Dysphagia 17:197±201 (2002) DOI: 10.1007/s00455-002-0050-y
Supraglottic Swallow, Eortful Swallow, and Chin Tuck Did Not Alter Hypopharyngeal Intrabolus Pressure in Patients with Pharyngeal Dysfunction Margareta BuÈlow, SLP, MSc, Rolf Olsson, MD, PhD, and Olle Ekberg, MD, PhD Department of Diagnostic Radiology, MalmoÈ University Hospital, Lund University, MalmoÈ, Sweden
Abstract. Simultaneous videoradiography and solidstate manometry (videomanometry) were performed in 8 patients (4 women, 4 men; age range = 46±81 years, mean age = 70 years) with pharyngeal dysfunction in order to disclose any changes in intrabolus pressure during swallowing maneuvers. Five of the patients had severe pharyngeal dysfunction with frequent misdirected swallows. Three of the patients had moderate pharyngeal dysfunction with delayed initiation of pharyngeal swallow. Three dierent swallowing techniques were applied: supraglottic swallow, eortful swallow, and chin tuck. Pharyngeal intrabolus pressure was analyzed at the level of the inferior pharyngeal constrictor. Supraglottic swallow, eortful swallow, and chin tuck did not alter peak amplitude or duration of the intrabolus pressure. Key words: Intrabolus pressure Ð Dysphagia Ð Videomanometry Ð Swallowing techniques Ð Supraglottic swallow Ð Eortful swallow Ð Chin tuck Ð Pharyngeal dysfunction Ð Deglutition Ð Deglutition disorder.
Intrabolus pressure is a term used to describe the pressure within a ¯uid when a manometric sensor is completely surrounded by a bolus [1±4]. It is a hydrodynamic pressure dependent on bolus volume and ¯ow rate but also on the characteristics of the pha-
Correspondence to: Margareta BuÈlow, Department of Radiology, MalmoÈ University Hospital, SE-205 02 MalmoÈ, Sweden. Telephone:+46-40-331519, e-mail:
[email protected]
ryngeal walls in terms of contraction and opening of the esophageal inlet. Intrabolus pressure should have great potential for determining the eects of swallowing therapy. In particular, an improved opening of the esophageal inlet would result in a lower pharyngeal intrabolus pressure. Swallowing therapy techniques often allow for a safe and ecient swallow in neurologically impaired patients [5±7]. Techniques often used are supraglottic swallow, eortful swallow, Mendelsohn's maneuver, and dierent head-positioning techniques such as the chin tuck. There are few reports in the literature that describe the eects on bolus passage and pharyngeal pressure achieved by these techniques [8±14]. In this study simultaneous videoradiography and intraluminal manometry were applied on three swallowing techniques to evaluate changes in intrabolus pressure.
Materials and Methods Simultaneous videoradiography and solid-state intraluminal manometry (videomanometry) were used in 8 patients (4 women, 4 men; age range = 46±81 years, mean age = 70 years), with pharyngeal dysfunction resulting from cerebrovascular accident (6 pts) and head and neck cancer (2 pts). The clinical examination by the speech±language pathologist revealed that 5 of the patients had severe pharyngeal dysfunction with a high frequency of misdirected swallows into the airways and that 3 of the patients had moderate pharyngeal dysfunction with delayed initiation of pharyngeal swallow. No patient had language disabilities. The manometry system was an intraluminal solid-state transducer system. The manometry catheter had a diameter of 4.6 mm, with four solid-state pressure transducers positioned 2 cm apart. The two proximal sensors were standard microtransducers (Konigsberg Instruments, lnc., Pasadena, CA) with a single recording site oriented radially to measure 120°. The two distal transducers (Konigsberg Instruments) were circumferential, allowing 360° measurements. The system was noncompliant; the
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Fig. 1. Hypopharyngeal intrabolus peak pressure in mm Hg. Control swallows and 3 dierent therapeutic maneuvers are displayed. All values are means of 3 swallows in 8 patients.
Fig 2. Hypopharyngeal intrabolus pressure duration in milliseconds. Control swallows and 3 dierent therapeutic maneuvers are displayed. All values are means of 3 swallows in 8 patients.
volumetric compliance was 7 ´ 10)6 mm3/mm Hg, and the pressure rise rate was over 2000 mm Hg/s. The analog signal was digitized by a Polygraph A/D converter (Medtronic, Synectics, Stockholm, Sweden). The software was the Polygram Upper-GI Edition by Gastrosoft Inc./Medtronic (Synectics). All pressure values were expressed in millimeters of mercury (1.0 mm Hg = 133 N/m2, 7.5 mm Hg = 1 kPa, 50 mm Hg = 68 cm H2O). The system was calibrated at 0 mm Hg and at 50 mm Hg. The calibration was done at 37°C. All given values are referred to atmospheric pressure. The sampling frequency was 64 Hz. The manometry catheter was introduced through the nose and ¯uoroscopically positioned with its distal transducer in the pharyngoesophageal sphincter (PES). All sensors were radiopaque and easy to identify during ¯uoroscopy. The two proximal transducers were positioned with the recording sites in a dorsal direction. During swallow, the pharynx±larynx elevation moved the PES in a cranial direction. When the catheter was correctly positioned in the cranial part of the PES, a characteristic Mshaped con®guration of the manometry wave appeared during swallowing. The videoradiography and pharyngeal manometry were performed simultaneously in an upright position. With the manometry catheter in place, all participants were instructed to swallow 10 mL of barium contrast medium (60% weight/volume). At least three wet swallows of each technique were recorded. The video¯uoroscopic image and the manometric registration were mixed using a Microeye Video Output Card (Digihurst Ltd., Roystone, UK), displayed together on a monitor, and recorded on videotape (S-VHS). Slow motion and frame-by-frame analysis performed video analysis. To ensure that the patient performed each technique correctly, the instructions applicable to each technique were repeated immediately before each swallow. Intrabolus pressure was de®ned as the hydrodynamic pressure within the swallowed barium bolus. This was con®rmed with simultaneous videoradiography to ensure that the manometric sensor was completely within the barium with no contact with the pharyngeal walls. The peak amplitude (mm Hg) and the duration (ms) of the intrabolus pressure were registered at the level of the pharyngeal inferior constrictor. Experimentally we also measured the hydrostatic intrabolus pressure in a column with the barium suspension. The circumferential manometric sensor was placed at dierent levels below the surface of the barium solution in a glass column. Instructions for the dierent swallowing techniques were given as follows: Every patient was given individual instructions for
at least 10 minutes half an hour before the procedure. None of the patients had received any swallowing therapy before. The procedure started with three normal wet swallows followed by the three swallowing techniques, each also performed three times, and all with 10-mL of thin barium liquid. When performing the supraglottic swallow, the patients were told to take the barium liquid into the mouth, take a deep breath, hold the breath after inhalation, and then swallow while keeping the breath. Immediately after swallowing, they were instructed to cough or clear the throat before breathing again. In the eortful swallow, the patients were instructed to swallow very hard while squeezing the tongue in an upward±backward motion toward the soft palate. The third technique was the chin tuck (head-positioning technique) swallow. After taking the barium liquid into the mouth, the patients were instructed to tuck the chin downward, swallow in that position, and after the swallow raise the head again.
Statistics All values are means of three swallows repeated for every single swallowing technique in every patient ( SEM, standard error of the mean). All variables were plotted on a histogram and found to be normally distributed and thus parametric statistics were used. Repeated measures analysis of variance (ANOVA) and multiple comparisons with Schee's and Newman±Keuls' methods were used to determine exactly which `` treatment '' means were significantly dierent. The signi®cance level was 0.05. All statistical calculations were made using STATISTICAÒ (StatSoft Inc., Tulsa, OK, USA).
Results The results are presented in Table 1. Supraglottic swallow, eortful swallow, and chin tuck did not alter peak intrabolus pressure or duration of this pressure when measured at the level of the inferior pharyngeal constrictor. There was a tendency to higher intrabolus pressure when the different swallowing techniques were performed, espe-
M. BuÈlow et al.: Hypopharyngeal Intrabolus Pressure in Pharyngeal Dysfunction Table 1. Intrabolus pressure (peak amplitude and duration) at the level of the inferior pharyngeal constrictor during barium swallow. Control swallow and 3 dierent swallowing techniquesa
Control Supraglottic Eortful Chin tuck a
Peak amplitude (mm Hg)
Duration (ms)
15.5 19.8 18.5 17.3
343 313 308 356
1.8 3.0 2.5 2.0
37 27 32 20
All values are means SEM (standard error of the mean).
cially during supraglottic swallow, but no p-value was lower than 0.38 when performing multiple comparisons with Schee's exact test. There was no signi®cant dierence of peak intrabolus pressure (IBP) or intrabolus pressure duration when we compared 4 patients with tracheal penetration during control swallows and the same patients during chin tuck. This maneuver reduced the tracheal penetration to supraglottic or higher. The IBP during control swallows was 17.5 2.6 (mm Hg) compared with 20.8 2.9 during chin tuck (pvalue 0.36). The IBP duration was 398 33 (ms) vs. 360 40 (p-value 0.22). Three of the 8 patients had incomplete pharyngeal constrictor activity with barium residue. They failed to produce a complete peristaltic stripping wave. The other 5 had complete peristaltic activity with no barium residue. Three of the 8 patients swallowed signi®cant amounts of air together with the barium, making the videoradiographic assessment of a true intrabolus pressure dicult. Several artifacts produced manometric registrations that resembled intrabolus pressure when only interpreted manometrically. Such artifacts were produced by interposition of the epiglottis and soft palate between the manometric sensor and the pharyngeal wall. Also, sensor movement prior to the oncoming peristaltic contraction could produce a manometric registration similar to an intrabolus pressure. The hydrostatic pressures in a glass column with barium contrast were found to be 7.1 mm Hg 5 cm below the surface of the barium suspension, 13.0 mm Hg 10 cm below, and 18.7 mm Hg 15 cm below the surface.
Discussion Swallowing therapy, commonly used in the rehabilitation of neurologically impaired patients, such as
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stroke patients but also head/neck cancer patients, has a prime goal of maintaining oral feeding and achieving a safe and ecient swallow, to ensure a good quality of life for the patients. Therapeutic strategies such as head-positioning techniques are widely used and considered successful, for example, in reducing misdirected swallows into the airways. We all know of patients successfully treated with such techniques but larger randomized studies are still missing. It is extremely dicult to randomize a study with stroke patients who also, in many cases, have a spontaneous recovery and then compare treated with untreated patients. Therefore, there is a quest for a quantitative outcome variable to do followup studies after swallowing therapy. Videoradiography during barium swallow is widely used but its interpretation is mainly qualitative, failing to quantify the results [15,16]. Theoretically pharyngeal manometry would be a better technique with quantitative results facilitating comparisons [17±22]. We have previously shown that dierence therapeutic maneuvers do not produce any signi®cant dierences in pharyngeal manometry regarding standard contraction and relaxation variables [13]. This article instead deals with the hydrodynamic pressure named intrabolus pressure. Our hypothesis was that intrabolus pressure is a reliable variable for monitoring the eect of therapeutic swallowing maneuvers. The main ®nding of this study, however, was that there were no statistically signi®cant dierences of the intrabolus pressure when performing the different swallowing techniques. However, there was a tendency to higher intrabolus pressure when the patients performed these maneuvers, most evident in supraglottic swallow. This should encourage further research with expanded studies. In a previous paper, we reported that the chin tuck signi®cantly reduced the level of barium penetration into the airways [23]. When we compared the patients with reduced penetration when performing the chin tuck, there were no signi®cant dierences regarding intrabolus pressure. The intrabolus pressures found in this study in general were lower than those previously reported by us in a study of 25 healthy volunteers: We found an average intrabolus pressure of 33 mm Hg [18]. The pharyngeal intrabolus pressure at the level of the inferior pharyngeal constrictor is highly dependent on an eective peristaltic contraction wave. If adequate, the contraction wave will produce a hydrodynamic pressure when the peristaltic wave moves toward the upper esophageal sphincter. Patients suering from stroke, however, often have unsatisfactory pharyngeal constrictor activity, thus failing to build up this
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hydrodynamic pressure. We have reported pharyngeal contractions of 255 24 mm Hg in 8 healthy volunteers compared with the mean average of 126 21 mm Hg for the 8 dysphagic patients in this study. Common ®ndings in a stroke patient with dysphagia are defective pharyngeal contractions and impairment of the laryngeal elevation. Also frequently found is a passive spillover of the bolus from the mouth into the pharynx creating ¯uid levels with severe retention in the piriform sinuses. This would be hydrostatic pressure with no oncoming peristaltic wave and absence of hydrodynamic pressure. Experimentally, we found a ¯uid level of 5 cm necessary to create a hydrostatic pressure of 7.1 mm Hg. However, this is not likely to be found in the pharynx indicating that hydrostatic pressures play a minor role when analyzing hypopharyngeal intrabolus pressure. A signi®cant intrabolus hydrodynamic pressure requires adequate pharyngeal peristalsis together with pharyngeal shortening and a timely coordination of upper esophageal sphincter opening. Therefore, we would probably downgrade the use of intrabolus pressure to serve as a quantitative marker in the evaluation of therapeutic maneuvers since the majority of patients are neurologically impaired by stroke. Despite the overall low intrabolus pressures found in this study, all patients had an adequate opening of the upper esophageal sphincter as assessed by the simultaneous videoradiography by means of a normal anterior±posterior opening diameter of more than 8 mm during barium contrast passage in a lateral projection. This is interesting because the bolus pressure was thought to be one of three important factors that ensure complete opening of this sphincter. We believe, as described in an earlier paper, that laryngeal elevation is the single most important factor for a successful pharyngeal swallowing sequence [24]. Another interesting observation was that a substantial amount of air was ingested, together with the barium as previously described by Kahrilas et al. [25±27]. This complicated the assessment of a true intrabolus pressure. The lateral view of the barium swallow was used to make sure that the manometric sensor was completely surrounded by barium but we could not be sure that air also was present. The 3dimensional geometry of the pharynx would necessitate the use of axial computed tomography or magnetic resonance imaging to de®nitely depict if the manometric sensor was solely in the barium or also in contact with air [25±29]. At a minimum, simultaneous videoradiography is necessary to depict intrabolus pressure since interposition of anatomical structures or movement
artifacts can cause manometric registration resembling an intrabolus pressure. We conclude that dierent swallowing techniques do not produce signi®cant dierences regarding intrabolus pressure. Stroke patients were found to have lower intrabolus pressure than healthy volunteers and any increase of the intrabolus pressure could be of physiological importance. Although not statistically signi®cant in this small group of patients, there was a promising tendency to an increased intrabolus pressure during the maneuvers and further research and expanded studies should be encouraged.
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