Manometric evidence for a phonation-induced UES contractile reflex

Abstract

The mechanism against entry of gastric content into the pharynx during high-intensity vocalization such as seen among professional singers is not known. We hypothesized that phonation-induced upper esophageal sphincter (UES) contraction enhances the pressure barrier against entry of gastroesophageal contents into pharynx. To determine and compare the effect of phonation on luminal pressures of the esophagus and its sphincters, we studied 17 healthy volunteers (7 male, 10 female) by concurrent high-resolution manometry and voice analysis. We tested high-and low-pitch vowel sounds. Findings were verified in six subjects by UES manometry using a water-perfused sleeve device. Eight of the volunteers (2 male, 6 female) had concurrent video fluoroscopy with high-resolution manometry and voice recording. Fluoroscopic images were analyzed for laryngeal movement. To define the sex-based effect, subgroup analysis was performed. All tested phonation frequencies and intensities induced a significant increase in UES pressure (UESP) compared with prephonation pressure. The magnitude of the UESP increase was significantly higher than that of the distal esophagus, the lower esophageal sphincter (LES), and the stomach. Concurrent videofluoroscopy did not show posterior laryngeal movement during phonation, eliminating a purely mechanical cause for phonation-induced UESP increase. Subgroup analysis demonstrated phonation-induced UESP increases in males that were significantly greater than those of females. Phonation induces a significant increase in UESP, suggesting the existence of a phonation-induced UES contractile reflex. UESP increase due to this reflex is significantly higher than that of the distal esophagus, LES, and stomach. The phonation-induced UESP increase is influenced by sex.upper esophageal sphincter ANATOMIC CONTINUITY OF THE stomach and lung necessitates the existence of elaborate defense mechanisms for prevention of retrograde aspiration. In the past several years our laboratory has been involved in studying these mechanisms. Our overall hypothesis has been that reflux-related upper gastrointestinal or respiratory events trigger a number of reflexes that prevent entry of refluxate into the aerodigestive tract and the lung. Examples of these mechanisms include upper esophageal sphincter (UES) contractile reflexes (14,18,22,28,30,34,36,37), secondary esophageal peristalsis (3,5,7,8,10,16,19,26), vocal cord closure reflexes (6,21,29,(31)(32)(33), and pharyngeal reflexive swallow (35) in response to esophageal or pharyngeal stimulation. The activation of airway-protective mechanisms in response to respiratory events with potential for causing reflux events such as phonation and cough has not been systematically studied.Phonation requires rapid opening and closing of the vocal folds to interrupt the air stream (25), accompanied by an increase in subglottal tracheal pressure that is believed to be generated by contraction of the diaphragm, simultaneously causing an increase in intra-abdominal pressure. This minimal su...

Characterization of the Upper Esophageal Sphincter Response During Cough

“…the cough refl ex. Similar to our previous reports in healthy young and elderly subjects during phonation events, 27,28 this fi nding suggests the presence of a UES contractile response as part of the cough refl ex. To further support this notion, there is electromyographic evidence of contraction of the cricopharyngeus muscle during cough in animal models.…”

Swallowing outcomes after cricopharyngeal myotomy: A systematic review

“…The upper esophageal sphincter functions as a gateway within the upper aerodigestive tract. Its resting muscle tone serves critical functions to regulate the opening of the esophagus for swallowing and belching, and protects the airways from invasion of gastric or esophageal contents . Furthermore, upper esophageal sphincter contraction provides post‐swallowing pressures against the tail of the bolus being swallowed to facilitate clearance into the cervical esophagus.…”

“…Its resting muscle tone serves critical functions to regulate the opening of the esophagus for swallowing and belching, [1][2][3][4] and protects the airways from invasion of gastric or esophageal contents. [5][6][7][8] Furthermore, upper esophageal sphincter contraction provides post-swallowing pressures against the tail of the bolus being swallowed to facilitate clearance into the cervical esophagus. The cricopharyngeus muscle together with the inferior constrictor and cervical esophageal fibers comprise the upper esophageal sphincter.…”

UES Pressure During Phonation Using High-resolution Manometry and 24-h Dual-probe pH-metry in Patients with Muscle Tension Dysphonia

“…The increased pressure in the UES could be due to a mechanical squeeze of the sphincter and the pharynx. It is hypothesized that this squeeze is caused by surrounding structures, such as posterior movement of the larynx pressing the sphincter and the hypopharynx against the spine due to increased (para)laryngeal muscle tension [5]. To what extent manometric recordings can document the diagnosis of MTD is worthwhile investigating.…”

“…To what extent manometric recordings can document the diagnosis of MTD is worthwhile investigating. Previous research with manometry by Perera et al [5] showed that phonation in normal speakers was associated with a different magnitude of increase in intraluminal pressure in the UES, esophagus, and lower esophageal sphincter (LES). This phenomenon was observed for both high and low pitch.…”