Oropharyngeal accommodation to swallow volume

doi:10.1053/gast.1996.v111.pm8690194

Gastroenterology

Volume 111, Issue 2, August 1996, Pages 297-306

https://doi.org/10.1053/gast.1996.v111.pm8690194 Get rights and content

Abstract

BACKGROUND & AIMS: The oropharyngeal swallow accommodates a range of bolus volumes with substantial impact on its dynamic radiographic appearance despite being a nearly reflexive sequence. The aim of this study was to analyze the mechanism of volume accommodation. METHODS: Coordination of the glossopalatal junction, velopharyngeal junction, laryngeal vestibule, and upper esophageal sphincter (UES) and intraluminal pharyngeal dimensions were measured from biplane videofluoroscopic swallowing studies in 8 volunteers during 1- and 20- mL swallows. These measurements were applied to three-dimensional reconstructions of the pharyngeal swallow, permitting analysis of their effect on intraluminal volume and propulsive function. RESULTS: Dividing the pharyngeal swallow into periods of reconfiguration, sustained reconfiguration, and offset of reconfiguration, volume accommodation occurred by a 0.2-second prolongation of reconfiguration, preserving the coordination of the onset and offset events. Augmented reconfiguration increased the dimensions of the pharyngeal chamber, caused more rapid bolus expulsion, and increased UES distention. However, maximal transphincteric flow per unit area across the UES was constant, showing its compliance. CONCLUSIONS: Volume accommodation is accomplished by augmenting and prolonging pharyngeal reconfiguration from a respiratory to deglutitive pathway. This modification in the timing of neurally mediated events is amplified by its mechanical consequences, resulting in the different cineradiographic appearance and propulsive attributes of large and small volume swallows. (Gastroenterology 1996 Aug;111(2):297-306)

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High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia
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La disfagia orofaríngea (DO) es una enfermedad con una alta prevalencia en diferentes fenotipos de pacientes. La manometría de alta resolución faringoesofágica (MARFE) con impedancia (MARFE-I) se ha convertido en los últimos años en una técnica fundamental para el mejor entendimiento de la fisiopatología de las disfunciones de la faringe y del esfínter esofágico superior (EES) en pacientes con DO. Diversos grupos de expertos han propuesto una metodología para la práctica de la MARFE-I y para la estandarización de las diferentes métricas para el estudio de las disfunciones de la motilidad faríngea y del EES basadas en el la cuantificación de 3 fenómenos principales: la relajación del EES, la resistencia al flujo a través del EES y la propulsión del bolo a través de la faringe hacia el esófago. De acuerdo a las alteraciones de estas métricas, se proponen 3 patrones de disfunción que permiten un abordaje terapéutico específico: a) restricción al flujo del EES con propulsión faríngea normal; b) restricción al flujo del EES con propulsión faríngea inefectiva, y c) contracción faríngea inefectiva con normal relajación del EES. Presentamos una revisión práctica de la metodología y la métrica que emplean los principales grupos de trabajo junto con la descripción de los principales patrones de disfunción de acuerdo con nuestra experiencia para poner de relevancia la utilidad de la MARFE-I en el estudio de la fisiopatología y selección de un tratamiento específico en pacientes con DO.
Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardization of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of 3 main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolo through the pharynx into the oesophagus. According to the alterations of these metrics, 3 patterns of dysfunction are proposed that allow a specific therapeutic approach: (a) UES flow restriction with normal pharyngeal propulsión; (b) UES flow restriction with ineffective pharyngeal propulsion, and (c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD.
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Citation Excerpt :
Furthermore, video esophagography is accurate in isolating the specific stages of swallowing and the muscle groups assigned to these phases, including tongue motion and other oral aspects of swallowing. As a result, there is a marked potential to determine a precise pathophysiology and, consequently, an etiology in patients with oropharyngeal dysphagia unlikely with endoscopy in the absence of structural deformity.7 Specifically, one can isolate disorders of asymmetric weakness or nonuniform weakness reflecting selective neuropathic dysfunction as opposed to global dysfunction as a result of diffuse myopathy or neuropathy.
Effect of bolus volume on pharyngeal swallowing assessed by high-resolution manometry
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Although no statistically significant volume effect was detected in our research, we found that as bolus volume increased, maximum hypopharyngeal pressure presented with a trend of decline, especially in water and thick liquid swallows, which was in tandem with the UES relaxation duration discussed above. We have always held the opinion that pharyngeal contraction was in cooperation with UES opening [33,34]. It is possible that prolonged UES relaxation duration is sufficient for increased bolus to pass the UES, so there is no need to increase the contraction force of pharyngeal muscles.
Solid-state high-resolution manometry (HRM) is fast becoming the gold standard for studying pharyngeal and esophageal motility. However, very few studies have ever evaluated the effect of bolus volume on the physiology of swallowing using HRM. We aimed to determine the effect of bolus volume on pressure, duration and velocity of the hypopharynx as well as the upper esophageal sphincter during pharyngeal swallowing using HRM.
Thirty-four healthy subjects completed nine swallows (3 ml, 5 ml and 10 ml of water, thick liquid, and paste, respectively) in the natural sitting position. Pressure and duration measurements were acquired from the hypopharynx and upper esophageal sphincter (UES) using HRM. The UES residual pressure, UES relaxation duration, maximum preopening UES pressure, maximum postclosure UES pressure, maximum hypopharyngeal pressure, maximum hypopharyngeal pressure rise rate and hypopharyngeal pressure duration were analyzed across bolus volumes using repeated measures of one-way analysis of variance.
A significant increase in UES residual pressure associated with increased bolus volume during water and paste swallowing was observed. Furthermore, UES relaxation duration was significantly increased with increasing in bolus volume for all three material swallows. No significant volume effects were found on the hypopharynx.
In summary, bolus volume has a significant effect on the residual pressure and relaxation duration, but no effect on maximum preopening pressure or maximum postclosure pressure of the UES. Maximum hypopharyngeal pressure, maximum hypopharyngeal pressure rise rate and pressure duration were also not affected by bolus volume. Consideration of these variables is paramount in understanding normal and pathological swallowing.
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