Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Upper Esophageal Sphincter Dysfunction in Children with Type 1 Laryngeal Cleft after Failed Primary Cleft Repair

Changes in pharyngeal and upper-esophageal-sphincter (UES) motor dynamics contribute to swallowing dysfunction. Children with type 1 laryngeal clefts can present with swallowing dysfunction and associated symptoms which may persist even after the initial endoscopic intervention. This study sought to characterize pharyngeal and esophageal motor function in children with type 1 laryngeal clefts who had persistent presenting symptoms after their initial therapeutic intervention. We retrospectively analyzed high-resolution esophageal manometry studies of children ≤ 18 years old with type 1 laryngeal clefts who had an esophageal manometry study performed for persistent symptoms after an initial repair. A total of 16 children were found to have significantly increased UES resting pressure, UES pre- and post-swallow maximum pressures, and duration of UES contraction during swallows in comparison to nine age-matched controls of children without pharyngeal anatomical abnormalities. There was no difference between UES residual pressures or pharyngeal dynamics between the two groups. UES resting and residual pressures did not correlate with VFFS in penetration and aspiration scores of children with type 1 laryngeal clefts status post repair. Our study is the first to identify specific changes in UES motor function in patients with type 1 laryngeal cleft post initial repair.

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

Correlating Dysphagia Severity with Fluoroscopic Parameters in Patients with Zenker's Diverticulum

Zenker's diverticulum (ZD) is an uncommon condition characterized by formation of a pseudodiverticulum in the hypopharynx that presents with considerable variability in swallowing symptomatology. Identifying radiographic features of ZD most associated with clinical impact could prove useful in counseling patients and predicting treatment response. This study was a retrospective case series of patients undergoing videofluoroscopic swallowing studies (VFSS) for Zenker's diverticulum at a tertiary dysphagia center. Anatomic parameters identified on VFSS of patients with ZD were correlated with subjective perception of swallowing using Eating Assessment Tool (EAT-10) scores. Upper esophageal sphincter (UES) opening at the point of maximal distention, area of diverticulum on the lateral view, height of the diverticulum, and entrance angle of the esophagus were measured. We identified 40 patients with ZD (52.5% male, mean age = 71.2 years). Narrow UES opening was significantly correlated with dysphagia severity (r = - 0.3445, p = 0.035). Largest area of diverticulum (r = 0.0188, p = 0.87), diverticulum height (r = 0.1435, p = 0.45), and esophageal entrance angle (r = 0.1677, p = 0.42) were not correlated with EAT-10 scores. Maximum UES opening size was predictive of severity of swallowing dysfunction in patients with ZD. Size of ZD and the angle of bolus entry in patients with ZD are not predictive of swallowing dysfunction. Understanding the predictors of swallowing dysfunction will assist in counseling patients on postoperative expectations.

Potential for Volitional Control of Resting Pressure at the Upper Oesophageal Sphincter in Healthy Individuals

Resting pressure at the upper oesophageal sphincter (UOS) has been reported to be susceptible to factors such as emotional stress or respiration. This exploratory study investigated the potential for behavioural modulation of UOS resting pressure in healthy adults to increase our understanding of volitional control of UOS pressure, and the potential development of rehabilitation approaches. Six healthy adults were seen one hour daily for two weeks (10 days) and for one post-training session after a training break of two weeks. Manipulation of UOS resting pressure was practised during a protocol of alternating increased and decreased pressure. A high-resolution manometry contour plot was used as a biofeedback modality. Participants were asked to explore how to achieve warmer and cooler colours (pressure increase and decrease, respectively) at the UOS resting pressure band, without changing head position or manipulating activity of other muscles. Performance was analysed prior to training start and following daily training. Participants were able to increase resting pressure following one week of practice; however, there was no evidence for purposeful pressure decrease. The increased resting pressure achieved by participants indicates a capacity for purposeful pressure modulation given intensive biofeedback training. The lack of volitional reduction in pressure may be explained by sustained pressure generation due to the intrinsic muscular characteristics of the UOS and a flooring effect in healthy subjects, in whom physiology mandates a minimum degree of resting pressure to fulfil the barrier function. Distention caused by the presence of the intraluminal catheter cannot be ruled out.

Is Myotomy Plus Diverticulopexy Suitable for Symptomatic Zenker's Diverticula?

The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007-2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum's features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3-4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient's compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.

Assessing Upper Esophageal Sphincter Function in Clinical Practice: a Primer

The upper esophageal sphincter constitutes an important anatomic and functional landmark in the physiology of pharyngeal swallowing. A variety of clinical circumstances may call for a dedicated evaluation of this mechanism, from the etiologic evaluation of indeterminate symptoms to the generation of complex locoregional therapeutic strategies. Multiple diagnostic tools exist for the assessment of pharyngeal swallowing generally and of upper esophageal sphincter function specifically, some well established and others not yet settled into routine practice. This report reviews five specific modalities for use in making this assessment, outlining the strengths, weaknesses, and logistical considerations of each with respect to its potential use in clinical settings. In many cases, these studies will provide complementary information regarding pharyngeal function, suggesting the relative advantage of a multimodal evaluation.

Treatment of cricopharyngeal dysfunction: a comparative pilot study

Background

Cricopharyngeal dysfunction is a narrowing at the level of the upper oesophageal sphincter caused by failed or incomplete sphincter opening as a result of lack of pharyngoesophageal coordination or reduction in the muscular compliance of the upper oesophageal sphincter. Oropharyngeal dysphagia is a typical symptom. Videomanometry allows direct comparison of pressure readings with dynamic anatomy during swallowing.

Methods

This is a prospective randomized pilot study that compares the effect of balloon dilatation and laser myotomy in cricopharyngeal dysfunction. We used videomanometry as an objective measure and the Swedish version of Sydney Swallowing Questionnaire as patient’s self-assessment at baseline and 1 and 6 months after treatment.

Results

The UES sagittal diameter increased from 5.6 mm pre-operatively to 8.4 mm 6 months post-operatively with no differences between treatment groups. Preoperative mean Sydney Swallowing Questionnaire score was 770 and 6 months post-operative score 559, with no difference between the treatments in our cohort.

Conclusion

Cricopharyngeal dysfunction treatment by either laser myotomy or balloon dilatation improved upper oesophageal sphincter opening during at least 6 months.

Trial registration: ISRCTN84905610, date: 081214

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.