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Background: Upper oesophageal sphincter (UES) serves as an important anatomical and functional landmark during swallowing. However, the precise UES location before and during swallowing has not been well established., Objective: This study aimed to determine upper oesophageal sphincter (UES) location and displacement during swallowing accounting for sex, age, and height in healthy adults using 320-row area detector computed tomography (320-ADCT)., Methods: Ninety-four healthy adults (43 males; 22-90 years) underwent 320-ADCT scanning while swallowing one trial of 10 mL honey thick barium. UES location at bolus hold and at maximum displacement and vertical displacement during swallowing were identified using the coordinates and the section classification of vertebrae (VERT scale). The differences and correlations of UES location and distance in terms of sex, age, and height were analysed using Mann-Whitney U test and Spearman's correlation coefficient., Results: UES locations at bolus hold and at maximum displacement were significantly lower and UES vertical displacement was significantly larger in males than in females (p < .001). UES location at bolus hold became lower with increasing age (r = -.312, p = .002), but the negative correlation was low at maximum displacement (r = -.230, p = .026), resulting in larger vertical distance with ageing. UES locations showed high negative correlation at bolus hold with height (r = -.715, p < .001), and showed moderate negative correlation at maximum displacement with height (r = -.555, p < .001), although this effect was unclear when analysed by sex., Conclusion: Males showed lower UES location and larger displacement than females. The impact of age was evident with lower location before swallowing and larger displacement during swallowing. Differences observed by sex were not completely explained by using the VERT scale to adjust for height., (© 2024 John Wiley & Sons Ltd.)

Background: Chagas disease causes digestive anatomic and functional changes, including the loss of the myenteric plexus and abnormal esophageal radiologic and manometric findings., Objective: To evaluate the association of abnormal esophageal radiologic findings, cardiac changes, distal esophageal contractions, and complaints of dysphagia and constipation in upper (UES) and lower (LES) esophageal sphincter basal pressure in Chagas disease patients., Methods: The study evaluated 99 patients with Chagas disease and 40 asymptomatic normal volunteers. The patients had normal esophageal radiologic examination (n=61) or esophageal retention without an increase in esophageal diameter (n=38). UES and LES pressure was measured with the rapid pull-through method in a 4-channel water-perfused round catheter. Before manometry, the patients were asked about dysphagia and constipation and submitted to electrocardiography and chest radiography., Results: The amplitude of esophageal distal contraction decreased from controls to chagasic patients with esophageal retention. The proportion of failed and simultaneous contractions increased in patients with abnormal radiologic examination (P<0.01). There were no significant differences in UES and LES pressure between the groups. UES pressure was similar between Chagas disease patients with cardiomegaly (n=27, 126.5±62.7 mmHg) and those without it (n=72, 144.2±51.6 mmHg, P=0.26). Patients with constipation had lower LES pressure (n=23, 34.7±20.3 mmHg) than those without it (n=76, 42.9±20.5 mmHg, P<0.03)., Conclusion: Chagas disease patients with absent or mild esophageal radiologic involvement had no significant changes in UES and LES basal pressure. Constipation complaints are associated with decreased LES basal pressure.

Study Design: A retrospective study., Objective: To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES)., Summary of Background Data: There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES., Materials and Methods: We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter 2 weeks postoperatively /US parameter at baseline ) and the existence of significant correlations with change in the EAT-10 score (=EAT-10 2 weeks postoperatively -EAT-10 at baseline ). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups., Results: A total of 46 patients (mean age, 61.3 y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group., Conclusion: Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Cricopharyngeal dysfunction is a common potential cause of pharyngoesophageal dysphagia. Contextual factors (i.e., personal demographics and bolus properties) appear to impact upper esophageal sphincter (UES) function but have yet to be assessed collectively in a large-scale study using psychometrically sound swallow task procedures. Using a standardized and validated videofluoroscopic approach, we investigated the collective effects of age, sex, and swallow task on UES opening duration (UESOdur) and UES maximum distension (UESmax) in a large sample of healthy adults., Methods: UESOdur and UESmax data were analyzed from existing videofluoroscopic images of 195 healthy adults (21-89 years old) across seven swallow tasks (thin liquid to viscous liquids, puree, and a solid). Generalized estimating equation modeling captured the effects of the aforementioned contextual factors (α = 0.05)., Results: UESOdur significantly increased with age, while UESmax had an inverse relationship. Females had significantly wider UESmax. UESOdur of 5 mL thin liquid was significantly shorter than all other liquid swallow tasks, while solid had an inverse effect. Compared to 5 mL thin liquid, all other swallow tasks resulted in significantly wider UESmax. Mildly and moderately thick liquid significantly increased UESOdur when isolating viscosity. UESmax was significantly wider with mildly and moderately thick liquid and puree than thin liquid. When isolating volume, cup sip thin liquid increased both measures significantly relative to 5 mL., Conclusion: Age, sex, and swallow task can influence the normal timing and extent of UES movement. These collective effects contribute to normal variability in UES function and should be considered for clinical decision-making., Level of Evidence: 4 Laryngoscope, 134:2306-2315, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: It is essential that clinicians have evidence-based benchmarks to support accurate diagnosis and clinical decision making. Recent studies report poor reliability for diagnostic judgments and identifying mechanisms of impairment from videofluoroscopy (VFSS). Establishing VFSS reference values for healthy swallowing would help resolve such discrepancies. Steele et al. (2019) released preliminary reference data for quantitative VFSS measures in healthy adults aged < 60 years. Here, we extend that work to provide reference percentiles for VFSS measures across a larger age span., Method: Data for 16 VFSS parameters were collected from 78 healthy adults aged 21-82 years (39 male). Participants swallowed three comfortable sips each of thin, slightly, mildly, moderately, and extremely thick barium (20% w/v). VFSS recordings were analyzed in duplicate by trained raters, blind to participant and task, using the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) Method. Reference percentiles (p2.5, 5, 25, 50, 75, 95, and 97.5) were determined as per Clinical and Laboratory Standards Institute EP28-A3c guidelines., Results: We present VFSS reference percentile tables, by consistency, for (a) timing parameters (swallow reaction time; the hyoid burst-to-upper esophageal sphincter (UES)-opening interval; UES opening duration; time-to-laryngeal vestibule closure (LVC); and LVC duration) and (b) anatomically scaled pixel-based measures of maximum UES diameter, pharyngeal area at maximum pharyngeal constriction and rest, residue (vallecular, pyriform, other pharyngeal locations, total), and hyoid kinematics (X, Y, XY coordinates of peak position; speed). Clinical decision limits are proposed to demarcate atypical values of potential clinical concern., Conclusion: These updated reference percentiles and proposed clinical decision limits are intended to support interpretation and reliability for VFSS assessment data., Supplemental Material: https://doi.org/10.23641/asha.24043041.

This study aims to compare the 2 methods of upper esophageal sphincter (UES) relaxation measurement and determine which method has better diagnostic value in UES relaxation impairment The study included 140 patients with pharyngeal dysphagia who underwent both videofluoroscopic swallow study (VFSS) and high-resolution manometry (HRM). Feeding method was determined to oral or non-oral feeding based on the severity of dysphagia; 103 patients were in oral feeding group and 37 were in non-oral feeding group. UES relaxation duration was measured using VFSS and HRM, respectively. Receiver-operating characteristic curve analysis was conducted to validate the UES relaxation duration in determination of feeding method. UES relaxation duration was more decreased in non-oral feeding group than in oral feeding group on both VFSS and HRM. Receiver-operating characteristic analysis revealed that the optimal cutoff value of UES relaxation duration to determine feeding method (oral or non-oral feeding) was 0.42 seconds on VFSS and 0.44 seconds on HRM. The sensitivity for feeding method was higher in VFSS than HRM (83.5% vs 70.9%), while the specificity was higher in HRM than VFSS (48.6% vs 54.1%). VFSS and HRM have complementary ability in evaluating UES relaxation duration in patients with oropharyngeal dysphagia., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Understanding bolus flow patterns in swallowing (rheology, the study of flow) is fundamental to assessment and treatment of dysphagia. These patterns are complex and poorly understood. A liquid swallow is typically biphasic, including air, so the actual bolus has both liquid and gas phases. We report a novel observation of annular two-phase flow (a ring of liquid around a core of air) as thin liquids passed through the upper esophageal sphincter (UES). Dynamic CT was performed on 27 healthy asymptomatic volunteers swallowing liquid barium in a semi-reclining position. Each subject swallowed 3, 10, and 20 ml of either thin (14 subjects) or thick liquid (13 subjects). Sagittal and axial images were analyzed. Flow patterns in the UES were assessed on cross-sectional images. Annular flow was seen in the majority of subjects with thin liquid but few with thick liquid swallows. The percentage of Annular flow during UES opening was 3 ml 58%, 10 ml 58%, 20 ml 56% in thin and 3 ml 0%, 10 ml 4%, 20 ml 1% in thick. Annular flow was usually observed from the second or third frames after onset of UES opening. The other pattern, Plug flow was seldom seen with thin but was typical with thick liquid swallows. Annular flow was the most common pattern for thin liquids (but not thick liquids) passing through the UES. Annular flow has been defined as a liquid continuum adjacent to the channel wall with a gas continuum (core) in the center of the channel. The two regions are demarcated by a gas-liquid interface. Annular flow is typical for two-phase gas-liquid flow in a vertical or inclined channel. It results from the interaction of viscosity with cohesive and adhesive forces in the two phases. We infer that the difference in flow pattern between thin liquid-air and thick liquid-air boluses resulted from the differing magnitudes of viscous forces., (© 2021. The Author(s).)

Cricopharyngeal dysfunction, especially cricopharyngeal achalasia, is a common cause of dysphagia, while patients with brainstem stroke and medullary damage have a relatively high risk of cricopharyngeal achalasia. The aim of this article was to introduce an improved method of CT-guided method of injecting botulinum toxin A into the cricopharyngeus muscle using esophageal balloon radiography, and to assess the effect of the botulinum toxin A injection on swallowing performance. Seventeen patients with cricopharyngeal dysphagia were treated with botulinum toxin A injection using esophageal balloon radiography combined with CT guidance to the cricopharyngeal muscle. Primary outcome measures, including Functional Oral Intake Scale and Deglutition Handicap Index, were performed at baseline, 1 week, and 1 month after treatment. The Levene method was used to test the homogeneity of variance, and the Kruskal-Wallis test was used to compare the scores between the timepoints. Botulinum toxin A injection resulted in obvious improvement in 15 patients (88.2%) and no improvement in two patients (11.8%). Compared with the scores prior to treatment, the Functional Oral Intake Scale and Deglutition Handicap Index scores were significantly improved at 1 week (P < 0.001 and P = 0.008, respectively) and 1 month after the treatment (P = 0.001 and P < 0.001, respectively). Thus, CT-guided percutaneous injection of botulinum toxin A is probably a relatively safe, well-tolerated, and viable technique for the treatment of cricopharyngeal dysphagia caused by brainstem injury. Localization with a balloon radiography made the needle guidance easier to visualize.

Competing Interests: Competing interests: None declared.

Purpose: Organ-at-risk (OAR) delineation is a key step in treatment planning but can be time consuming, resource intensive, subject to variability, and dependent on anatomical knowledge. We studied deep learning (DL) for automated delineation of multiple OARs; in addition to geometric evaluation, the dosimetric impact of using DL contours for treatment planning was investigated., Methods and Materials: The following OARs were delineated with DL developed in-house: both submandibular and parotid glands, larynx, cricopharynx, pharyngeal constrictor muscle (PCM), upper esophageal sphincter, brain stem, oral cavity, and esophagus. DL contours were benchmarked against the manual delineation (MD) clinical contours using the Sørensen-Dice similarity coefficient. Automated knowledge-based treatment plans were used. The mean dose to the manually delineated OAR structures was reported for the MD and DL plans., Results: DL delineation of all OARs took <10 seconds per patient. For 7 of 11 OARs, the average Sørensen-Dice similarity coefficient was good (0.78-0.83). However, performance was lower for the esophagus (0.60), brainstem (0.64), PCM (0.68), and cricopharynx (0.73), often because of variations in MD. Although the average dose was statistically significantly higher in the DL plans for the inferior PCM (1.4 Gy) and esophagus (2.2 Gy), these average differences were not clinically significant. Dose to 28 of 209 (13.4%) and 7 of 209 (3.3%) OARs was >2 Gy higher and >2 Gy lower, respectively, in the DL plans., Conclusions: DL-based segmentation for head and neck OARs is fast; for most organs and most patients, it performs sufficiently well for treatment-planning purposes. It has the potential to increase efficiency and facilitate online adaptive radiation therapy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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.

Previous research has established that a great deal of variation exists in the temporal sequence of swallowing events for healthy adults. Yet, the impact of aging on swallow event sequence is not well understood. Kendall et al. (Dysphagia 18(2):85-91, 2003) suggested there are 4 obligatory paired-event sequences in swallowing. We directly compared adherence to these sequences, as well as event latencies, and quantified the percentage of unique sequences in two samples of healthy adults: young (< 45) and old (> 65). The 8 swallowing events that contribute to the sequences were reliably identified from videofluoroscopy in a sample of 23 healthy seniors (10 male, mean age 74.7) and 20 healthy young adults (10 male, mean age 31.5) with no evidence of penetration-aspiration or post-swallow residue. Chi-square analyses compared the proportions of obligatory pairs and unique sequences by age group. Compared to the older subjects, younger subjects had significantly lower adherence to two obligatory sequences: Upper Esophageal Sphincter (UES) opening occurs before (or simultaneous with) the bolus arriving at the UES and UES maximum distention occurs before maximum pharyngeal constriction. The associated latencies were significantly different between age groups as well. Further, significantly fewer unique swallow sequences were observed in the older group (61%) compared with the young (82%) (χ 2  = 31.8; p < 0.001). Our findings suggest that paired swallow event sequences may not be robust across the age continuum and that variation in swallow sequences appears to decrease with aging. These findings provide normative references for comparisons to older individuals with dysphagia.

Objectives: To assess the effect of age on swallowing with a focus on structural movement, timing and duration of physiologic events., Design: Cross-sectional study., Setting: Tertiary University Medical Center., Participants: Community-dwelling adults (3 age groups): younger 20 to 39 (n = 23; mean 32 ± 5), middle-aged 40 to 59 (n = 29; mean 49 ± 5) and older adults 60 to 74 (n = 15; mean 67 ± 5)., Intervention: One 10-mL honey-thick liquid (1700 mPa) swallow was studied using 320-row area detector computed tomography scanning., Measurements: Kinematic analysis was performed for each swallow including temporal characteristics and structural movements., Results: The duration of velopharyngeal closure and laryngeal closure (including epiglottis inversion, laryngeal vestibule closure, true vocal cord closure) was significantly different by age group (P = 0.002, P < 0.001, P = 0.017, P = 0.041, respectively). Events were prolonged in older adults compared with middle-aged and younger adults. The pharyngeal phase was longer for older adults. Velopharyngeal closure started earlier and continued until after complete UES opening. In younger adults, velopharyngeal and laryngeal opening occurred before complete UES opening. No differences were found in bolus movement through the oropharynx by group., Conclusion: During swallowing, older adults had a longer pharyngeal phase characterised by prolonged velopharyngeal and laryngeal closure. This difference may be a protective mechanism to compensate for age-related weakness. A better understanding of the mechanism by which this adaptation occurs is needed to tailor rehabilitation strategies and to maintain swallowing function during the lifespan., (© 2018 John Wiley & Sons Ltd.)

Introduction and Aims: Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP ® ) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection., Methods: EndoFLIP ® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12., Results: Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain., Conclusions: EndoFLIP ® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus., (Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

The upper esophageal sphincter (UES) has various important functions, such as protection of the airway from aspiration and conduct of bolus into esophagus, which are controlled by complex neuronal mechanisms. The functions will be affected when there is malfunction of the UES due to various etiologies. Here we present an 80-year-old male with non-progressive dysphagia and patulous UES incidentally found on esophagoduodenoscopy. There are no documented cases of idiopathic patulous UES in literature. Endoscopists must be aware of this rare condition while evaluating a patient presenting with oropharyngeal dysphagia.

This study investigated the effects of three different volumes of honey-thick liquid on the temporal characteristics of swallowing. Twenty-six healthy subjects (15 males, 11 females) underwent 320-row area detector CT scan while swallowing 3, 10 and 20 mL of honey-thick liquid barium. Three-dimensional images were created at 10 images/s. Kinematic events involving six structures (velopharynx, hyoid bone, epiglottis, laryngeal vestibule (LV), true vocal cords (TVC), upper esophageal sphincter (UES)) and timing of bolus movement were timed using frame by frame analysis. The overall sequence of events did not differ across three volumes; however, increasing bolus volume significantly changed the onset and termination of events. The bolus head reached to pharynx and esophagus earlier and the duration of bolus passing through UES was significantly longer in 10 and 20 mL compared to 3 mL (P < .05). Consequently, the onset of UES opening was significantly earlier with increased volume (P < .05). LV and TVC closure occurred later in 20 mL compared to 3 mL (P < .05). These changes in motion of pharynx and larynx appeared to promote swallow safety by preventing aspiration, suggesting that anatomical structure movements adapt in response to bolus volume. Our findings also suggest that the pharyngeal swallow behaviours may be modified by afferents in the oral cavity. The three-dimensional visualization and quantitative measurements provided by 320-ADCT provide essential benchmarks for understanding swallowing, both normal and abnormal., (© 2017 John Wiley & Sons Ltd.)

Objectives/hypothesis: Quantitative measures of swallowing function may improve the reliability and accuracy of modified barium swallow (MBS) study interpretation. Quantitative study analysis has not been widely instituted, however, secondary to concerns about the time required to make measures and a lack of research demonstrating impact on MBS interpretation. This study compares the accuracy of the penetration/aspiration (PEN/ASP) scale (an observational visual-perceptual assessment tool) to quantitative measures of airway closure timing relative to the arrival of the bolus at the upper esophageal sphincter in identifying a failure of airway protection during deglutition., Study Design: Retrospective review of clinical swallowing data from a university-based outpatient clinic., Methods: Swallowing data from 426 patients were reviewed. Patients with normal PEN/ASP scores were identified, and the results of quantitative airway closure timing measures for three liquid bolus sizes were evaluated. The incidence of significant airway closure delay with and without a normal PEN/ASP score was determined. Inter-rater reliability for the quantitative measures was calculated., Results: In patients with a normal PEN/ASP score, 33% demonstrated a delay in airway closure on at least one swallow during the MBS study. There was no correlation between PEN/ASP score and airway closure delay. Inter-rater reliability for the quantitative measure of airway closure timing was nearly perfect (intraclass correlation coefficient = 0.973)., Conclusions: The use of quantitative measures of swallowing function, in conjunction with traditional visual perceptual methods of MBS study interpretation, improves the identification of airway closure delay, and hence, potential aspiration risk, even when no penetration or aspiration is apparent on the MBS study., Level of Evidence: 4. Laryngoscope, 127:2314-2318, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

This study aimed to evaluate the effect of effortful swallow combined with surface electrical stimulation as a form of resistance training on pharyngeal constriction function in post-stroke patients with dysphagia. Nineteen patients post-stroke with dysphagia received 20 min effortful swallow training with resistive electrical stimulation for 5 days per week for 4 weeks. Electrical stimulation was applied on the infrahyoid area as resistance against hyoid elevation. Stimulation intensity was adjusted daily up to the maximum tolerable level of the participant. Blinded biomechanical measurements of the extent of hyoid elevation were taken and the pharyngeal constriction ratio (PCR) determined after training. The change of the PCR and the relationship between hyoid elevation and the PCR were evaluated. The post-training PCR was significantly decreased compared to pre-training PCR (P < 0·05). There was a high inverse correlation between the hyoid elevation and the PCR (r = -1·992, P < 0·05). Effortful swallow with resistive electrical stimulation training increases pharyngeal constriction. It can be used as a treatment to improve pharyngeal constriction in patients with dysphagia., (© 2017 John Wiley & Sons Ltd.)

Objectives/hypothesis: To determine the association of the electrophysiological activity of the pharyngoesophageal transition with tracheoesophageal speech proficiency in total laryngectomees., Study Design: An observational (nonexperimental) study of the correlation type with a descriptive approach., Methods: Thirty-four individuals (26 males), average age 62.5 years, total laryngectomees rehabilitated with the use of a tracheoesophageal prosthesis, were assessed for tracheoesophageal speech proficiency using an adapted protocol and classified as good, moderate, or poor speakers. Next they were submitted to electromyography of the muscles of the pharyngoesophageal transition with a needle electrode. The area to be examined was located by videofluoroscopy. Electromyographic analysis was characterized as normal, neurogenic injury (moderate to severe, severe, severe to total), myopathic injury, or inconclusive. The Fisher exact test was used to determine the association between the speech proficiency variables and electromyography., Results: in the final rating of tracheoesophageal speech proficiency, most laryngectomees were categorized as moderate (n = 24) and a few as good (n = 3). Electromyography revealed neurogenic injury in all laryngectomees, which was severe in most cases (n = 20), followed by severe to total (n = 10), and moderate to severe injury (n = 4). There was no significant association between he electromyographic analyses of neurogenic injuries and tracheoesophageal speech proficiency., Conclusions: Whether or not the musculature of the pharyngoesophageal transition of tracheoesophageal speakers had a preserved motor unit, did not prevent voice acquisition and was not associated with tracheoesophageal speech proficiency. However, further studies are needed in this area., Level of Evidence: 4. Laryngoscope, 127:1369-1375, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Achalasia may present in a non-advanced or an advanced (end stage) stage based on the degree of esophageal dilatation. Manometric parameters and esophageal caliber may be prognostic for the outcome of treatment. The correlation between manometry and disease stage has not been yet fully studied. This study aims to describe high-resolution manometry findings in patients with achalasia and massive dilated megaesophagus. Eighteen patients (mean age 61 years, 55% females) with achalasia and massive dilated megaesophagus, as defined by a maximum esophageal dilatation >10 cm at the barium esophagram, were studied. Achalasia was considered secondary to Chagas' disease in 14 (78%) of the patients and idiopathic in the remaining. All patients underwent high-resolution manometry. Upper esophageal sphincter was hypotonic and had impaired relaxation in the majority of patients. Aperistalsis was seen in all patients with an equal distribution of Chicago type I and type II. No type III was noticed. Lower esophageal sphincter did not have a characteristic manometric pattern. In 50% of the cases, the manometry catheter was not able to reach the stomach. Our results did not show a manometric pattern in patients with achalasia and massive dilated esophagus., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: Cricopharyngeal achalasia (CPA) is a rare clinical condition that is characterized by aspiration, choking, and nasopharyngeal regurgitation. The aim of this study is to introduce the outcomes of dilatation alone in children with CPA., Patients and Method: After the evaluation of upper esophageal sphincter with endoscopy, dilatation was performed. All patients underwent videofluoroscopic evaluation and swallowing therapy after the surgical procedure. A retrospective chart review was performed in children with CPA., Results: Thirty children who were videofluoroscopically proven to have CPA were included in the study. Their age range was 15days-7years (median 11months). Twenty-one of them were neurologically impaired. Two children were lost to follow-up. Nineteen patients (68%) had a total resolution of CPA and were symptom-free with 1-6 dilatations (median 2). Three of the children (11%) who were severely neurologically impaired had resistant CPA. Three children (11%) treated recently with short follow-up were added to the group. Their VFS evaluations demonstrated improvement, thus we accepted their result as successful. There were two perforations in the series. Three patients died; one 2-month-old (2500g) baby who was accepted from the intensive care unit passed away on postoperative on the 7th day. Two other babies who were unresponsive to dilatation therapy died on follow-up., Conclusion: Dilatation can be a safe and effective method on children who are correctly diagnosed to have CPA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Swallowing function progressively deteriorates with advancing age, leading to high morbidity and mortality in the elderly population. To establish strategies for treatment of age-related swallowing disorders, the mechanisms of such disorders must be quantitatively clarified. The purpose of this paper was to elucidate the swallowing function of healthy elderly individuals by comparison with that of young adults by videofluorographic and manometric examinations., Methods: The subjects were 70 healthy volunteers with no history of diseases affecting swallowing function. They were classified into three groups according to age: the young adult group (21-32 years of age, n=8), early elderly group (60-69 years of age, n=39), and late elderly group (70-83 years of age, n=23). Their swallowing functions were quantitatively evaluated by videofluorographic and manometric studies., Results: Videofluorographic examination showed no significant differences in the moving distances of the hyoid bone and larynx in the pharyngeal swallowing phase between the young and elderly groups. The pharyngeal transit time (PTT) of the bolus in the elderly group was longer and the percentage of laryngeal elevation (%LE) was lower than those in the young group. Manometric examination revealed higher hypopharyngeal swallowing pressure in the elderly groups. The traveling velocity of the swallowing pressure in the upper esophageal sphincter (UES) region and the UES relaxation time decreased with aging. Reduction of the UES pressure during the pharyngeal swallowing phase was insufficient in 15.4% of the early elderly group and 30.4% of the late elderly group. Additionally, the UES zone was broadened in 20.5% of the early elderly group and 26.1% of the late elderly group., Conclusion: Videofluorographic and manometric examinations quantitatively demonstrated that the swallowing reflex was delayed and UES opening was impaired by aging. UES dysfunction may develop secondary by increased tonicity and decreased elasticity of the cricopharyngeal muscle. Stimulation of oropharyngeal sensory function and exercising the laryngeal levator muscles may be effective for age-related swallowing disorders., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The aim of this study was to find whether there are manometric pharyngeal changes that may have diagnostic and prognostic relevance in the amyotrophic lateral sclerosis (ALS) patient who does not show changes in contrast-medium oropharyngeal transit in a videofluoroscopic swallowing study. Ten ALS patients, with an ALS Severity Scale Score of at least 7, no need to change dietary habit, no aspiration and/or penetration, and no other changes in contrast-medium oropharyngeal transit, were collected from our institution's database of videofluoromanometric swallowing studies. They were included in the study together with a group of 11 healthy volunteers. For each subject, 12 manometric items-7 for the pharyngeal phase and 5 for UES functionality-were evaluated. Statistically significant differences between the ALS patients and the healthy volunteers were found for pharyngeal contraction time of the upper region (median = 1,120, range = 880-1,420 vs. median = 970, range = 800-1,140), pharyngeal contraction time of the intermediate region (median = 1140, range = 960-1,360 vs. median = 770, range = 280-1,180), pharyngeal contraction time of the lower region (median = 1,320, range = 920-1,760 vs. median = 800, range = 620-1,780), and residual pressure after the relaxation of the UES (median = 2.2, range = -20.2 to 27.8 vs. median = -5.7, range = -2.9 to 8.4). A videofluoromanometric swallowing study may show an increase in the pharyngeal contraction time and in residual pressure after relaxation of the UES in ALS patients without videofluoroscopic changes in contrast-medium oropharyngeal transit.

Plummer-Vinson syndrome manifests as cervical dysphagia, iron deficiency anemia, an upper esophageal web, and atrophic glossitis. The cause of the esophageal web is thought to be iron deficiency anemia; however, the cause of Plummer-Vinson syndrome has not been established. Crohn's disease is usually accompanied by malnutrition and iron deficiency anemia; however, no case of concomitant Crohn's disease and Plummer-Vinson syndrome with aggravated malnutrition and anemia has been previously reported. Here, we report on a rare case of Plummer-Vinson syndrome in a Crohn's disease patient, which caused malnutrition and constipation.

This study builds on previous work by Kendall, Leonard, and McKenzie, which investigated event sequence variability for 12 paired events during swallowing by healthy volunteers. They identified four event pairs that always occurred in a stereotyped order and a most common occurring overall order of events during swallowing. In the current study, we investigated overall event sequencing and the same four paired events in a sample of swallows by healthy young (under 45 years old) volunteers. Data were collected during a 16-swallow lateral videofluoroscopy protocol, which included manipulations of bolus volume, barium density, bolus viscosity, and swallow cueing. Our results agreed with previous findings that variable event sequencing is found in healthy swallowing, and, in regard to obligatory sequencing of two paired events, movement of the arytenoids toward the base of the epiglottis begins prior to upper esophageal sphincter (UES) opening and maximum hyolaryngeal approximation occurs after UES opening. However, our data failed to replicate the previous findings that there is obligatory sequencing of maximum pharyngeal constriction after maximal UES distension and the UES opens before bolus arrival at the UES. The most common observed overall event sequence reported by Kendall et al. was observed in only 4/293 swallows in our dataset. Manipulations of bolus volume, bolus viscosity, barium concentration, swallow cueing, and swallow repetitions could not completely account for the differences observed between the two studies.

Objectives: The purpose of this study was to develop a methodology and standard settings for ultrasound study of the upper esophageal sphincter (UES) during swallowing., Material and Methods: This was a prospective study of 25 healthy volunteers (15 women and 10 men) aged 20 to 56 years. Neck ultrasonography was performed as each volunteer swallowed 10 mL of water three times. The parameters studied were: diameter of the closed UES; diameter of the open UES; anterior and lateral displacement (measured in cm) of the UES as the water bolus flowed through it; duration of UES opening; and average duration of UES displacement (measured in ms). Student's t tests for paired and unpaired samples were applied for the statistical analysis., Results: The mean diameter of the closed UES was 0.78 ± 0.13 cm, while the mean duration of opening was 415 ± 57.66 ms and the mean duration of displacement was 937 ± 120.98 ms. Maximum anterior and lateral displacement of the UES was 0.42 ± 0.12 cm and 0.35 ± 0.18 cm, respectively. There was a significant difference between men and women for lateral displacement of the UES (P=0.04)., Conclusion: This study established standards for ultrasound study of the UES during swallowing, using a non-invasive readily accessible method that may be useful for assessing swallowing disorders involving the UES (Zenker's diverticulum, fibrosis, stricture)., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus., (© 2013 New York Academy of Sciences.)

Background: The term Cricopharyngeal Bar (CPB) describes a posterior indentation at the pharyngoesophageal junction which becomes apparent during a Video Fluoroscopic Swallowing Exam (VFSE, modified barium swallow). The eff ect CPBs might have on swallowing is still under debate. This paper intends to review appearance, eff ects and the associated therapy of CPBs., Method: For this systematic review a selective literature research in PubMed has been carried out., Results: CPBs are usually diagnosed during VFSE. As VFSEs are mostly carried out in dysphagic patients, CBPs were also associated with dysphagia. Even though, CPBs are often related to dysphagia, they do also appear in patients without dysphagia. Therefore, the appearance of a CBP does not automatically represent the cause of dysphagic symptoms. Its impact on swallowing might, however, depend on the dimension of the protrusion as well as the weakening and dysfunction of the inferior pharyngeal constrictor muscle., Discussion: CBPs often present as an incidental finding during a modified barium swallow. A relation to dysphagia can only be assumed for severe CPBs. Therapy options include cricopharyngeal myotomy or esophago-gastro endoscopy using either bougies or balloons., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives/hypothesis: Prolonged obstruction at the level of the lower esophageal sphincter is associated with a dilated, poorly contractile esophagus. The association between prolonged obstruction at the level of the upper esophageal sphincter (UES) and dilation and diminished contractility of the pharynx is uncertain. The purpose of this investigation was to evaluate the association between prolonged obstruction at the level of the UES and dilation and diminished contractility of the pharynx., Study Design: Case-control study., Methods: The fluoroscopic swallow studies of all persons with cricopharyngeus muscle dysfunction (CPD) diagnosed between January 1, 2006 and December 31, 2008 were retrospectively reviewed from a clinical database. Three categories of CPD were defined: nonobstructing cricopharyngeal bars (CPBs), obstructing CPBs, and Zenker diverticulum (ZD). The primary outcome measure was the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength on fluoroscopy. Secondary outcome measures included pharyngeal area in the lateral fluoroscopic view and UES opening. The outcome measures were compared between groups and to a cohort of nondysphagic age- and gender-matched controls with the analysis of variance., Results: A total of 100 fluoroscopic swallow studies were evaluated. The mean age (+ or -standard deviation) of the cohort was 70 years (+ or -10 years). Thirty-six percent were female. The mean PCR progressively increased, indicating diminishing pharyngeal strength, from the normal (0.08), to the nonobstructing CPB (0.13), to the obstructing CPB (0.22), to the ZD group (0.28) (P < .001 with trend for linearity). There was a linear increase in pharyngeal area from the normal (8.75 cm(2)) to the nonobstructing CPB (10.00 cm(2)), to the obstructing CPB (10.46 cm(2)), to the ZD group (11.82 cm(2)) (P < .01 with trend for linearity)., Conclusions: The data suggest that there is an association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of the pharynx. Laryngoscope, 2010.

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.

Objective: To determine radiographically the anatomic length difference between the nasal and oral aerodigestive tracts and to clarify gaps in the literature regarding standardized landmark measurements and documentation techniques in transnasal esophagoscopy, as opposed to traditional transoral esophagoscopy., Study Design: This is a prospective radiographic cohort study., Methods: Digital computerized tomography measurement techniques were used to determine the difference in length between the nasal and oral aerodigestive tracts. Using sagittal plane images from consecutive patients, the mean nares-cricoid (NC) distance, upper incisor-cricoid (IC) distance, and their mean differences were determined. Male, female, and overall distances and differences were calculated. Standard deviations, 95% confidence intervals, and 90% prediction intervals were also calculated. Mean difference data were applied to reported standard oral esophagoscopy landmark measurements to convert to standard landmark measurements from the nares., Results: Overall mean NC and IC distances were 175.4 mm and 147.5 mm, respectively. For males, these mean distances were 185.5 mm and 155.0 mm, respectively. For females, these mean distances were 165.3 mm and 140.0 mm, respectively. Overall mean NC to IC difference was 27.9 mm. The mean NC to IC difference for males and females was 30.5 mm and 25.2 mm, respectively., Conclusions: Historically, landmark and report measurements in esophagoscopy have been measured and standardized from the upper incisor. This study demonstrates and clarifies the inherent anatomic length difference of the nasal and oral aerodigestive tracts and the resultant documentation dilemma produced by transnasal esophagoscopy techniques. These data provide easy conversion of esophagoscopy measurements reported from the incisors or nares, providing better communication between endoscopists of different disciplines and techniques.

Purpose: To examine the effects of verbal cuing to initiate swallowing on bolus flow measures in healthy adults., Method: Videofluoroscopic examinations were completed in 12 healthy older adults (median age=69 years) as they swallowed 5 ml of self-administered liquid barium in 2 conditions: verbally cued and noncued swallows. In the cued condition, participants held the liquid in their mouths until instructed to swallow. In the noncued condition, participants swallowed in their usual manner., Results: Verbal cue affected bolus position at onset of timing measures, thereby influencing duration. The bolus was positioned more posterior in the oral cavity at onset of oral transit for cued as compared with noncued swallows. The leading edge of the bolus at onset of the pharyngeal swallow was more superior in the pharynx for cued as compared with noncued swallows. Durations of the cued swallows were significantly shorter than for noncued swallows for all timing measures. Bolus direction scores were not significantly different between conditions., Conclusions: Findings suggest that swallowing is altered by the use of verbal cues to initiate swallowing in healthy adults. Determining whether shorter durations with implementation of verbal cues are evident in individuals with dysphagia and whether effects are beneficial or deleterious requires continued research.

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.

This interpretation corner case, reporting a man with suspicion of ingestion and perforation of the oesophagus by a foreign body, highlights the danger of false appearances on plain radiographs for detection of foreign bodies in the aerodigestive tract. Plain radiographs and CT revealed a needle-shaped calcified object between the cricoid plate and the oesophagus lumen, which turned out to be an abnormal cricoid calcification. There is also a discussion about the role of radiology in the detection of foreign bodies in the aerodigestive tract.

Catheter-based high-frequency intraluminal ultrasound imaging is a powerful tool to study esophageal sensory and motor function and dysfunction in vivo in humans. It can be combined with manometry, pH, and impedance measurement techniques to determine the relationships between different physiologic parameters. High-frequency intraluminal ultrasound imaging has provided a number of important insights regarding the longitudinal muscle function of the esophagus. On the basis of the ultrasound images and intraluminal pressure recordings, it seems that there is synchrony in the timing and the amplitude of contraction between the circular and longitudinal muscle layers. A sustained contraction of the longitudinal muscle layer is temporally related to esophageal chest pain and heartburn. The biomechanics of the esophageal wall and its relationship to sensory and motor function can be studied in humans in vivo by using high-frequency intraluminal ultrasound much more precisely than has previously been possible. Achalasia, diffuse esophageal spasm, and nutcracker esophagus are associated with hypertrophy of circular and longitudinal muscle layers. Finally, high-frequency intraluminal ultrasound imaging is the only technique that can detect reflux-related distention of the esophagus and its role in esophageal symptoms. Future approaches to display and quantify ultrasound image data are discussed. The principles of high-frequency intraluminal ultrasound described here are also applicable to study of the motor and sensory function of the other regions of the gastrointestinal tract.