Globus sensation and gastroesophageal reflux

Recent studies suggest that gastroesophageal reflux disease (GERD) may be a major cause of globus sensation. However, the incidence and severity of GERD in patients with globus sensation without reflux symptoms are unknown. In order to establish the relationship between globus sensation in the jugular fossa and GERD, 20 patients attending our ear, nose and throat (ENT) outpatient clinic with globus sensation were investigated with 24-h pH monitoring. A four-channel pH catheter was used with the pH electrodes spaced 5 cm apart in order to detect reflux along the whole length of the esophagus. Fifteen patients complained about globus sensation only; five patients complained additionally about classical reflux symptoms. Thirteen patients showed pathologic reflux measurements. Most of the patients had reflux limited to the distal one-third of the esophagus. Patients with pathologic pH measurements were treated with proton pump inhibitors. Ten out of 13 patients improved with treatment. This study suggests that globus may be associated with reflux, and acidity does not have to reach the pharynx to produce globus sensation.     

Structural and functional organization of the upper esophageal sphincter

Using traditional anatomical and histological methods, the muscle envelope of the pharynx-esophagus junction was investigated in humans and dogs. In the upper (cranial) portion of the esophagus of man and dogs, an inferior anatomical sphincter was detected which histologically can be referred to the group of rhabdo-sphincters. The upper esophageal sphincter is a purely esophageal structure which in man is located at a distance of 25-30 cm from the maxillary incisors. In adult humans, it is 25-30 mm long and is situated obliquely to the long esophageal axis. The posterior semicircle of the sphincter is located higher than the anterior one. In the area of the upper esophageal sphincter the esophageal wall is of different thickness. Due to the muscle envelope and submucous membrane of the base, the right wall is 1.7-2.0 times thicker than the left, anterior or posterior wall. The data obtained from fiber esophagoscopy of patients and electromyography of the pharynx-esophagus junction of dogs have shown that the upper (cranial) esophageal sphincter control food passage from the pharynx to the esophagus and prevents food reflux to the laryngopharynx, protecting airways from aspiration.     

Techniques in electromanometry of the upper esophageal sphincter

The various pull-through techniques used to measure pressure and length of the upper esophageal sphincter have not been studied in depth. Because of the importance of obtaining further information about these techniques, a group of 25 dogs was submitted to upper esophageal sphincter pressure and length measurements by three different pull-through techniques (two of the continuous type and one of the station type), each with three replications per animal, to determine possible differences among techniques. A single introduction provided reliable results, with no sequential effect of the measurements or of any one technique on resting pressure. However, each technique yielded different sphincter lengths, higher values being obtained when the continuous techniques were used.     

咽喉反流性疾病患者食管上括约肌压力高分辨测量的诊断价值

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

Videofluoroscopic upper esophageal sphincter function in elderly dysphagic patients

OBJECTIVES/HYPOTHESIS: The intent of the study was to identify and characterize abnormalities of the timing and extent of upper esophageal sphincter (UES) opening in an elderly population complaining of dysphagia. STUDY DESIGN: A retrospective review of dynamic swallow studies performed on patients greater than 65 years of age without an obvious medical or surgical cause for their dysphagia. METHODS: Measures of UES opening timing and extent in the patient population were compared with those from 60 young, normal control subjects and 23 elderly control subjects. The relationship of UES function and other swallowing abnormalities was also evaluated. RESULTS: No decrease in the size of UES opening was identified in the patient population. The coordination of UES opening relative to the position of the bolus in the pharynx was normal. UES opening was prolonged and was correlated with poor pharyngeal clearing suggestive of weak pharyngeal constriction. CONCLUSION: No primary abnormality of UES function was identified in this elderly dysphagic patient population.     

Abnormal elevation of resting pressure at the upper esophageal sphincter of Parkinson’s disease patients

We investigated the oral and pharyngeal swallowing function in seven Parkinson’s disease (PD) patients, using videomanofluorometry, which is videofluorographic and manometric evaluation conducted simultaneously. Abnormal elevations of resting pressure were found at the upper esophageal sphincter (UES) in three of the seven cases, when they were asked to hold a bolus in the mouth and initiate swallowing. One of these three cases showed an abnormal elevation of resting pressure, intermingled with a normal pressure pattern. Since the UES showed complete relaxation in these three cases, it is inappropriate to suppose that irreversible pathophysiological changes at the level of peripheral nerves had occurred. Our results suggested that altered resting pressure resulted from dysfunction at a more central level, such as a lack of dopaminergic stimulation at the supramedullary level causing skeletal muscle rigidity. Since a tonic abnormality of the UES cannot be measured by only videofluorography, both videofluorographic and manometric evaluation will be necessary to assess the pharyngeal phase of swallowing in PD patients. Received: 14 December 2000 / Accepted: 5 July 2001     

上食管括约肌在咽喉反流性疾病中的作用

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

Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction

OBJECTIVES: To investigate the efficacy of botulinum toxin A (BTA)-induced chemodenervation of the upper esophageal sphincter (UES) in patients with dysphagia and UES dysfunction. STUDY DESIGN: Prospective clinical trial in 10 selected patients with pure UES dysfunction. METHODS: In each patient 30 units of BTA were injected into the UES under brief general anesthesia. Videofluoroscopic swallowing study (VSS) was done and a clinical symptom score was determined before and after treatment. RESULTS: On VSS relative opening of the UES improved in all patients (mean +/- SD: 47 +/- 14% before versus 71 +/- 24% after treatment; P < .01). Hypopharyngeal retention or laryngeal penetration of barium was significantly reduced in four of seven patients. Clinical symptom scores improved in all patients. One patient was free of symptoms, mild dysphagia persisted in six patients, and moderate dysphagia persisted in three patients. CONCLUSIONS: Our results support the use of BTA in selected patients with pure UES dysfunction. Its efficacy is limited by the possibility of a persistent structural stenosis of the UES and the risk of BTA diffusion into the larynx or hypopharynx.