Safety and Tolerability of Pharyngeal High-Resolution Manometry

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial

OBJECTIVE

High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM.

METHODS

Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings.

RESULTS

Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035).

CONCLUSION

The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1118-1126, 2024.

Usefulness of nasal cavity evaluation before high-resolution esophageal manometry in high-risk patients

BACKGROUND/AIMS

A catheter is inserted through the nasal cavity during high-resolution esophageal manometry (HRM), which may cause adverse events such as pain or epistaxis. Despite these possible safety considerations, studies on this subject are very limited. We aimed to investigate the usefulness of nasal cavity evaluation before HRM to reduce the risk of adverse events and test failure.

METHODS

Patients who underwent HRM after consultation with the ear-nose-throat department for nasal evaluation were retrospectively enrolled between December 2021 and May 2022. The included patients had a previous history of sinonasal disease or surgery or had subjective nasal discomfort. All patients answered the Sino-Nasal Outcome Test (SNOT-22) questionnaire, and subjective nasal discomfort was scored using a visual analog scale. Nasal endoscopy and acoustic rhinometry were performed for disease evaluation and volumetric assessment.

RESULTS

The analysis included 22 patients with a mean age of 58.9 years. The mean SNOT-22 score was 24.2, and 16 patients (72.7%) complained of subjective nasal obstruction. The HRM catheter was successfully inserted in 20 patients (90.9%), without any significant adverse events. The objective measurement outcomes of acoustic rhinometry and sinus endoscopy did not always correspond to subjective symptoms. Narrowed nasal airways unresponsive to decongestants were observed in two patients with failed catheter insertion.

CONCLUSION

To reduce the risk of adverse events and test failure during HRM, a site-specific questionnaire to evaluate nasal obstruction might be helpful. When nasal obstruction is suspected, objective nasal cavity evaluation could be recommended for the safe and successful performance of HRM.

Using high resolution manometry impedance to diagnose upper esophageal sphincter and pharyngeal motor disorders

BACKGROUND

Oro-pharyngeal pathophysiology, including upper esophageal sphincter (UES) and pharyngeal disorders, can be assessed by pharyngeal high-resolution manometry impedance (P-HRM-I). We aimed to establish methodology to diagnose disorders utilizing P-HRM-I, hypothesizing that the objective measures could be used to diagnose disordered deglutition evidenced by greater aspiration scores.

METHODS

Patients (n = 509, 18-91 years) were compared to controls (n = 120, 20-94 years). Variables measuring UES relaxation, UES opening extent, intrabolus pressure, and pharyngeal contractile strength were derived for 10 ml liquid swallows. Three associated pharyngeal pressurization patterns, which may be indicative of obstructed flow, were characterized: pan-pressurization (Type 1), distal compartmentalized pressurization (Type 2), and transient pressurization (Type 3). Deglutitive aspiration was determined from video fluoroscopy.

RESULTS

UES relaxation pressure was best able to differentiate patients from controls (T 6.528, p < 0.0001). Patients with abnormal relaxation pressure (>8 mmHg) more frequently exhibited pharyngeal pressurization patterns and had adjunct evidence of reduced luminal distensibility (high intrabolus pressure and/or reduced UES opening). Utilizing this information, a diagnostic scheme was devised identifying 138 patients with UES disorder. A further 96 patients without evidence of UES disorder had abnormally weak pharyngeal pressures, confirming propulsive disorder. Amongst a sub-sample of 320 patients undergoing video fluoroscopy, those with pharyngeal pressurizations and adjunct evidence of reduced UES relaxation and/or distensibility had higher aspiration scores (Chi-square 60.169, p < 0.0001).

CONCLUSION

P-HRM-I can provide evidence for UES disorder based on pharyngeal pressurization patterns and abnormal findings for UES relaxation pressure, UES opening, and intrabolus pressure. Measuring pharyngeal contractility requires further optimization.

Accuracy of High-Resolution Pharyngeal Manometry Metrics for Predicting Aspiration and Residue in Oropharyngeal Dysphagia Patients with Poor Pharyngeal Contractility

Several physiological metrics can be derived from pharyngeal high-resolution impedance manometry (HRPM), but their clinical relevance has not been well established. We investigated the diagnostic performance of these metrics in relation to videofluoroscopic (VFS) assessment of aspiration and residue in patients with oropharyngeal dysphagia. We analyzed 263 swallows from 72 adult patients (22-91 years) with diverse medical conditions. Metrics of contractility, upper esophageal sphincter (UES) opening and relaxation, flow timing, intrabolus distension pressure, and a global Swallow Risk Index (SRI) were derived from pressure-impedance recordings using pressure-flow analysis. VFS data were independently scored for airway invasion and pharyngeal residue using the Penetration-Aspiration Scale and the Normalized Residue Ratio Scale, respectively. We performed multivariate logistic regression analyses to determine the relationship of HRPM metrics with radiological outcomes and receiver-operating characteristic (ROC) analysis to evaluate their diagnostic accuracy. We identified aspiration in 25% and pharyngeal residue in 84% of the swallows. Aspiration was independently associated with hypopharyngeal peak pressure < 65 mmHg (HypoPeakP) [adjusted odds ratio (OR) 5.27; 95% Confidence Interval (CI) (0.99-28.1); p = 0.051], SRI > 15 [OR 4.37; 95% CI (1.87-10.2); p < 0.001] and proximal esophageal contractile integral (PCI) < 55 mmHg·cm·s [OR 2.30; 95% CI (1.07-4.96); p = 0.034]. Pyriform sinus residue was independently predicted by HypoPeakP < 65 mmHg [OR 7.32; 95% CI (1.93-27.7); p = 0.003], UES integrated relaxation pressure (UES-IRP) > 3 mmHg [OR 2.96; 95% CI (1.49-5.88); p = 0.002], and SRI > 15 [OR 2.17; 95% CI (1.04-4.51); p = 0.039]. Area under ROC curve (AUC) values for individual HRPM metrics ranged from 0.59 to 0.74. Optimal cut-off values were identified. This study demonstrates the diagnostic value of certain proposed and adjunct HRPM metrics for identifying signs of unsafe and inefficient bolus transport in patients with oropharyngeal dysphagia.

Comparison of methods for evaluation of upper esophageal sphincter (UES) relaxation duration: Videofluoroscopic swallow study versus high-resolution manometry

This study aims to compare the 2 methods of upper esophageal sphincter (UES) relaxation measurement and determine which method has better diagnostic value in UES relaxation impairment The study included 140 patients with pharyngeal dysphagia who underwent both videofluoroscopic swallow study (VFSS) and high-resolution manometry (HRM). Feeding method was determined to oral or non-oral feeding based on the severity of dysphagia; 103 patients were in oral feeding group and 37 were in non-oral feeding group. UES relaxation duration was measured using VFSS and HRM, respectively. Receiver-operating characteristic curve analysis was conducted to validate the UES relaxation duration in determination of feeding method. UES relaxation duration was more decreased in non-oral feeding group than in oral feeding group on both VFSS and HRM. Receiver-operating characteristic analysis revealed that the optimal cutoff value of UES relaxation duration to determine feeding method (oral or non-oral feeding) was 0.42 seconds on VFSS and 0.44 seconds on HRM. The sensitivity for feeding method was higher in VFSS than HRM (83.5% vs 70.9%), while the specificity was higher in HRM than VFSS (48.6% vs 54.1%). VFSS and HRM have complementary ability in evaluating UES relaxation duration in patients with oropharyngeal dysphagia.

Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.

Use of Pharyngeal High-Resolution Manometry to Evaluate Dysphagia in Adults with Motor Neurone Disease: A Scoping Review

There has been a recent shift towards proactive dysphagia intervention in motor neurone disease (MND) to maintain physiological reserve. Pharyngeal high-resolution manometry (PHRM) can quantify swallowing pathophysiology to inform and evaluate proactive dysphagia intervention. This study aims to explore the current use of PHRM as a dysphagia evaluation in adults with MND. A scoping review based on the Joanna Briggs Framework was completed. Four electronic databases (PubMed, EMBASE, CINAHL and Web of Science core) were searched (inception to March 2021) by two independent researchers. Data were analysed according to (i) PHRM protocol and analysis methods and the feasibility of same, (ii) swallow biomechanics data and (iii) dysphagia intervention effects as measured by PHRM. Six studies with 78 people with MND (PwMND) were included. There was considerable variation in PHRM protocol and analysis methods. Five studies reported a 100% completion rate and three studies reported no adverse events. Swallow biomechanics data were reported across all studies. The effects of sensory stimulation, increased bolus consistency, effortful swallow and cricopharyngeal myotomy were evaluated using PHRM with 20 PwMND across four studies with varying effects. Literature on the use of PHRM in PwMND is limited. Variability in PHRM methods restricts comparison of metrics. PHRM appears to be a feasible tool for PwMND. PHRM can provide novel swallow physiology data in PwMND and quantify discrete effects of compensatory and surgical dysphagia interventions not detectable by videofluoroscopy or FEES. Further research on the effects of proactive dysphagia intervention as measured by PHRM is required.

Perceived Professional and Institutional Factors Influencing Clinical Adoption of Pharyngeal High-Resolution Manometry

Purpose We assessed experienced clinicians' perceptions of benefits and drawbacks to the clinical adoption of pharyngeal high-resolution manometry (HRM). This article focuses on the professional and institutional factors that influence the clinical adoption of pharyngeal HRM by speech-language pathologists (SLPs). Method Two surveys (closed- and open-ended questions) and a series of focus groups were completed with SLP members of both the American Speech-Language-Hearing Association and the Dysphagia Research Society (DRS). Transcripts were inductively coded for emergent themes. Results Thirteen SLPs were recruited to attend focus group sessions at the American Speech-Language-Hearing Association. Eighty-seven SLPs responded to the DRS open-set response survey. Two additional focus groups of 11 SLPs were convened at the DRS meeting. Conventional content analysis revealed overall SLP enthusiasm for the clinical use of HRM, with some concerns about the technology adoption process. The following themes related to the professional and institutional factors influencing clinical adoption were identified: (a) scope of practice, (b) access, (c) clinical workflow, and (d) reimbursement. Conclusion These data serve to elucidate the most salient factors relating to the clinical adoption of pharyngeal HRM into routine speech-language pathology clinical practice. While enthusiasm exists, a variety of systems-level issues must be addressed to support this process.

Effect of Lidocaine on Comfort and Swallowing Pressures During Pharyngeal High-Resolution Manometry

The purpose of this study is to determine the level of patient comfort during pharyngeal high-resolution manometry (HRM) with and without the use of atomized lidocaine. A secondary aim of the study was to explore whether differences in pharyngeal pressure measurements exist between HRM conducted with the use of atomized lidocaine verses HRM conducted without. Twenty-nine participants underwent two HRM procedures under two conditions, 5-7 days apart: 2% viscous lidocaine to nares or 0.4 mL 4% atomized and 2% viscous lidocaine to nares. During each procedure, participants received six boluses of water. Following catheter removal, participants were asked to rate comfort using a visual analog scale (VAS) and upon completion of both conditions, participants indicated which procedure they preferred. A paired t-test was used to compare pharyngeal pressure measurements at the velopharynx, tongue base region and during upper esophageal sphincter opening. Pharyngeal pressures were categorized as normal or outside of normal limits and compared using a McNemar's test. Twenty-eight of the 29 participants indicated they preferred the use of atomized lidocaine. VAS ratings yielded a significant difference (p = 0.001). No significant difference in pharyngeal pressures were detected between the two groups. Patients prefer atomized lidocaine when undergoing HRM. The use of atomized lidocaine did not affect measurement outcomes.