Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier

Abstract

Objectives/Hypothesis Incompetence of the upper esophageal sphincter (UES) is fundamental to the occurrence of esophagopharyngeal reflux (EPR), and development of supraesophageal manifestations of reflux disease (SERD). However, therapeutic approaches to SERD have not been directed to strengthening of the UES barrier function. Our aims were to demonstrate that EPR events can be experimentally induced in SERD patients and not in healthy controls, and ascertain if these events can be prevented by application of a modest external cricoid pressure. Study Design Individual case control study. Methods We studied 14 SERD patients (57±13 years, 8 females) and 12 healthy controls (26±3 years, 7 females) by concurrent intraesophageal slow infusion and pharyngoscopic and manometric technique without and with the application of a sustained predetermined cricoid pressure to induce, detect, and prevent EPR, respectively. Results Slow esophageal infusion (1 mL/s) of 60 mL of HCl resulted in a total of 16 objectively confirmed EPR events in none patients and none in healthy controls. All patients developed subjective sensation of regurgitation. Sustained cricoid pressure resulted in a significant UES pressure augmentation in all participants. During application of sustained cricoid pressure, slow intraesophageal infusion resulted in only one EPR event (P<.01). Conclusions Slow esophageal liquid infusion unmasks UES incompetence evidenced as the occurrence of EPR. Application of 20 to 30 mm Hg cricoid pressure significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion. These techniques can be useful in diagnosis and management of UES incompetence in patients suffering from supraesophageal manifestations of reflux disease.

How uncomplicated total thyroidectomy could aggravate the laryngopharyngeal reflux disease?

“…The pathophysiologic mechanisms of supra-esophageal manifestations of reflux disease or LPR are still today poorly understood [20], but there is another unsolved question: can surgery worsen LPR? The aim of this article is just speculative; starting from other important investigations in the literature and from our personal experiences, we have developed three main hypotheses.…”

“…Indeed, the striated muscles of UES are the most important barriers against pharyngeal reflux of acid contents; the cricopharyngeal muscle is one of the principal components of the UES, placed in front of the cervical vertebrae and behind the cricoid cartilage, very close to the thyroid capsule [20].…”

Prospective Study of Upper Esophageal Sphincter Assist Device for Treating Extraesophageal Reflux

“…This question was addressed in a recent physiologic study by Shaker et al in 14 patients with extraesophageal symptoms and 12 healthy volunteers. 6 The authors reported that slow esophageal liquid infusion resulted in UES incompetence with subsequent laryngeal reflux events. However, reflux events were significantly reduced by application of a sustained predetermined externally applied cricoid pressure between 20-30 mmHg.…”

“…4,5 The Upper Esophageal Sphincter (UES) Assist Device is a novel medical device designed to prevent the reflux of gastric contents into the laryngopharynx. 6 It is a non-pharmacologic non-surgical medical device worn while sleeping and applies a standardized external pressure to the cricoid cartilage in order to decrease retrograde reflux of gastroduodenal contents ( Figure 1). Physiologic studies with this device have shown that application of 20-30 mmHg cricoid pressure by an external UES Assist Device, significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion.…”

“…Physiologic studies with this device have shown that application of 20-30 mmHg cricoid pressure by an external UES Assist Device, significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion. 6 Outside initial important physiologic tests, there are currently no clinical data regarding the efficacy and safety of the UES Assist Device in patients with EER. Thus, the aim of this multi-center prospective cohort study was to employ validated tools to evaluate clinical benefit and safety of the UES Assist Device in patients with chronic EER symptoms.…”