Skip to main content
SpringerLink
Log in

The upper esophageal sphincter in the high-resolution manometry era

  • Review Article
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Background

The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM).

Methods

This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era.

Results

We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson – UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker’s diverticulum (UES has impaired relaxation).

Conclusion

This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Bhatia SJ, Shah C (2013) How to perform and interpret upper esophageal sphincter manometry. J Neurogastroenterol Motil 19(1):99–103

    PubMed  PubMed Central  Google Scholar 

  2. Pandolfino JE, Kahrilas PJ, Association AG (2005) AGA technical review on the clinical use of esophageal manometry. Gastroenterology 128(1):209–224

    PubMed  Google Scholar 

  3. Oezcelik A, DeMeester SR (2011) General anatomy of the esophagus. Thorac Surg Clin  21(2):289–97, x. https://doi.org/10.1016/j.thorsurg.2011.01.003.

  4. Singh S, Hamdy S (2005) The upper oesophageal sphincter. Neurogastroenterol Motil 17(Suppl. 1):3–12

    PubMed  Google Scholar 

  5. Pinna BR, Herbella FAM, de Biase N, Vaiano TCG, Patti MG (2017) High-resolution manometry evaluation of pressures at the pharyngo-upper esophageal area in patients with oropharyngeal dysphagia due to vagal paralysis. Dysphagia 32(5):657–662

    PubMed  Google Scholar 

  6. Kuhn MA, Belafsky PC (2013) Management of cricopharyngeus muscle dysfunction. Otolaryngol Clin North Am 46(6):1087–1099

    PubMed  Google Scholar 

  7. Salvador R, Dubecz A, Polomsky M, Gellerson O, Jones CE, Raymond DP, Watson TJ, Peters JH (2009) A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. J Am Coll Surg 208(6):1035–1044

    PubMed  Google Scholar 

  8. Domingues GR, Michelsohn NH, Viebig RG, Chinzon D, Nasi A, Andrade CG, Lemme EM, AbrahÃo Junior LJ, Bravim MG, Nobre-E-Souza MÂ, Carvalho NS, Carvalho PJPC, Rodrigues TN, Moraes Filho JPP (2020) Normal values of esophageal high-resolution manometry: a Brazilian multicenter study. Arq Gastroenterol 57(2):209–215

    PubMed  Google Scholar 

  9. Xiang XL, Wang A, Tu L et al (2017) The motility of esophageal sphincters during liquid and solid bolus swallows: a multicenter normative value study of high-resolution manometry in China. Neurogastroenterol Motil 29(1). https://doi.org/10.1111/nmo.12914

  10. Ghosh SK, Pandolfino JE, Zhang Q, Jarosz A, Kahrilas PJ (2006) Deglutitive upper esophageal sphincter relaxation: a study of 75 volunteer subjects using solid-state high-resolution manometry. Am J Physiol Gastrointest Liver Physiol 291:G525–G531

    CAS  PubMed  Google Scholar 

  11. do Carmo GC, Jafari J, Sifrim D, de Oliveira RB (2015) Normal esophageal pressure topography metrics for data derived from the sandhill-unisensor high-resolution manometry assembly in supine and sitting positions. Neurogastroenterol Motil. 27(2):285–92

    PubMed  Google Scholar 

  12. Choi WS, Kim TW, Kim JH, Lee SH, Hur WJ, Choe YG, Lee SH, Park JH, Sohn CI (2013) High-resolution manometry and globus: comparison of globus, gastroesophageal reflux disease and normal controls using high-resolution manometry. J Neurogastroenterol Motil 19(4):473–478

    PubMed  PubMed Central  Google Scholar 

  13. Bogte A, Bredenoord AJ, Oors J, Siersema PD, Smout AJ (2013) Normal values for esophageal high-resolution manometry. Neurogastroenterol Motil 25(9):762-e579

    CAS  PubMed  Google Scholar 

  14. Weijenborg PW, Kessing BF, Smout AJ, Bredenoord AJ (2014) Normal values for solid-state esophageal high-resolution manometry in a European population; an overview of all current metrics. Neurogastroenterol Motil 26(5):654–659

    CAS  PubMed  Google Scholar 

  15. Zhang XJ, Xiang XL, Tu L, Xie XP, Hou XH (2015) The effect of position on esophageal structure and function determined with solid-state high-resolution manometry. J Dig Dis 16(6):350–356

    PubMed  Google Scholar 

  16. Silva LC, Herbella FA, Neves LR, Vicentine FP, Neto SP, Patti MG (2013) Anatomophysiology of the pharyngo-upper esophageal area in light of high-resolution manometry. J Gastrointest Surg 17(12):2033–8

    PubMed  Google Scholar 

  17. Takasaki K, Umeki H, Enatsu K, Tanaka F, Sakihama N, Kumagami H, Takahashi H (2008) Investigation of pharyngeal swallowing function using high-resolution manometry. Laryngoscope 118(10):1729–1732

    PubMed  Google Scholar 

  18. Silva RMBD, Herbella FAM, Gualberto D (2018) Normative values for a new water-perfused high resolution manometry system. Arq Gastroenterol 55 Suppl 1(Suppl 1):30–34

    Google Scholar 

  19. Burgos-Santamaría D, Marinero A, Chavarría-Herbozo CM, Pérez-Fernández T, López-Salazar TR, Santander C (2015) Normal values for water-perfused esophageal high-resolution manometry. Rev Esp Enferm Dig 107(6):354–358

    PubMed  Google Scholar 

  20. DeMeester TR (2002) Evolving concepts of reflux: the ups and downs of the LES. Can J Gastroenterol 16(5):327–331

    PubMed  Google Scholar 

  21. Nadaleto BF, Herbella FA, Pinna BR, Patti MG (2017) Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry. Dis Esophagus 30(4):1–5

    CAS  PubMed  Google Scholar 

  22. Rezende DT, Herbella FA, Silva LC, Panocchia-Neto S, Patti MG (2014) Upper esophageal sphincter resting pressure varies during esophageal manometry. Arq Bras Cir Dig 27(3):182–183

    PubMed  PubMed Central  Google Scholar 

  23. Kim CK, Ryu JS, Song SH, Koo JH, Lee KD, Park HS, Oh Y, Min K (2015) Effects of head rotation and head tilt on pharyngeal pressure events using high resolution manometry. Ann Rehabil Med 39(3):425–431

    PubMed  PubMed Central  Google Scholar 

  24. Omari TI, Ciucci M, Gozdzikowska K, Hernández E, Hutcheson K, Jones C, Maclean J, Nativ-Zeltzer N, Plowman E, Rogus-Pulia N, Rommel N, O’Rourke A (2020) High-resolution pharyngeal manometry and impedance: protocols and metrics-recommendations of a high-resolution pharyngeal manometry international working group. Dysphagia 35(2):281–295

    PubMed  Google Scholar 

  25. Menezes MA, Herbella FA, Patti MG (2015) High-resolution manometry evaluation of the pharynx and upper esophageal sphincter motility in patients with achalasia. J Gastrointest Surg 19:1753–1757

    PubMed  Google Scholar 

  26. Ren Y, Tang X, Chen F et al (2016) Myotomy of distal esophagus influences proximal esophageal contraction and upper esophageal sphincter relaxation in patients with achalasia after peroral endoscopic myotomy. Neurogastroenterol Motil 22(1):78–85

    Google Scholar 

  27. Blais P, Patel A, Sayuk GS et al (2017) Upper esophageal sphincter (UES) metrics on high-resolution manometry (HRM) differentiate achalasia subtypes. Neurogastroenterol Motil. 29(12):10.1111/nmo.13136. https://doi.org/10.1111/nmo.13136

    Article  PubMed Central  Google Scholar 

  28. Triantafyllou T, Theodoropoulos C, Mantides A et al (2018) Can the upper esophageal sphincter contractile integral help classify achalasia? Ann Gastroenterol 31:456–461

    PubMed  PubMed Central  Google Scholar 

  29. Wauters L, Van Oudenhouve L, Selleslagh M et al (2014) Balloon dilation of the esophago-gastric junction affects lower and upper esophageal sphincter function in achalasia. Neurogastroenterol Motil 26:69–76

    CAS  PubMed  Google Scholar 

  30. Anefalos A, Herbella FAM, Patti MG (2020) Upper esophageal sphincter motility and thoracic pressure are determinants of pressurized waves in achalasia subtypes according to the Chicago classification. World J Surg 44:1932–1938

    PubMed  Google Scholar 

  31. Mathews SC, Ciarleglio M, Chavez YH et al (2014) Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia. World J Clin Cases 2(9):448–454

    PubMed  PubMed Central  Google Scholar 

  32. Chavez YH, Ciarleglio MM, Clarke JO et al (2015) Upper esophageal sphincter abnormalities frequent finding on high-resolution esophageal manometry and associated with poorer treatment response in achalasia. J Clin Gastroenterol 49(1):17–23

    CAS  PubMed  Google Scholar 

  33. Lippincott M, Velanovich V (2021) The Upper esophageal sphincter in astroesophageal reflux disease. Ann Esophagus. https://doi.org/10.21037/aoe-21-3

    Article  Google Scholar 

  34. Passaretti S, Mazzoleni G, Vailati C, Testoni PA (2016) Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus. World J Gastroenterol 22(40):8991–8998

    PubMed  PubMed Central  Google Scholar 

  35. Allaix ME, Fisichella PM, Noth I, Herbella FA, Borraez Segura B, Patti MG (2014) Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment. J Gastrointest Surg 18(1):100–104

    PubMed  Google Scholar 

  36. Gao F, Hobson AR, Shang ZM, Pei YX, Gao Y, Wang JX, Huang WN (2015) The prevalence of gastro-esophageal reflux disease and esophageal dysmotility in Chinese patients with idiopathic pulmonary fibrosis. BMC Gastroenterol 19(15):26

    Google Scholar 

  37. Del Grande LM, Herbella FA, Bigatao AM, Abrao H, Jardim JR, Patti MG (2016) Pathophysiology of gastroesophageal reflux in patients with chronic pulmonary obstructive disease is linked to an increased transdiaphragmatic pressure gradient and not to a defective esophagogastric barrier. J Gastrointest Surg 20(1):104–110

    PubMed  Google Scholar 

  38. Patti MG, Debas HT, Pellegrini CA (1992) Esophageal manometry and 24-hour pH monitoring in the diagnosis of pulmonary aspiration secondary to gastroesophageal reflux. Am J Surg 163(4):401–406

    CAS  PubMed  Google Scholar 

  39. Järvenpää P, Arkkila P, Aaltonen LM (2018) Globus pharyngeus: a review of etiology, diagnostics, and treatment. Eur Arch Otorhinolaryngol 275(8):1945–1953

    PubMed  Google Scholar 

  40. Nevalainen P, Walamies M, Kruuna O, Arkkila P, Aaltonen LM (2016) Supragastric belch may be related to globus symptom - a prospective clinical study. Neurogastroenterol Motil 28(5):680–686

    CAS  PubMed  Google Scholar 

  41. Tang Y, Huang J, Zhu Y, Qian A, Xu B, Yao W (2017) Comparison of esophageal motility in gastroesophageal reflux disease with and without globus sensation. Rev Esp Enferm Dig 109(12):850–855

    CAS  PubMed  Google Scholar 

  42. Peng L, Patel A, Kushnir V, Gyawali CP (2015) Assessment of upper esophageal sphincter function on high-resolution manometry: identification of predictors of globus symptoms. J Clin Gastroenterol 49(2):95–100

    PubMed  PubMed Central  Google Scholar 

  43. Ding H, Duan Z, Yang D, Zhang Z, Wang L, Sun X, Yao Y, Lin X, Yang H, Wang S, Chen JDZ (2017) High-resolution manometry in patients with and without globus pharyngeus and/or symptoms of laryngopharyngeal reflux. BMC Gastroenterol 17(1):109

    PubMed  PubMed Central  Google Scholar 

  44. Kwiatek MA, Mirza F, Kahrilas PJ, Pandolfino JE (2009) Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation. Am J Gastroenterol 104(2):289–298

    PubMed  PubMed Central  Google Scholar 

  45. Lee T, Park JH, Sohn C, Yoon KJ, Lee YT, Park JH, Jung IS (2017) Failed deglutitive upper esophageal sphincter relaxation is a risk factor for aspiration in stroke patients with oropharyngeal dysphagia. J Neurogastroenterol Motil 23(1):34–40

    PubMed  PubMed Central  Google Scholar 

  46. Kim DY, Park CI, Ohn SH, Moon JY, Chang WH, Park SW (2006) Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction. Arch Phys Med Rehabil 87(10):1346–1351

    PubMed  Google Scholar 

  47. Lan Y, Xu G, Dou Z, Wan G, Yu F, Lin T (2013) Biomechanical changes in the pharynx and upper esophageal sphincter after modified balloon dilatation in brainstem stroke patients with dysphagia. Neurogastroenterol Motil 25(12):e821–e829

    CAS  PubMed  Google Scholar 

  48. Sung HY, Kim JS, Lee KS, Kim YI, Song IU, Chung SW, Yang DW, Cho YK, Park JM, Lee IS, Kim SW, Chung IS, Choi MG (2010) The prevalence and patterns of pharyngoesophageal dysmotility in patients with early stage Parkinson’s disease. Mov Disord 25(14):2361–8

    PubMed  Google Scholar 

  49. Taira K, Fujiwara K, Fukuhara T, Koyama S, Morisaki T, Takeuchi H (2021) Evaluation of the pharynx and upper esophageal sphincter motility using high-resolution pharyngeal manometry for Parkinson’s disease. Clin Neurol Neurosurg. 201:106447

    PubMed  Google Scholar 

  50. Herbella FA, Patti MG (2012) Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg 397(1):29–35

    PubMed  Google Scholar 

  51. Rosen SP, Jones CA, Hoffman MR, Knigge MA, McCulloch TM (2020) Pressure abnormalities in patients with Zenker’s diverticulum using pharyngeal high-resolution manometry. Laryngoscope Investig Otolaryngol 5(4):708–717

    PubMed  PubMed Central  Google Scholar 

  52. Rommel N, Van Oudenhove L, Arts J, Caenepeel P, Tack J, Pauwels A (2016) Esophageal sensorimotor function and psychological factors each contribute to symptom severity in globus patients. Am J Gastroenterol 111(10):1382–1388

    PubMed  Google Scholar 

  53. Dias PNG, Neto RML, Herbella FAM et al (2020) Psychiatric symptoms and the upper esophageal sphincter. Surg Gastroenterol Oncol 25(3):121–124

    Google Scholar 

  54. Vaiano TG, Herbella FAM, Behlau M (2021) Pharyngeal, upper esophageal sphincteric and esophageal pressures responses related to vocal tasks at the light of high resolution manometry. Arq Gastroenterol 2021 in press

  55. Perera L, Kern M, Hofmann C, Tatro L, Chai K, Kuribayashi S, Lawal A, Shaker R (2008) Manometric evidence for a phonation-induced UES contractile reflex. Am J Physiol Gastrointest Liver Physiol 294:885–891

    Google Scholar 

  56. Vaiano T, Herbella FAM, Behlau M (2019) High-resolution manometry as a tool for biofeedback in vertical laryngeal positioning. J Voice 26:S0892-1997(19)30356-X

  57. Van Houtte E, Van Lierde K, Dhaeseleer E, Van Imschoot B, Claeys S (2012) UES pressure during phonation using high-resolution manometry and 24-h dual-probe pH-metry in patients with muscle tension dysphonia. Dysphagia. 27(2):198–209

    PubMed  Google Scholar 

  58. Kibar E, Erdur O, Ozturk K (2018) Evaluation of upper esophageal sphincter in benign vocal lesions. Eur Arch Otorhinolaryngol 275(12):3033–3037

    PubMed  Google Scholar 

  59. Lippert D, Hoffman MR, Britt CJ, Jones CA, Hernandez J, Ciucci MR, McCulloch TM (2016) Preliminary evaluation of functional swallow after total laryngectomy using high-resolution manometry. Ann Otol Rhinol Laryngol 125(7):541–549

    PubMed  PubMed Central  Google Scholar 

  60. Santos TL, Herbella FAM, Azevedo RR (2020) The applicability of high resolution manometry in total laryngectomy. Codas 32(6):e20190006

    PubMed  Google Scholar 

  61. Zhang T, Bai S, Cook I, Szczesniak M, Maclean J, Dokos S (2016) Modeling of pharyngoesophageal segment during tracheoesophageal phonation in total laryngectomy patients with preliminary validation. Annu Int Conf IEEE Eng Med Biol Soc 2016:2917–2920

    Google Scholar 

  62. Lee SM, Lee BH, Kim JW, Jang JY, Jang EG, Ryu JS (2020) Effects of chin-down maneuver on pharyngeal pressure generation according to dysphagia and viscosity. Ann Rehabil Med 44(6):493–501

    PubMed  PubMed Central  Google Scholar 

  63. Umeki H, Takasaki K, Enatsu K, Tanaka F, Kumagami H, Takahashi H (2009) Effects of a tongue-holding maneuver during swallowing evaluated by high-resolution manometry. Otolaryngol Head Neck Surg 141(1):119–122

    PubMed  Google Scholar 

  64. Doeltgen SH, Witte U, Gumbley F, Huckabee M (2009) Evaluation of manometric measures during tongue-hold swallows. Am J Speech Lang Pathol 18(1):65–73

    PubMed  Google Scholar 

  65. Aoyagi Y, Ohashi M, Ando S, Inamoto Y, Aihara K, Matsuura Y, Imaeda S, Saitoh E (2021) Effect of tongue-hold swallow on pharyngeal contractile properties in healthy individuals. Dysphagia. https://doi.org/10.1007/s00455-020-10217-9

    Article  PubMed  PubMed Central  Google Scholar 

  66. Takasaki K, Umeki H, Hara M, Kumagami H, Takahashi H (2011) Influence of effortful swallow on pharyngeal pressure: evaluation using a high-resolution manometry. Otolaryngol Head Neck Surg 144(1):16–20

    PubMed  Google Scholar 

  67. Hoffman MR, Mielens JD, Ciucci MR, Jones CA, Jiang JJ, McCulloch TM (2012) High-resolution manometry of pharyngeal swallow pressure events associated with effortful swallow and the Mendelsohn maneuver. Dysphagia 27(3):418–426

    PubMed  PubMed Central  Google Scholar 

  68. Takasaki K, Umeki H, Kumagami H, Takahashi H (2010) Influence of head rotation on upper esophageal sphincter pressure evaluated by high-resolution manometry system. Otolaryngol Head Neck Surg 142(2):214–217

    PubMed  Google Scholar 

  69. Yadlapati R, Kahrilas PJ, Fox MR et al (2021) Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©. Neurogastroenterol Motil 33(1):e14058

    PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil

    Pedro Norton, Fernando A. M. Herbella, Francisco Schlottmann & Marco G. Patti

  2. Department of Surgery, Escola Paulista de Medicina, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil

    Pedro Norton, Fernando A. M. Herbella, Francisco Schlottmann & Marco G. Patti

Authors
  1. Pedro Norton
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fernando A. M. Herbella
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francisco Schlottmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marco G. Patti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Fernando A. M. Herbella.

Ethics declarations

Ethics approval

Ethics approval is waived for this type of manuscript.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Norton, P., Herbella, F.A.M., Schlottmann, F. et al. The upper esophageal sphincter in the high-resolution manometry era. Langenbecks Arch Surg 406, 2611–2619 (2021). https://doi.org/10.1007/s00423-021-02319-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-021-02319-1

Keywords

Search

Navigation