Three-dimensional manometry of the upper esophageal sphincter in swallowing and nonswallowing tasks

Abstract

Objectives/hypothesis: High-resolution manometry (HRM) is useful in identifying disordered swallowing patterns and quantifying pharyngeal and upper esophageal sphincter (UES) physiology. HRM is limited by unidirectional sensors and circumferential averaging of pressures, resulting in an imperfect understanding of pressure from asymmetrical pharyngeal anatomy. This study aims to evaluate UES pressures simultaneously from different axial directions.

Study design: Case series.

Methods: Three-dimensional HRM was performed on eight healthy subjects to evaluate circumferential UES pressure patterns at rest, during the Valsalva maneuver, and during water swallowing.

Results: Multivariate analysis of the variance revealed a significant main effect of circumferential direction on pressure while at rest (P < .001); pressure was greater in the anterior and posterior portions of the UES versus lateral portions. A significant main effect of direction on pressure was not found during the Valsalva maneuver. During swallowing of a 5-mL water bolus, circumferential direction had a significant main effect on pressure immediately before UES pressure dropped (P = .001), while the UES was open (P = .01) and at UES closure (P < .001). There was also a significant main effect of sensor level along the vertical axis on pressure immediately before UES pressure dropped (P = .032) and at UES closure (P < .001). Anterior and posterior pressures were again greater than lateral pressures at all swallowing events.

Conclusions: These results confirm that UES pressures vary significantly based on their circumferential origin, with the majority of the total pressure generated in anterior and posterior regions. Improved understanding of UES pressure in a three-dimensional space can lead to more sophisticated treatments for pharyngeal and UES dysfunction.

Level of evidence: 4. Laryngoscope, 126:2539-2545, 2016.

Keywords: Deglutition; Valsalva maneuver; high-resolution manometry; upper esophageal sphincter.

© 2016 The Authors. The Laryngoscope published by Wiley Periodicals, Inc. on behalf of American Laryngological, Rhinological and Otological Society Inc, “The Triological Society” and American Laryngological Association (ALA).

Figures

Figure 1

Diagram of a single pressure sensor from a three‐dimensional (3D) high‐resolution manometry catheter. Eight individual sensors are located around the perimeter of the catheter, and each one outputs a unique pressure trace. To simplify results, sensors were grouped by averaging pairs of pressure traces into four regions: anterior, posterior, left, and right. Twelve of these 3D sensor levels are included along the length of the catheter.

Figure 2

Position of the three‐dimensional (3D) catheter within the pharynx and superior esophagus at rest and midswallow. 3D sensors were positioned within the upper esophageal sphincter region, involving the cricopharyngeus (CP) muscle. During swallowing, the CP muscle elevates relative to the catheter due to laryngeal movement.

Figure 3

Pressure trace from a typical swallow of 5 mL of water at a single sensor level. Directional sensors around the perimeter of the catheter were averaged into a single pressure trace (solid grey line) to identify landmarks typical of a traditional high‐resolution manometry (HRM) pressure recording. These landmarks were then analyzed with the three‐dimensional HRM system to identify inherent asymmetries within the upper esophageal sphincter during a swallow, demonstrated by the inset polar graphs showing pressure values from the original eight circumferential sensors before averaging into pairs.

Figure 4

Average upper esophageal sphincter (UES) pressures at baseline for anterior, posterior, left, and right directions. Sensor levels 1, 2, and 3 represent the superior, middle, and inferior portions of the UES, respectively. Multivariate analysis of the variance indicated a significant main effect for sensor direction on pressure, where anterior and posterior positions were found to have significantly higher pressures compared to left and right positions. Error bars indicate standard error of the mean. **P < .01. ***P < .001.

Figure 5

Average upper esophageal sphincter (UES) pressures during the Valsalva maneuver for anterior, posterior, left, and right directions. Sensor levels 1, 2, and 3 represent the superior, middle, and inferior portions of the UES, respectively. No significant main effects were found for direction or sensor level on pressure. Error bars indicate standard error of the mean.

Figure 6

Average upper esophageal sphincter (UES) pressures during a swallow of 5 mL of water for anterior, posterior, left, and right directions. Sensor levels 1 to 5 correspond to the superior‐most to inferior‐most portions of the UES, respectively. (A) Pre‐UES opening pressures. Significant differences between sensor levels were found. A main effect of direction on pressure was also found, with significant differences occurring between anterior and posterior versus left and right directions. (B) UES pressures during the nadir period. A main effect for direction on pressure was still found, with significant differences occurring between anterior and posterior versus left and right directions. (C) UES pressures upon UES closure after bolus passage. Significant differences between sensor levels and between directions were found, with significant differences occurring between anterior and posterior versus left and right directions. Error bars indicate standard error of the mean. *P < .05. **P < .01. ***P < .001.