Anatomic and Manometric Abnormalities of the Upper and Lower Esophageal Sphincters in Patients With Reflux Disease

RESEARCH QUESTION

Laryngopharyngeal reflux (LPR) may cause inflammation of the laryngeal and pharyngeal mucosa. Gastroesophageal reflux disease (GERD) involves retrograde flow of gastric content into the esophagus below the upper esophageal sphincter (UES). The goal of this study was to investigate the esophageal anatomical and manometric variations of the esophagus in patients with LPR and/or GERD.

METHODS

Adult voice center patients who underwent diagnostic workup for reflux complaints with 24-hour multichannel intraluminal pH-impedance testing and esophageal manometry were included in this retrospective study. Subjects were classified as having LPR (>10 proximal reflux events), LPR + GERD (>10 proximal reflux events plus >73 distal reflux events) or were assigned to a control group (≤10 proximal events and ≤73 distal reflux events) based on pH study results. Anatomic and manometric parameters were evaluated between groups.

RESULTS

There were 169 cases (65 male, 104 female) included in this study. The average age was 50.50 ± 17.29. Subjects in the LPR group had significantly higher UES relaxation pressures and greater UES length compared with the control group. Lower esophageal sphincter relaxation pressure was significantly higher in the control group compared with the LPR group or the GERD + LPR group. Subjects in the GERD + LPR group had a significantly shorter intra-abdominal portion of the lower esophageal sphincter compared with the LPR only group and the control group. Intrabolus pressure was significantly lower in both the LPR group and the LPR + GERD group compared with the control group. Distal wave amplitude was significantly lower in the LPR + GERD group compared to both the LPR group and the control group. The percentage of swallows with incomplete clearance was significantly greater in the LPR + GERD group than both the control group and the LPR group. The LPR group had significantly fewer swallows with incomplete clearance than the control group.

CONCLUSIONS

Anatomic and manometric abnormalities are present in subjects with LPR with or without GERD and may contribute to the pathogenesis of reflux disease. Further research is needed to confirm or refute these findings.

Pediatric retrograde cricopharyngeal dysfunction diagnosed by high-resolution impedance manometry

OBJECTIVES

The inability to burp, known as retrograde cricopharyngeal dysfunction (R-CPD), was initially described in adults. The proposed clinical diagnostic criteria for R-CPD include belching inability, abdominal bloating and discomfort/nausea, postprandial chest pain, and involuntary noises. Botulinum toxin injection to the cricopharyngeal muscle has been reported to be beneficial. High-resolution esophageal impedance-manometry (HRIM) features in adolescent patients with R-CPD have not been described yet.  The aim of our study was to describe the clinical and HRIM findings of pediatric patients with R-CPD.

METHODS

Clinical and manometric features of five pediatric patients diagnosed with R-CPD were reviewed. HRIM study protocol was modified to include the consumption of carbonated drink to provoke symptoms and distinctive manometric features.

RESULTS

We report five female patients aged 15-20 years who presented with an inability to burp and involuntary throat sounds. HRIM revealed normal upper esophageal sphincter (UES) relaxation during swallowing, but abnormal UES relaxation with concurrent high esophageal impedance reflecting air entrapment and secondary peristalsis following the carbonated drink challenge. Four patients exhibited esophageal motility disorder. All patients reported improvement or resolution of symptoms after botulinum toxin injection to the cricopharyngeus muscle.

CONCLUSIONS

Adolescents with an inability to burp, reflux-like symptoms, bloating, and involuntary throat noises should be assessed for R-CPD by pediatric gastroenterologists with HRIM. The relatively recent recognition of this novel condition is the likely reason for its under- and misdiagnosis in children.

Bolus transit of upper esophageal sphincter on high-resolution impedance manometry study correlate with the laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux symptom is a troublesome upper esophageal problem, and reflux symptom index (RSI) is commonly applied for the assessment of clinical severity. We investigated the relationship between the upper esophageal sphincter impedance integral (UESII) and RSI scores in this study. Totally 158 subjects with high-resolution esophageal impedance manometry (HRIM) with RSI questionnaire assessment were recruited. There are 57 (36.08%), 74 (46.84%), 21 (13.29%), and 6 (3.79%) patients were categorized as normal, ineffective esophageal motility disorder, absent contractility, and achalasia by HRIM examination, respectively. Subjects with RSI > 13 were noted to have lower UESII than others with RSI ≦ 13 (7363.14 ± 1085.58 vs. 11,833.75 ± 918.77 Ω s cm; P < 0.005). The ROC analysis yielded a UESII cutoff of < 2900 Ω s cm for the best prediction of subjects with RSI > 13 (P = 0.002). Both female gender and UESII cutoff of < 2900 Ω s cm were significant predictors of RSI > 13 in logistic regression analysis (OR = 3.84 and 2.83; P = 0.001 and 0.01; respectively). Lower UESII on HRIM study, indicating poor bolus transit of UES during saline swallows, is significantly associated with prominent laryngopharyngeal reflux symptoms scored by RSI score.

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.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification

BACKGROUND

Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia.

METHODS

A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure.

RESULTS

Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure.

CONCLUSIONS

Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

Ultrasonography-guided botulinum toxin injection to the cricopharyngeus muscle: a case report and technical notes

Dysphagia associated with the cricopharyngeus muscle (CPm) dysfunction negatively influences the quality of life. This high-pressure region must relax and the lumen must open for smooth food passage. The CP muscle is therefore a common target of chemodenervation with botulinum toxin (BTX). Here we presented a patient with severe left lateral medullary syndrome and non-relaxation of the CPm. We described how to localize the CPm in the transverse and longitudinal views under ultrasonography and offered a video demonstrating ultrasonography-guided BTX injection. Ultrasonography-guided CPm injection with BTX may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

Simultaneous double balloon dilatation using double channel therapeutic endoscope in patients with cricopharyngeal muscle dysfunction: An observative study

The role of endoscopic balloon dilatation (EBD) using double-balloon catheters in patients with cricopharyngeal muscle dysfunction (CPD) is still unclear. Thus, the aim of this study was to compare the functional outcomes between patients receiving EBD and rehabilitative balloon swallowing (RBS).A total of 36 patients with CPD, who visited a teaching hospital from February 2014 to June 2017, were included in the study. Among them, 12 patients with severe dysphagia underwent EBD. After propensity score matching, 24 patients who underwent RBS were selected for comparison. We compared the effects of EBD and RBS using 4 functional swallowing parameters: functional dysphagia scale score, penetration-aspiration scale score, pharyngeal transit time, and percentage of pharyngeal remnant (PR) at baseline and after the first and second treatments. Using simple and multiple regression, we examined the associations between EBD/RBS and changes of 4 parameters after the treatments since the baselineAll functional parameters significantly decreased after RBS and EBD (P < .05). After the first therapy session, significant differences in the pharyngeal transit time (P = .034), percentage of PR (P = .008), and penetration-aspiration scale score (P = .014) were observed in the EBD group, compared with those in the RBS group. The regression analysis showed significant improvements in the PR after EBD compared with that after RBS (β = 0.95, SE = 0.31, P = .005).EBD may be an alternative treatment for patients with severe CPD. A significant improvement would be expected in such patients with PR.

Transcranial direct current stimulation improves the swallowing function in patients with cricopharyngeal muscle dysfunction following a brainstem stroke

OBJECTIVE

This study investigated the effects of transcranial direct current stimulation (tDCS) combined with conventional swallowing training on the swallowing function in brainstem stroke patients with cricopharyngeal muscle dysfunction (CPD).

METHODS

Twenty-eight brainstem stroke patients with CPD were assigned randomly to an anodal tDCS group or a sham tDCS group. The patients received anodal tDCS or sham tDCS over the bilateral oesophageal cortical area combined with simultaneous catheter balloon dilatation and conventional swallowing therapy for 20 days. Swallowing function was assessed using the functional oral intake scale (FOIS) and the functional dysphagia scale (FDS) and by measuring the pharyngoesophageal Segment Opening (PESO) before and immediately after the intervention.

RESULTS

Both groups showed a significant improvement in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005). However, compared with the sham stimulation group, the anodal tDCS group showed greater improvements in the FDS, FOIS and PESO scores immediately after the intervention (all p < .005).

CONCLUSION

The bihemispheric anodal tDCS combined with simultaneous catheter balloon dilatation and conventional swallowing therapy effectively improves the swallowing function in patients with CPD caused by a brainstem stroke. tDCS may be an effective adjuvant therapy in CPD rehabilitation.

A Rare Case Involving the Inability to Belch

A 17-year-old girl was referred to our hospital with an inability to belch, while experiencing chest gurgling noises, and severe abdominal bloating. She reported having these symptoms all her life. A timed barium esophagogram revealed a moderate amount of bubbles in the esophagus and gastric fundus, which significantly increased after the examination. High resolution manometry revealed that the basal upper esophageal sphincter pressure increased with a rise in the cervical esophageal pressure. A pathological inability to belch is rare; at present, no specific name exists to describe the disorder. Further research is needed in this unexplored field.

Diagnosis of Swallowing Disorders: How We Interpret Pharyngeal Manometry

PURPOSE OF REVIEW

We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases.

RECENT FINDINGS

In our Centre, we base our interpretation of HRIM recordings upon a qualitative assessment of pressure-impedance waveforms during individual swallows, as well as a quantitative assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility. Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.

Electromyography Findings of the Cricopharyngeus in Association with Ipsilateral Pharyngeal and Laryngeal Muscles

Objectives:

We reviewed a large series of cricopharyngeal (CP) muscle electromyography (EMG) results and compared them with the EMG results from the inferior constrictor (IC), thyroarytenoid, (TA), cricothyroid (CT), and posterior cricoarytenoid (PCA) muscles.

Methods:

We performed a retrospective review of all CP muscle EMG reports from studies performed between January 1996 and June 2003. All of the tested elements from the CP muscle EMG reports were recorded. The EMG results were recorded for the ipsilateral IC, TA, CT, and PCA muscles if they were simultaneously tested. Each muscle result was classified as normal, neurogenic inactive axonal injury (IAI), or neurogenic active axonal injury (AAI), and the muscle findings were compared. A patient chart review was performed to determine a clinical correlation.

Results:

Fifty-nine patients underwent CP muscle EMG. Eighteen patients had bilateral EMG studies, making a total of 77 CP muscle studies. Nineteen sets of CP muscle results were normal, 43 demonstrated neurogenic IAI, and 15 demonstrated neurogenic AAI. The ipsilateral IC and CP muscles had the same innervation status in 27 of 28 studies (p > .0001). When the ipsilateral TA muscle was studied simultaneously with the CP muscle, 31 of 50 studies had the same innervation status (p = .005). The ipsilateral CT and CP muscles demonstrated the same innervation status in 40 of 50 studies (p > .0001). The correlations between the CP and IC muscle findings and between the CP and CT muscle findings were both stronger than the correlation between the CP and TA muscle findings (p > .0001 and p = .024, respectively). The chart review demonstrated the clinical findings to be consistent with the EMG results.

Conclusions:

The EMG studies demonstrated that CP muscle findings have the strongest correlation with IC muscle findings, followed by the CT and TA muscles. This outcome does not support theories indicating that the recurrent laryngeal nerve innervates the CP muscle in all cases.

Videofluoroscopic Findings in Dysphagic Patients with Cricopharyngeal Dysfunction: Before and after Open Cricopharyngeal Myotomy

Objectives:

Functional outcomes after open cricopharyngeal myotomy (CPM) for Zenker's diverticulum (ZD) and cricopharyngeal dysfunction without diverticulum (CPD) have not been uniformly measured by videofluorographic swallow study (VFSS). Here we characterize preoperative VFSS findings in these groups and evaluate the effect of CPM on swallowing via postoperative VFSS.

Methods:

We performed a retrospective review of paired preoperative and postoperative VFSS results from 50 patients (36 with ZD and 14 with CPD) over 6 years. Semiquantitative scales were used to assess 1) degree of stasis in the pharyngeal recesses; 2) degree of narrowing at the pharyngoesophageal sphincter (PES); 3) aspiration; and 4) diverticular size. Findings were compared between the groups and across subjects.

Results:

Pharyngeal stasis was more severe in subjects with CPD than in subjects with ZD, both before and after CPM (p = .02 and p = .0002, respectively). The CPM improved PES narrowing in both groups (p = .03; p = .06) and reduced diverticular size in the ZD group (p < .001), but it did not significantly reduce the stasis severity or the proportion of patients with aspiration.

Conclusions:

According to VFSS, CPM opens up the PES and decreases diverticular size. More severe stasis in CPD suggests that diffuse pharyngeal weakness may play a role in this disease, and may partially explain the variable post-CPM outcomes that have been observed in CPD.

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.

[Analysis of the characteristic of pharyngeal paraesthesia patients by high resolution manometry]

OBJECTIVE

To discuss the pressure changing characteristics of upper esophageal sphincter (UES), lower esophageal sphincter (LES) and the esophagus kinetic characteristics of pharyngeal paraesthesia patients.

METHOD

To take high resolution manometry in 44 cases of pharyngeal paraesthesia patients and 23 normal subjects separately. According to the RSI score,the 44 patients were divided into group A (the group without reflux, RSI < 13, n = 25) and group B (the group with reflux, RSI ≥ 13, n = 19).

RESULT

The UES average resting pressure and average residual pressure of patients group were higher than the control group (P < 0.05); The UES average resting pressure and average residual pressure of group B were higher than group A (P < 0.05); The LES average resting pressure and average residual pressure of group B were lower than group A and the control group (P < 0.05); The comparison of LES average resting pressure and average residual pressure between group A and the control group was not statistically significant (P > 0.05). The esophagus DCI of group B was lower than that of group A and control group (P < 0.05). The esophagus DCI comparison between group A and control group was not statistically significant (P > 0.05).

CONCLUSION

The pharyngeal paresthesia symptoms of'patients was associated with the increasing of UES pressure. The pharyngeal paresthesia symptoms of group with reflux was related to low pressure of LES and high pressure of UES. The last part of esophagus of group with reflux had obstacles in powers, which weaken the peristalsis and declined the ability to clear the bolus and gastric reflux material.

[Analyses of the characteristics of esophageal motility in patients with pharyngeal paraesthesia who visit the Department of gastroenterology]

OBJECTIVE

To investigate the influence of the local sensory abnormality in throat while the change of motility in the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), as well as the change of esophageal body in pharyngeal paraesthesia.

METHODS

From January 2014 to January 2015 there were sixty-four patients who had pharyngeal susceptible syndrome (PSS) but without confirmed organic disease were enrolled as the PSS group, forty healthy volunteers as the control group. High resolution manometry (HRM) was utilized to distinguish esophageal motility patterns of PSS, including the muscular tension of LES and UES, the integrity, adaptability, amplitude, speed and duration of esophageal peristalsis at 10 swallows.

RESULTS

The resting LES and UES pressures and the distal contractile integral (DCI) of esophagus in PSS group were lower than that in control group (P < 0.05). The esophageal peristalsis was decelerated and shortened in duration, and amplitude of contraction notably lower in PSS group compared with its counterpart (P < 0.05). The integrity of esophageal peristalsis was impaired in PSS with remarkable changes in motility patterns, involving ratio of major and minor interrupts, and synchronous contraction rate (P < 0.05). As for the time course from relaxation to the lowest pressure point of UES and time for restoration, no definite difference was noticed between the two groups (P > 0.05). The average peak pressure was similar in two groups (P > 0.05).

CONCLUSIONS

Muscle tension around the UES has no obvious change when pharyngeal paraesthesia occurred, but the reduction of esophageal motor function, clearance ability, anti-reflux gastroesophageal junction, causing the abnormal reflux which hurt the pharyngeal surface mucosa maybe one of the most important reasons leading to pharyngeal paresthesia.

[Paradoxical sphincters in the abdomen]

Nitric oxide molecules serve as neurotransmitters to relax smooth muscle tension in many parts of the body. In humans and other mammals they play an important role for correct smooth muscle function in unusual locations. We previously described this mechanism (Stelzner, Chirurg. doi:10.1007/s00104-014-2777-z, 2014) using the occlusive mechanism of the upper and lower esophageal sphincters as an example. Cells producing nitric oxide can be found in the gastric fundus, the anorectal continence organ, vesicourethraltract and also in the uterine cervix in the final trimester of pregnancy. In all these locations they serve as elements of anatomical sphincter structures that have a paradoxical function. These observations confirm the points made in the introduction of this article on the stretch sphincter mechanism of the lower esophageal sphincter and the treatment of gastroesophageal reflux disease by retensioning of the esophagus in the diaphragmatic hiatus. In particular, high-resolution esophageal manometry of the lower esophageal sphincter can easily detect every functional disturbance caused by gastric plication and such changes were to be expected based on what we described in articles I and II.

Peroral endoscopic myotomy can improve esophageal motility in patients with achalasia from a large sample self-control research (66 patients)

Background

Peroral endoscopic myotomy (POEM) as a new approach to achalasia attracts broad attention. The primary objective of this study was to evaluate the results with esophageal motility after POEM through the first large sample clinical research.

Patients and Methods

We have a self-control research with all patients (205 in total) who underwent POEM from 2010 to 2014 at our Digestive Endoscopic Center, 66 patients of which underwent high resolution manometry (HRM) before and after POEM in our motility laboratory. Follow-ups last for 5.6 months on average. Outcome variables analyzed included upper esophageal sphincter pressure (UESP), upper esophageal sphincter residual pressure (UESRP), lower esophageal sphincter pressure (LESP), lower esophageal sphincter residual pressure (LESRP) and esophageal body peristalsis. We have a statistical analysis to illustrate how POEM impacts on the change of esophageal motility.

Results

The symptoms related to dysphagia were relieved in 95% of patients in recent term after POEM. While HRM showed a statistically significant reduction of URSRP, LESP and LESRP (P<0.01), however, peristalsis was not consistently affected. There were 11 patients who had undergone other prior endoscopic treatment (endoscopic dilation or botulinum toxin injection) and 55 patients had not. The statistical difference (P>0.05) did not occur for these two groups on LESP and LESRP reduction.

Conclusions

POEM clearly relieved the symptoms related to dysphagia by lowering the pressure of upper esophageal sphincter (UES) and lower esophageal sphincter (LES),and other endoscopic treatment before POEM did not affect the improvement of LES pressure. These results are concluded from our short-term follow-up study, while the long-term efficacy remains to be further illustrated.

Trial Registration

Chinese Clinical Trial Register ChiCTR-TRC-12002204)

Implementation of high-resolution manometry in the clinical practice of speech language pathology

Visual imaging modalities, videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow, for assessment of oropharyngeal dysphagia have been part of the speech language pathologist's (SLPs) armamentarium for the diagnosis and treatment of dysphagia for decades. Recently, the addition of high-resolution manometry (HRM) has enabled the SLP to evaluate pharyngeal pressures and upper esophageal sphincter relaxation. Taken together, the use of visual imaging modalities with HRM can improve interpretation of swallowing physiology and facilitate more effective treatment planning. The goal of this article is to describe a clinical paradigm using HRM as an adjunct to VFSS, by the SLP, in the assessment of complex dysphagia. Moreover, in three cases described, the value of manometric measurements in elucidating swallowing imaging studies and documenting physiologic change in response to treatment is highlighted. As technology in this area is evolving, so will the clinical use of HRM by the SLP. Limitations of current HRM systems and applications are discussed.

Can mano-videoendoscopy substitute for videofluorography in evaluation of upper esophageal sphincter function?

CONCLUSIONS

Mano-videoendoscopy (MVE), a manometry technique with endoscopic confirmation of the pressure catheter, can supplement the information on upper esophageal sphincter (UES) function, and overcomes the drawbacks of videoendoscopic swallowing study (VESS).

OBJECTIVES

This study aimed to investigate the possibility of replacing videofluorographic swallowing study (VFSS) with MVE, as a test to precisely evaluate UES function.

METHODS

Data from 52 patients with dysphagia were retrospectively reviewed. All patients underwent both MVE and VFSS for evaluation of dysphagia. The manometry was performed with a transnasally inserted catheter (2.6 mm outer diameter and four pressure sensors) under endoscopic observation. The sensors were kept at the tongue base, upper pyriform sinus, apex of pyriform sinus, and UES. We statistically compared the manometric parameters of UES relaxation with fluorographic UES opening.

RESULTS

Fluorographic UES opening was diagnosed as good in 34 patients and poor in 18 patients. The nadir pressure, pressure drop, and pressure rise in the UES had significant correlation on the fluorographic UES opening. Stepwise logistic regression test revealed that pressure drop, the gap between the resting pressure and the nadir of UES pressure, was a robust parameter for predicting fluorographic UES opening, and the cut-off level to anticipate good fluorographic opening was ≥ 33.5 mmHg (specificity, 0.853; sensitivity, 0.759).

[Reflux and hiatus hernia in the controversy between conservative and operative therapy]

Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.

Impedance-high resolution manometry analysis of patients with nonerosive reflux disease

BACKGROUND & AIMS

Transient lower esophageal sphincter relaxations (TLESRs) contribute to episodes of reflux. Few studies have assessed the frequencies or compositions of TLESRs and reflux episodes in patients with reflux disease. We used combined high-resolution manometry and impedance monitoring to analyze reflux episodes and esophageal motility in these patients, compared with those of healthy individuals.

METHODS

We evaluated the frequency of TLESRs and the relationship between the reflux pattern and esophageal pressures during TLESRs in 14 patients with nonerosive reflux disease (NERD) and 11 controls. Study participants underwent combined high-resolution manometry and impedance monitoring before and 60 minutes after a solid and liquid meal. The diagnosis of NERD was confirmed by a 24-hour pH impedance test.

RESULTS

The frequency of TLESRs did not differ between patients with NERD and controls. In patients with NERD, TLESRs were associated more often with reflux episodes than in controls (93% ± 6% vs 66% ± 19%; P < .05). Patients with NERD had a higher percentage of pure liquid reflux episodes (33% ± 15% vs 10% ± 2%; P < .05), whereas controls had a higher percentage of mixed reflux episodes (45% ± 16% vs 67% ± 17% in patients with NERD; P < .05). Patients with NERD also had a higher percentage of reflux (liquid and mixed) associated with common cavities (74% ± 18% vs 50% ± 20% in controls; P < .05).

CONCLUSIONS

In contrast to previous studies, we found that TLESRs are associated more often with reflux in patients with NERD than control subjects; this association increases when only liquid and mixed refluxes are considered. These findings indicate that factors involved in the occurrence of reflux in patients with NERD during TLESRs are different from those in healthy subjects.

[Effect of balloon dilatation on upper esophageal sphincter in brainstem stroke patients with dysphagia: an investigation using high-resolution solid-state manometry]

OBJECTIVE

To explore the effects of balloon dilation intervention on function of upper esophageal sphincter ( UES) in brainstem stroke patients with dysphagia before and after treatment by high resolution solid-state manometry.

METHODS

Thirty brainstem stroke patients with pharyngeal dysphagia were recruited. The dilatation treatment group ( n = 15) completed a 3-week regimen of modified balloon dilatation and traditional swallowing including E-stim, Mendelsohn Maneuver and supraglottic swallowing. And the control group ( n = 15) only completed 3 weeks of traditional swallowing therapy. Before, and after dilatation, the nadir of UES and its duration were measured during swallowing of thin liquid, thick liquid and pasty material in 3-ml volumes. The results of both groups were compared for identical parameters.

RESULTS

In the experimental group, post-treatment UES residual pressure (for water, P = 0. 008; for thick liquid,P = 0. 004 ; for paste, P = 0. 001 ) and relaxation duration ( for water, P = 0. 006 ; for thick liquid, P =0. 002; for paste, P < 0. 001 ) both significantly improved for all three materials. UES resting pressure approximated normal (Pre-treatment 30 ± 3 mm Hg; post-treatment 59 ± 6 mm Hg, P < 0. 001 ) . In the control group, there was no improvement in post-treatment UES residual pressure and relaxation duration for all three materials ( P > 0. 05). In the experimental group, feeding tube was removed in 12 /15 versus 2/15 patients in the control group. The experimental group had 3. 5 points improvement (P =0. 001) while the control group improved by a mere 0. 63 point ( P = 0. 026) in FOIS scores.

CONCLUSION

Failed UES is a major cause of dysphagia in brainstem stroke patients. Dysphagia therapy with dilatation improves relaxation of UES. Moreover, it is helpful for restoring UES resting pressure. Traditional swallowing therapy has no positive effect on UES.

Cricopharyngeal achalasia in children: surgical and medical treatment

BACKGROUND

Cricopharyngeal achalasia (CA) is a rare cause of dysphagia in children presenting with non-specific symptoms such as choking, food regurgitation, nasal reflux, coughing, recurrent pneumonia, cyanosis, and failure to thrive. It results from failure of relaxation of the upper esophageal sphincter (UES) and may appea reither as an isolated lesion or in conjunction with other pathologies. Recognition and early diagnosis of this condition may minimize morbidity in children.

OBJECTIVES

To evaluate the clinical course of four children with cricopharyngeal achalasia presenting to our clinic.

METHODS

We conducted a 5 year retrospective chart review in a tertiary referral center.

RESULTS

Four children were diagnosed with primary cricopharyngeal achalasia between 2006 and 2010. Diagnosis was established by videofluoroscopy and all underwent uneventful cricopharyngeal myotomy. Three children recovered completely and one child showed partial improvement. For residual UES spasm in a partially improved patient, botulinum toxin was injected into the UES which led to further improvement. Dysphagia recurred in one child who was successfully treated with botulinum toxin injection.

CONCLUSIONS

Cricopharyngeal myotomy is a safe procedure in infants and young children. Botulinum toxin injection of the UES was found to be effective in refractory cases.

Current evaluation of upper oesophageal sphincter opening in dysphagia practice: an international SLT survey

BACKGROUND

The assessment of adequate upper oesophageal sphincter (UOS) opening during swallowing is an integral component of dysphagia evaluation.

AIMS

To ascertain speech and language therapists' (SLTs) satisfaction with current methods for assessing UOS function in people with dysphagia and to identify challenges encountered by SLTs with UOS evaluation.

METHODS & PROCEDURES

A survey was disseminated to 82 SLT managers in Ireland; to two dysphagia Special Interest Groups in the UK; and to the Royal College of Speech & Language Therapists'Bulletin periodical. A survey link was also posted on the American Speech and Hearing Association (ASHA) Division 13 (Dysphagia) web forum.

OUTCOMES & RESULTS

Surveys from 224 SLTs with active dysphagia caseloads were included in data analysis. Only 17.9% (40/224) of SLTs were satisfied with the accuracy and reliability of UOS evaluations currently being employed in dysphagia practice. Satisfaction with current UOS evaluation was not associated with the level of clinical experience (r= 0.078; p= 0.246). Eighty-seven per cent (195/224) of SLTs working with dysphagia experience challenges in UOS evaluation. Challenges reported include lack of resources/equipment (55.9%), limited quantitative information (45.6%), lack of training (41%) and knowledge (39%) in UOS function, and limited multidisciplinary team involvement (34%).

CONCLUSIONS & IMPLICATIONS

SLTs across all levels of clinical experience are not satisfied with current UOS evaluation in dysphagia practice. Based on the specific challenges identified, recommendations to progress SLT evaluation of UOS function in people with dysphagia are proposed.

Mechanisms of esophago-pharyngeal acid regurgitation in human subjects

Esophago-pharyngeal regurgitation is implicated in various otolaryngologic and respiratory disorders. The pathophysiological mechanisms causing regurgitation are still largely unknown.

Failed antireflux surgery: results after reoperation

BACKGROUND

Since laparoscopy has become a common surgical approach for antireflux surgery, little is known regarding reoperation for failed antireflux surgery.

METHODS

Records of all patients who underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease or hiatal hernia between July 1, 1995 and April 1, 2004 were reviewed. There were 126 patients. Two patients declined research participation. The remaining 124 patients (71 women and 53 men) formed the basis for this study. Median age was 53 years (range, 19 to 83 years). The initial operation was a laparoscopic antireflux procedure in 76 patients (61.3%) and an open repair in 48 (38.7%). A single previous operation had been done in 100 patients, two operations in 20, and three operations in 4. The median interval between the most recent reoperation and the previous operation was 28 months. All patients were symptomatic. The surgical approach was a thoracotomy in 83 patients, laparotomy in 36, laparoscopy in 4, and thoracoabdominal in 1. A Nissen fundoplication was performed in 86 patients (69.4%), Belsey fundoplication in 31(25.0%), and others in 7.

RESULTS

There were no operative deaths. Complications occurred in 27 patients (21.7%). Median hospitalization was 6 days (range, 5 to 58 days). Follow-up ranged from 10 days to 10 years (median, 9.7 months). Improvement was observed in 114 patients (91.9%). Functional results were classified as excellent in 69 patients (55.6%), good in 19 (15.4%), fair in 26 (20.9%), and poor in 10 (8.1%). No single operative approach was functionally superior.

CONCLUSIONS

We conclude that reoperation for failed antireflux surgery is safe and effective. Results of reoperation were not affected by the type of reoperation or whether the previous approach was laparoscopic or open.

Swallowing Function Following Extensive Resection of Oral or Oropharyngeal Cancer With Laryngeal Suspension and Cricopharyngeal Myotomy

OBJECTIVE

To investigate factors that influence postoperative swallowing function in patients who underwent tongue and oropharynx resection.

METHODS

Sixty-two subjects who had undergone extensive resection of oral or oropharyngeal cancer between 1993 and 2005 participated in this study. All surgical procedures involved excision of the bilateral suprahyoid muscles or of >or=50% of the tongue base. Laryngeal suspension and cricopharyngeal myotomy were performed on all subjects. A multivariate analysis of the effects of extensive tongue and oropharynx resection on swallowing function was performed.

RESULTS

A total of 53 (85.5%) of the 62 subjects achieved independent oral intake and no longer required tube feeding. Six months after surgery, better eating capabilities had been attained by younger patients as compared with older patients; patients with less extensive tongue base resections; patients who had not undergone radiotherapy; and patients reconstructed with free flaps rather than pedicled flaps.

CONCLUSIONS

Age was found to be the most important factor in determining whether a patient could achieve independent oral intake after extensive oral or oropharyngeal resection. The main factors in determining the quality of diet attained by the patient were found to be age, the percentage of tongue base resection, and the method of postoperative reconstruction.

Dysphagia in inflammatory myopathy: clinical characteristics, treatment strategies, and outcome in 62 patients

OBJECTIVE

To assess the clinical characteristics, treatment, and outcome of patients with inflammatory myopathy-associated dysphagia.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of all patients with inflammatory myopathy-associated dysphagia seen at the Mayo Clinic in Rochester, Minn, between January 1, 1997, and December 31, 2001.

RESULTS

A total of 783 patients were diagnosed as having inflammatory myopathy during the 5-year study period. Of these, 62 patients (41 women and 21 men; mean age, 68.6 years) had inflammatory myopathy-associated dysphagia: 26 with inclusion body myositis (IBM), 18 with dermatomyositis, 9 with polymyositis, and 9 with overlap syndrome. Dysphagia was a presenting symptom in 13 patients (21%), with the highest incidence in the IBM group. Videofluoroscopic examinations revealed pharyngeal pooling and impaired oropharyngeal and cricopharyngeal function. The benefits of swallowing compensation techniques and exercises were difficult to establish. Interventional procedures were performed in 24 patients (39%) and most frequently (62%) in patients with IBM, with cricopharyngeal myotomy being most beneficial. Patients with IBM had the least symptomatic improvement. Overall, 11 patients died during the median follow-up of 38 months, with respiratory failure due to aspiration pneumonia as the most common cause. Mortality was high in patients who required percutaneous endoscopic gastrostomy (7/11, 64%), and 1- year mortality was highest (31%) in those with dermatomyositis.

CONCLUSION

Dysphagia is a serious and at times presenting problem in patients with inflammatory myopathy. It occurs most frequently and appears to be most refractory in patients with IBM. The mortality rate was high in patients who required percutaneous endoscopic gastrostomy, and the 1-year mortality rate was the highest in patients with dermatomyositis.

Ösophageale Schluckstörungen

Eine ösophageale Schluckstörung oder Dysphagie kann durch eine mechanische Obstruktion, entzündliche Läsionen oder funktionell durch eine Motilitässtörung bedingt sein. Bei Dysphagie muss stets mit entsprechender Diagnostik, insbesondere der Endoskopie, das Vorliegen eines Malignoms ausgeschlossen werden. Diese Übersicht fasst die häufigsten Ursachen einer funktionell oder entzündlich bedingten Dysphagie zusammen. Symptomatik, Diagnostik und Therapie von Motilitätsstörungen des Ösophagus wie Achalasie und diffuse Ösophagusspasmen, der Refluxkrankheit als Folge einer Funktionsstörung vorwiegend des unteren Ösophagussphinkters sowie der eosinophilen Ösophagitis werden dargestellt.

Endoscopic cricopharyngeal myotomy: indications and technique

PURPOSE OF REVIEW

Cricopharyngeal muscle myotomy to treat swallowing disorders has a definite role in the management of cervical dysphagia. Several reports emphasize the benefits of the endoscopic approach compared with the transcervical technique. This review examines recent surgical management of cricopharyngeus dysmotility.

RECENT FINDINGS

Several investigations have provided pertinent information on selecting patients for cricopharyngeal myotomy. Manofluorography appears to be more accurate in detecting intrabolus pressure anomalies during swallowing. Isolated cricopharyngeus dyscoordination, however, is not easily identified using this method. Electromyographic activity of the inferior pharyngeal constrictor and cricopharyngeus recorded by transcutaneous electrodes at rest and during deglutition has shown different dysfunction patterns. Ambulatory 24 h double probe pH monitoring and the triple sensor combination pH test demonstrate clinical correlation between pH results and symptoms in patients suffering from dysphagia related to laryngopharyngeal reflux. Transoral cricopharyngeal myotomy for the treatment of cricopharyngeus dysmotility is now established as a safe and effective method. The development of new devices has enhanced the procedure's efficacy and the overall success rate without major complications.

SUMMARY

Diagnosis of cricopharyngeus dysfunction is based on anamnesis and videoradiograph findings. In doubtful cases manofluorography and electromyography should be performed. Endoscopic cricopharyngeal myotomy is a safe and effective treatment option for patients with cricopharyngeus dysphasia.

Botulinum toxin as treatment for a unique case of subcutaneous emphysema

A developmentally delayed 11-year-old male developed extensive spontaneous subcutaneous emphysema 6 weeks after a laryngotracheal separation. Computed tomography demonstrated a small amount of air at the distal end of the laryngeal stump and significant esophageal air. Aerophagia was diagnosed with air presumed diverted through the laryngeal stump due to cricopharyngeal hypertension. Cricopharyngeal botulinum toxin injection was coordinated with a minimal neck dissection to drain the subcutaneous emphysema. The subcutaneous emphysema gradually improved and the patient was discharged home. His subcutaneous emphysema has not returned after four total botulinum toxin injections every 3 months.

Anatomy of reflux: a growing health problem affecting structures of the head and neck

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are sibling diseases that are a modern-day plague. Millions of Americans suffer from their sequelae, ranging from subtle annoyances to life-threatening illnesses such as asthma, sleep apnea, and cancer. Indeed, the recognized prevalence of GERD alone has increased threefold throughout the 1990s. Knowledge of the precise etiologies for GERD and LPR is becoming essential for proper treatment. This review focuses on the anatomical, physiological, neurobiological, and cellular aspects of these diseases. By definition, gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus; when excessive and damaging to the esophageal mucosa, GERD results. Reflux that advances to the laryngopharynx and, subsequently, to other regions of the head and neck such as the larynx, oral cavity, nasopharynx, nasal cavity, paranasal sinuses, and even middle ear results in LPR. While GERD has long been identified as a source of esophageal disease, LPR has only recently been implicated in causing head and neck problems. Recent research has identified four anatomical/physiological "barriers" that serve as guardians to prevent the cranial incursion of reflux: the gastroesophageal junction, esophageal motor function and acid clearance, the upper esophageal sphincter, and pharyngeal and laryngeal mucosal resistance. Sequential failure of all four barriers is necessary to produce LPR. While it has become apparent that GER must precede both GERD and LPR, the head and neck distribution of the latter clearly separates these diseases as distinct entities warranting specialized focus and treatment.

Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction

OBJECTIVE

To evaluate the therapeutic effectiveness of botulinum toxin type A (BTX-A) in poststroke patients with cricopharyngeal muscle dysfunction.

DESIGN

Before-after trial.

SETTING

University hospital.

PARTICIPANTS

Eight poststroke patients.

INTERVENTION

BTX-A injection into the cricopharyngeal muscle under endoscope guidance for poststroke cricopharyngeal muscle dysfunction.

MAIN OUTCOME MEASURES

Clinical symptom score, disability rating scale for swallowing impairment, videofluoroscopic swallowing study, and upper esophageal sphincter (UES) manometry.

RESULTS

Clinical symptom score, disability rating scale for swallowing impairment, residue in piriform sinus, and UES pressure were all significantly improved at 2 weeks after BTX-A injection compared with evaluations before injection (P<.05). The effects on the clinical symptom score and disability rating scale for swallowing impairment continued to be significantly improved to 12 weeks after injection (P<.05). However, the residue in piriform sinus and the UES pressure at 12 weeks postinjection were reduced compared with before-injection evaluations; these results were not significant. The pharyngeal transit time was not changed after injection. There were no side effects observed in the patients studied.

CONCLUSIONS

The results of the present study suggest that BTX-A injection may be an effective and safe treatment in patients with poststroke cricopharyngeal muscle dysfunction.

Cricothyroid muscle function and vocal fold stability in exercising horses

OBJECTIVES

To determine (1) if the cricothyroid muscle had respiratory-related electromyographic (EMG) activity that increased with respiratory effort and (2) if bilateral cricothyroid myotomy resulted in vocal fold instability and collapse in exercising horses.

STUDY DESIGN

Experimental.

ANIMALS

Seven (3 EMG; 4 cricothyroid myotomy) Standardbred horses.

METHODS

Three horses exercised on a treadmill at speeds corresponding to the speed that produced maximum heart rate (HR(max)), 75% of maximum heart rate (HR(75%max)), and 50% of maximum heart rate (HR(50%max)) for 60 seconds at each speed while EMG activity of the cricothyroid muscle and nasopharyngeal pressures were measured. Another 4 normal horses were exercised on the treadmill at HR(max) and HR(75%max) for 60 seconds at each speed before and after bilateral cricothyroid myotomy. Upper airway pressures were measured and videoendoscopic examinations were performed and videotaped at each speed.

RESULTS

Peak phasic EMBG activity of the cricothyroid muscle was coincident with inspiration and increased with treadmill speed. Bilateral cricothyroid myotomy resulted in vocal fold collapse in all horses. Mean peak inspiratory pressures were significantly more negative compared with control values at both HR(max) and HR(75%max).

CONCLUSIONS

Cricothyroid muscle dysfunction may be implicated in vocal fold collapse and likely causes inspiratory airway obstruction in exercising horses.

CLINICAL RELEVANCE

Conditions compromising cricothyroid muscle function or motor innervation could result in vocal fold collapse.

Is the Anatomical Protrusion on the Posterior Hypopharyngeal Wall Associated with Cadavers of Only the Elderly?

Cricopharyngeal bars are commonly seen on a barium swallow radiologic examination and represent the failure of the cricopharyngeus to relax. Traditionally, the bars have been considered as functional or physiologic protrusions. Recently, anatomical cricopharyngeal protrusion has been found in about 30% of cadavers of the elderly, suggesting that such a structural change may become a physical barrier that affects the normal deglutition in a living person. This suggests that such a radiographic finding should be carefully considered when interpreting radiologic and manometrical examinations and managing dysphagia of the elderly. However, the finding of the anatomical cricopharyngeal protrusion was based on the observation of cadavers of the elderly (mean age = 77 years). The aim of this study was to further investigate whether such an anatomical cricopharyngeal protrusion exists in cadavers of other ages. Using the dissection method, we examined 63 human cadavers that were divided into three age groups: young adult (6 females and 10 males, age = 16-24 years old), adult (8 females and 23 males, age = 25-64 years old), and early elderly (5 females and 11 males, age = 65-69 years old). We found that 57 of the 63 cadavers had a smooth mucosal surface on the posterior hypopharyngeal and upper esophageal wall. A slightly thickened posterior muscular wall was observed at the cricoid level in six cadavers (five from the adult group and one from the early elderly group), but its boundary was not clearly identified. Taking the previous reports together, our results suggest that an anatomical cricopharyngeal protrusion is closely associated with the aging process.

Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery

BACKGROUND

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO2 laser have been described.

METHODS

Endoscopic cricopharyngeal myotomy using a CO2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker's diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy.

RESULTS

In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure.

CONCLUSIONS

Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction.

Avaliação eletromanométrica do esfíncter superior do esôfago em portadores da forma indeterminada da doença de Chagas

Objetivou-se avaliar as alterações do esfíncter superior esofágico pela eletromanometria em 37 pacientes portadores da forma clínica indeterminada da doença de Chagas. Foram encontrados 18 (48,6%) pacientes portadores de ondas sincrônicas. A média das pressões máximas do esfíncter foi significativamente maior entre os portadores de ondas sincrônicas. Assim, alguns indivíduos portadores da forma indeterminada da doença de Chagas possuem alterações funcionais caracterizadas pelo aumento da pressão do esfíncter superior do esôfago, que podem ser detectadas à eletromanometria.

Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction

OBJECTIVE

The development of a cricopharyngeal dysfunction is associated with a hypertonic cricopharyngeus (CP) muscle. Therefore, CP myotomy has been advocated by some authors to be an essential part of repair of this condition. However, little objective data exists to show that there is improvement in the upper esophageal sphincter (UES) after CP myotomy. This study assesses the impact of CP myotomy on UES opening.

STUDY DESIGN

Prospective.

METHODS

Twenty patients treated at a university tertiary care center for cricopharyngeal dysfunction between 1998 and 2003 were identified. All patients underwent CP myotomy with or without Zenker's diverticulectomy. These patients had videofluoroscopic swallow studies before and after repair. The values of UES opening for 3 mL boluses from pre- and postrepair studies were compared with each other as well as with normal controls. Sixty percent (12/20) of the patients had a Zenker's diverticulum. Of these 12 patients, 5 had undergone previous attempts at surgical correction. Cricopharyngeal myotomy by way of an external approach, with or without Zenker's diverticulectomy, was performed in all patients by the senior author.

RESULTS

Before Zenker's diverticulectomy and CP myotomy, the mean UES opening (n = 20) for a 3 mL bolus was 0.30 cm +/- 0.17, which was 57% of the mean of 60 normal controls (0.52 cm +/- 0.15) (P < .001). After repair, the mean UES opening for the same bolus size improved to 0.51 cm +/- 0.16 (P < .0001). The UES opening size in patients who have undergone repair is comparable with that of the normal controls (P > .05).

CONCLUSIONS

UES opening size in patients with cricopharyngeal dysfunction is 57% of the size in normal controls. CP myotomy helps to normalize the UES opening in cricopharyngeal dysfunction repair.

Esophageal contractions in Chagas' disease and in idiopathic achalasia

GOALS

The aim of this study was to compare the esophageal contractions in Chagas' disease and in idiopathic achalasia.

BACKGROUND

It is suggested that the esophageal involvement caused by Chagas' disease and by idiopathic achalasia, although similar, shows some differences.

STUDY

We studied the contractions at 2, 7, 12, and 17 cm below the upper esophageal sphincter in 25 patients with idiopathic achalasia (15 with dilatation), 52 with Chagas' disease (22 with dilatation), and 18 controls. Each subject performed 5 swallows of a 5-mL bolus of water alternated with 5 dry swallows.

RESULTS

In the distal esophageal body, the amplitude was lower in patients than in controls. Among patients with esophageal dilatation, the proximal amplitude was lower in patients with idiopathic achalasia, and the time interval between the contractions at 2 and 7 cm was longer in patients with Chagas' disease, the number of failed contractions was higher in Chagas' disease, and simultaneous contractions were more frequent in idiopathic achalasia. The simultaneous isobaric pressure in the distal esophagus was associated with an increase in proximal pressure that was higher than distal but lower than proximal swallowing pressure.

CONCLUSION

The results suggested that idiopathic achalasia and Chagas' disease cause similar impairment of distal esophageal motility, but in patients with esophageal dilatation the impairment of proximal motility may be not the same.

The upper oesophageal sphincter

The upper oesophageal sphincter (UOS) is a high-pressure zone comprising functional activity of three adjacent muscles together with cartilage and connective tissue. Its primary function is to allow food into the oesophagus and prevent air ingestion. However, it must also allow the reflux of material during belching or vomiting. Cricopharyngeus is the most important muscle with contributions from inferior pharyngeal constrictor and cervical oesophagus. Basal tone within the UOS is contributed to by all three muscles with asymmetry in the axial plane. Relaxation of the UOS occurs during swallowing as well as in sleep while UOS pressure rises with stress, slow oesophageal distension, intra-oesophageal acid infusion and pharyngeal stimulation with air or water. Many physiological characteristics have been attributed to UOS function following videofluoroscopic swallow examinations, manometry and electromyography but a range of normal values remains controversial and their utility uncertain. The result has been that pathological change is inconsistently characterized and management is instigated without a satisfactory evidence base. In this article, we review the anatomy, physiology and pathophysiology of the UOS along with the current opinions on investigation and treatment of UOS dysfunction.

Eosinophilic esophagitis in adults, an emerging cause of dysphagia. Description of 9 cases

BACKGROUND

Eosinophilic esophagitis is a rare condition mainly affecting children, although the number of cases reported in adults is on the increase. It is characterized by intense infiltration of eosinophilic leukocytes in the esophageal mucosa, without involvement of other sections of the alimentary canal.

MATERIAL AND METHODS

Over the past year, following the performance of endoscopies and biopsies, our service identified nine patients who were diagnosed with suffering from this disorder. Each patient sought medical help for episodes of long-term, self-limited dysphagia or food impaction in the alimentary canal.

RESULTS

Endoscopy revealed esophageal stenosis in the form of simultaneous contraction rings or regular stenosis. In six cases, the manometric study showed a nonspecific motor disorder of severe intensity affecting the esophageal body, and another patient had a disorder characterized by the presence of simultaneous waves and secondary peristaltic waves in the three thirds of the organ. These disorders are presumably due to eosinophilic infiltration of the muscular layer or ganglionar cells of the esophagus, and account for symptoms in these patients. Although the etiopathogenesis of this illness is uncertain, it is clearly an immunoallergic manifestation.

CONCLUSIONS

As the number of diagnosed cases is on the increase, eosinophilic esophagitis is in adults a specific entity within the differential diagnosis of dysphagia in young males with a history of allergies. Eosiniphilic esophagitis responds in a different number of ways to therapies used. We successfully used fluticasone propionate, a synthetic corticoid applied topically, which proved to be efficient in the treatment of this illness by acting on the pathophysiological basis of the process. It does not have any adverse effects, thus offering advantages over other therapies such as systematic corticoids or endoscopic dilations.

Oropharyngeal dysphagia in polymyositis/dermatomyositis

The nature of the oropharyngeal dysphagia in polymyositis/dermatomyositis (PM/DM) has been investigated by EMG methods. Nineteen patients with PM/DM were studied. The oropharyngeal phase of swallowing was evaluated by the electrophysiological methods measuring the laryngeal relocation time, pharyngeal transit time and the triggering of the pharyngeal phase of swallowing reflex. The EMG of cricopharyngeal muscle of the upper esophageal sphincter was also recorded in 10 patients. The patients have been compared with a group of 22 healthy controls matched with age and gender. Dysphagia limit was also measured for all patients and control subjects. Fourteen out of 19 patients could not swallow 20 ml or less amount of water at one go and divided the bolus into two or more pieces (piecemeal deglutition) in comparison to normal subjects. In PM/DM patients, the triggering of the swallowing reflex for the voluntarily initiated swallow was normal while the pharyngeal phase of swallowing was significantly prolonged. The cricopharyngeal sphincter muscle EMG demonstrated severe abnormalities in halves of the patients investigated. These findings demonstrated the weakness of the striated oropharyngeal muscles. Cricopharyngeal sphincter muscle was affected less frequently and showed either hyperreflexic or hyporeflexic states during swallowing. It is concluded that the pharyngeal stage of oropharyngeal swallowing is mainly involved in patients with PM/DM.

[The management of dysphagia -- part 2: therapy]

In the first part of the article we described diagnostic methods aiming to resolve the individual underlying pathomechanism of chronic swallowing disorders (dysphagia). From these, we deducted different therapeutic measures that can be applied either alone or in combination. Weakening of the upper esophageal sphincter with botulinum toxin is reserved for patients with structural stenosis or a relative hyperfunction of the sphincter. It can be tried to use the "Passy-Muir Valve" for tracheostomized patients that aspirate. Most cases benefit from a therapy that consists of specific exercises. "Restitution" relies on exercises to practice new movement patterns as well as improvement of muscle strength. "Compensation" is based on exercises to counteract structural and/or functional deficits. Through "adaptation" residual, therapy resistant disease can be alleviated through dietary planning of consistency, temperature, and nutrient content of food. In many cases it is necessary to combine "restitution", "compensation", and "adaptation".

Airway Protection: Evaluation with Videofluoroscopy

During videofluoroscopic swallowing studies performed in the lateral view, the arytenoid cartilages are seen to elevate and approximate the down-folding epiglottis, effectively closing the supraglottic larynx and protecting the airway. This mechanism may be incomplete or delayed in patients complaining of dysphagia and may lead to "penetration" of bolus material into the airway. This study evaluates the timing of supraglottic closure relative to the arrival of the bolus at the upper esophageal sphincter in 60 young control subjects and in 63 elderly control subjects without dysphagia. Event timing was measured in 0.01-s intervals from videofluoroscopic studies for two liquid bolus size categories. Results of the analysis revealed that, in most individuals, the arytenoid cartilages approximate the epiglottis prior to the arrival of the bolus at the upper esophageal sphincter. However, in both bolus size categories, there were individuals who achieved complete supraglottic closure after the bolus had arrived at the sphincter, but never greater than 0.1 s later. No delay in the timing of supraglottic closure relative to bolus arrival at the sphincter was found in the elderly subject group compared with the young subject group. The information from this study has allowed us to objectively determine if supraglottic closure timing is delayed in patients with dysphagia and to address any delay with strategies and exercises designed specifically to correct the delay. A case study is presented to illustrate the clinical significance of this study.