Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenker's diverticulum.

BACKGROUND AND AIMS: Flexible endoscopic cricopharyngeal myotomy (FECM) allows minimally invasive treatment of patients with Zenker's diverticulum (ZD); however, retreatment rates are substantial. We hypothesized that the functional lumen imaging probe (FLIP) may provide insight into ZD pathophysiology and serve as an intraprocedural guide to adequacy of myotomy. METHODS: We prospectively evaluated 11 ZD patients undergoing FECM and compared the baseline cricopharyngeal (CP) distensibility with 16 control subjects. Intraprocedural CP distensibility was measured immediately pre- and postmyotomy. The CP distensibility index (CP-DI) was defined as a ratio of the narrowest cross-sectional area (nCSA) and the corresponding intrabag pressure at 40 mL distension. Same-procedure myotomy extension was undertaken in a subgroup if threshold distensibility changes were not met. RESULTS: ZD patients had reduced baseline nCSA and CP-DI compared with control subjects, (169.6 vs 227.5 mm2 [P < .001] and 3.8 vs 7.6 mm2/mm Hg [P < .001], respectively). After CP myotomy, both nCSA and CP-DI increased significantly by an average of 74.2 mm2 (95% confidence interval [CI], 35.1-113.3; P = .002) and 2.2 mm2/mm Hg (95% CI, .6-3.8; P = .01), respectively. In the subgroup with no significant change in CP distensibility after initial myotomy (n = 6), myotomy extension resulted in significant increases in both mean nCSA and CP-DI of 66.6 mm2 (95% CI, 16.4-116.8; P = .03) and 1.9 mm2/mm Hg (95% CI, .4-3.3; P = .015), respectively. There were no adverse events. CONCLUSIONS: CP distensibility is reduced in ZD patients and is partially reversible by FECM. An intraprocedural FLIP CP distensibility measurement is safe and sensitive in detecting myotomy-induced changes. These findings support using FLIP to optimize FECM outcome. Further studies are required to derive precise metrics predictive of clinical response.

The normative range for and age and gender effects on the Sydney Swallow Questionnaire (SSQ).

The Sydney Swallow Questionnaire (SSQ) is a validated measure of the symptomatic severity of oral-pharyngeal dysphagia. Up until now no normative ranges have been established for the questionnaire. This is a limitation in its utility as it makes it difficult to use the tool to identify the prevalence and burden of oral-pharyngeal dysphagia in the general population or within patient populations. The study's aim was to derive the normative range of dysphagia scores for the SSQ and to determine whether, in nondysphagic individuals, there are any age or gender effects on these scores. The questionnaire was administered to 73 eligible nondysphagic individuals who had been screened for any dysphagia or conditions that might predispose them to dysphagia. The frequency distribution of SSQ scores was first examined for normality and appropriate transformations performed before determining the upper limit of normal. Of the 73 healthy participants, 45 were male, and the cohort had a mean age of 58.6 years (range = 22.0-82.1 years). No statistically significant relationship between SSQ scores and either age (r s[73] = 0.140, p = 0.239) or gender (r pb[73] = 0.021, p = 0.857) was found. The mean total SSQ score (maximum possible score = 1,700) was 59.0 (SD = 56.7; range = 2-241). The frequency distribution of scores was non-normal and markedly skewed. After a Box-Cox transformation to normalise the distribution, the calculated upper limit of the reference interval was 234 with a 90 % CI of [193, 277]. The SSQ scores in a nondysphagic population are not influenced by age or gender. These data complement the existing reliability and validation data and thereby improve the overall utility of the SSQ in the context of future studies of oral-pharyngeal dysphagia prevalence, efficacy, and outcome.

Mechanisms of esophago-pharyngeal acid regurgitation in human subjects.

UNLABELLED: Esophago-pharyngeal regurgitation is implicated in various otolaryngologic and respiratory disorders. The pathophysiological mechanisms causing regurgitation are still largely unknown. AIM: To determine the principal mechanisms behind esophago-pharyngeal regurgitation. METHODS: We studied 11 patients with extra-esophageal GORD symptoms in whom esophago-pharyngeal acid regurgitation had previously been demonstrated using ambulatory, dual (pharyngo-esophageal) pH metry (>2 episodes/day using previously validated pH-metric criteria). Patients underwent continuous, 24 hr, stationary monitoring of pharyngo-esophageal manometry and dual (pharyngeal and esophageal) pH recordings. They were intubated with a 14-channel manometric assembly incorporating 2 sleeve sensors monitoring the upper and lower esophageal sphincters simultaneously. A dual pH catheter recorded pH signals 2 cm above the UES midpoint and 7 cm above the LES midpoint. RESULTS: A total of 32 episodes of spontaneous esophago-pharyngeal acid regurgitation were recorded. All episodes occurred in the upright posture and 91% occurred within 3 hrs post-prandium. All regurgitation events were associated with a relaxation of the UES, which were classified as transient non-swallow related relaxations in 29 (91%) and swallow-related in the remaining 3 (9%). Straining was an additional associated factor in 41% of regurgitation events, but strain alone was not sufficient to cause esophago-pharyngeal regurgitation. CONCLUSION: Some form of active UES relaxation is necessary for regurgitation to occur. The dominant mechanism underlying esophago-pharyngeal acid regurgitation is the non-swallow related, transient UES relaxation. LEVEL OF EVIDENCE: N/A.

Intermittent dysphagia for solids associated with a multiringed esophagus: clinical features and response to dilatation.

The entity of the multiringed esophagus, generally presenting in adults as intermittent dysphagia for solids, is relatively uncommon and its pathogenesis is unknown. The goal of this study was to describe the demographic, clinical, and endoscopic features of patients presenting with this condition, their response to esophageal dilatation, and the relationship of multiple esophageal rings to eosinophilic esophagitis. Between 1989 and June 2004, 32 patients at this adult hospital fulfilled the following inclusion criteria: (1) intermittent dysphagia for solids, (2) multiple esophageal rings at endoscopy, and (3) esophageal dilatation(s) performed. Response to esophageal dilatation was measured by need for subsequent dilatations. Seventy-five percent of the patients were male. Median age at onset of dysphagia was 21 years and at presentation 36.5 years. All had multiple rings in the proximal or midesophagus on endoscopy and had undergone a total of 73 esophageal dilatations with no esophageal perforations. Median maximal dilator size was 15 mm; however, 16% developed significant esophageal mucosal tears even with 11-mm dilators. Sixty-six percent required repeat dilatation, with the median time interval before recurrence being 8 months. Eosinophilic esophagitis (mucosal eosinophil count > 20/HPF) was present in 50% of this cohort. From this study we conclude that a multiringed esophagus causing intermittent dysphagia occurs predominantly in young males, responds well to dilatation, but repeated dilatations are often necessary. Dilatation can lead to extensive mucosal tears and should be performed with caution. Eosinophilic esophagitis is commonly but not invariably associated with this entity. Frequent relapse of dysphagia highlights the need for effective pharmacotherapy.