Esophageal contractions and oropharyngeal and esophageal transits in patients with iron deficiency anemia

OBJECTIVE: Patients with iron deficiency may have reduced power of the pharyngeal muscle for bolus propulsion into the esophagus. We hypothesized that esophageal muscle is similarly impaired. METHODS: We studied the oropharyngeal and esophageal transits and esophageal motility of 12 patients (11 women) aged 31-50 yr (median 36 yr) with iron deficiency anemia (serum iron less than 40 microg/dl) and 17 normal volunteers (16 women) aged 26-52 yr (median 37 yr) with serum iron greater than 60 microg/dl. The esophageal motility was studied by the manometric method, with continuous perfusion and 10 swallows of a 2-ml bolus of water alternated with 10 swallows of a 7-ml bolus; and the oropharyngeal and esophageal transits were studied by scintigraphy, with swallows of a 10-ml bolus for the study of oropharyngeal transit and of a 10-ml bolus for the study of esophageal transit. Motility and transit were studied in the supine position. RESULTS: The amplitude, duration and area under the curve of contractions were lower in patients than in volunteers. There were no differences in peristaltic contraction velocity, lower esophageal sphincter pressure, and lower esophageal sphincter relaxation duration. There was no difference in oropharyngeal transit. In the esophagus the transit was slower in patients than in volunteers. The time needed by the scintigraphic activity to reach a peak in the proximal esophagus was longer in patients than in volunteers. CONCLUSIONS: Iron deficiency may decrease esophageal contractions and impair esophageal transit.     

Clarification of the esophageal function defect in patients with manometric ineffective esophageal motility: studies using combined impedance-manometry.

BACKGROUND & AIMS: Combined multichannel intraluminal impedance (MII) and manometry (MII-EM) recently became available as an esophageal function test. Initial studies in healthy volunteers have shown that a proportion of ineffective contractions actually have complete bolus transit. The aim of our study is to evaluate esophageal bolus transit in patients with manometric patterns of ineffective esophageal motility (IEM). METHODS: All patients referred for esophageal function testing during a 9-month period underwent combined MII-EM studies, including 10 liquid and 10 viscous swallows. IEM is defined as >or=30% liquid swallows with contraction amplitude <30 mm Hg in the distal esophagus. Diagnosis of esophageal transit abnormalities is defined as abnormal bolus transit if >or=30% of liquid and >or=40% of viscous swallows had incomplete bolus transit. RESULTS: Seventy patients (35 women; mean age, 54 yr; range, 17-86 yr) with a manometric diagnosis of IEM were identified of a total of 350 combined MII-EM studies. In these patients, 68% of liquid and 59% of viscous swallows showed normal bolus transit, and almost one third of patients received an overall diagnosis of normal bolus transit for both liquid and viscous swallows. CONCLUSIONS: Our experience with combined MII-EM in patients with a manometric diagnosis of IEM confirms the suspicion that "effectiveness" should only be determined by using a test of esophageal function. Furthermore, we believe our results support a conclusion that a higher level of esophageal diagnostic information is best obtained by combined MII-EM. Future outcome studies should establish its value in patients with nonobstructive dysphagia and in prefundoplication assessment.     

Esophageal function testing with combined multichannel intraluminal impedance and manometry: multicenter study in healthy volunteers.

BACKGROUND & AIMS: Combined multichannel intraluminal impedance and manometry (MII-EM) assesses esophageal function by simultaneous measurement of both pressure and bolus transit. Normative data for this method have not been published. The aim of this study was to establish normative data for combined MII-EM and to correlate liquid and viscous bolus transit by impedance with esophageal contractions by manometry. METHODS: Forty-three normal volunteers recruited from 4 centers (15 women, 28 men; age range, 21-72 years) underwent combined MII-EM with a catheter containing 4 impedance-measuring segments and 4 solid-state pressure transducers. Each center recruited and analyzed subjects independently, according to pre-established criteria. Each subject received 20 x 5 mL swallows, 10 liquid and 10 viscous material. Tracings were analyzed manually for bolus presence time, bolus head advance time, segmental transit times, total bolus transit time, contraction amplitude, duration, and onset velocity. RESULTS: Ninety-seven and four-tenths percent of manometrically normal liquid and 96.1% of manometrically normal viscous swallows had complete bolus transit by impedance. Almost half (47.2%) of manometrically ineffective liquid and 34.7% of ineffective viscous swallows had complete bolus transit, whereas 91.7% of manometric simultaneous liquid swallows and 54.5% of simultaneous viscous swallows had complete bolus transit. More than 93% of normal individuals had at least 80% complete liquid or at least 70% complete viscous bolus transit. CONCLUSIONS: This study establishes normative data for combined MII-EM. Combined MII-EM may be a more sensitive tool in assessing esophageal function compared to standard manometry because impedance can distinguish different bolus transit patterns. Studies in patients with manometrically defined esophageal motility abnormalities should help clarify the functional importance of manometric ineffective and simultaneous swallows.     

Manometry and radiology. Complementary studies in the assessment of esophageal motility disorders

The relationship between radiological and manometric findings in esophageal motility disorders is poorly understood. Therefore, 20 subjects (4 normal; 13 diffuse spasm; 3 other motility disorders) were studied using synchronous manometry and videofluoroscopy with alternate 5-ml and 10-ml barium swallows. A total of 181 swallows were analyzed. Concordance between manometry and fluoroscopy was excellent for individual swallows (98%), groups of 5 swallows (97%), and final diagnoses (90%). Contraction onset intervals less than 0.8 s apart over 5 cm (velocity greater than 6.25 cm/s) were critical in determining abnormal bolus transit (98% sensitivity and positive predictive value). Radiologically, segmental tertiary activity (complete luminal obliteration) was always associated with disrupted primary peristalsis, but nonsegmental tertiary activity was often seen with normal bolus transit and did not have a specific manometric correlate. Four patterns of interrupted peristalsis radiologically were found--segmental tertiary contractions, a generalized esophageal contraction, absence of motor activity, or discoordinated "to-and-fro" movement. Surprisingly, nearly complete barium clearance occurred by the first two mechanisms in two thirds of swallows. Thus, the authors believe radiology and manometry are both excellent studies for identifying abnormal esophageal peristalsis. In difficult cases, these tests give complementary information because radiology assesses bolus movement while manometry provides quantitative pressure data.     

Sequential swallows have no influence on esophageal contractions of patients with iron deficiency anemia

BACKGROUND: An experimental study showed that thyropharyngeal, cricopharyngeal and cervical esophageal muscles of rabbits with iron deficiency anemia had morphological changes similar to those observed in muscular dystrophy, causing myastenic changes in muscles involved in swallowing. Our hypothesis is that patients with iron deficiency anemia may have a decrease in esophageal contractions with successive swallows. PATIENTS AND METHOD: We studied the esophageal motility of 12 women with iron deficiency anemia aged 31 to 50 years (median 36 years) with serum iron from 11 to 40 mug/dL (median 21 mug/dL), and 13 asymptomatic women aged 26 to 49 years (median 35 years) with serum iron over 60 mug/dL. We used the manometric method with continuous perfusion. The esophageal contractions were measured at 3, 9 and 15 cm from the upper margin of a sleeve that straddled the lower esophageal sphincter. Each subject performed 10 swallows of a 2 mL bolus of water alternated with 10 swallows of a 7 mL bolus, with an interval of 30 seconds between swallows. We measured the amplitude, duration, velocity and area under the curve of contractions. RESULTS: There was no difference between the swallows of a 2 mL or 7 mL bolus. The amplitude, duration and area under the curve were lower in patients with iron deficiency than in asymptomatic volunteers, mainly in the proximal and middle esophageal body. There was no difference in velocity. Sequential swallows did not change contraction amplitude, duration, velocity or area under curve in patients and volunteers. CONCLUSION: Although the power of esophageal contractions was decreased in patients with iron deficiency anemia, sequential swallows did not cause further impairment.     

Effect of bolus volume on proximal esophageal contractions of patients with Chagas' disease and patients with idiopathic achalasia

Chagas' disease and idiopathic achalasia patients have similar impairment of distal esophageal motility. In Chagas' disease, the contractions occurring in the distal esophageal body are similar after wet or dry swallows. Our aim in this investigation was to evaluate the effect of wet swallows and dry swallows on proximal esophageal contractions of patients with Chagas' disease and with idiopathic achalasia. We studied 49 patients with Chagas' disease, 25 patients with idiopathic achalasia, and 33 normal volunteers. We recorded by the manometric method with continuous water perfusion the pharyngeal contractions 1 cm above the upper esophageal sphincter and the proximal esophageal contractions 5 cm from the pharyngeal recording point. Each subject performed in duplicate swallows of 3‐mL and 6‐mL boluses of water and dry swallows. We measured the time between the onset of pharyngeal contractions and the onset of proximal esophageal contractions (pharyngeal‐esophageal time [PET]), and the amplitude, duration, and area under the curve (AUC) of proximal esophageal contractions. Patients with Chagas' disease and with achalasia had longer PET, lower esophageal proximal contraction amplitude, and lower AUC than controls (P≤ 0.02). In Chagas' disease, wet swallows caused shorter PET, higher amplitude, and higher AUC than dry swallows (P≤ 0.03).There was no difference between swallows of 3‐ or 6‐mL boluses. There was no difference between patients with Chagas' disease and with idiopathic achalasia. We conclude that patients with Chagas' disease and with idiopathic achalasia have a delay in the proximal esophageal response and lower amplitude of the proximal esophageal contractions.     

Esophageal Motility of Patients with Chagas' Disease and Idiopathic Achalasia

Chagas' disease and idiopathic achalasia have the same neuropathic lesion—the loss of ganglion cells within the esophageal myenteric plexus—with similar clinical, radiologic, and manometric features. However, it is suggested that there are some differences between them. We studied the esophageal motility of 45 patients with Chagas' disease (seven with esophageal dilation), 27 patients with idiopathic achalasia (13 with esophageal dilation), and 40 asymptomatic volunteers. We used the manometric method with continuous perfusion. The lower esophageal sphincter (LES) pressure was measured by the rapid pull-through method. Esophageal contractions was evaluated at 5, 10, and 15 cm above the LES, after 10 swallows of a 5-ml bolus of water alternated with 10 dry swallows. LES pressure was higher in achalasia than in Chagas' disease patients and controls (P < 0.05). Amplitude of contraction was lower in all patient groups compared with controls (P < 0.01) and lower in patients with dilation compared with patients without dilation (P < 0.05). The contraction duration was longer in patients with achalasia than in patients with Chagas' disease and controls (P < 0.05). The percentage of failed contractions was higher in Chagas' disease than in achalasia and controls (P < 0.05), and the percentage of simultaneous contractions was higher in patients with idiopathic achalasia than in patients with Chagas' disease and controls (P < 0.05). The results suggest the possibility that the extent of impairment of esophageal innervation differs between Chagas' disease and idiopathic achalasia.     

The Effect of Topical Pharyngeal Anesthesia on Esophageal Motility

A strong gag reflex may be a limiting factor to perform esophageal motility in some patients. Even though local anesthetics could alleviate such a problem, they are not used for fear of interfering with various manometric parameters. In this study, we evaluated the effect of topical pharyngeal local anesthesia on lower esophageal sphincter pressure, amplitude, duration, and velocity of esophageal contractions. We also studied its effects on the patient's tolerance. Esophageal motility was performed before and after topical anesthesia with 20% benzocaine. The baseline tracing and the tracing obtained after topical anesthesia were number coded and separated. They were evaluated blindly as to the pressure in the lower esophageal sphincter, amplitude, duration, and velocity of esophageal contractions. An average of 10 wet swallows was used to determine the above values. There was no significant change in the lower esophageal sphincter pressure or the amplitude of esophageal contractions after benzocaine. Similarly, there was no change in the duration or velocity of peristaltic activity. The patient's tolerance to the tube was unchanged or improved in 12 of 14 patients. Six patients had some difficulty in swallowing, but were able to compensate by sucking on the syringe. Our results indicate that topical pharyngeal anesthesia does not affect the usually measured manometric parameters; and while it may improve the patient's tolerance to the manometric catheter, it interferes with the ability to swallow.     

Hypocontraction of the esophagus in patients with Chagas' disease and with primary achalasia

The esophageal contraction amplitude is low in patients with Chagas' disease and patients with primary achalasia but not every swallow is followed by low contraction amplitude. We evaluated the number of low contraction amplitude in 40 normal volunteers, 99 Chagas' disease patients and 14 patients with primary achalasia. Each subject performed 10 swallows of a 5 mL bolus of water and the esophageal motility was measured at 5, 10 and 15 cm above the lower esophageal sphincter by the manometric method with continuous perfusion. The amplitude of contraction was considered to be low when its value was below 30 mm Hg. There was a hypotensive contraction when the amplitude was low or when the contraction failed. The number of hypotensive contractions was higher in patients with Chagas' disease and patients with achalasia than in healthy volunteers (P < 0.05). Patients with Chagas' disease and abnormal esophageal radiological examination but without dilation had more frequent hypotensive contraction than patients with normal esophageal radiologic examination (P < 0.01). The same results were obtained for subjects with three or more hypotensive contractions (P < 0.01). The patients with Chagas' disease and dysphagia had more hypotensive contractions than patients without dysphagia (P < 0.05). We conclude that patients with Chagas' disease and patients with primary achalasia have a higher number of hypotensive contractions following wet swallows than normal volunteers, a fact that should influence the symptomatology of the patients.     

Aging and esophageal motility in patients with gastroesophageal reflux disease

BACKGROUND: Alterations of esophageal contractions may worsen the esophageal lesions caused by gastroesophageal reflux. The impairment of the contractions may be localized only in the distal esophagus or in the entire esophageal body, and may be worse with the aging process. AIMS: To evaluate the proximal and distal esophageal contractions in patients with gastroesophageal reflux symptoms with or without esophagitis. PATIENTS AND METHODS: We studied esophageal motility in 104 patients with gastroesophageal reflux symptoms, 42 with normal esophageal endoscopic examination, 47 with mild esophagitis and 15 with severe esophagitis. The esophageal contractions were measured by the manometric method at 2, 7, 12 and 17 cm from the upper esophageal sphincter, after five swallows of a 5 mL bolus of water. RESULTS: The amplitude and area under the curve of contractions were lower in patients with severe esophagitis than in patients without esophagitis or with mild esophagitis in the distal part of the esophageal body (17 cm from the upper esophageal sphincter). In the proximal esophageal body there was no difference in amplitude or area under the curve. In the entire esophageal body there was no difference between the three groups of patients in duration, velocity of peristaltic contractions, or proportion of failed, simultaneous, non-propagated or peristaltic contractions. There was no difference between the patients with less than 50 years or with more than 50 years of age. CONCLUSIONS: Patients with severe esophagitis had lower distal esophageal contraction amplitude than patients without esophagitis or with moderate esophagitis. There was no effect of aging on esophageal contractions.     

Accuracy of abbreviated manometry in detecting esophageal motility abnormalities

We determined whether an abbreviated motility study that is commonly employed in clinical esophageal manometrics was as accurate as an extended manometric evaluation in detecting abnormalities in the esophageal body. One hundred patients underwent both abbreviated (stationary catheter, 10 wet swallows) and extended manometries (stepwise catheter withdrawal, 62±1 wet swallows). Classification by the two techniques was identical in 83 patients. Abbreviated manometry failed to recognize nine abnormal motility patterns. The abbreviated method was least accurate in the identification of intermittent and focal motility abnormalities (sensitivity=0.50). Misclassifications were related to catheter position and not solely to differences in the total number of swallows. Of the individual wave parameters measured by each method, detection of multipeaked contraction waves was the most discrepant (R=0.59). These findings indicate that abbreviated esophageal manometry is reasonably well correlated with a more extended method in detecting esophageal motility disorders and, because of its relative simplicity, appears appropriate for use in clinical practice. Errors related to stationary recording port positions may interfere with the overall accuracy of the abbreviated technique.This work was supported in part by National Institutes of Health grant AM-07130.     

Comparison of esophageal motility impairment caused by Chagas' disease in two age groups

BACKGROUND: Chagas' disease and the aging process cause loss of neurons of the esophageal myenteric plexus. AIM: To evaluate the esophageal motility impairment caused by Chagas' disease in two age groups. Our hypothesis was that the aging process may cause further esophageal motility impairment in patients with Chagas' disease. METHODS: We studied the esophageal motility of 30 patients with Chagas' disease and dysphagia, with esophageal retention of barium sulfate and an esophageal diameter within the normal range. Fifteen were 34 to 59 years old (younger group, median 51 years) and 15 were 61 to 77 years old (older group, median 66 years). As a control group we studied 15 subjects aged 33 to 58 years (median 42 years) and 7 subjects aged 61 to 73 years (median 66 years). The esophageal contractions were measured by the manometric method with continuous perfusion after five swallows of a 5 mL bolus of water at 2, 7, 12 and 17 cm below the upper esophageal sphincter. RESULTS: Patients with Chagas' disease had lower amplitude of contractions and fewer peristaltic, more simultaneous, and more non-conducted contractions than controls. Older patients with Chagas' disease had lower amplitude of contractions in the distal esophagus (mean +/- SE: 30.8 +/- 4.3 mm Hg) than younger patients (51.9 +/- 8.6 mm Hg). From 12 to 17 cm, older patients had more non-conducted (41%) and fewer peristaltic (8%) contractions than younger patients (non-conducted: 16%, peristaltic: 21%). CONCLUSION: Older patients with Chagas' disease with clinical and radiological examinations similar to those of younger patients had motility alterations suggesting that the aging process may cause further deterioration of esophageal motility.     

Esophageal solid bolus transit: studies using combined multichannel intraluminal impedance and manometry in healthy volunteers

The purpose of this study is to apply combined multichannel intraluminal impedance and esophageal manometry (MII‐EM) to test esophageal function during solid swallowing in a normal healthy population. We determined whether combined MII‐EM with solid bolus is more sensitive than that with viscous bolus in the detection of motility abnormality. Eighteen healthy volunteers (11 men and 7 women; mean age 22 years, range 20–26 years) underwent combined MII‐EM with a catheter containing four impedance‐measuring segments and five solid‐state pressure transducers. Each subject received 10 viscous and 10 solid materials. Tracings were analyzed manually for bolus presence time, total bolus transit time, contraction amplitude, duration, and onset velocity. Three hundred and sixty swallows including viscous and solid materials were analyzed. Contraction amplitude for the viscous swallows was higher at 20 cm above the lower esophageal sphincter (LES) (P= 0.049) but lower at 15 cm above the LES (P < 0.001). Duration of contractions for the solid swallows was longer at 15 cm (P= 0.002) and 10 cm above the LES (P= 0.011) compared with viscous swallows. The total bolus transit time for solid was significantly shorter than that for viscous boluses (6.8 vs. 7.7 seconds, P < 0.001). Bolus presence time appeared to be similar between viscous and solid boluses (except in the proximal esophagus). The percentage of swallows with ineffective peristalsis by manometry, as well as those with incomplete bolus transit by impedance, did not differ between viscous and solid swallows. The proportion of manometrically ineffective solid swallows with incomplete bolus transit was greater than that of viscous swallows (62.1% vs. 34.8%, P= 0.05). Application of solid boluses may potentially enhance diagnostic capability of esophageal function testing. Solid boluses can be regarded as a valuable complement to viscous boluses in the detection of esophageal motility abnormalities when applied with combined MII‐EM.     

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.     

Symptom and function heterogenicity among patients with distal esophageal spasm: studies using combined impedance-manometry

BACKGROUND: Combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is a clinically available tool that assesses the functional defect of various manometric abnormalities. The aim of our study was to evaluate esophageal bolus transit in patients with manometrically defined distal esophageal spasm (DES). METHODS: Patients referred for esophageal function testing underwent combined MII-EM studies including 10 liquid and 10 viscous swallows. Individual swallows were classified using previously published manometric and impedance criteria. DES is traditionally defined as > or =20% simultaneous contractions in the distal esophagus. Diagnosis of esophageal transit abnormalities was defined by the presence of > or =30% incomplete liquid or > or =40% incomplete viscous swallows. RESULTS: Data from 71 patients (43 female, mean age 57 yr, range 16-85) with a manometric diagnosis of DES were analyzed. During liquid swallows, patients with chest pain had higher (p < 0.05) distal esophageal amplitudes (202.3 +/- 34.5 mmHg) and a higher (p < 0.05) percentage of swallows with complete bolus transit (89%+/- 3%) compared to patients presenting with dysphagia (amplitude 117.8 +/- 8.7 mmHg; percentage of complete transit 69%+/- 5%) and patients with reflux symptoms (amplitude 116.4 +/- 12.7 mmHg; percentage of complete transit 74%+/- 5%). Fifty-one percent of the DES patients had a normal bolus transit for liquid and viscous, 24% abnormal bolus transit for one substance, and 25% abnormal bolus transit for liquid and viscous. CONCLUSION: Pressure and bolus transit information in patients with manometrically defined DES points toward heterogenicity of this group of patients. Outcomes data are warranted to evaluate whether stratifying DES patients based on pressure and bolus transit information may improve the clinical approach.     

Evaluation of esophageal function in patients with esophageal motor abnormalities using multichannel intraluminal impedance esophageal manometry

INTRODUCTION Esophageal manometry has been considered the “gold standard” test for the evaluation of esophageal motility. Esophageal manometry allows physicians to assess peri- stalsis by using informations about the shape, amplitude and duration of the…     

Spasm, nutcracker, and IEM: real or manometry findings?

In 1987, Richter and colleagues published the results of an esophageal motility study conducted on 95 normal healthy volunteers between the ages of 22 and 79. In accordance with these results, abnormal esophageal motility was defined on the basis of the percentage of manometric normal, ineffective, and simultaneous swallows and on lower esophageal sphincter dynamics during liquid swallows. For example, Richter and colleagues found that the mean amplitude of contraction in the distal body of the esophagus >180 mm Hg in association with wet swallows was above the 95% confidence interval of normal. Richter's study also showed a wide variation among individuals and that the mean distal esophageal contractile amplitude increased with age without sex predominance. Likewise, as no subjects had >20% simultaneous contractions (though a considerable number, 4%, had 10% simultaneous contractions), esophageal spasm was defined at the >20% mark.     

Rhythmic Spontaneous Contractions in Patients with Esophageal Symptoms

Eight patients were identified over a 4-yr period with rhythmic spontaneous contractions of the esophagus. The contraction waves were found to originate immediately below the region of the upper esophageal sphincter in all patients, and propagated a short distance into the proximal esophagus. Mean interval between waves varied from 3.8 to 7.2 s, and all described patients had sequences of at least 5 repetitive waves. Contraction sequences were often initiated and terminated by swallows, but at other times occurred and ceased independent of swallows. Long periods of esophageal baseline pressure elevation were observed in the distal esophageal body, an indicator of poor esophageal clearance presumably related to the rhythmic contraction sequences. Half of the patients had endoscopic or radiographic evidence of reflux-related esophageal injury, yet dysphagia was the most commonly reported symptom. Concomitant manometric abnormalities of the esophageal body may have contributed to symptom production in several of the patients. This rare finding occurring singularly or in combination with other disorders may represent a symptomatic motility derangement that can be detected by systematic sampling of the entire esophagus during manometric examination.     

Influence of Esophageal Motility on Esophageal Speech of Laryngectomized Patients

After laryngectomy for treatment of cancer of the larynx, the patient may have vocal rehabilitation by esophageal speech. Some patients fail to achieve the esophageal speech due to reasons involving surgery, radiotherapy, and psychological alterations. Our hypothesis is that the esophageal motility alterations consequent to laryngectomy may be involved in the failure to achieve esophageal speech. Using manometry with continuous perfusion, we studied the esophageal motility of 25 laryngectomized patients, 10 of them able to produce esophageal speech and 15 unable to produce esophageal speech, and 40 asymptomatic normal volunteers. The lower esophageal sphincter (LES) pressure was measured by the rapid pull-through method and the upper esophageal sphincter (UES) pressure by the station pull-through method. The contractions were measured at 5, 10, and 15 cm above the LES after the subjects performed 10 swallows with a 5-mL bolus of water. By comparing volunteers and laryngectomized patients, we found a lower UES pressure, lower amplitude of contractions, and increased percentage of simultaneous contractions in laryngectomized patients (p <0.05). There was no difference between patients able and unable to produce esophageal speech in LES and UES pressure, esophageal contraction duration and velocity, or in the percentage of failed and simultaneous contractions. The esophageal contraction amplitude was lower in patients who acquired esophageal speech than in patients who did not (p <0.05 at 10 cm from LES). We conclude that there are esophageal motility alterations in laryngectomized patients but only the decrease of esophageal contraction amplitude seems to be associated with the acquisition of esophageal speech.     

Proximal Esophageal Contractions in Laryngectomized Patients

After laryngectomy for treatment of laryngeal cancer, the distal esophageal contractions have low amplitude. Our hypothesis is that proximal esophageal contractions are also impaired. We studied the proximal esophageal contractions in 20 laryngectomized patients (16 men) with a mean age of 44.2 years, 12 rehabilitated patients with esophageal speech, and 12 controls (7 men, mean age of 46.5 years). We used the manometric method with continuous perfusion. All subjects were studied in the sitting position and performed five swallows of a 5-ml bolus of water alternated with five dry swallows. The contractions were measured 2 cm below the high-pressure zone of the pharyngoesophageal transition. The results showed that the amplitude and duration of contractions were different in laryngectomized patients compared with controls. The amplitude of contractions of patients (wet swallows: 37.3 ± 20.7 mmHg, mean ± SD) was lower than that of controls (81.1 ± 31.7 mmHg). The duration of contractions was also lower in laryngectomized patients (2.2 ± 0.7 s) than in controls (2.6 ± 0.6 s). We conclude that the proximal esophageal contraction amplitude and duration of laryngectomized patients are lower than controls, a fact suggesting that laryngectomy may affect the proximal esophageal contractions.