pressures. Respiratory flow rates during deglutition were measured with a heat-wave flowmeter as part of phonatory function testing system. Respiratory movements were recorded with a respiration pick-up band set at the diaphragm. Findings demonstrated that SAT did not change with aging but was prolonged in subjects over age 50 years. When topical anesthesia was omitted during study, SAT tended to be shorter during wet swallowing than during dry swallowing in all age groups. Statistically significant differences were observed between wet and dry swallowing SAT in subjects under the age of 39 years. When a topical anesthetic was applied to pharyngeal mucous mambranes, SAT was prolonged. Finally, SAT results during wet swallowing determined in a anesthetized dog before and after topical anesthesia of the pharyngeal mucous membranes showed significant prolongation after topical anesthesia. These findings suggest that the sensation of the pharyngeal mucous membrane may be important in producing swallowing-related apnea and controlling its duration.     

Videofluoroscopic evaluation of mastication and swallowing in individuals with TMD

To study mastication and swallowing disorders in patients with temporomandibular disorders (TMD).Objective: To investigate mastication and swallowing disorders in patients with severe TMD referred to surgery.Materials and Methods: Clinical and experimental study involving ten individuals with TMD submitted to deglutition videofluoroscopy. These patients did not have posterior teeth, mastication pain and food replacement in favor of pasty consistence food. The assessment of the oral and pharyngeal phases approached the following aspects: side of onset and preferential side for chewing, premature escape, remains of food residues in the oral cavity or in the pharyngeal recesses, number of necessary swallowing efforts, laryngeal penetration and/or tracheal aspiration.Results: During mastication and the oral phase we observed tongue compensatory movements upon chewing (n = 7; 70%), premature escape (n = 4; 40%), food remains in the cavity after swallowing (n = 5; 50%) and an excessive number of deglutition efforts (n = 5; 50%). On the pharyngeal phase we observed food remains in the valleculae (n = 6; 60%), in the pyriform sinuses (n = 4; 40%); laryngeal penetration (n = 1; 10%) and tracheal aspiration (n = 4; 40%).Conclusion: TMD patients may have alterations in their chewing and swallowing patterns, with laryngeal penetration and/or tracheal aspiration. The study indicates the need for a multidisciplinary assessment because of dysphagia in TMD patients.     

Otolaryngology and Speech Therapy evaluation in the assessment of oropharyngeal dysphagia: a combined protocol proposal

Dysphagia is a symptom associated with an array of anatomical and functional changes which must be assessed by a multidisciplinary team to guarantee optimal evaluation and treatment, preventing potential complications.AimThe aim of the present study is to present the combined protocol of clinical and swallowing videoendoscopy carried by ENT doctors and speech therapists in the Dysphagia Group of the ENT Department - University Hospital.Materials and MethodsRetrospective study concerning the use of a protocol made up of patient interview and clinical examination, followed by an objective evaluation with swallowing videoendoscopy. The exam was performed in 1,332 patients from May 2001 to December 2008. There were 726 (54.50%) males and 606 (45.50%) females, between 22 days and 99 years old.ResultsWe found: 427 (32.08%) cases of normal swallowing, 273 (20.48%) mild dysphagia, 224 (16.81%) moderate dysphagia, 373 (27.99%) severe dysphagia and 35 (2.64%) inconclusive exams.ConclusionThe combined protocol (Otolaryngology and Speech Therapy), is a good way to approach the dysphagic patient, helping to achieve early and safe deglutition diagnosis as far as disorder severity and treatment are concerned.     

Biomechanical correlates of surface electromyography signals obtained during swallowing by healthy adults.

PURPOSE: The purpose of this study was to describe biomechanical correlates of the surface electromyographic signal obtained during swallowing by healthy adult volunteers. METHOD: Seventeen healthy adults were evaluated with simultaneous videofluoroscopy and surface electromyography (sEMG) while swallowing 5 mL of liquid barium sulfate. Three biomechanical swallowing events were analyzed: hyoid elevation, pharyngeal constriction, and opening-closing of the pharyngoesophageal segment. For each biomechanical event and from the sEMG signal, the authors identified onset, peak, and offset time points. From these points, duration measures were calculated. Means and 95% confidence intervals were calculated for each measure. Subsequently, correlations were evaluated between timing aspects of the sEMG traces and each biomechanical event. RESULTS: Swallow onset in the sEMG signal preceded the onset of all biomechanical events. All biomechanical events demonstrated a strong correspondence to the sEMG signal. The strongest relationship was between hyoid elevation-anterior displacement and the sEMG signal. CONCLUSIONS: These results suggest that the sEMG signal is a useful indicator of major biomechanical events in the swallow. Future studies should address the impact of age and disease processes, as well as bolus characteristics, on the biomechanical correlates of sEMG signals obtained during swallowing.     

Epiglottic dysfunction during deglutition in patients with dysphagia

Among 250 patients with dysphagial complaints, 83 had dysfunction of the epiglottis as revealed by high-speed cineradiography. Nineteen patients had a totally immobile epiglottis and of these 11 had concomitant pharyngeal constrictor paresis. Sixteen of the patients with immobile epiglottis had misdirected swallowing. An absence of the second movement of the epiglottis during deglutition was registered in 53 patients. Thirteen of these had pharyngeal constrictor paresis and 45 had misdirected swallowing. In 11 patients the epiglottis attained an obliquity of 30 degrees to 90 degrees as seen in the anteroposterior projection during its second movement. One of these had a pharyngeal constrictor paresis, while four had misdirected swallowing. The results of this study indicate that epiglottic dysfunction is common among patients with dysphagia and is often accompanied by other functional abnormalities.     

Manometry and electromyography of the pharyngeal muscles in patients with dysphagia

Simultaneous recording of the electromyographic activity of the pharyngeal muscles and the intraluminal pressure in the upper sphincter zone was performed routinely in patients with swallowing problems for the first time, to our knowledge. This technique was found to be very useful for the localization of the "site of lesion." The procedure is safe, easy to master, and causes minimal inconvenience. It can reveal, in the most direct way, whether the disturbance is in the hypopharyngeal musculature (represented by the inferior constrictor muscle), in the cricopharyngeal muscle (spasm or lack of relaxation), or in the synchronization between them. Simultaneous recording of intraluminal pressure adds valuable information about the mechanical events associated with electromyographic activity. It was found that in pathologic cases there is quite often no correlation between the electrical and mechanical events. Thus, simultaneous recording of both electrical and mechanical events is essential for the understanding of the pathophysiology of disturbances of deglutition.