May 26, 2009 Feature

The Role of Pharyngeal and Upper Esophageal Manometry in Swallowing Assessment

by Susan G Butler

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Speech-language pathologists in medical settings have long tried to quantify the degree of clinical pharyngeal impairment they see, and even experts often fail to agree on the major source of residue in a patient with dysphagia. For example, is residue in the pyriform sinuses the result of decreased pharyngeal contraction and/or decreased esophageal sphincter (UES) opening?

Diagnosing the cause from the videofluoroscopic swallowing examination (VFSE) and flexible endoscopic evaluation of swallowing (FEES) is subjective, and misdiagnosing the cause of residue has therapeutic implications. That is, if decreased UES relaxation/opening is suspected, the SLP may choose to initiate the Mendelsohn maneuver as a compensatory technique or the Shaker exercise (Easterling, Grande, Kern, Sears, & Shaker, 2005; Ferdjallah, Wertsch, & Shaker, 2000; Shaker et al., 2002) as part of the treatment plan.

However, if decreased pharyngeal contraction is suspected, the SLP may initiate exercises of effortful swallow via surface electromyography biofeedback (Crary & Baldwin, 1997; Huckabee & Cannito, 1999). Uncertainty may lead SLPs—for lack of a better strategy—to prescribe treatment aimed at all potential causes. To advance our field toward a more evidence-based clinical practice base, quantitative measures of swallowing are needed.

Manometric evaluation of oropharyngeal swallowing may provide a positive step toward these more quantitative evaluations. Manometry supplements the VFSE and/or the FEES and provides quantitative information on swallowing physiology: timing and pressure associated with the swallow, strength of the oropharyngeal phase, degree of upper UES relaxation, and duration of the pharyngeal pressures and the onset of UES relaxation relative to pharyngeal pressures.

Manometric evaluation of oropharyngeal swal-lowing is unfamiliar to many SLPs. In the past, manometry failed to become a widespread clinical tool because SLPs were not well-versed in transnasal procedures, the use of a 4.6 mm catheter for the procedure required nasal anesthetic that possibly anesthetized the oropharynx, and the use of a large-bore catheter for manometry altered temporal measures of swallowing physiology. Today, clinical integration of manometry is more realistic because SLPs are well-versed in transnasal procedures (e.g., FEES), a much smaller (2.1 mm) catheter is available that does not require nasal anesthetic, and the smaller nasopharyngeal catheter causes minimal changes in swallowing physiology.

Manometry Use

In our clinic we use manometry for two main purposes, to:

  • Elucidate the breakdown in swallowing physiology and to plan treatment. We use manometry with patients after cerebrovascular accidents, head injuries, head and neck surgery, and/or radiation and chemotherapy, and with patients who have diagnoses of globus and neurodegenerative diseases as appropriate. Manometry is helpful with patients who exhibit residue after the swallow by indicating if the pharyngeal contraction is decreased. It is also helpful to document whether the UES is not relaxing sufficiently or long enough for the bolus to move through the UES completely. Treatment plans will differ depending on which of these physiologic mechanisms is not working properly.
  • Determine cricopharyngeal dysfunction. If an elevated UES resting pressure (e.g., globus) and/or decreased UES relaxation (e.g., dysphagia) are identified, the SLP confers with the otolaryngologist, who may potentially offer UES dilatation and/or Botox® injection to lower the UES pressures.

Although manometric data on normal individuals have been published, normative data are still lacking. Factors such as age, gender, catheter size, bolus volume, and bolus type all can affect manometric measurements (Butler et al., 2009; Hiss & Huckabee, 2005; Huckabee, Butler, Barclay, & Jit, 2005; Kahrilas, Logemann, Lin, & Ergun, 1992; Perlman, Schultz, & VanDaele, 1993; Robbins, Hamilton, Lof, & Kempster, 1992). Replication of prior research is needed before firm conclusions can be made. Nevertheless, current information can enhance the SLP's understanding of the breakdown of swallowing in an individual with dysphagia, and improve the SLP's ability to determine the most appropriate swallowing treatment.

Just as further research on VFSE and FEES continues to enhance our accuracy and skill with each of those tools, so will upcoming and continued research on manometry. Meanwhile, manometry is a tool that may add value to the VFSE and FEES by providing quantitative information to the dysphagia evaluation, allowing for more accurate diagnoses and treatment planning.

Susan G Butler, PhD, CCC-SLP, is an associate professor in the Department of Otolaryngology, Center for Voice and Swallowing Disorders, at Wake Forest University Health Sciences in Winston-Salem, N.C., and is a Board-recognized specialist in swallowing. Her research focuses on identification of the range of normal swallowing function as assessed endoscopically and on assessing the associations among swallowing, tongue composition, and overall physical functioning. Contact her at sbutler@wfubmc.edu.

cite as: Butler, S. G. (2009, May 26). The Role of Pharyngeal and Upper Esophageal Manometry in Swallowing Assessment. The ASHA Leader.

Performing Manometry

There are three ways to perform manometry: with fluoroscopy (manofluoroscopy), with endoscopy (manoendoscopy), or without visualization.

With these techniques, SLPs can quantify pharyngeal strength or weakness, UES functioning, and coordination of pharyngeal and UES relaxation and then can prescribe an appropriate diet and rehabilitation program.

Figure 1. A normal manoendoscopic
swallow and patterns of pressure measured
at each sensor.
Manometry without visualization is helpful in therapeutic planning or to gain quantitative information on progress in treatment when the bolus flow parameters have already been studied instrumentally and a diet recommended. In individuals with normal swallowing, the SLP should observe a rapid onset and offset of pharyngeal pressures at the first sensor (base of tongue) and the second sensor (hypopharynx). The peak pressure and durational ranges should fall within the normal range (Butler et al., 2009; Hiss & Huckabee, 2005; Huckabee et al., 2005).

The second increase in pressure of the "M wave" is the UES closing back around the third sensor, causing another increase in pressure. As the larynx descends back to its original position, the pressure reading in the third sensor should also decrease to roughly the same pressure as before the swallow.

A well-coordinated swallow will exhibit pharyngeal peaks that fall within the relaxation of the UES. Furthermore, the peak onset measured at the first sensor (base of tongue) should precede that measured at the second sensor. Typically, UES relaxation onset (sensor three) begins before the peak onset captured at the first sensor. See Figure 1 for an example of a normal manoendoscopic swallow. Patterns of pressure measured at each sensor appear in the insets.



Case Example: The Use of Manometry in Assessment

A 26-year-old female came to an otolaryngology clinic complaining of a constant sensation of a lump in her throat, and the inability to swallow normal-sized bites of solids. She was primarily consuming liquids, purees, and small bites of very soft solids. The otolaryngologist suspected the globus was due to reflux disease and prescribed a proton pump inhibitor twice a day for six weeks. At the six-week follow-up, the globus had not improved. The patient was taken off the proton pump inhibitor and a pH/impedance test was performed two weeks later. The test was normal, substantiating the absence of reflux disease. The otolaryngologist referred the patient to the SLP for a manoendoscopic examination.

The FEES examination revealed residue above the UES after the swallow, which cleared on the subsequent swallow. The manometric examination revealed a markedly elevated resting peak UES pressure and greatly elevated pharyngeal pressures (approximately 250 mmHg). The presence of the two abnormalities indicated that this young patient had cricopharyngeal hypertonicity. The results were discussed with the referring otolaryngologist, who recommended the patient undergo UES dilation with Botox.®

Three days later, the patient received UES dilation with Botox,® and then returned to the SLP one week later for a repeat manoendoscopic examination. At that visit, the patient reported her globus sensation was almost completely eliminated and her swallowing felt normal. She had been eating a full range of liquids and solids without difficulty. The follow-up FEES examination revealed no residue after the swallow. Manometry documented UES resting pressures of 0 and normalized pharyngeal swallowing pressures. The findings were reported to the referring otolaryngologist. If the patient's globus returned, the otolaryngologist would know how much the treatment had improved the symptoms. If the UES resting pressure was still elevated, the otolaryngologist could subsequently increase the amount of Botox® to achieve lower UES resting pressures.



References

Butler, S. G., Stuart, A., Castell, D., Russell, G. B., Koch, K., & Kemp, S. (2009). Effects of age, gender, bolus condition, viscosity, and volume on pharyngeal and upper esophageal sphincter pressure and temporal measurements during swallowing. Journal of Speech, Language and Hearing Research, 52(1), 240–253.

Crary, M. A., & Baldwin, B. O. (1997). Surface electromyographic characteristics of swallowing in dysphagia secondary to brainstem stroke. Dysphagia, 12(4), 180–187.

Easterling, C., Grande, B., Kern, M., Sears, K., & Shaker, R. (2005). Attaining and maintaining isometric and isokinetic goals of the Shaker exercise. Dysphagia, 20(2), 133–138.

Ferdjallah, M., Wertsch, J. J., & Shaker, R. (2000). Spectral analysis of surface electromyography (EMG) of upper esophageal sphincter-opening muscles during head lift exercise. Journal of Rehabilitation Research and Development, 37(3), 335–340.

Hiss, S. G., & Huckabee, M. L. (2005). Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia, 20(2), 149–156.

Huckabee, M. L., Butler, S. G., Barclay, M., & Jit, S. (2005). Submental surface electromyographic measurement and pharyngeal pressures during normal and effortful swallowing. Archives of Physical Medicine and Rehabilitation, 86(11), 2144–2149.

Huckabee, M. L., & Cannito, M. P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, 14(2), 93–109.

Kahrilas, P. J., Logemann, J. A., Lin, S., & Ergun, G. A. (1992). Pharyngeal clearance during swallowing: A combined manometric and videofluoroscopic study. Gastroenterology, 103(1), 128–136.

Perlman, A. L., Schultz, J. G., & VanDaele, D. J. (1993). Effects of age, gender, bolus volume, and bolus viscosity on oropharyngeal pressure during swallowing. Journal of Applied Physiology, 75(1), 33–37.

Robbins, J., Hamilton, J. W., Lof, G. L., & Kempster, G. B. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103(3), 823–829.

Shaker, R., Easterling, C., Kern, M., Nitschke, T., Massey, B., Daniels, S., et al. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122(5), 1314–1321.



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