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To compare swallowing function between healthy subjects and patients with pharyngeal dysphagia using high resolution manometry (HRM) and to evaluate the usefulness of HRM for detecting pharyngeal dysphagia.
Seventy-five patients with dysphagia and 28 healthy subjects were included in this study. Diagnosis of dysphagia was confirmed by a videofluoroscopy. HRM was performed to measure pressure and timing information at the velopharynx (VP), tongue base (TB), and upper esophageal sphincter (UES). HRM parameters were compared between dysphagia and healthy groups. Optimal threshold values of significant HRM parameters for dysphagia were determined.
VP maximal pressure, TB maximal pressure, UES relaxation duration, and UES resting pressure were lower in the dysphagia group than those in healthy group. UES minimal pressure was higher in dysphagia group than in the healthy group. Receiver operating characteristic (ROC) analyses were conducted to validate optimal threshold values for significant HRM parameters to identify patients with pharyngeal dysphagia. With maximal VP pressure at a threshold value of 144.0 mmHg, dysphagia was identified with 96.4% sensitivity and 74.7% specificity. With maximal TB pressure at a threshold value of 158.0 mmHg, dysphagia was identified with 96.4% sensitivity and 77.3% specificity. At a threshold value of 2.0 mmHg for UES minimal pressure, dysphagia was diagnosed at 74.7% sensitivity and 60.7% specificity. Lastly, UES relaxation duration of <0.58 seconds had 85.7% sensitivity and 65.3% specificity, and UES resting pressure of <75.0 mmHg had 89.3% sensitivity and 90.7% specificity for identifying dysphagia.
We present evidence that HRM could be a useful evaluation tool for detecting pharyngeal dysphagia.
Citations
To assess the correlation between the anorectal function and bladder detrusor function in patients with complete spinal cord injury (SCI) according to the type of lesion.
Medical records of twenty-eight patients with SCI were included in this study. We compared the anorectal manometric and urodynamic (UD) parameters in total subjects. We analyzed the anorectal manometric and UD parameters between the two groups: upper motor neuron (UMN) lesion and lower motor neuron (LMN) lesion. In addition, we reclassified the total subjects into two groups according to the bladder detrusor function: overactive and non-overactive.
In the group with LMN lesion, the mean value of maximal anal squeeze pressure (MSP) was slightly higher than that in the group with UMN lesion, and the ratio of MSP to maximal anal resting pressure (MRP) was statistically significant different between the two groups. In addition, although the mean value of MSP was slightly higher in the group with non-overactive detrusor function, there was no statistical correlation of anorectal manometric parameters between the groups with overactive and non-overactive detrusor function.
The MSP and the ratio of MSP to MRP were higher in the group with LMN lesion. In this study, we could not identify the correlation between bladder and bowel function in total subjects. We conclude that the results of UD study alone cannot predict the outcome of anorectal manometry in patients with SCI. Therefore, it is recommended to perform assessment of anorectal function with anorectal manometry in patients with SCI.
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Many reports of changes in cervical alignment after posterior occipitocervical (O-C) fusion causing dysphagia are available. The clinical course can range from mild discomfort to severe aspiration. However, the underlying pathogenesis is not well known. We report an 80-year-old female with videofluoroscopic swallowing study evidence of aspiration that developed after occiput-C3/4 posterior fusion. Pharyngeal pressure was analyzed using high resolution manometry (HRM). Impaired upper esophageal sphincter opening along with diminished peristalsis and pharyngeal pressure gradient were revealed by HRM to be the main characteristics in such patients. The patient fully recovered after a revision operation for cervical angle correction. Distinct pressure patterns behind reversible dysphagia caused by a change in cervical alignment were confirmed using HRM analysis.
Citations
To observe changes in pharyngeal pressure during the swallowing process according to postures in normal individuals using high-resolution manometry (HRM).
Ten healthy volunteers drank 5 mL of water twice while sitting in a neutral posture. Thereafter, they drank the same amount of water twice in the head rotation and head tilting postures. The pressure and time during the deglutition process for each posture were measured with HRM. The data obtained for these two postures were compared with those obtained from the neutral posture.
The maximum pressure, area, rise time, and duration in velopharynx (VP) and tongue base (TB) were not affected by changes in posture. In comparison, the maximum pressure and the pre-upper esophageal sphincter (UES) maximum pressure of the lower pharynx in the counter-catheter head rotation posture were lower than those in the neutral posture. The lower pharynx pressure in the catheter head tilting posture was higher than that in the counter-catheter head tilting. The changes in the VP peak and epiglottis, VP and TB peaks, and the VP onset and post-UES time intervals were significant in head tilting and head rotation toward the catheter postures, as compared with neutral posture.
The pharyngeal pressure and time parameter analysis using HRM determined the availability of head rotation as a compensatory technique for safe swallowing. Tilting the head smoothes the progress of food by increasing the pressure in the pharynx.
Citations
Videofluoroscopic swallowing study (VFSS) used for the diagnosis of dysphagia has limitations in objectively assessing the contractility of the pharyngeal muscle or the degree of the upper esophageal sphincter relaxation. With a manometer, however, it is possible to objectively assess the pressure changes in the pharynx caused by pharyngeal muscle contraction during swallowing or upper esophageal sphincter relaxation, hence remedying the limitations of VFSS. The following case report describes a patient diagnosed with lateral medullar infarction presenting a 52-year-old male who had dysphagia. We suggested that the manometer could be used to assess the specific site of dysfunction in patients with dysphagia complementing the limitations of VFSS. We also found that repetitive transcranial magnetic stimulation was effective in treating patients refractory to traditional dysphagia rehabilitation.
Citations
Method: To determine the baseline differences, thirty three patients were classified into two groups: cord injured level above T9 and from T9 to L2. And thirteen patients were included in follow-up study to evaluate the effects of 4 weeks electrical stimulation.
Results: There was no significant difference in the baseline colon transit time on two groups. After electrical stimulation, the left and rectosigmoid transit time was more improved in lower level injured group comparing with upper level injured group. In the rectoanal manometry the mean resting anal pressure, mean squeezing pressure, high pressure zone, and threshold of rectoanal inhibitory reflex were increased after the electrical stimulation on two groups. And the mean squeezing pressure on T9-L2 injured patients was significantly increased (p＜0.05).
Conclusion: The elecrical stimulation to the sacral dermatomes increased the mean squeezing pressure of rectoanal manometry more significantly on the T9-L2 injured patients than the group of spinal cord injured level above T9. However, there was no statistically significant difference in the colon transit time before and after the electrical stimulation between two groups (J Korean Acad Rehab Med 2003; 27: 880-885)
Objective: To evaluate effects of the electrical stimulation to the sacral dermatomes for the neurogenic bowel of the spinal cord injured patients.
Method: Eleven patients with cervical and thoracic cord injury were enrolled, and classified into two groups, control and electrical stimulation (ES) group. The colon transit time before and after electrical stimulation for 4 weeks to the sacral dermatomes were measured on the ES group, and measured at the same time on control group. The rectoanal manometries were performed after studies of colon transit time on the ES group.
Results: The colon transit time measured before electrical stimulation were 16.1⁑13.8 hours for the right colon; 20.1⁑23.3 hours for the left colon; 14.7⁑12.3 hours for the rectosigmoid colon; and the total transit time was 51.0⁑23.4 hours. The time of after electrical stimulation was 8.0⁑5.7 hours for the right colon; 12.8⁑2.2 hours for the left colon; 15.4⁑13.8 hours for the rectosigmoid colon; and the total transit time was 36.2⁑12.8 hours. The left colon transit time and total colon transit time before electrical stimulation were significantly improved compared to after electrical stimulation on the ES group (p＜0.05). The left colon transit time of the ES group was significantly improved compared with control group (p＜0.05). In the rectoanal manometry, the mean resting anal pressure and threshold of rectoanal inhibitory reflex were increased after the electrical stimulation.
Conclusion: The electrical stimulation to the sacral dermatomes on the spinal cord injured patient could effectively enhance colon transit, especially on the left colon. In addition, muscular activity of the anal sphincter was enhanced.
Objective: To evaluate changes of colon transit time according to prokinetic medication and characteristics of the anorectal manometry in patients with neurogenic bowel due to spinal cord injury.
Method: Twelve patients with cervical and thoracic cord injury were enrolled, and classified into complete and incomplete spinal cord injury according to the severity of injury. The colon transit time before and after prokinetic medications were measured. The anorectal manometry was performed after the first study of colon transit time.
Results: The colon transit time of pre-prokinetic medications were 17.1⁑12.6 hours for the right colon, 26.9⁑13.2 for the left colon, 21.5⁑14.0 for the rectosigmoid colon, and the total transit time was 65.5⁑5.3 hours. The time of post-prokinetic medications was 14.3⁑7.6 hours for the right colon, 25.8⁑10.3 for the left colon, 7.4⁑5.3 for the rectosigmoid colon, and the total transit time was 33.1⁑11.5 hours. The rectosigmoid colon transit time and total colon transit time were significantly different between pre- and post-prokinetic medications (p＜0.05). In the anorectal manometry, mean resting anal pressure was 33.3⁑10.7 mmHg and maximal resting anal pressure was 99.0⁑43.4 mmHg. There were no difference in the colon transit time and anorectal manometry between complete and incomplete injured patients.
Conclusion: The difficulties of defecation in spinal cord injured patients were not only due to uncontrolled anal sphincter but also due to dysfunction of colon motility. The prokinetic medications were effective in reducting the rectosigmoid and total colon transit time.
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