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Calderon LF, Kline M, Hersh M, Shah KP, Kundu S, Tkaczuk A, McColloch N, Jain A. The Upper Esophageal Sphincter Distensibility Index Measured Using Functional Lumen Imaging Probe Identifies Defective Barrier Function of the Upper Esophageal Sphincter. J Neurogastroenterol Motil 2022; 28:463-473. [PMID: 35799240 PMCID: PMC9274470 DOI: 10.5056/jnm21197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Lucie F Calderon
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Marc Hersh
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin P Shah
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Suprateek Kundu
- Department of Medicine, Emory Data Analytics and Biostatistics Core, Atlanta, GA, USA
| | - Andrew Tkaczuk
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nancy McColloch
- Department of Speech Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - AnS Jain
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Edeani FO, Kern M, Ulualp K, Kovacic K, Sanvanson P, Mei L, Shaker R. Variables influencing manometric parameters of deglutitive and non-deglutitive upper esophageal sphincter: A study of 89 asymptomatic participants. Neurogastroenterol Motil 2022; 34:e14175. [PMID: 34431179 PMCID: PMC10128622 DOI: 10.1111/nmo.14175] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/19/2021] [Accepted: 04/28/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Francis O Edeani
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mark Kern
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kenan Ulualp
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karlo Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Patrick Sanvanson
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ling Mei
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Meisoll FJ, Jungheim M, Fast JF, Miller S, Ptok M. Upper Esophageal Sphincter Response to Laryngeal Adductor Reflex Elicitation in Humans. Laryngoscope 2020; 131:E1778-E1784. [PMID: 33111975 DOI: 10.1002/lary.29166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The laryngeal adductor reflex (LAR) is an important mechanism to secure the airways from potential foreign body aspiration. An involvement of the upper esophageal sphincter (UES) in terms of a laryngo-UES contractile reflex has been identified after laryngeal mucosa stimulation. However, the LAR-UES relationship has not yet been fully explained. This study aimed to determine the magnitude, latency, and occurrence rate of the UES pressure response when the LAR is triggered in order to elucidate the functional relationship between the larynx and the UES. METHODS This prospective study included seven healthy volunteers (5 female, 2 male, age 22-34 years). Laryngeal penetration was simulated by eliciting the LAR 20 times in each individual by applying water-based microdroplets onto the laryngeal mucosa. UES pressures were measured simultaneously using high-resolution manometry. RESULTS Two distinct pressure phases (P1, P2) associated with the LAR were identified. P1 corresponded with a short-term UES pressure decrease in two subjects and a pressure increase in five subjects occurring 200 to 500 ms after the stimulus. In P2, all subjects experienced an increase in UES pressure with a latency time of approximately 800 to 1700 ms and an average of 40 to 90 mmHg above the UES resting tone. CONCLUSION Foreign bodies penetrating the laryngeal inlet lead to a reflex contraction of the UES. Phase P1 could be a result of vocal fold activity caused by the LAR, leading to pressure changes in the UES. The constriction during P2 could strengthen the barrier function of the UES in preparation to a subsequent cough that may be triggered to clear the airways. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1778-E1784, 2021.
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Affiliation(s)
- Frederik J Meisoll
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
| | - Michael Jungheim
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
| | - Jacob F Fast
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany.,Institute of Mechatronic Systems, Leibniz Universität Hannover, Hannover, Germany
| | - Simone Miller
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
| | - Martin Ptok
- Department of Phoniatrics and Pediatric Audiology, Hannover Medical School, Hannover, Germany
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Winiker K, Gozdzikowska K, Guiu Hernandez E, Kwong SL, Macrae P, Huckabee ML. Potential for Volitional Control of Resting Pressure at the Upper Oesophageal Sphincter in Healthy Individuals. Dysphagia 2020; 36:374-383. [PMID: 32556520 DOI: 10.1007/s00455-020-10146-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/06/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Katharina Winiker
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand.
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand.
| | - Kristin Gozdzikowska
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand
- The Laura Fergusson Trust, 279 Ilam Road, Christchurch, 8053, New Zealand
| | - Esther Guiu Hernandez
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand
| | - Seh Ling Kwong
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand
- Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Phoebe Macrae
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand
| | - Maggie-Lee Huckabee
- Department of Psychology, Speech and Hearing, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand
- The University of Canterbury Rose Centre for Stroke Recovery and Research, Leinster Chambers, Level one, 249 Papanui Rd, Private Bag 4737, Christchurch, 8140, New Zealand
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Maturation Modulates Pharyngeal-Stimulus Provoked Pharyngeal and Respiratory Rhythms in Human Infants. Dysphagia 2017; 33:63-75. [PMID: 28828751 DOI: 10.1007/s00455-017-9833-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
Pharyngeal-provocation induced aerodigestive symptoms in infants remain an enigma. Sources of pharyngeal provocation can be anterograde as with feeding, and retrograde as in gastroesophageal reflux. We determined maturational and dose-response effects of targeted pharyngeal-stimulus on frequency, stability, and magnitude of pharyngeal and respiratory waveforms during multiple pharyngeal swallowing responses in preterm-born infants when they were of full-term postmenstrual age (PMA). Eighteen infants (11 male) were studied longitudinally at 39.8 ± 4.8 weeks PMA (time-1) and 44.1 ± 5.8 weeks PMA (time-2). Infants underwent concurrent pharyngo-esophageal manometry, respiratory inductance plethysmography, and nasal airflow thermistor methods to test sensory-motor interactions between the pharynx, esophagus, and airway. Linear mixed models were used and data presented as mean ± SEM or %. Overall, responses to 250 stimuli were analyzed. Of the multiple pharyngeal swallowing responses (n = 160), with maturation (a) deglutition apnea duration decreases (p < 0.01), (b) number of pharyngeal waveform peaks and duration decreases for initial responses (p < 0.01), and subsequent responses have lesser variation and greater stability (p < 0.01). With increment in stimulus volumes we noted (a) increased prevalence (%) of pharyngeal responses (p < 0.05), (b) increased number of pharyngeal peaks (p < 0.05), yet pharyngeal frequency (Hz), variability, and stability remain unaffected (p > 0.05), and (c) respiratory changes were unaffected (p > 0.05). Initial and subsequent pharyngeal responses and respiratory rhythm interactions become more distinct with maturation. Interval oromotor experiences and volume-dependent increase in adaptive responses may be contributory. These mechanisms may be important in modulating and restoring respiratory rhythm normalcy.
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Abstract
The upper esophageal sphincter (UES) forms a barrier between the pharynx and the esophagus. When opened, the UES allows the food bolus to pass into the esophagus, as well as permitting emesis and eructation. The basal sphincter tone constitutes a barrier function which serves to prevent reflux and passive aerophagia in the case of deep breathing. Basal sphincter tone is dependent on several influencing factors; during swallowing, sphincter opening and closure follow a complex multiphase pattern. This article presents an overview of the current understanding of UES physiology.
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Malkar MB, Jadcherla S. Neuromotor mechanisms of pharyngoesophageal motility in dysphagic infants with congenital heart disease. Pediatr Res 2014; 76:190-6. [PMID: 24819378 PMCID: PMC4104136 DOI: 10.1038/pr.2014.68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 02/07/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Aero-digestive morbidities are common in congenital heart disease infants, and the mechanisms are unclear. We hypothesized that adaptive pharyngoesophageal motility reflexes are different in surgical congenital heart disease infants (S-CHD) vs. nonsurgical congenital heart disease infants (CHD) and healthy controls. METHODS Abrupt pharyngeal provocation was performed with graded water infusions using purpose-built micromanometry. The data from 12 S-CHD were compared with data from 10 CHD and 12 controls. One hundred and ninety-seven water stimulations were examined for the frequency, latency, duration, and magnitude of pharyngo-upper esophageal sphincter contractile response (PUCR), pharyngeal reflexive swallow (PRS), esophageal body peristalsis, and lower esophageal sphincter (LES) relaxation characteristics. Mixed statistical models were applied. RESULTS Frequency distribution (%) of PUCR: PRS: none in S-CHD vs. CHD vs. controls, respectively, were 36:46:17 vs. 9:80:11 vs. 15:61:24 (P < 0.05). Response latency to the final esophageal body waveform (P = 0.01) and the response duration of esophageal body peristalsis (P = 0.04) were prolonged in S-CHD vs. controls but were similar to CHD (P = 0.22). Pharyngeal infusion-induced LES relaxation characteristics were similar in all three groups. CONCLUSION Abnormality in the recruitment of PUCR or PRS reflexes and esophageal body peristalsis in S-CHD implicate dysregulation in vagal cholinergic excitatory neuromotor responses.
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Affiliation(s)
- Manish B. Malkar
- Section of Neonatology, The Neonatal and Infant Feeding Disorders Program, Nationwide Children’s Hospital, Columbus, Ohio, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sudarshan Jadcherla
- Section of Neonatology, The Neonatal and Infant Feeding Disorders Program, Nationwide Children’s Hospital, Columbus, Ohio, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA,Section of Pediatric Gastroenterology and Nutrition, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
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Dua KS, Surapaneni SN, Kuribayashi S, Hafeezullah M, Shaker R. Effect of aging on hypopharyngeal safe volume and the aerodigestive reflexes protecting the airways. Laryngoscope 2014; 124:1862-8. [PMID: 24281906 DOI: 10.1002/lary.24539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 11/05/2013] [Accepted: 11/25/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Studies on young volunteers have shown that aerodigestive reflexes are triggered before the maximum volume of fluid that can safely collect in the hypopharynx before spilling into the larynx is exceeded (hypopharyngeal safe volume [HPSV]). The objective of this study was to determine the influence of aging on HPSV and pharyngo-glottal closure reflex (PGCR), pharyngo-UES contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS). STUDY DESIGN Comparison between two groups of different age ranges. METHODS Ten young (25 ± 3 standard deviation [SD] years) and 10 elderly (77 ± 3 SD years) subjects were studied. PGCR, PUCR, and RPS were elicited by perfusing water into the pharynx rapidly and slowly. HPSV was determined by abolishing RPS with pharyngeal anesthesia. RESULTS Frequency-elicitation of PGCR and PUCR were significantly lower in the elderly compared to the young during slow water perfusion (47% vs. 97% and 40% vs. 90%, respectively, P < .001). RPS was absent in five of the 30 (17%) slow injections in the elderly group. In these elderly subjects, HPSV was exceeded and laryngeal penetration of the water was seen. The threshold volume to elicit PGCR, PUCR, and RPS was significantly lower than the HPSV during rapid injections. Except for RPS, these volumes were also significantly lower than HPSV during slow injections. CONCLUSIONS PGCR, PUCR, and RPS reflexes are triggered at a threshold volume significantly lower than the HPSV in both young and elderly subjects. Lower frequency-elicitation of PGCR, PUCR, and RPS in the elderly can predispose them to the risks of aspiration.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.; VA Medical Center, Milwaukee, Wisconsin, U.S.A
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Kessing BF, Weijenborg PW, Smout AJPM, Hillenius S, Bredenoord AJ. Water-perfused esophageal high-resolution manometry: normal values and validation. Am J Physiol Gastrointest Liver Physiol 2014; 306:G491-5. [PMID: 24481604 DOI: 10.1152/ajpgi.00447.2013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Water-perfused high-resolution manometry (HRM) catheters with 36 unidirectional pressure channels have recently been developed, but normal values are not yet available. Furthermore, the technique has not been validated and compared with solid-state HRM. We therefore aimed to develop normal values for water-perfused HRM and to assess the level of agreement between water-perfused HRM and solid-state HRM. We included 50 healthy volunteers (mean age 35 yr, range 21-64 yr; 15 women, 35 men). Water-perfused HRM and solid-state HRM were performed in a randomized order. Normal values were calculated as 5th and 95th percentile ranges, and agreement between the two systems was assessed with intraclass correlation coefficient (ICC) statistics. The 5th-95th percentile range was 3.0-6.6 cm/s for contractile front velocity (CFV), 141.6-3,674 mmHg·s·cm for distal contractile integral (DCI), 6.2-8.7 s for distal contraction latency (DL), and 1.0-18.8 mmHg for integrated relaxation pressure (IRP 4s). Mean (SD) and ICC for water-perfused HRM and solid-state HRM were 4.4 (1.1) vs. 3.9 (0.9) cm/s, ICC: 0.49 for CFV; 1,189 (1,023) vs. 1,092 (1,019) mmHg·s·cm, ICC: 0.90 for DCI; 7.4 (0.8) vs. 6.9 (0.9) s, ICC: 0.50 for DL; and 8.1 (4.8) vs. 7.9 (5.1), ICC: 0.39 for IRP 4s. The normal values for this water-perfused HRM system are only slightly different from previously published values with solid-state HRM, and moderate to good agreement was observed between the two systems, with only small differences in outcome measures.
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Affiliation(s)
- Boudewijn F Kessing
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, Netherlands
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Leslie E, Bhargava V, Mittal RK. A novel pattern of longitudinal muscle contraction with subthreshold pharyngeal stimulus: a possible mechanism of lower esophageal sphincter relaxation. Am J Physiol Gastrointest Liver Physiol 2012; 302:G542-7. [PMID: 22173917 PMCID: PMC3311436 DOI: 10.1152/ajpgi.00349.2011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 12/10/2011] [Indexed: 01/31/2023]
Abstract
A subthreshold pharyngeal stimulus induces lower esophageal sphincter (LES) relaxation and inhibits progression of ongoing peristaltic contraction in the esophagus. Recent studies show that longitudinal muscle contraction of the esophagus may play a role in LES relaxation. Our goal was to determine whether a subthreshold pharyngeal stimulus induces contraction of the longitudinal muscle of the esophagus and to determine the nature of this contraction. Studies were conducted in 16 healthy subjects. High resolution manometry (HRM) recorded pressures, and high frequency intraluminal ultrasound (HFIUS) images recorded longitudinal muscle contraction at various locations in the esophagus. Subthreshold pharyngeal stimulation was induced by injection of minute amounts of water in the pharynx. A subthreshold pharyngeal stimulus induced strong contraction and caudal descent of the upper esophageal sphincter (UES) along with relaxation of the LES. HFIUS identified longitudinal muscle contraction of the proximal (3-5 cm below the UES) but not the distal esophagus. Pharyngeal stimulus, following a dry swallow, blocked the progression of dry swallow-induced peristalsis; this was also associated with UES contraction and descent along with the contraction of longitudinal muscle of the proximal esophagus. We identify a unique pattern of longitudinal muscle contraction of the proximal esophagus in response to subthreshold pharyngeal stimulus, which we propose may be responsible for relaxation of the distal esophagus and LES through the stretch sensitive activation of myenteric inhibitory motor neurons.
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Affiliation(s)
- Eric Leslie
- Division of Gastroenterology, San Diego VA Healthcare System, CA, USA
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Dua K, Surapaneni SN, Kuribayashi S, Hafeezullah M, Shaker R. Pharyngeal airway protective reflexes are triggered before the maximum volume of fluid that the hypopharynx can safely hold is exceeded. Am J Physiol Gastrointest Liver Physiol 2011; 301:G197-202. [PMID: 21566013 PMCID: PMC3154610 DOI: 10.1152/ajpgi.00046.2011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Aerodigestive reflexes triggered by pharyngeal stimulation can protect the airways by clearing fluid from the pharynx. The objective of this study was to determine the relationship between the maximum capacity of fluid that can safely dwell in the hypopharynx [hypopharyngeal safe volume (HPSV)] before spilling into the larynx and the threshold volumes required to trigger pharyngoglottal closure reflex (PGCR), pharyngo-upper esophageal sphincter contractile reflex (PUCR), and reflexive pharyngeal swallow (RPS). Twenty-five healthy volunteers (mean age 24 yr, 8 males) were studied in the semi-inclined supine position. PGCR, PUCR, and RPS were elicited using techniques of concurrent upper esophageal sphincter manometry and pharyngo-laryngoscopy. The hypopharynx was then anesthetized to abolish RPS. HPSV was determined by infusing water in the pharynx, and perfusion was stopped when the infusate reached the superior margin of the interarytenoid fold. The threshold volumes for triggering PGCR, PUCR, and RPS by slow and rapid injections before pharyngeal anesthesia were 0.18 ± 0.02 and 0.09 ± 0.02 ml; 0.20 ± 0.020 and 0.13 ± 0.04 ml; and 0.61 ± 0.04 and 0.4 ± 0.06 ml, respectively. All of the above volumes were significantly smaller than the HPSV (0.70 ± 0.06 ml, P < 0.01) except for the threshold volume to elicit RPS during slow perfusion, which was not significantly different (P = 0.23). We conclude that pharyngeal aerodigestive reflexes are triggered by both slow and rapid pharyngeal perfusion of water at significantly smaller volumes than the maximum capacity of the hypopharynx to safely hold contents without spilling into the airway. These reflexes thereby aid in prevention of aspiration.
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Affiliation(s)
- Kulwinder Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin and The Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Sri Naveen Surapaneni
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin and The Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Shiko Kuribayashi
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin and The Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Muhammad Hafeezullah
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin and The Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin and The Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Milwaukee, Wisconsin
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Perera L, Kern M, Hofmann C, Tatro L, Chai K, Kuribayashi S, Lawal A, Shaker R. Manometric evidence for a phonation-induced UES contractile reflex. Am J Physiol Gastrointest Liver Physiol 2008; 294:G885-91. [PMID: 18239061 DOI: 10.1152/ajpgi.00470.2007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The mechanism against entry of gastric content into the pharynx during high-intensity vocalization such as seen among professional singers is not known. We hypothesized that phonation-induced upper esophageal sphincter (UES) contraction enhances the pressure barrier against entry of gastroesophageal contents into pharynx. To determine and compare the effect of phonation on luminal pressures of the esophagus and its sphincters, we studied 17 healthy volunteers (7 male, 10 female) by concurrent high-resolution manometry and voice analysis. We tested high- and low-pitch vowel sounds. Findings were verified in six subjects by UES manometry using a water-perfused sleeve device. Eight of the volunteers (2 male, 6 female) had concurrent video fluoroscopy with high-resolution manometry and voice recording. Fluoroscopic images were analyzed for laryngeal movement. To define the sex-based effect, subgroup analysis was performed. All tested phonation frequencies and intensities induced a significant increase in UES pressure (UESP) compared with prephonation pressure. The magnitude of the UESP increase was significantly higher than that of the distal esophagus, the lower esophageal sphincter (LES), and the stomach. Concurrent videofluoroscopy did not show posterior laryngeal movement during phonation, eliminating a purely mechanical cause for phonation-induced UESP increase. Subgroup analysis demonstrated phonation-induced UESP increases in males that were significantly greater than those of females. Phonation induces a significant increase in UESP, suggesting the existence of a phonation-induced UES contractile reflex. UESP increase due to this reflex is significantly higher than that of the distal esophagus, LES, and stomach. The phonation-induced UESP increase is influenced by sex.
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Affiliation(s)
- Lilani Perera
- Division of Gastroenterology and Hepatology, Froedtert Hospital/Medical College of Wisconsin Dysphagia Institute, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA
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Jadcherla SR, Gupta A, Stoner E, Fernandez S, Shaker R. Pharyngeal swallowing: defining pharyngeal and upper esophageal sphincter relationships in human neonates. J Pediatr 2007; 151:597-603. [PMID: 18035137 PMCID: PMC2211414 DOI: 10.1016/j.jpeds.2007.04.042] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 04/05/2007] [Accepted: 04/19/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that the sensorimotor characteristics of the reflexes evoked on stimulation with air and water infusions differ by studying the effect of pharyngeal stimulation on pharyngeal-upper esophageal sphincter (UES) interactions in healthy neonates. STUDY DESIGN Pharyngo-UES-esophageal manometry was recorded in 10 neonates at 39 +/- 4 weeks postmenstrual age. Pharyngeal infusions (n = 155) of air (0.1 to 2.0 mL) and sterile water (0.1 to 0.5 mL) were given. Two types of reflexes were recognized: pharyngeal reflexive swallowing (PRS) and pharyngo-UES-contractile reflex (PUCR). Frequency occurrence, distribution of reflexes, threshold volume, response time, and stimulus-response relationship were evaluated. RESULTS The reflex response rates were 30% for air and 76% for water (P < .001). PRS was more frequent than PUCR with air and water (P < .05), even though the stimulation thresholds and response latencies were similar. Graded volumes of water but not air resulted in an increased frequency of PRS (P < .01). CONCLUSIONS PRS is more frequent than PUCR, and the 2 reflexes have distinctive characteristics in air and water stimuli. Both PRS and PUCR have implications for the evaluation of swallowing in infants.
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Affiliation(s)
- Sudarshan Rao Jadcherla
- Section of Neonatology, Columbus Children's Hospital and Department of Pediatrics, Ohio State University College of Medicine and Public Health, Columbus, OH 43205, USA.
| | - Alankar Gupta
- Section of Neonatology, Columbus Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205
| | - Erin Stoner
- Section of Neonatology, Columbus Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205
| | - Soledad Fernandez
- Center for Biostatistics at The Ohio State University College of Medicine and Public Health, Columbus Children’s Research Institute, 700 Children’s Drive, Columbus, OH 43205
| | - Reza Shaker
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Dysphagia Institute, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
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14
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Abstract
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 tone-generating 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.
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Affiliation(s)
- I M Lang
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee 53266, USA.
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15
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Abstract
The upper esophageal sphincter (UES) and lower esophageal sphincter (LES) comprise the basal mechanisms against entry of gastric content into the aerodigestive tract and the airway. There are, however, other mechanisms referred to here as "response mechanisms" that become activated after certain stimulation, such as distention of the esophagus or tactile/pressure stimulation of the pharyngeal wall, and result either in fortification of the UES barriers--i.e., esophago-UES, pharyngo-UES, and laryngo-UES contractile reflexes--or closure of the glottis--i.e., esophagoglottal and pharyngoglottal closure reflexes. In addition, there are other reflexes included among the response mechanisms--such as pharyngeal swallow and secondary peristalsis induced by pharyngeal stimulation by liquid and esophageal distention by refluxate--that result in pharyngeal and esophageal volume clearance, thus reducing the chance for contact of refluxate with the tracheal, bronchial, and glottal structures.
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Affiliation(s)
- R Shaker
- Division of Gastroenterology and Hepatology, MCW Dysphagia Institute, Medical College of Wisconsin, Milwaukee, USA
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Bardan E, Saeian K, Xie P, Ren J, Kern M, Dua K, Shaker R. Effect of pharyngeal stimulation on the motor function of the esophagus and its sphincters. Laryngoscope 1999; 109:437-41. [PMID: 10089972 DOI: 10.1097/00005537-199903000-00018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/HYPOTHESIS Sensory impulses from the pharynx induce contraction of the upper esophageal sphincter (UES), relaxation of the lower esophageal sphincter (LES), and inhibition of peristalsis. To determine 1) the magnitude of UES contractile response to threshold volume of fluid that induces LES relaxation and 2) the effect of rapid pharyngeal air stimulation on LES resting pressure and its concurrent influence on the UES and progression of esophageal peristalsis. METHODS Eleven healthy volunteers (age, 31 +/- 2 y) were studied by concurrent UES, esophagealbody, and LES manometry. RESULTS At a threshold volume of 0.3 +/- 0.05 mL, injections of water into the pharynx directed posteriorly, resulted in complete LES relaxation. Duration of these relaxations averaged 19 +/- 1 seconds. In 10 of 11 subjects, these relaxations were accompanied by a simultaneous increase in UES resting tone that averaged 142% +/- 27% above preinjection values. Pharyngeal stimulation by rapid air injection resulted in complete LES relaxation in 8 of the 11 subjects (threshold volume, 14 +/- 6 mL). Five of 8 developed a concurrent mild increase in resting UES pressure (17% +/- 6% above preinjection values) (P < .05). Pharyngeal water injection inhibited the progression of the peristaltic pressure wave at all tested sites and in all subjects, but pharyngeal air injection in only 2 of the 11 studied subjects. CONCLUSIONS The inhibitory effect of pharyngeal water injection on LES resting pressure is accompanied by a substantial contractile effect on the UES. Although stimulation of the pharynx by rapid air injection may induce LES relaxation, its inhibitory effect on esophageal peristalsis and stimulatory effect on UES pressure are negligible compared with that of water injection.
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Affiliation(s)
- E Bardan
- Chaim Sheba Medical Center, Tel Hashomer, Israel
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Mason RJ, Bremner CG, DeMeester TR, Crookes PF, Peters JH, Hagen JA, DeMeester SR. Pharyngeal swallowing disorders: selection for and outcome after myotomy. Ann Surg 1998; 228:598-608. [PMID: 9790349 PMCID: PMC1191543 DOI: 10.1097/00000658-199810000-00016] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To develop selection criteria based on the mechanical properties of pharyngoesophageal swallowing that indicate when patients with pharyngeal dysphagia will benefit from a myotomy. SUMMARY BACKGROUND DATA The pathophysiology of pharyngoesophageal swallowing disorders is complex. The disorder is of interest to several medical specialists (gastroenterologists, otorhinolaryngologists, general and thoracic surgeons), which contributes to confusion about the entity. The management is compounded because it is most frequently seen in the elderly, is often associated with generalized neuromuscular disease, and occurs with a high prevalence of concomitant disease. The selection of patients for myotomy is difficult and of major importance to the quality of life of the affected patients. METHOD One hundred seven patients without a Zenker diverticulum but with pharyngeal dysphagia underwent a detailed manometric assessment of the upper esophageal sphincter (UES). Cricopharyngeal opening was identified by the presence of a subatmospheric pressure drop before bolus arrival. Impaired pharyngoesophageal segment compliance resulting in a resistance to pharyngoesophageal flow was determined by measuring the intrabolus pressure generated by a 5-ml liquid bolus. RESULTS Thirty-one of 107 patients underwent a myotomy (29%). Both impaired sphincter opening and increased intrabolus pressure predicted a good outcome. CONCLUSION Myotomy is beneficial in patients with pharyngeal swallowing disorders and manometric evidence of defective sphincter opening and increased intrabolus pressure.
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Affiliation(s)
- R J Mason
- Department of Surgery, University of Southern California School of Medicine, Los Angeles 90033-4612, USA
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