Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural ...defects leading to weak, incoordinate or absent peristalsis and impaired oesophago‐gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high‐resolution manometry is now more widely available. This review describes the potential value of high‐resolution manometry in paediatric gastroenterology practise.
Esophageal peristalsis consists of initial inhibition (relaxation) followed by excitation (contraction), both of which move sequentially in the aboral direction. Initial inhibition results in ...receptive relaxation and bolus-induced luminal distension, which allows propulsion by the contraction with minimal resistance to flow. Similar to the contraction wave, luminal distension has unique waveform characteristics in normal subjects; both are modulated by bolus volume, bolus viscosity, and posture, suggesting a possible cause-and-effect relationship between the two. Distension contraction plots in patients with dysphagia with normal bolus clearance high-amplitude esophageal contractions (HAECs), esophagogastric junction outflow obstruction (EGJOO), and functional dysphagia (FD) reveal two major findings:
) unlike normal subjects, there is luminal occlusion distal to bolus during peristalsis in certain patients, i.e., with type 3 achalasia and nonobstructive dysphagia; and
) bolus travels through a narrow lumen esophagus during peristalsis in patients with HAECs, EGJOO, and FD. Aforementioned findings indicate a relative dynamic obstruction to the bolus flow during peristalsis and reduced distensibility of esophageal wall in the bolus segment of the esophagus. We speculate that a normal or supernormal contraction wave pushing bolus against resistance is the mechanism of dysphagia sensation in significant number of patients. Representations of distension and contraction, combined with objective measures of flow timing and distensibility are complementary to the current scheme of classifying esophageal motility disorders based solely on the characteristics of contraction phase of peristalsis. Better understanding of the distensibility of the bolus-containing segment of the esophagus during peristalsis will lead to the development of novel medical and surgical therapies in the treatment of dysphagia in significant number of patients.
High-resolution manometry has traditionally been utilized in gastroenterology diagnostic clinical and research applications. Recently, it is also finding new and important applications in speech ...pathology and laryngology practices. A High-Resolution Pharyngeal Manometry International Working Group was formed as a grass roots effort to establish a consensus on methodology, protocol, and outcome metrics for high-resolution pharyngeal manometry (HRPM) with consideration of impedance as an adjunct modality. The Working Group undertook three tasks (1) survey what experts were currently doing in their clinical and/or research practice; (2) perform a review of the literature underpinning the value of particular HRPM metrics for understanding swallowing physiology and pathophysiology; and (3) establish a core outcomes set of HRPM metrics via a Delphi consensus process. Expert survey results were used to create a recommended HRPM protocol addressing system configuration, catheter insertion, and bolus administration. Ninety two articles were included in the final literature review resulting in categorization of 22 HRPM-impedance metrics into three classes: pharyngeal lumen occlusive pressures, hypopharyngeal intrabolus pressures, and upper esophageal sphincter (UES) function. A stable Delphi consensus was achieved for 8 HRPM-Impedance metrics: pharyngeal contractile integral (CI), velopharyngeal CI, hypopharyngeal CI, hypopharyngeal pressure at nadir impedance, UES integrated relaxation pressure, relaxation time, and maximum admittance. While some important unanswered questions remain, our work represents the first step in standardization of high-resolution pharyngeal manometry acquisition, measurement, and reporting. This could potentially inform future proposals for an HRPM-based classification system specifically for pharyngeal swallowing disorders.
Objectives/Hypothesis
Modulation of the pharyngeal swallow to bolus volume and viscosity is important for safe swallowing and is commonly studied using high‐resolution pharyngeal manometry (HRPM). ...Use of unidirectional pressure sensor technology may, however, introduce variability in swallow measures and a fixed bolus administration protocol may induce time and order effects. We aimed to overcome these limitations and to investigate the effect of time by repeating randomized measurements using circumferential pressure sensor technology.
Study Design
Sub‐set analysis of data from the placebo arm of a randomized, repeated measures trial.
Methods
HRPM with impedance was recorded using a solid‐state catheter with 36 circumferential pressure sensors and 18 impedance segments straddling from hypopharynx to stomach. Testing included triplicates of 5, 10, and 20 ml thin liquid and 10 ml thick liquid boluses, the order of the thin liquid boluses was randomized. The swallow challenges were repeated approximately 10 minutes after finishing the baseline measurement.
Results
We included 19 healthy adults (10/9 male/female; age 24.5 ± 4.1 year). Intrabolus pressure, all upper esophageal sphincter (UES) opening and relaxation metrics, and flow timing metrics increased with larger volumes. A thicker viscosity decreased UES relaxation time, UES basal pressure, and flow timing metrics, whereas UES opening extent increased. Pre‐swallow UES basal pressure and post‐swallow UES contractile integral decreased over time.
Conclusion
Using circumferential pressure sensor technology, the effects of volume and viscosity were largely consistent with previous reports. UES contractile pressures reduced over time. The growing body of literature offers a benchmark for recognizing aberrant pharyngo‐esophageal motor responses.
Level of Evidence
3 Laryngoscope, 132:1817–1824, 2022
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder that requires repeat endoscopic evaluation(s) to assess response to treatment. This results in high health care costs and a ...procedural burden in affected children. Noninvasive alternate modalities to reassess disease activity have not been established. Low baseline impedance measured by multichannel pH impedance (pH-MII) is seen in adults with EoE, in keeping with poor mucosal integrity. We aimed to investigate the relationship between esophageal eosinophilia (or severity of eosinophilic infiltration) and baseline impedance in children with EoE.
We retrospectively identified 15 children diagnosed with EoE at our institution who had undergone pH-MII within 30 days of 3-level esophageal biopsy. This group were not concurrently prescribed proton pump inhibitors and had negligible reflux parameters on pH-MII. Average impedance baseline was calculated upper, mid, and lower esophageal segments via baseline impedance automated analysis (RIAA) and mean nocturnal baseline impedance (MNBI) methods. Eosinophil count data for upper, mid, and lower esophageal segments in the EoE group was collated.
A significantly lower baseline impedance was seen across the esophageal length in children with EoE, compared with 30 controls who had no differences in age or reflux burden on nonparametric testing. A relationship between baseline impedance and eosinophil number at corresponding esophageal segments was not established.
Baseline impedance may be an important, less invasive adjunct in clinical practice to monitor treatment response in children with EoE. Larger prospective cohort studies should delineate optimally predictive baseline impedance thresholds for active and inactive disease.
Aim
This study was twofold: (i) it aimed to investigate the morphometric changes of three temperature‐sensitive nickel–titanium (NiTi) instruments at different temperatures, and (ii) to conduct an ...in vivo real‐time analysis of intracanal temperature changes.
Methods
Changes in the shape and length of XP‐Endo Shaper, XP‐Endo Finisher, and XP‐Endo Finisher‐R were evaluated in real time whilst heated in a temperature‐controlled water bath from 22 to 45°C. Instruments were fixed to a laminated water‐resistant 1 mm graph paper attached to a stone block. Instruments were imaged whilst subjected to increasing temperature using a digital camera attached to an operating microscope. From recorded videos, still frames were extracted at 10‐s intervals and changes in the length and shape of each instrument were measured and changes were plotted against time. Moreover, the intracanal temperature of distal roots of lower molars was measured in vivo for patients attending the clinic for non‐surgical root canal treatments. The temperature was measured using a K‐type thermocouple probe inserted into the mid‐root level after irrigating the canal with a solution set at room temperature (22°C) or heated to 45°C. The intraoral and intracanal temperatures were recorded using a video camera for 180 s at 5‐s intervals to plot the change in the intraoral and intracanal temperature, after both irrigation solution temperatures, with time.
Results
The shape transformation of XP‐Endo Shaper began at 31.5 ± 2.0°C and reached its optimal transformation at 35.1 ± 1.0°C. For the Finisher and Finisher‐R, shape transformations began at 29.2 ± 1.9 and 26.9 ± 2.2°C reaching the optimal transformation at 33.9 ± 1.4 and 32.7 ± 1.7°C, respectively. The average decreases in lengths of XP‐Endo Shaper, Finisher, and Finisher‐R after full transformation were 0.43 ± 0.23, 1.07 ± 0.22, and 1.15 ± 0.22 mm, respectively. The intracanal temperature reached 32.9 ± 0.8 and 33.2 ± 1.0°C after 3 min of application of irrigation solutions set at 22 or 45°C, respectively.
Conclusion
The tested instruments exhibited diverse changes in their shapes and lengths at varying temperatures. Despite the temperature of the irrigation solution, the intracanal temperature consistently remained lower than the intracanal temperature once equilibrium was reached. This highlights the importance of considering the temperature of irrigation solution during in vitro testing of endodontic instruments.
Purpose of review
We provide an overview of the clinical application of novel pharyngeal high-resolution impedance manometry (HRIM) with pressure flow analysis (PFA) in our hands with example cases.
...Recent findings
In our Centre, we base our interpretation of HRIM recordings upon a
qualitative
assessment of pressure-impedance waveforms during individual swallows, as well as a
quantitative
assessment of averaged PFA swallow function variables. We provide a description of two global swallowing efficacy measures, the swallow risk index (SRI), reflecting global swallowing dysfunction (higher SRI = greater aspiration risk) and the post-swallow impedance ratio (PSIR) detecting significant post-swallow bolus residue. We describe a further eight swallow function variables specific to the hypopharynx and upper esophageal sphincter (UES), assessing hypo-pharyngeal distension pressure, contractility, bolus presence and flow timing, and UES basal tone, relaxation, opening and contractility.
Summary
Pharyngeal HRIM has now come of age, being applicable for routine clinical practice to assess the biomechanics of oropharyngeal swallowing dysfunction. In the future, it may guide treatment strategies and allow more objective longitudinal follow-up on clinical outcomes.
To compare the amount of extruded debris caused by different motions using a single-file system. Fifty mandibular first molar teeth were randomized into 5 groups (
n
= 10) according to the motion ...tested: Optimize Torque Reverse (OTR), TF Adaptive Motion (TFA), continuous rotation (CR), reciprocation motion (+ 150°, −30°) (REC), and Jeni motion (Jeni). One Curve single file 25/06 (Micro-Mega, Besançon, France) was used in all experimental groups. The root canals were irrigated with 2.5% NaOCl, and the extruded debris were collected at pre-weighted glass vials. The glass vials were kept inside an incubator for one week at 70 °C to dry out the irrigating solution. The extruded debris was quantified by subtracting the pre-instrumentation from the post-instrumentation weight of the glass vials. The time required for each instrumentation procedure was digitally recorded. All data were analyzed statistically with one way ANOVA and post hoc Tukey test (
P
< 0.05). All the motions extruded apically debris with Jeni mode caused significantly less debris extrusion than TFA, REC, and CR (
P
< 0.05) while no significant difference emerged with OTR. Preparation time was not significantly different in all groups. Within the limits of the present study, all the kinematics produced apically debris extrusion, with Jeni reporting a similar amount of debris compared with OTR and significantly less than TFA, REC, and CR. Preparation time was similar among the tested kinematics.
To investigate the quality of life (QoL) impact on primary caregivers of children with esophageal atresia.
We used a prospective cohort study design, inviting primary caregivers of children with ...esophageal atresia to complete the following questionnaires: Parent Experience of Child Illness (PECI), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, 12-Item Short Form Survey (SF-12), and Pediatric Quality of Life Inventory (PedsQL). The PECI, PROMIS Anxiety and Depression, and SF-12 assessed caregiver QoL, and the PedsQL assessed patient QoL. Patients with Gross type E esophageal atresia served as controls.
The primary caregivers of 100 patients (64 males, 36 females; median age, 4.6 years; range, 3.5 months to 19.0 years) completed questionnaires. The majority (76 of 100) of patients had Gross type C esophageal atresia. A VACTERL (vertebral anomalies, anorectal malformation, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb anomalies) association was found in 30, ≥1 esophageal dilatation was performed in 57, and fundoplication was performed in 11/100. When stratified by esophageal atresia types, significant differences were found in 2 PECI subscales (unresolved sorrow/anger, P = .02; uncertainty, P = .02), in PROMIS Anxiety (P = .02), and in SF-12 mental health (P = .02) and mental component summary scores (P = .02). No significant differences were found for VACTERL association, nor esophageal dilatation. Requirement for fundoplication resulted in lower SF-12 general health score, and lower PedsQL social and physical functioning scores.
We have demonstrated that caring for a child with esophageal atresia and a previous requirement for fundoplication impacts caregiver QoL.
Background
Dysphagia post head and neck cancer (HNC) multimodality treatment is attributed to reduced pharyngeal strength. We hypothesized that pharyngeal tongue base augmentation for dysphagia (PAD ...therapy) would increase pharyngeal pressures during swallowing thereby improving swallow symptoms.
Methods
Adults with moderate–severe dysphagia post‐HNC treatment had PAD therapy using a temporary filler (hyaluronic acid HA), with follow‐up long‐lasting lipofilling. Swallowing preprocedure and postprocedure was assessed with the Sydney Swallow Questionnaire (SSQ), High‐Resolution Pharyngeal Manometry (HRPM), and Videofluoroscopic Swallowing Study (VFSS). Statistical comparison utilized paired tests.
Results
Six participants (all male; median age 64 years IQR 56, 71) underwent PAD therapy at a median of 47 IQR 8, 95 months post‐treatment. SSQ scores reduced from baseline (mean 1069 95%CI 703, 1434) to post‐HA (mean 579 76, 1081, p > 0.05), and post‐lipofilling (491 95%CI 913, 789, p = 0.003, n = 4). Individual participants demonstrated reduced Swallow Risk Index, Bolus Presence Time, and increased Upper Esophageal Sphincter opening, but mesopharyngeal contractile pressures were unchanged. VFSS measures of aspiration, residue, and severity were unchanged.
Conclusions
Novel PAD therapy is safe and improves dysphagia symptoms. Biomechanical swallowing changes are suggestive of more efficacious bolus propulsion with conservative filler volume, but this was unable to resolve residue or aspiration measures.
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