Anatomic-manometric correlation of the upper esophageal sphincter: a concurrent US and manometry study

The Manometric Representation of the Upper Esophageal Sphincter During the Resting State: A Descriptive Study

The upper esophageal sphincter (UES) is the high-pressure zone marking the transition between the hypopharynx and esophagus. There is limited research surrounding the resting UES using pharyngeal high-resolution manometry (HRM) and existing normative data varies widely. This study describes the manometric representation of the resting UES using a clinically accessible method of measurement. Data were obtained from 87 subjects in a normative database of pharyngeal HRM with simultaneous videofluoroscopy. The resting UES manometric region was identified and ten measurement segments of this region were taken throughout the duration of the study using the Smart Mouse function within the manometry software. Intraclass correlation coefficients (ICC) were used to analyze within-subject reliability across measurements. Linear mixed-effects regression models were used to analyze how subject characteristics and manometric conditions influence resting UES pressure. There was excellent within-subject reliability between resting UES mean pressures (ICC = 0.96). In bivariate analysis, there were significant effects of age, number of sensors contained within the resting UES, and preceding swallow volume on mean resting UES pressure. For every 1 unit increase in age, there was a 0.19 unit decrease in resting UES pressure (p = 0.008). For every 1 unit increase in number of sensors contained within the resting UES, there was a 3.71 unit increase in resting UES pressure (p < 0.001). This study presents normative data for the resting UES, using a comprehensive and clinically accessible protocol that can provide standard comparison for the study of populations with swallowing disorders, particularly UES dysfunction, and provides support for UES-directed interventions.

Oral Intake Difficulty and Aspiration Pneumonia Assessment Using High-Resolution Manometry

OBJECTIVE

The sequential generation of swallowing pressure (SP) from the nasopharynx to the proximal esophagus is important for the bolus to pass from the oral cavity to the esophagus. The purpose of this study was to investigate the correlation of the SP sequence mode on high-resolution manometry (HRM) with oral intake difficulty and aspiration pneumonia.

METHODS

Consecutive patients with dysphagia who were admitted to our dysphagia clinic between November 2016 and November 2020 were enrolled in this cross-sectional study. We classified the HRM pressure topography data according to the SP sequence mode into type A, normal; B, partially decreased; C, totally decreased; and D, sequence disappeared, and according to the upper esophageal sphincter (UES) during pharyngeal swallowing into type 1, flattening and 2, non-flattening. Clinical dysphagia severity was determined based on oral intake difficulty and aspiration pneumonia.

RESULTS

In total, 202 patients with dysphagia (mean [standard deviation] age, 68.3 [14.5] years; 140 [69.8%] male) were enrolled. Type C (odds ratio [OR], 10.48; 95% confidence interval [CI], 2.89-51.45), type D (OR, 19.90; 95% CI, 4.18-122.35), and type 2 (OR, 6.36; 95% CI, 2.88-14.57) were significantly related to oral intake difficulty. Type C (OR, 3.23; 95% CI, 1.08-11.12) and type 2 (OR, 4.18; 95% CI, 1.95-9.15) were significantly associated with aspiration pneumonia.

CONCLUSION

The failure of sequential generation of SP was associated with higher risk of oral intake difficulty and aspiration pneumonia. These assessments are useful in understanding the pathophysiology and severity of dysphagia and in selecting safety nutritional management methods.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2127-2135, 2024.

The Upper Esophageal Sphincter Distensibility Index Measured Using Functional Lumen Imaging Probe Identifies Defective Barrier Function of the Upper Esophageal Sphincter

Background/Aims

The mechanism via which supra-esophageal symptoms are generated is unclear. We assessed upper esophageal sphincter (UES) function in novel fashion using functional lumen imaging probe (FLIP) topography. We hypothesize that symptoms related to aspiration of esophageal contents may be associated with a more distensible UES.

Methods

FLIP and reflux symptom index score data from patients undergoing diagnostic evaluation for an esophageal complaint over a 10-month period were analyzed retrospectively. UES distensibility on FLIP was studied at 40-70 mL volumes with in-depth analysis at 50 and 60 mL. Symptoms were compared between patients with low, middle, and high UES-distensibility index (UES-DI). Receiver-operating characteristic analysis was performed to determine associations between the UES-DI and individual reflux symptom index symptom item scores.

Results

One hundred and eleven subjects were included. Overall, the associations between UES-DI and symptoms that could be related to supra-esophageal aspiration were strongest at the 50 mL FLIP volume. Choking item score was highest in the high UES-DI group (2.8) vs 1.4 (P < 0.001) in the middle UES-DI and 1.1 (P = 0.004) in the low UES-DI groups. Similarly, the cough item score was highest in the high UES-DI group (2.7) vs 1.5 (P = 0.009) and 0.9 (P = 0.002) groups.

Conclusion

A higher UES-DI measures defective barrier function which could may be the main pathophysiology that generates supra-esophageal symptoms.

Botulinum Toxin Injection for the Treatment of Upper Esophageal Sphincter Dysfunction

Dysphagia associated with upper esophageal sphincter (UES) dysfunction remarkably affects the quality of life of patients. UES injection of botulinum toxin is an effective treatment for dysphagia. In comparison with skeletal muscles of the limb and trunk, the UES is a special therapeutic target of botulinum toxin injection, owing to its several anatomical, physiological, and pathophysiological features. This review focuses on (1) the anatomy and function of the UES and the pathophysiology of UES dysfunction in dysphagia and why the entire UES rather than the cricopharyngeal muscle before/during botulinum toxin injection should be examined and targeted; (2) the therapeutic mechanisms of botulinum toxin for UES dysfunction, including the choice of injection sites, dose, and volume; (3) the strengths and weaknesses of guiding techniques, including electromyography, ultrasound, computed tomography, and balloon catheter dilation for botulinum toxin injection of the UES.

Variables influencing manometric parameters of deglutitive and non-deglutitive upper esophageal sphincter: A study of 89 asymptomatic participants

BACKGROUND

High-resolution manometry overcomes limitations imposed by axial and radial asymmetry as well as swallow and respiration-induced movement of the upper esophageal sphincter (UES), allowing for its reliable use in evaluation of dysphagic and reflux patients. The aim of this study was to determine normative values and their variability across position, sex, age, height, weight, BMI, and volume for clinically relevant deglutitive and non-deglutitive UES parameters.

METHODS

We studied 89 asymptomatic volunteers age 19-90 years, (45 female) during 3-10 repetitions of dry, 5 and 10 ml water swallows at 30-s intervals using high-resolution manometry.

KEY RESULTS

Upper esophageal sphincter high-pressure zone was longer in men than women and in supine than upright position. UES basal contractile integral and mean basal pressure were higher in supine compared to upright; higher in men than women, inversely correlated with age, correlated positively with height and with weight in the supine position only. UES relaxation duration was longer in upright than in supine position but not affected by age, sex, height, weight, or BMI. It was longer with 5 and 10 ml compared with dry swallows. UES minimum/nadir relaxation and mean relaxation pressures were lower in upright than supine position, increased with increase in age and were higher in men than women.

CONCLUSIONS AND INFERENCES

Position, sex, age, height, weight, and volume affect some deglutitive and non-deglutitve UES manometric parameters. BMI does not affect the studied manometric parameters. These effects should be taken into consideration in clinical evaluation of UES.

Comparative Analysis of Relaxation Time Interval and Integrated Relaxation Pressure as Risk Factors for Aspiration in Patients With Oropharyngeal Dysphagia

Background/Aims

Integrated relaxation pressure (IRP) is an important metric for functional evaluation of the lower esophageal sphincter. However, the effectiveness of IRP for evaluation of upper esophageal sphincter (UES) function has not yet been clarified.

Methods

High-resolution manometry (HRM) was performed in 180 patients with dysphagia. For comparison, 26 asymptomatic subjects were also recruited. IRP of the UES was defined as means of 0.2, 0.25, or 0.3 seconds (sIRPs) of maximal deglutitive relaxation in a 0.4-second window (a new equation for IRP calculation was developed using MATLAB). Also, the relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were evaluated using HRM.

Results

In normal subjects, mean values of 0.2, 0.25, and 0.3 sIRPs differed significantly from each other (P < 0.05). They were not associated with the relaxation time interval of the UES. In contrast, in patients with dysphagia, mean values of 0.2, 0.25, and 0.3 sIRPs were strongly related to relaxation time intervals of the UES (P < 0.05), and mean values of 0.2, 0.25, and 0.3 sIRPs in patients with aspiration were significantly higher than those of patients without aspiration (P < 0.01). However, in multivariate regression analyses, the main risk factor for aspiration was only a shorter relaxation time interval.

Conclusions

IRP values were significantly higher in patients with dysphagia and aspiration. However, its usefulness as a predictive factor for aspiration was less than the relaxation time interval of the UES.

Ultrasound, electromyography, and balloon guidance for injecting botulinum toxin for cricopharyngeal achalasia: A case report

INTRODUCTION

Botulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment.

PATIENT CONCERNS

We describe the case of a 74-year-old man who could not swallow food or saliva for 8 months.

DIAGNOSIS

The patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts.

INTERVENTIONS

To manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound.

OUTCOMES

The patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown.

CONCLUSION

The unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.

Treatment for upper esophageal sphincter dysfunction in a patient with poststroke dysphagia: A case report

RATIONALE

Botulinum toxin injection is a widely used procedure for the treatment of the dysfunction of the upper esophageal sphincter (UES). Although the injection can be guided by ultrasound, electromyography, or computed tomography, such techniques cannot determine the exact extent of narrowed UES and ensure that the narrowed extent is fully covered by the treatment. This report describes a dual guiding technique with ultrasound and the balloon catheter in a patient with poststroke dysphagia to improve these weaknesses.

PATIENT CONCERNS

The patient was admitted to a rehabilitation hospital 2 weeks postcerebral infarction.

DIAGNOSES

Clinical presentation of the patient included severe hemiplegia and dysphagia. The fiberoptic endoscopic evaluation of swallowing (FEES) revealed penetration/aspiration when swallowing 1 ml water and 1 ml yogurt and pooling in the postcricoid region.

INTERVENTIONS

Balloon catheter dilatation procedures and Botulinum toxin injection were performed. We used a dual guiding technique with ultrasound and the balloon catheter to determine the whole segment of UES dysfunction by locating the lowest level of the impaired UES opening and to reduce difficulty in differentiating UES from adjacent tissues during Botulinum toxin injection.

OUTCOMES

No persistent progress was observed on the symptoms and volume of the balloon during dilatation. The patient showed quick responses after Botulinum toxin injection. The postinjection balloon catheter dilatation showed an increased maximum volume (preinjection, 5.5 ml vs. postinjection, 14 ml), and the patient was able to eat yogurt, congee, or semi-solid food 100-150 ml 4 weeks after the injection.

LESSONS

The dual guiding method holds several advantages, suggesting that it may be considered as a promising choice in dealing with UES dysfunction.

Swallowing outcomes after cricopharyngeal myotomy: A systematic review

BACKGROUND

No practice guidelines have been established for swallowing outcomes after cricopharyngeal myotomy (CPM). The purpose of this systematic review was to summarize evidence for swallowing outcomes in patients undergoing CPM to treat symptomatic cricopharyngeal dysfunction, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol.

METHODS

Swallowing outcomes examined included penetration/aspiration ratings, manometric measures, patient-rated dysphagia scales, clinician-rated dysphagia scales, diet level, and weight.

RESULTS

Three databases were queried for studies published between January 1995 and July 2015, resulting in a total of 122 full-text eligible records. Studies were screened and reviewed, culminating in 10 studies meeting inclusion criteria. Critical appraisal of study design, swallowing outcomes measures, and statistical analysis were summarized.

CONCLUSION

This systematic review revealed insufficient evidence for guiding clinical practice. Future investigations should use validated patient-rated and clinician-rated instruments as well as detailed high-resolution manometry measures to optimally capture postoperative swallowing outcomes.

Comparative effect of the sites of anterior cervical pressure on the geometry of the upper esophageal sphincter high-pressure zone

OBJECTIVES/HYPOTHESIS

External cricoid pressure is increasingly used to augment the upper esophageal sphincter (UES). Our objective was to determine the effect of 1) pressures applied to cricoid, supracricoid, and subcricoid regions on the length and amplitude of the UES high-pressure zone (UESHPZ), and 2) the external cricoid pressure on lower esophageal sphincter (LES) tone.

STUDY DESIGN

Case-control study.

METHODS

We studied 11 patients with supraesophageal reflux (mean age 58 ± 12 years) and 10 healthy volunteers (mean age 47 ± 19 years). We tested 20, 30, and 40 mm Hg pressures to cricoid, 1 cm proximal and 1 cm distal to the cricoid. In an additional 15 healthy volunteers (mean age 46 ± 23 years), we studied the effect of external cricoid pressure on LES tone. UES and LES pressures were determined using high-resolution manometry.

RESULTS

There was significant increase of UESHPZ length with application of pressure at all sites. The increase of UESHPZ length was relatively symmetric, more orad, and more caudad when the pressure was applied at the cricoid, supracricoid, and subcricoid levels, respectively. The magnitude of pressure increase was greatest at the middle and orad part of the UESHPZ when the pressure was applied at the cricoid and supracricoid levels, respectively. The corresponding magnitude of increase in the caudad part of the UESHPZ was not observed with pressure at the subcricoid level. There was no change of the LES pressure with application of cricoid pressure.

CONCLUSIONS

The effect of external pressure on the UESHPZ is site dependent. Subcricoid pressure has the least effect on UESHPZ. External cricoid pressure at 20 to 40 mm Hg has no effect on the LES pressure.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:2466-2474, 2017.

Oropharyngeal dysphagia: manifestations and diagnosis

Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.

Physiology of the upper segment, body, and lower segment of the esophagus

The following discussion on the physiology of the esophagus includes commentaries on the function of the muscularis mucosa and submucosa as a mechanical antireflux barrier in the esophagus; the different mechanisms of neurological control in the esophageal striated and smooth muscle; new insights from animal models into the neurotransmitters mediating lower esophageal sphincter (LES) relaxation, peristalsis in the esophageal body (EB), and motility of esophageal smooth muscle; differentiation between in vitro properties of the lower esophageal circular muscle, clasp muscle, and sling fibers; alterations in the relationship between pharyngeal contraction and relaxation of the upper esophageal sphincter (UES) in patients with dysphagia; the mechanical relationships between anterior hyoid movement, the extent of upper esophageal opening, and aspiration; the application of fluoroscopy and manometry with biomechanics to define the stages of UES opening; and nonpharmacological approaches to alter the gastroesophageal junction (GEJ).

The upper esophageal sphincter is not round: a pilot study evaluating a novel, physiology-based approach to upper esophageal sphincter dilation

OBJECTIVES

Recent basic science investigations have suggested that the upper esophageal sphincter (UES), in cross section, is not round, but that it more closely approximates a kidney shape. Dilation with simultaneous use of two cylindrical dilators provides a novel, physiology-based approach to UES distention. We evaluated the initial safety and efficacy of UES dilation with simultaneous use of two controlled radial expansion balloon dilators.

METHODS

Using a computerized database, we reviewed the charts of all persons who underwent UES dilation with simultaneous use of two radial expansion balloon dilators between December 1, 2011, and March 15, 2012. Information regarding patient demographics, indications, technique, and complications was abstracted. Self-reported swallowing impairment was assessed with the validated 10-item Eating Assessment Tool (EAT-10).

RESULTS

Ten individuals underwent simultaneous dilation with two dilators. Their mean age was 65 years (SD, 14 years), and 7 (70%) of them were male. The indications for dilation were radiation-induced UES stenosis (50%), cricopharyngeus muscle dysfunction (30%), upper esophageal web (10%), and anastomotic stricture (10%). After the double-balloon dilation, no complications were reported. The mean EAT-10 score improved significantly, from 34.3 (SD, 13.5) to 16.7 (SD, 8.4), after the simultaneous dilation (p = 0.003).

CONCLUSIONS

Pilot data suggest that simultaneous dilation of the UES with two controlled radial expansion balloon dilators is feasible, safe, and effective. Future investigation is necessary to confirm the safety of this technique in a larger cohort and to use objective measures of efficacy to compare the technique to conventional dilation with a single dilator.

Topographic description of an alternative insertion technique for percutaneous approach of cricopharyngeus muscle electromyography: a cadaveric and clinical study

BACKGROUND

Cricopharyngeus is the only muscle for which electromyography is used in the differential diagnosis of swallowing disorders. Because of some practical difficulties, electrophysiologic tests for this muscle are not performed routinely. Thus we aimed to describe an alternative topographic way to reach the muscle easily.

METHODS

On 10 cadavers, a spinal needle (20 G) and on 37 patients a concentric needle electrode (26 G) were used. The needle was inserted percutaneous at the level of the superior border of the cricoid cartilage, anterior to the anterior border of the sternocleidomastoid muscle at 60 degrees angle to the frontal plane in the posteromedial direction.

RESULTS

We reached the muscle in all cadavers. In all of the patients, the needle entered the muscle on the first attempt; that was confirmed by electromyographic responses.

CONCLUSION

Our results show that this method can be useful for the practical application of cricopharyngeus muscle electromyography.