June A. Castell

Modern solid state computerized manometry of the pharyngoesophageal segment

There has been renewed interest in the use of manometry of the pharyngoesophageal segment in the investigation of pharyngeal dysphagia. Advances in technology have alleviated previous difficulties presented by factors such as the rapid response rate of the striated muscle and asymmetry of the upper esophageal sphincter. Close attention to technique can overcome difficulties with movement artifacts encountered during deglutition. Manometry is being used to study normal swallow function and the effects of physiologic changes. There are also increasing numbers of reports in the literature of manometric studies in patients with oropharyngeal dysphagia. This technique provides information on pressure changes and augments that information obtained from a barium swallow.

Globus sensation is associated with hypertensive upper esophageal sphincter but not with gastroesophageal reflux

Globus sensation (globus) is best described asa constant feeling of a lump or fullness in the throat.Although the etiology of globus remains unclear, it hasbeen attributed to a hypertensive upper esophageal sphincter (UES) resting pressure and togastroesophageal reflux (GER). The aim of this studywas, therefore, to determine if significant associationsexisted among globus, UES resting pressure, and GER. We reviewed the records of all patients who hadstationary esophageal manometry over a 21 -year intervalwith specific attention to symptoms of globus, UESpressures, and ambulatory pH studies. Patients with hypotensive UES (<30 mm Hg) wereexcluded. Chi square (χ2) test was usedto determine significant associations. Six hundred fiftypatients had normal UES resting pressures and 101patients had hypertensive UES (>118 mm Hg). Seventeen ofthe 650 (3%) (16 women/1 man; mean age: 48, range 32-81years) with normal UES described globus. Conversely, 28of the 101 (28%) (15 women/13 men; mean age: 43, range 23- 61 years) patients withhypertensive UES described globus. There was asignificant association between hypertonicity of the UESand globus (χ2 = 93.42, P < 0.0001).In patients with normal UES, globus occurred predominantly infemales (χ2 = 6.33, P < 0.01).Twenty-three (16 women/7 men; mean age: 43, range 23-60years) of the 45 patients with globus had priorambulatory pH studies. Six of 23 (26%) had GER. Compared to an age-,sex-, and UES-pressure-matched group of 23 patients (16women/7 men; mean age: 44, range 22-75 years) withoutglobus, nine (39%) had GER, thus showing no significant association of globus with GER (P = 0.35).There also was no significant association of GER withnormal UES or with hypertensive UES in these patients.In conclusion, there is a significant association between hypertensive UES and globus. The datasuggest two possible etiologies: female patients withnormal UES pressure potentially having increasedafferent sensation and a group with equal sexdistribution but abnormally elevated UES resting pressure.This study does not support GER as an etiology ofglobus.

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.

Manometric abnormalities of the oesophagus in patients with Parkinson's disease.

Dysphagia in Parkinson’s disease (PD) is known to correlate with abnormalities of oropharyngeal function. Oesophageal abnormalities have not been previously demonstrated to correlate with dysphagia. The aim of the study was to determine if motor dysfunction of the oesophageal body correlates with dysphagia or disease severity in PD. Twenty‐two patients with PD were assessed for the severity of their dysphagia (scale of 1–7) and severity of PD (Hoehn and Yahr scale 1–4). All underwent oesophageal manometry. Dysphagia was present daily in 10 patients (45%). Parkinson’s disease was graded as severe (Hoehn and Yahr >=3) in eight (36%) patients. Oesophageal manometry was abnormal in 16 (73%) patients. Thirteen patients had either complete aperistalsis or multiple simultaneous contractions (diffuse oesophageal spasm). These findings were significantly more common in patients with daily dysphagia (90% vs. 33%; P < 0.005), and were not related to duration or severity of PD. We conclude that the presence of aperistalsis or multiple simultaneous contractions in the oesophagus does correlate with dysphagia and is independent of PD severity or duration. This may reflect selective involvement of either the dorsal motor nucleus of the vagus or the oesophageal myenteric plexus.

Are Manometric Parameters of the Upper Esophageal Sphincter and Pharynx Affected by Age and Gender

The effects of age and gender on the upper esophageal sphincter’s (UES) and pharyngeal manometric parameters were investigated in 84 healthy subjects (45 men, 39 women, mean age=44 years, range = 18–91). Manometric recordings were performed with solid-state circumferential transducers. Subjects older than 60 years (n = 23) showed a significant lower UES resting pressure. In addition, during water swallows they had a higher UES residual pressure, shorter UES relaxation interval and UES relaxation duration, and a decreased UES relaxation rate. Furthermore, pharyngeal contraction had significant higher amplitude and longer duration in subjects older than 60 years during water swallows. Some of these findings were also observed during cookie and pudding swallows. Women had a higher UES resting pressure and a longer UES relaxation interval than men. The observed changes with increasing age indicate loss of basal tone and decreased compliance of the UES. Increased pharyngeal contraction amplitude and its prolonged duration in the elderly might be compensatory to this. These physiologic effects of age and gender on UES and pharyngeal parameters should be taken into account during analysis of manometric studies.

Solid-state computerized manometry improves diagnostic yield in pharyngeal dysphagia: simultaneous videoradiography and manometry in dysphagia patients with normal barium swallows.

Objective:Dynamic barium radiology with cine- or video recording has been the most frequently used technique for assessing patients with pharyngeal dysphagia. Although the diagnostic yield of the barium swallow has been high, many patients with pharyngeal dysphagia have normal dynamic barium radiology and remain a diagnostic dilemma. Could manometry add important diagnostic information in these patients?Material and methods:We examined 19 patients (12 men and 7 women, mean age 47 years, range 19–69 years) with pharyngeal dysphagia but a normal barium swallow with simultaneous videoradiography and pharyngeal manometry and compared their manometry to that found in 24 normal volunteers (11 men and 13 women, mean age 37 years, range 23–59 years).Results:Comparing mean values, the patient group showed statistically significant differences from the control group for eight of 10 manometric parameters. Fourteen of 19 patients showed at least one (five patients) and in most cases multiple (nine patients) manometric abnormalities (values exceeding normal mean by ±2SD) which might have contributed to their dysphagia: five patients with high upper esophageal sphincter (UES) resting pressures, five with high LIES residual pressures, three with weak pharyngeal contractions, three with pharyngeal “spasms,” seven with prolonged contraction/relaxation times, five with reduced compliance, and seven with UES/P incoordination.Conclusions:Solid-state computerized manometry is a useful adjunct to videoradiography and can provide potentially important additional information in the diagnosis of dysphagia patients.

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.

Repetitive Proximal Esophageal Contractions: A New Manometric Finding and a Possible Further Link Between Parkinson's Disease and Achalasia

Repetitive, spontaneous contractions of the proximal esophagus have recently been identified as a feature of achalasia. This article documents similar findings in six patients with Parkinsons disease. Parkinsons disease and achalasia share many common features neurologically. Both have Lewy bodies in the esophageal myenteric plexuses and the substantia nigra, in addition to evidence of degeneration of the dorsal motor nucleus of the vagus. The esophageal features radiologically and manometrically are also similar. Repetitive proximal esophageal contractions may represent another link between these diseases. They have also been reported in scleroderma. We speculate that the common link between all three disease processes may be poor distensibility of the esophagus.

Effect of age on differences in upper esophageal sphincter and pharynx pressures between patients with dysphagia and control subjects.

OBJECTIVES:The aim of this study was to explore the effect of age and food consistency on manometric data of the swallow sequence in patients with dysphagia.METHODS:Manometric data from 41 patients (age range, 32–88 yr) and 41 age-matched control subjects was examined for differences between subgroups <60 yr and ≥60 yr of age, as well as for changes with food consistency.RESULTS:Only pharynx peak pressure showed an age-dependent decrease (144.1 ± 21.4 mm Hg vs 95.8 ± 15.1 mm Hg, p < 0.05) in patients. Significant higher upper esophageal sphincter residual pressure and delayed onset of upper esophageal sphincter relaxation were noted in patients aged <60 yr compared to age-matched controls, whereas only pharynx peak pressure was significantly lower in patients compared to controls aged ≥60 yr. Food consistency did not have a consistent effect on manometric results in patients with dysphagia.CONCLUSIONS:This is the first study to systematically explore the influence of age and food consistency on manometric parameters in dysphagia patients. These results may provide useful insights when identifying actual manometric abnormalities in patients with dysphagia. They also suggest possible different underlying mechanisms of dysphagia in younger versus older patients.

Combined videomanometric identification of abnormalities related to pharyngeal retention

RATIONALE AND OBJECTIVES The authors determined the usefulness of performing videoradiography and pharyngeal solid-state manometry during barium swallow in dysphagic patients with pharyngeal retention. METHODS Results were retrospectively analyzed of simultaneous videoradiography and manometry examinations in 14 patients with retention of barium in the pharynx. Twelve age-matched patients without retention served as a control group. RESULTS Patients with retention regularly had less opening of the upper esophageal sphincter than patients without retention (7.6 vs 10.3 mm, respectively; P = .003). In patients with retention, the laryngeal elevation was lower (17.1 vs 23.8 mm, respectively; P = .001), and the resting pressure of the upper esophageal sphincter was significantly lower (42.4 vs 54.0 mm Hg, respectively; P = .04). The duration of upper esophageal sphincter relaxation was also shorter in patients with retention (374 vs 603 msec, respectively; P = .003). The peak pharyngeal contraction pressure was not significantly different. CONCLUSION The constrictors play a minor role in the conveyance of the bolus through the pharynx. Pharyngeal shortening could be the most important mechanism in bolus transport.