The Effect of an Effortful Swallow on the Normal Adult Esophagus

The effect of an effortful swallow on the healthy adult esophagus was investigated using concurrent oral and esophageal manometry (water perfusion system) on ten normal adults (5 males and 5 females, 20-35 years old) while swallowing 5-ml boluses of water. The effects of gender, swallow condition (effortful versus noneffortful swallows), and sensor site within the oral cavity, esophageal body, and lower esophageal sphincter (LES) were examined relative to amplitude, duration, and velocity of esophageal body contractions, LES residual pressure, and LES relaxation duration. The results of this study provide novel evidence that an effortful oropharyngeal swallow has an effect on the esophageal phase of swallowing. Specifically, effortful swallowing resulted in significantly increased peristaltic amplitudes within the distal smooth muscle region of the esophagus, without affecting the more proximal regions containing striated muscle fibers. The findings pertaining to the LES are inconclusive and require further exploration using methods that permit more reliable measurements of LES function. The results of this study hold tremendous clinical potential for esophageal disorders that result in abnormally low peristaltic pressures in the distal esophageal body, such as achalasia, scleroderma, and ineffective esophageal motility. However, additional studies are necessary to both replicate and extend the present findings, preferably using a solid-state manometric system in conjunction with bolus flow testing on both normal and disordered populations, to fully characterize the effects of an effortful swallow on the esophagus.     

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.     

Training Effects of the Effortful Swallow Under Three Exercise Conditions

The effortful swallow achieves overload through high effort. It was predicted that both immediate effects on biomechanics and long-term neuromuscular adaptations would be facilitated by maximal overload during this exercise. This study examined how high-effort sips from small-diameter straws influenced linguapalatal swallow pressures. Additionally, training effects of effortful swallows preceded by high-effort sips were compared to two other exercise conditions: effortful swallows preceded by maximum effort lingual elevation and effortful swallows performed in isolation. Training outcomes included linguapalatal pressures produced during effortful and noneffortful swallows, and maximum isometric pressure (MIP) produced during tongue elevation and interlabial compression. Forty healthy adults participated in the experiment. Lingual–palatal swallowing pressure during non effortful and effortful swallows and MIPs were measured prior to and after 4 weeks of training. Prior to training, anterior linguapalatal pressures were significantly higher during effortful compared to noneffortful swallows. Anterior linguapalatal pressures did not significantly differ during swallows preceded by sips from high-resistance straws. Weak correlations were observed between tongue MIP and linguapalatal pressures during effortful swallows. After training, anterior linguapalatal pressures significantly increased, with training effects more dramatic for effortful swallows. Anterior tongue MIP also significantly increased. Gains in anterior linguapalatal pressure were not correlated with gains in tongue MIP. Training effects did not vary across exercise condition. The study failed to find a training advantage of pairing the effortful swallow with a precursor movement. The results demonstrated specificity of training, with more dramatic benefits observed for effortful swallows relative to noneffortful swallows. Further investigation is needed to characterize training effects in older adults and patients with dysphagia.     

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.     

Differentiating Effortful and Noneffortful Swallowing with a Neck Force Transducer: Implications for the Development of a Clinical Feedback System

This study sought to determine whether effortful saliva swallows could be differentiated from habitual, noneffortful saliva swallows on the basis of swallow-related changes in neck circumference in humans. Gender differences in swallow-related neck circumference were examined as a secondary question. Twenty-seven healthy adults (14 females; mean age = 26.6 years, SD = 3.9 years) participated in two experimental runs (run duration = 10 min) during which they produced single trials of three visually cued tasks in random order: effortful saliva swallowing, saliva swallowing, and a control task involving repetitive apposition of the dominant thumb and index finger. Neck and ribcage circumference were simultaneously collected from the output of force transducers positioned around the neck and ribcage, respectively. The primary outcome variables were the positive and negative voltage peak amplitudes associated with changes in neck circumference during single-swallow trials. Effects of the swallowing task on positive and negative voltage peaks were examined with separate two-way analysis of variance procedures. Results indicated that both positive (F = 6.49, p < 0.05) and negative (F = 12.05, p < = .05) voltage peaks were significantly greater for effortful swallows compared with those for noneffortful swallows. The gender main effect and the swallow type by gender interaction were not significant. Effortful and noneffortful swallows of saliva can be differentiated from the output of a noninvasive force transducer worn around the neck. This type of physiologic recording may have potential as a biofeedback technique in training dysphagic patients on the effortful swallow maneuver.

Supraglottic swallow,effortful swallow,and chin tuck did not alter hypopharyngeal intrabolus pressure in patients with pharyngeal dysfunction

Simultaneous videoradiography and solid-state manometry (videomanometry) were performed in 8 patients (4 women, 4 men; age range = 46–81 years, mean age = 70 years) with pharyngeal dysfunction in order to disclose any changes in intrabolus pressure during swallowing maneuvers. Five of the patients had severe pharyngeal dysfunction with frequent misdirected swallows. Three of the patients had moderate pharyngeal dysfunction with delayed initiation of pharyngeal swallow. Three different swallowing techniques were applied: supraglottic swallow, effortful swallow, and chin tuck. Pharyngeal intrabolus pressure was analyzed at the level of the inferior pharyngeal constrictor. Supraglottic swallow, effortful swallow, and chin tuck did not alter peak amplitude or duration of the intrabolus pressure.     

The Effect of Voluntary Pharyngeal Swallowing Maneuvers on Esophageal Swallowing Physiology

The purpose of our study was to evaluate whether swallowing maneuvers designed to impact pharyngeal physiology would also impact esophageal physiology. Healthy volunteers underwent high-resolution manometry while performing three randomized swallowing maneuvers with and without a 5-ml bolus: normal swallowing, Mendelsohn maneuver, and effortful swallowing. We examined esophageal parameters of peristaltic swallows, hypotensive or failed swallows (“nonperistaltic swallows”), distal contractile integral (DCI), contractile front velocity (CFV), intrabolus pressure, and transition zone (TZ) defect. Four females and six males (median age 39 years; range 25–53) were included in the study. The overall number of nonperistaltic swallows was 21/40 (53 %) during normal swallowing, 27/40 (66 %) during the Mendelsohn maneuver, and 13/40 (33 %) during effortful swallowing. There were significantly more overall nonperistaltic swallows with the Mendelsohn maneuver compared with effortful swallowing (p = 0.003). While swallowing a 5-ml bolus, there were more nonperistaltic swallows during the Mendelsohn maneuver (12/20, 60 %) compared to that during normal swallowing (6/20, 30 %) (p = 0.05) and more peristaltic swallows during effortful swallowing as compared to Mendelsohn maneuver (p = 0.003). Intrabolus esophageal pressure was greater during the Mendelsohn maneuver swallows in the bolus-swallowing condition as compared to normal swallowing (p = 0.02). There was no statistical difference in DCI, CFV, or TZ defect between swallowing conditions. The Mendelsohn maneuver may result in decreased esophageal peristalsis while effortful swallowing may improve esophageal peristalsis. Because it is important to understand the implications for the entire swallowing mechanism when considering retraining techniques for our patients, further investigation is warranted.     

Surface Electromyography in Preoperative Evaluation and Postoperative Monitoring of Zenker’s Diverticulum

Patients with Zenker’s diverticulum (ZD) underwent surface electromyography (sEMG) evaluation to determine sEMG patterns specific for ZD. Group 1 comprised patients with proven long-standing ZD that refused surgical treatment (n = 11, age mean = 55.7 years). Group 2 comprised surgically operated on patients with ZD (n = 6, age mean = 61 years). The timing, amplitude, and graphic patterns of activity of the masseter, submental, and laryngeal strap muscles were examined during voluntary single water swallows (“normal”), single swallows of excessive amounts of water (20 ml, “stress test”), and continuous drinking of 100 cc of water. The muscle activity in pharyngeal and initial esophageal stages of swallowing was measured, and graphic records were evaluated in relation to timing and voltage. The data were compared with the previously established normative database. The main sEMG patterns of ZD are (1) duration of swallowing and drinking is longer than normal (p < 0.05), (2) electric amplitude of laryngeal strap muscles during swallowing activity is higher than normal (p < 0.05), and (3) regurgitation peaks immediately after swallow followed by secondary swallow of the regurgitated portion of a bolus as seen at the sEMG records are specific graphic patterns for the ZD. Zenker’s diverticulum has its own specific sEMG patterns. Surface EMG, being an important screening method for patients with dysphagia, is a valuable additional diagnostic tool for ZD. Because it is noninvasive and nonradiographic, it can be used for monitoring of long-standing cases of the disease as well as monitoring of postsurgical recovery.     

High-Resolution Manometry of Pharyngeal Swallow Pressure Events Associated with Effortful Swallow and the Mendelsohn Maneuver

Effortful swallow and the Mendelsohn maneuver are two common strategies to improve disordered swallowing. We used high-resolution manometry (HRM) to quantify the effects of these maneuvers on pressure and timing characteristics. Fourteen normal subjects swallowed multiple, 5-ml water boluses using three techniques: normal swallow, effortful swallow, and the Mendelsohn maneuver. Maximum pressure, rate, duration, area integral, and line integral were determined for the velopharynx and tongue base. Minimum pressure, duration of pressure-related change, duration of nadir pressure, maximum preopening and postclosure pressure, area integral, and line integral were recorded for the upper esophageal sphincter (UES). Area and line integrals of the velopharyngeal pressure curve significantly increased with the Mendelsohn maneuver; the line integral increased with the effortful swallow. Preopening UES pressure decreased significantly for the Mendelsohn, while postclosure pressure tended to increase insignificantly for both maneuvers. UES area and line integrals as well as nadir UES pressure duration increased with both maneuvers. Maneuver-dependent changes were observed primarily at the velopharynx and UES. These regions are critical to safe swallowing, as the velopharynx provides positive pressure at the bolus tail while the UES allows a bolus to enter the esophagus without risk of regurgitation. Integrals were more responsive than maximum pressure or duration and should be investigated further.     

Videomanometric Analysis of Supraglottic Swallow, Effortful Swallow, and Chin Tuck in Patients with Pharyngeal Dysfunction

Simultaneous videoradiography and solid-state manometry (videomanometry) was performed in 8 patients (4 women, 4 men; age range = 46-81 years, mean age = 70 years) with pharyngeal dysfunction. Five patients had severe pharyngeal dysfunction with frequent misdirected swallows. Three patients had moderate pharyngeal dysfunction with delayed initiation of pharyngeal swallow. Three different swallowing techniques were used: supraglottic swallow, effortful swallow, and chin tuck. Ten video radiographic variables and six manometric variables were analyzed. Contrast media penetration to the airways was analyzed regarding number of events and level of penetration. Supraglottic swallow, effortful swallow, and chin tuck did not reduce the number of misdirected swallows, but effortful swallow and chin tuck significantly (p = 0.008) reduced the depth of contrast penetration into the larynx and trachea. There was no significant improvement of pharyngeal retention. Chin tuck reduced the distance between the thyroid and the hyoid and the distance between the mandible and the hyoid. No other measured variable was significantly altered. This study shows that none of the different swallowing techniques reduced the number of misdirected swallows. However, there was a significantly reduced depth of the misdirected swallows. The swallowing techniques did not seem to prevent the occurrence of retention or improve weak pharyngeal constrictor muscles in this group of patients with severe to moderate dysfunction.     

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

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

Videomanometric Analysis of Supraglottic Swallow, Effortful Swallow, and Chin Tuck in Healthy Volunteers

Simultaneous videoradiography and solid-state manometry (videomanometry) was applied in eight healthy volunteers (four women, four men; age range 25–64 years, mean age 41 years) without swallowing problems. Three different swallowing techniques were tested; supraglottic swallow, effortful swallow, and chin tuck. Seven videoradiographic variables and six manometric variables were analyzed. The supraglottic swallowing technique did not differ significantly from that of the control swallows. The effortful swallow had a significantly (p= 0.0001) reduced hyoid–mandibular distance preswallow due to an elevation of the hyoid and the larynx, which caused a significantly (p= 0.007) reduced maximal hyoid movement and a significantly (p= 0.009) reduced laryngeal elevation during swallow. The chin tuck swallow had a significantly (p= 0.001) reduced laryngohyoid distance and also a significantly (p= 0.004) reduced hyoid–mandibular distance. The chin tuck swallow also displayed significantly (p= 0.003) weaker pharyngeal contractions. Videomanometry allows for analysis of bolus transport, movement of anatomical structures, and measurement of intraluminal pressures. These variables are important when evaluating swallowing techniques. In the present study, we made a few observations that never have been reported before. When healthy volunteers performed supraglottic swallow, they performed the technique somewhat differently. Therefore, we assume dysphagic patients would need a substantial period of training to perform a technique efficiently. Chin tuck could impair protection of the airways in dysphagic patients with weak pharyngeal constrictor muscles.     

Quantitative assessment of swallowing in healthy adults

Swallowing has hitherto been evaluated during physical examination, radiologic barium studies, manometry, and cervical auscultation. Radiography principally demonstrates qualitative aspects of oral and pharyngeal function, whereas quantitative aspects have primarily been documented by manometry. To evaluate swallowing quantitatively, without using invasive methods or radiation, we have applied a combined test of water drinking, i.e., the Repetitive Oral Suction Swallow test (ROSS). The test provides reliable measurements of suction pressure, bolus volume, timing of important events in oral and pharyngeal swallow, and respiration. The test is described and results from 292 healthy, nondysphagic subjects are presented. We found a mean bolus volume of 25.6±8.5 ml during single swallow and 21.1±8.2 ml during stress (forced, repetitive swallow). During forced, repetitive swallow, the bolus volume was more strongly associated with suction time (r²=0.55) than with peak suction pressure (r²=0.04), indicating that suction time is more important than suction pressure in determining the bolus volume. The oral-pharyngeal transit time decreased: single swallow 0.56±0.36 sec, forced repetitive swallow 0.23±0.11 sec, as did the coefficient of variation (48% and 64%, respectively) indicating a more automatic neural process for pharyngeal function in forced, repetitive swallow. The postswallow respiration started with inspiration in 10% of studied individuals, but did not correlate with deviations in other variables in the test. Thus, postswallow inspiration must be considered as normal. The ROSS test offers a rapid and easy quantitative assessment of swallowing.     

Effect of the Effortful Swallow and the Mendelsohn Maneuver on Tongue Pressure Production against the Hard Palate

Although effortful swallow and the Mendelsohn maneuver are commonly used in dysphagia rehabilitation, little is known about their effects on tongue-palate pressure production. The purpose of this study was to investigate the effects of effortful swallow and the Mendelsohn maneuver on tongue pressure production. Fourteen healthy volunteers (10 men, 4 women; age range = 21–41 years) participated. Tongue pressures during dry swallow, water swallow, effortful swallow, and the Mendelsohn maneuver were measured using a sensor sheet system with five measurement points on the hard palate. Sequential order, duration, maximal magnitude, and the integrated value of tongue pressure at each measurement point were compared among the four tasks. Onset of tongue pressure at the posterior-circumferential parts occurred first in the Mendelsohn maneuver; that at the anterior-median part was earlier than at other parts in the effortful swallow. At all measurement points, tongue pressure duration was significantly longer in the Mendelsohn maneuver than in other tasks. Effortful swallow was most effective in increasing tongue pressure. The integrated value of tongue pressure at the posterior-circumferential parts in the Mendelsohn maneuver and at the median parts in the effortful swallow showed a tendency to increase. These results suggest that tongue pressure increases along a wide part of the hard palate in effortful swallow because the anchor of tongue movement is emphasized at the anterior part of the hard palate. The Mendelsohn maneuver provides prolonged and accentuated tongue-palate contact at the posterior-circumferential parts, which might be important for hyoid-laryngeal elevation during swallowing.     

Bolus Location at the Initiation of the Pharyngeal Stage of Swallowing in Healthy Older Adults

This study characterized the vertical position of the bolus head at the onset of the pharyngeal swallow in healthy older adults. Lateral-view videofluoroscopic (VF) images were obtained from ten healthy volunteers (age-71.6 ± 7.5 years, mean± SD) as they swallowed 5-cc thin liquid barium aliquots. For each swallow, the bolus head and several anatomic landmarks were digitally recorded from the image in which pharyngeal swallow-related hyoid bone elevation began. Vertical distance between the bolus head and the intersection of the tongue base and mandibular ramus (TMI) was computed. Bolus head position at swallow onset ranged from 47.4-mm above to 34.9-mm below the TMI (2.2 ± 14.4-mm, mean ± SD). Although the bolus head was below the level of the TMI for the majority of swallows, neither penetration nor aspiration occurred. For individual subjects, mean bolus head position ranged from 25.8 ± 5.0-mm above to 15.5 ± 6.5-mm below the TMI. Whereas five of ten subjects initiated the pharyngeal swallow with the bolus head consistently above or consistently below the TMI, five subjects initiated swallowing with the bolus head either above or below the TMI across trials. Older adults commonly initiate thin-liquid swallows with the bolus head well below the TMI without associated penetration or aspiration. Thus, bolus position alone does not differentiate between normal and pathologic swallowing within the healthy elderly. Bolus position at pharyngeal swallow onset can vary substantially from trial to trial within an individual, suggesting that the triggering of swallowing depends on multiple influences. This research was supported by NSERC grant No. 0GPO171208 and an Ontario Ministry of Health Career Scientist Award to REM.     

Surface Electromyographic Activity of the Submental Muscles During Swallow and Expiratory Pressure Threshold Training Tasks

The use of expiratory muscle strength trainers improves parameters related to pulmonary function, speech, and cough in both healthy and patient populations. Recently, it has been speculated that expiratory strength training may alter the force generation of muscles used during the swallow process. Specifically, the use of the trainer may result in increased activation of the submental muscle complex. Support for this hypothesis was tested by examining the timing and amplitude of submental muscle activity obtained using surface EMG. These muscles are known to be important for normal swallow function. Twenty participants (10 males, 10 females; mean age = 29 years) were recruited to participate in a one-session study. Participants were asked to perform two swallows (saliva swallow and water swallow) and develop an expiratory pressure set at 25% and 75% of their maximum expiratory pressure (MEP) using an expiratory muscle strength trainer. These tasks allowed comparison of muscle activity during both the swallow and expiratory tasks completed with the trainer. Results indicated that the patterns of activation in the submental muscle group while training on the expiratory device had longer duration of activation with higher amplitude of EMG activity when compared with the swallowing condition. These findings indicate that expiratory muscle strength training (EMST) increases motor unit recruitment of the submental muscle complex. Discussion centers on the potential benefit of EMST as a treatment modality for dysphagia characterized by decreased amplitude of hyoid movement during swallowing. This study was completed at the Oral Motor-Human Performance Laboratory of the Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, Florida     

Lateral Pharyngeal Wall Motion during Swallowing Using Real Time Ultrasound

B-mode ultrasound imaging has been used primarily to detect temporal and spatial movements of the tongue during the oral preparatory and oral stages of swallowing. The purpose of this study was to investigate the application of M-mode (motion mode) ultrasound imaging as a method to quantify the duration and displacement of single regions along the lateral pharyngeal wall during swallows of two bolus volumes and during three swallow maneuvers (supraglottic, super-supraglottic and Mendelsohn maneuver). In 5 normal subjects, simultaneous B/M-mode images were captured at two regions along the lateral pharyngeal wall. Computer-assisted video analysis of each swallow sequence provided spatial coordinates and durational measures. Results indicated no significant differences in displacements of the lateral pharyngeal wall across bolus volumes, swallow maneuvers, or recording sites. Significant differences (p < 0.001) in lateral pharyngeal wall duration occurred as a function of volitional swallow maneuvers. Greater durations (p < 0.05) were found for the Mendelsohn and super-supraglottic swallow maneuvers. The data demonstrate that B/M-mode ultrasound imaging provides a simple, noninvasive method to visually examine movements of the lateral pharyngeal wall and may provide a clinical method for assessing the effects of direct swallowing therapies at the level of the mid-oropharynx.     

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.     

Effects of Bolus Volume on Pharyngeal Contact Pressure During Normal Swallowing

This cross-sectional study investigated the effect of bolus volume on contact pressure within the pharynx and upper esophageal sphincter (UES). Three solid-state manometric pressure sensors were placed transnasally into the pharynx and the proximal esophagus of 40 participants (gender equally represented and between the ages of 20 and 45 years). Participants completed five repetitions each of three swallowing conditions: 5-, 10-, and 20-ml water bolus swallows. Repeated-measures ANOVA revealed no significant differences in the amplitude of pharyngeal contact pressure between the three swallowing conditions (sensor 1: p = 0.627, sensor 2: p = 0.764). Similarly, for durational measures nonsignificant main effects were found at both sensor 1 (p = 0.436) and sensor 2 (p = 0.350). Significant differences were found in UES pressure between the three conditions of bolus swallows (p = 0.000), with negative pressure in the UES inversely proportionate to bolus volume. However, durational measures of UES relaxation pressure were not significantly different between all conditions (p = 0.473). This study demonstrates no significant pressure differences of amplitude and duration between swallowing conditions in the pharynx. At the level of the UES, smaller boluses generated greater negative pressure.     

Relationship Between Manometric and Videofluoroscopic Measures of Swallow Function in Healthy Adults and Patients Treated for Head and Neck Cancer with Various Modalities

Pharyngeal manometry complements the modified barium swallow with videofluoroscopy (VFS) in diagnosing pressure-related causes of dysphagia. When manometric analysis is not feasible, it would be ideal if pressure information about the swallow could be inferred accurately from the VFS evaluation. Swallowing function was examined using VFS and concurrent manometry in 18 subjects (11 head and neck patients treated with various modalities and 7 healthy adults). Nonparametric univariate and multivariate analyses revealed significant relationships between manometric and fluoroscopic variables. Increases in pressure wave amplitude were significantly correlated with increased duration of tongue base to pharyngeal wall contact, reduced bolus transit times, and oropharyngeal residue. Pharyngeal residue was the most important VFS variable in reflecting pharyngeal pressure measurements. Certain VFS measures were significantly correlated with measures of pressure assessed with manometry. Further research is needed before observations and measures from VFS alone may be deemed sufficient for determining pressure-generation difficulties during the swallow in patients who are unable or unwilling to submit to manometric testing.