UES Opening and Cricopharyngeal Bar in Nondysphagic Elderly and Nonelderly Adults

The intent of the study was to investigate upper esophageal sphincter (UES) opening and cricopharyngeal bar, and their relationship to other swallowing variables, in elderly, nondysphagic subjects. Extent and duration of UES opening, hypopharyngeal transit time, hyoid displacement, hyoid-to-larynx approximation, and incomplete pharyngeal clearing were determined from fluoroscopic swallow studies in 84 nonelderly control subjects and 88 elderly subjects. No differences in these measures were found between elderly subjects with and without medical conditions, and data were subsequently pooled. Mild, moderate, or marked cricopharyngeal bars were identified in more than 30% of elderly subjects, and subsequent analyses were performed on the control group, the elderly group without bars, and the elderly group with bars. Maximum opening of the UES in the elderly bar group was significantly reduced compared with that of the elderly group without bars and the nonelderly control group. However, timing measures did not differentiate elderly subjects with bars from other elderly subjects and they suggest that prolonged transit times in the elderly cannot be explained by the presence of a cricopharyngeal bar. With the exception of hyoid displacement, all variables investigated differed significantly between the nonelderly and one or both of the elderly groups. With the exception of UES opening, variables examined generally did not differentiate the two elderly groups.     

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 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.     

Kinematic and Temporal Factors Associated with Penetration–Aspiration in Swallowing Liquids

In this study we undertook careful analysis of 13 quantitative physiological variables related to oropharyngeal swallowing from a sample of 42 subacute patients referred for dysphagia assessment. Each patient underwent a videofluoroscopic swallowing examination in which they swallowed up to five boluses of 22 % w/v ultrathin liquid barium suspension administered by teaspoon. Our goal was to determine whether scores on 13 kinematic or temporal parameters of interest were independently associated with the presence of penetration–aspiration in the final compiled dataset of 178 swallows. Participants were classified as aspirators based on the presence of at least one swallow that demonstrated a Penetration–Aspiration Scale score of ≥3. The parameters of interest included six kinematic parameters for capturing hyoid position, three swallow durations [laryngeal closure duration, hyoid movement duration, and upper esophageal sphincter (UES) opening duration], and four swallow intervals (laryngeal closure to UES opening, bolus dwell time in the pharynx prior to laryngeal closure, stage transition duration, and pharyngeal transit time). Mixed-model repeated-measures ANOVAs were conducted to determine the association between each parameter and aspiration status. Only 1 of the 13 parameters tested distinguished aspirators from nonaspirators: aspirators demonstrated significantly shorter UES opening duration. In addition, a trend toward reduced maximum superior position of the hyoid was seen in aspirators. Limitations and future considerations are discussed.     

Upper esophageal sphincter opening and modulation during swallowing

Studies were done on 8 normal subjects with synchronized videofluoroscopy and manometry to facilitate a biomechanical analysis of upper esophageal sphincter opening and volume-dependent modulation during swallowing. Movements of the hyoid and larynx, dimensions of sphincter opening, and intraluminal sphincter pressure were determined at 1/30th-s intervals during swallows of 1, 5, 10, and 20 ml of liquid barium. Our analysis subdivided upper esophageal sphincter activity during swallowing into five phases: (a) relaxation, (b) opening, (c) distention, (d) collapse, and (e) closure. Sphincter relaxation occurred during laryngeal elevation and preceded opening by a mean period of 0.1 s. Opening occurred as the sphincter was pulled apart via muscular attachments to the hyoid such that the hyoid coordinates at which sphincter opening and closing occurred were constant among bolus volumes. Sphincter distention after opening was modulated by intrabolus pressures rather than graded hyoid movement. The generation of intrabolus pressure coincided with the posterior thrust of the tongue that culminated in pharyngeal wall contact and the initiation of pharyngeal peristalsis. Larger volume swallows were associated with greater intrabolus pressure and increased bolus head velocity. The duration of sphincter opening increased in conjunction with a prolongation of the anterior-superior excursion of the hyoid and a delay in the onset of pharyngeal peristalsis (the event that determined the timing of sphincter closure). We conclude that transsphincteric transport of increasing swallow bolus volumes is accomplished by modulating sphincter diameter, opening interval, and flow rate (reflected by bolus head velocity). Furthermore, upper esophageal sphincter opening is an active mechanical event rather than simply a consequence of cricopharyngeal relaxation.     

Evaluating Oral Stimulation as a Treatment for Dysphagia after Stroke

Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 ± 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 ± 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 ± 0.07 s and pharyngeal transit time was 0.94 ± 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 ± 3.01; sham: 24.9 ± 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.Abbreviations: mA = milliamps; FP = faucial pillar; LCD = laryngeal closure duration; OTT = oral transit time; PTT = pharyngeal transit time; SRT = swallow response time; TMS = transcranial magnetic stimulation; UES = upper esophageal sphincter.     

Upper esophageal sphincter function during deglutition

Upper esophageal sphincter function was investigated during swallows of graded volumes in 8 normal volunteers. Concurrent recordings of video-fluoroscopic and manometric studies were obtained and correlated with each other by means of a videotimer. Maximal upper esophageal sphincter (UES) pressure was typically located 1.5 cm distal to the air-tissue interface between the hypopharynx and the proximal margin of the sphincter. The region in which UES pressure was greater than or equal to 50% maximal averaged 1.0 cm in length. Thus, the physiologic high-pressure zone of the UES corresponds in size and location to that of the cricopharyngeus muscle. Fluoroscopic analysis of sphincter movement indicated that the sphincter high-pressure zone moved 2.0-2.5 cm orally during swallowing and that the magnitude of the orad movement was directly related to the volume of barium swallowed. The maximal anterior-posterior diameter of sphincter opening during a swallow ranged from 0.9 to 1.5 cm and was also directly related to the volume swallowed. The intervals of UES opening and relaxation increased significantly with increasing bolus volume; the duration of UES relaxation ranged from a mean of 0.37 s for dry swallows to 0.65 s for 20-ml swallows. Thus, the dynamics of UES function during deglutition are dependent upon the volume of the swallowed bolus. Larger bolus volumes are accommodated by both an increased diameter of sphincter opening and by prolongation of the interval of sphincter relaxation. Analysis of the timing of other reference points within the pharyngeal swallow sequence indicated that as the manometric interval of UES relaxation increased, the period of laryngeal elevation was prolonged, the UES relaxed earlier and contracted later, and the interval between the onset of laryngeal elevation and hypopharyngeal contraction increased.     

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.     

Pharyngeal/upper esophageal sphincter pressure dynamics in humans

Extensive physiological studies of swallowing have been carried out in laboratory animals; however, similar studies in humans have been limited by available technology. In this study we describe the use of a solid-state circumferential sphincter transducer to define manometric characteristics of the human pharynx and upper esophageal sphincter (UES). Effects of pharmacologic agents and thermal stimulation are also described. We studied nine normal volunteers on three separate days. All studies were done in the upright position and consisted of a station pull-through of the UES and six wet swallows with the sphincter transducer in the most proximal segment of the UES and a posteriorly oriented single transducer 5 cm proximal in the pharynx. Baseline studies preceded all drug studies. Effects of bethanechol were studied on day 1, cold stimulation and benzonatate on day 2, edrophonium and atropine on day 3. The UES resting pressure showed large intrasubject day-to-day variations; however, mean values did not differ. There were no effects on UES relaxation or swallow coordination with any of the pharmacologic agents, although benzonatate produced multiple pharyngeal contractions.     

Timing of Pharyngeal and Upper Esophageal Sphincter Pressures as a Function of Normal and Effortful Swallowing in Young Healthy Adults

The effect of effortful swallow on pharyngeal pressure and UES relaxation onsets and durations was examined. Eighteen adults, nine males and nine females (mean age = 27.9 yr), participated. Timing of pharyngeal pressure and onset and duration of UES relaxation were measured across ten trials of normal and ten trials of effortful swallows. Results revealed that manometric timing measurements are consistent across trials. The first and second statistical analyses investigated the pharyngeal pressure and UES relaxation onsets and durations, respectively. Both analyses identified a significant interaction of swallow type (i.e., effortful vs. normal) by manometric sensor location (p < 0.05). Across normal and effortful swallows, UES relaxation preceded pharyngeal pressure onsets, yet the rate of change (or degree of delay) varied across the sensors. Furthermore, the effortful swallow elicited longer pharyngeal pressure and UES relaxation durations, yet the pressure duration measured in the upper pharynx was significantly longer than that measured lower in the pharynx. These findings offer insight as to the potential positive and negative influence of the effortful swallow on pharyngeal timing.     

Sequence Variability During Hypopharyngeal Bolus Transit

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. Individual variability has not been studied, however. The purpose of this study was to determine the amount of sequence variability that normally occurs during the hypopharyngeal phase of deglutition. Dynamic swallow studies from 60 normal volunteers were evaluated and event sequence variability was determined for 12 two-event sequences during swallowing of three bolus sizes. There was found to be some variability in event sequences for almost all events evaluated except for the following : (1) arytenoid cartilage elevation always began prior to opening of the upper esophageal sphincter, (2) the sphincter always opened prior to the arrival of the bolus at the sphincter, (3) larynx-to-hyoid approximation always occurred after the onset of upper esophageal sphincter opening, and (4) maximum pharyngeal constriction always occurred after maximal distension of the upper esophageal sphincter. Variability was more common during swallowing of the smallest bolus size. This information may be helpful in evaluating event coordination in patients with dysphagia.     

Effects of the Mendelsohn Maneuver on Extent of Hyoid Movement and UES Opening Post-Stroke

The Mendelsohn maneuver, voluntary prolongation of laryngeal elevation during the swallow, has been widely used as a compensatory strategy to improve upper esophageal sphincter (UES) opening and bolus flow. Recent research suggests that when used as a rehabilitative exercise, it significantly improves duration of hyoid movement and positively impacts duration of UES opening (DOUESO). The data presented here were derived from that same prospective crossover study of 18 participants with dysphagia post-stroke evaluated with videofluoroscopy after treatment using the Mendelsohn maneuver versus no treatment. Results demonstrate gains in the extent of hyoid movement and UES opening and improvements in coordination of structural movements with each other as well as with bolus flow.     

Videofluorographic Study of Swallowing in Parkinson's Disease

We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.     

An overview of the upper esophageal sphincter

The anatomy and physiology of the upper esophageal sphincter (UES) are complex. Much progress has been made over the past few years in our understanding this important sphincter. The closing muscles of the UES include the inferior pharyngeal sphincter, the cricopharyngeus (CP), and the cervical esophagus. The CP is composed of two parts, which may have different functions. The CP is innervated by the pharyngeal plexus and the recurrent laryngeal nerve. Tone of the UES is probably generated by numerous reflexes rather than by specific tone-generating circuitry. The major tonegenerating muscle is the CP, which is highly elastic and produces more active tension the more it is stretched. The UES opens by relaxation of the closing muscles, traction by muscles attached to the hyoid bone and thyroid cartilage, and pulsion of the bolus. The various muscles of the UES behave differently during its many dynamic states, so that similar functions are accomplished by different muscles.     

Upper esophageal sphincter function during belching

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

Structural Displacements in Normal Swallowing: A Videofluoroscopic Study

Dynamic videofluoroscopic swallow studies were performed on 60 normal adult volunteers to establish normative data for displacement of upper aerodigestive tract structures during deglutition. Variables evaluated included hyoid bone displacement, larynx-to-hyoid bone approximation, pharyngeal constriction, and the extent of pharyngoesophageal sphincter (PES) opening during liquid swallows of 1, 3, and 20 cc. Results showed direct relationships between bolus size and hyoid displacement, between bolus size and PES opening, and between bolus size and pharyngeal constriction. Only hyoid-to-larynx approximation remained unchanged across bolus sizes. Sex differences were noted for all variables except PES opening. Reliability for most measurement variables was excellent. To our knowledge, normative data for pharyngeal constriction and larynx-to-hyoid approximation have not previously been described.     

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...     

Swallowing Physiology of Toddlers with Long-Term Tracheostomies: A Preliminary Study

This study investigated the swallowing physiology of toddler-aged patients with long-term tracheostomies. Structural movements and motility of the pharyngeal stage of swallowing were studied in four toddlers ranging in age from 1:2 (years:months) to 2:9 with long-term tracheostomies. A patient aged 1:2 years with no tracheostomy served as a toddler model for comparison. Videofluoroscopic recordings of the patients' liquid and puree bolus swallows were analyzed for a) onset times for pharyngeal stage events, laryngeal vestibule closure, and tracheostomy tube movement; b) timeliness of swallow response initiation; and c) pharyngeal transport function. Results found differences in timing of pharyngeal stage movements between the tracheostomized patients and the patient with no tracheostomy. Laryngeal vestibule closure occurred before or within the same 0.033-s video frame as onset of upper esophageal sphincter (UES) opening in the patient with no tracheostomy, but occurred 0.033–.099 s after onset of UES opening in the tracheostomized patients. The time line required to close the laryngeal vestibule once the arytenoids began their anterior movement was longer in the tracheostomized patients than in the patient with no tracheostomy and was associated with laryngeal penetration. The patient with no tracheostomy displayed superior excursion of the arytenoid and epiglottis during the swallowing; the tracheostomized patients did not. No association was found between onset of tracheostomy tube movement and laryngeal vestibule closure. Delayed swallow response initiation was observed across tracheostomized patients at a mean frequency of 45% with associated penetration. Pharyngeal dysmotility was not observed. Findings supported the concept that long-term tracheostomy in toddler-aged patients affects swallowing physiology.     

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.     

Hyoid-Bolus Transit Latencies in Normal Swallow

Pharyngeal swallow delay is frequently found in dysphagic patients and is thought to be a factor in a range of swallowing problems, including aspiration. Implicit in notions of swallow “delay” is a temporal interval between two events that is longer than normal. However, there appears to be little agreement about which referent events should be considered in determining delay. A number of pharyngeal bolus transit points and various pharyngeal gestures have been used in delays determined from fluoroscopic evidence, and other referents have been used in electromyographic and manometric studies of swallow. In this study latencies between the first movement of the hyoid and several pharyngeal bolus transit points were calculated from fluoroscopic swallow studies in normal nondysphagic adults. Means and standard deviations of these latencies are provided for a 3-cc and a 20-cc bolus and for both nonelderly and elderly adults. The data may be a useful resource for relating the specific latencies investigated to concepts of pharyngeal swallow delay, in particular, when assessing videofluoroscopic studies using a similar protocol.