High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia | Gastroenterología y Hepatología (English Edition)

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"documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Gastroenterol Hepatol. 2024;47:272-85" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "Manometría de alta resolución con impedancia para el estudio de la motilidad faríngea y del esfínter esofágico superior: claves para su utilización en el estudio de la fisiopatología de la disfagia orofaríngea" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "285" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figura 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 3003 "Ancho" => 3000 "Tamanyo" => 708201 ] ] "descripcion" => array:1 [ "es" => "Trazado manométrico de alta resolución e impedanciometría de una deglución de 20ml viscosidad néctar (250 mPa·s), fraccionada, en un paciente anciano con barra del cricofaríngeo que muestra una restricción al flujo con una relajación incompleta del EES y una propulsión faríngea débil. La presión faríngea máxima que evalúa la fuerza de la contracción faríngea está disminuida, así como el vigor (PhCI) y la amplitud de la fuerza de propulsión faríngea. La onda faríngea está fragmentada y presenta baja amplitud principalmente en la mesofaringe (MCI). Presenta una UES-IRP aumentada (IRP-0,2s 13mmHg) que demuestra la relajación incompleta del EES. Vista la alteración en la relajación del EES, esperaríamos un aumento de la presión intrabolo faríngea (HIBP) que, sin embargo, es normal por la ineficaz propulsión faríngea." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miguel Martínez-Guillén, Pere Clavé, Mónica Zavala, Silvia Carrión" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Miguel" "apellidos" => "Martínez-Guillén" ] 1 => array:2 [ "nombre" => "Pere" "apellidos" => "Clavé" ] 2 => array:2 [ "nombre" => "Mónica" "apellidos" => "Zavala" ] 3 => array:2 [ "nombre" => "Silvia" "apellidos" => "Carrión" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382424000646" "doi" => "10.1016/j.gastre.2023.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000646?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523004351?idApp=UINPBA00004N" "url" => "/02105705/0000004700000003/v4_202404281047/S0210570523004351/v4_202404281047/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2444382424000634" "issn" => "24443824" "doi" => "10.1016/j.gastre.2023.09.002" "estado" => "S300" "fechaPublicacion" => "2024-03-01" "aid" => "2116" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Gastroenterol Hepatol. 2024;47:286-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Letter to the Editor" "titulo" => "Dysphagia megalatriensis diagnosed by esophageal manometry in a patient with double compressive etiology. A diagnostic challenge" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "286" "paginaFinal" => "287" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico de disfagia megalatriensis por manometría en paciente con doble fenómeno compresivo esofágico. Un reto diagnóstico" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1303 "Ancho" => 1675 "Tamanyo" => 257795 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0150" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Dysphagia megalatriensis and esophageal compression by cervical osteophyte. a) HRM showing pulsatile mid-esophageal hyperpressure (orange arrows) and secondary compartmentalised pressurisation (yellow arrow). b) TTE showing left atrial dilation. c) Barium swallow with double mid-esophageal compression phenomenon and narrowing (yellow arrow) by left atrium and cervical osteophyte (red arrowheads). d) Chest CT with contrast showing esophageal collapse due to extrinsic compression (red arrowheads). L.A.: left atrium; C.O.: cervical osteophyte." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raúl José Díaz Molina, Antonia Perelló Juan, Maria José Bosque López, Carmen Garrido Durán" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Raúl José" "apellidos" => "Díaz Molina" ] 1 => array:2 [ "nombre" => "Antonia" "apellidos" => "Perelló Juan" ] 2 => array:2 [ "nombre" => "Maria José" "apellidos" => "Bosque López" ] 3 => array:2 [ "nombre" => "Carmen" "apellidos" => "Garrido Durán" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210570523004284" "doi" => "10.1016/j.gastrohep.2023.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523004284?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000634?idApp=UINPBA00004N" "url" => "/24443824/0000004700000003/v2_202405192000/S2444382424000634/v2_202405192000/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2444382424001342" "issn" => "24443824" "doi" => "10.1016/j.gastre.2023.03.010" "estado" => "S300" "fechaPublicacion" => "2024-03-01" "aid" => "2066" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Gastroenterol Hepatol. 2024;47:270-1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Image of the month" "titulo" => "Gastric hamartomatous inverted polyp coexisting with inflammatory fibroid polyp" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "270" "paginaFinal" => "271" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pólipo gástrico hamartomatoso invertido coexistente con pólipo fibroide inflamatorio" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 832 "Ancho" => 987 "Tamanyo" => 95019 ] ] "descripcion" => array:1 [ "en" => "Endosonographic image depicted a hypoechoic mass protruding from deep mucosa into a unilocular submucosal cyst." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yu Tang, Xianfei Zhong, Zhengyu Cheng" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Yu" "apellidos" => "Tang" ] 1 => array:2 [ "nombre" => "Xianfei" "apellidos" => "Zhong" ] 2 => array:2 [ "nombre" => "Zhengyu" "apellidos" => "Cheng" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424001342?idApp=UINPBA00004N" "url" => "/24443824/0000004700000003/v2_202405192000/S2444382424001342/v2_202405192000/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "272" "paginaFinal" => "285" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Martínez-Guillén, Pere Clavé, Mónica Zavala, Silvia Carrión" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Miguel" "apellidos" => "Martínez-Guillén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Pere" "apellidos" => "Clavé" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mónica" "apellidos" => "Zavala" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Silvia" "apellidos" => "Carrión" "email" => array:1 [ 0 => "scarrion@csdm.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Pruebas Funcionales Digestivas, Hospital de Mataró, Mataró, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universidad La Salle México, Mexico City, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manometría de alta resolución con impedancia para el estudio de la motilidad faríngea y del esfínter esofágico superior: claves para su utilización en el estudio de la fisiopatología de la disfagia orofaríngea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4088 "Ancho" => 2500 "Tamanyo" => 572485 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Adaptation of the flow chart proposed by the International Working Group (Ascona-II) for the process of classifying categories of pharyngoesophageal dysfunction. B) Adaptation of the flow chart proposed at the Ascona-III International Working Group meeting for the classification of categories of pharyngoesophageal dysfunction based on the study by Omari et al.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> This diagram proposes to classify patients according to an initial pressurisation pattern. In pressurisation pattern type 1 (number 1) a clear biomechanical pattern of flow obstruction would appear. Patterns 2 or 3 are considered as UOS abnormalities/disorders when observing a combination of incomplete UOS relaxation (type 2), according to UOS IRP, or findings of altered distensibility (maximum UOS admittance) (type 3). To confirm UOS impairment in patients in whom there is no pressurisation pattern, both incomplete UOS relaxation and other distensibility impairments would be required (number 4). In patients where no UOS disorder is demonstrated (numbers 5–7), if pharyngeal propulsion is taken into account and is weak or absent, they would be classified as propulsion disorder (number 5). The remaining cases would be classified as "other disorders" if they have abnormal findings in one or more metrics (number 6), or no alterations if all variables are within normal ranges. HIBP: hypopharyngeal intrabolus pressure; LLN: lower limit of normal; PP: peak pressure; ULN: upper limit of normal; UOS: upper oesophageal sphincter; UOSRP: UOS relaxation pressure.<a class="elsevierStyleCrossRef" href="#bib0200">40</a>" ] ] ] "textoCompleto" => "IntroductionOropharyngeal dysphagia. Definition and prevalence in different patient phenotypesOropharyngeal dysphagia (OD) is a gastrointestinal motility disorder recognised by the World Health Organization’s International Classification of Diseases (ICD) with specific codes 787.2 (ICD-9) and R13.1 (ICD-10).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is caused by physiological disorders affecting the oropharyngeal motor response (OMR), such as ageing, degenerative and acute neurological diseases, such as cerebral vascular accident, or anatomical changes (head and neck tumours or radiotherapy).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> OD is recognised as a geriatric syndrome affecting 27% of older adults living independently and up to 51% of those who living in institutional care.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Biomechanics of oropharyngeal dysphagia in healthy people and in patientsThe process of swallowing is a complex phenomenon involving the passage of the bolus from the mouth into the oesophagus and a temporary transformation of the airway into a gastrointestinal tract.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The process involves motor and sensory structures and involves three distinct phases: an oral, voluntary phase in which the bolus is prepared and propelled into the pharynx<a class="elsevierStyleCrossRef" href="#bib0025">5</a>; a pharyngeal involuntary phase in which the temporary transformation of the oropharyngeal structures takes place, allowing the bolus to pass into the oesophagus via the upper oesophageal sphincter (UOS)<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>; and an oesophageal involuntary phase, which accompanies the bolus into the stomach.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Biomechanical changes in the oropharyngeal motor responseThe pathophysiology of the impaired safety is related to a delay in the activation of several physiological reflexes aimed at pharyngeal reconfiguration from airway to gastrointestinal tract, resulting in a slow neural swallowing response. Failures to swallow safely in OD patients are associated with an increased risk of aspiration and respiratory penetration with the risk of aspiration pneumonia<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> and failures in efficacy are related to impaired bolus transport due to decreased pharyngeal propulsive force or altered UOS opening, with the presence of residual food in the oropharynx and increased risk of malnutrition and dehydration.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Some of the most common causes are pathophysiological changes associated with ageing and neurodegenerative and pharmacological diseases.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Anatomical and histological factors of the pharynx and upper oesophageal sphincterThe UOS is a high-pressure anatomical region at the pharyngoesophageal junction about 3−4cm in length, comprising the lower pharyngeal constrictor, cricopharyngeus and cervical oesophageal striated muscles.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> The cricopharyngeus is located in the transition zone between the lower pharyngeal constrictor and the cervical oesophageal musculature, and the area of greatest pressure is in the upper region, which is anatomically bound by muscle tissue, cartilage and aponeurosis rather than a simple muscular ring.Histologically, the cricopharyngeus is a striated muscle of small, slow-twitch type I fibres, not set in parallel, which allows basal tone to be maintained.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> The presence of some fast-twitch fibres allows rapid contraction during swallowing, belching and vomiting. Relative to other skeletal muscles, the cricopharyngeus has a large proportion of connective tissue.Pathophysiological mechanisms involved in the opening of the UOS and different pathological patternsThe UOS is closed in the resting state and the following four phenomena are necessary for it to open: 1) interruption of vagal tone over the cricopharyngeus, allowing muscle relaxation; 2) anterior sphincter traction caused by hyoid muscle contraction; 3) propulsive forces of the tongue and pharynx on the bolus; and 4) sphincter compliance allowing complete relaxation, low residual pressures and absence of resistance during swallowing.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>The alterations in the mechanisms described above give rise to three major pathophysiological patterns of UOS dysfunction: a) restrictive change in flow at the UOS, where propulsive capacity at the base of the tongue and pharynx will be normal but with altered relaxation of the UOS due to neurological disease (central or spastic, such as Parkinson’s disease) with inability to interrupt the vagal tone on the cricopharyngeus, or isolated at the UOS with alteration of its compliance, as in the case of cricopharyngeal bars; b) weakness in the contraction of the hyoid musculature or the base of the tongue, secondary to neurodegenerative disease or sarcopenia with normal relaxation of the UOS; and c) mixed processes with both altered relaxation of the UOS and altered propulsive capacity of the tongue and pharynx, for example, in patients with previous radiotherapy treatment.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>Clinical and instrument-based diagnosis of oropharyngeal dysphagiaThe aim of diagnosis in OD is for a multidisciplinary team to assess swallowing efficiency and safety early, using clinical screening methods, such as medical history, specific questionnaires and validated clinical methods (for example, Volume-Viscosity Swallow Test [V-VST]). Subsequently, patients in whom abnormalities are detected in the validated clinical methods should have instrument-based assessment with videofluoroscopy (VFS) or assessment of swallowing by laryngoscopy (Fiberoptic Endoscopic Evaluation of Swallowing — FEES). Tests may then be supplemented with high-resolution pharyngoesophageal manometry (HRPM).The main aims of this article are to review the current accepted methodology for performing and interpreting HRPM; to provide guidelines for classifying the different patterns of UOS dysfunction using HRPM; and to be able to decide the most appropriate treatment for each patient.How useful is high-resolution oesophageal manometry?Background: high-resolution manometry and Chicago Classification (CC)High-resolution pharyngoesophageal manometry with impedance (HRPM-I) is a method for studying the pharyngoesophageal segment by recording the pressures and flow generated by the pharyngeal musculature during swallowing.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> The method has undergone major development over the last 10 years following the popularisation of high-resolution oesophageal manometry. UOS disorders account for 3% in manometry reports and are not currently included in the latest classifications of oesophageal motor disorders, such as the Chicago Classification version 4.0.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The High-Resolution Pharyngeal Manometry International Working Group (for the study of the pharynx and the UOS by HRPM-I) has recently published recommendations for the HRPM-I protocol and metrics,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> which we will discuss later. The recommendations were revised and updated at the last meeting of the group (the Ascona III Meeting) in May 2023 in line with the latest advances and published studies and are summarised in this review (Ascona III Advances in Clinical Measurement of Gastrointestinal Motility and Function). As regards the most suitable probe for the study of the pharyngoesophageal segment, the following phenomena should be taken into account: a) the UOS has a radial asymmetry and its major axis is transversely orientated, causing the manometry values to be higher in the anterior/posterior direction (9); b) during swallowing there is a rapid upward movement of the UOS; and c) all the muscles of the UOS and pharynx are striated and have very fast and intense contractions of up to 600mmHg/s. As such, accurate recording requires a probe with multiple radially and circumferentially orientated recording channels and high-frequency capture of pressure changes, as offered by solid-state probes.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Relationship between videofluoroscopy and high-resolution pharyngoesophageal manometry with impedanceVideofluoroscopy (VFS) is a dynamic radiological test which obtains imaging sequences of the swallowing of different boluses and viscosities in lateral and anterior/posterior profile,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> enabling visualisation of the anatomy and the functioning of the oropharynx and cervical oesophageal phase, assessing the efficacy and safety of swallowing and evaluating the opening of the UOS. With HRPM, it is possible to assess the relaxation of the UOS and to estimate UOS opening by measurement of impedance.A recent review proposes HRPM-I as a second line of investigation for swallowing disorders in the event that VFS or FEES does not provide a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> This is a conservative recommendation based on the lack of availability of HRPM-I in many centres<a class="elsevierStyleCrossRef" href="#bib0065">13</a> and the current lack of a protocol for its interpretation; in fact, the decision to perform HRPM-I after, during, or as the only technique would have to depend on the patient's characteristics, the main indication usually being the study of alterations of upper sphincter opening visible on VFS as cricopharyngeal "bars".<a class="elsevierStyleCrossRef" href="#bib0095">19</a>HRPM and impedance measurement: what is the added value?Impedance is a non-radiological tool enabling the study of fluid flow through the lumen of the pharyngoesophageal segment, which has a direct correlation with the opening area of the UOS.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> It also allows the speed and direction of the flow to be assessed. The passage of a bolus with high conductivity (mostly liquids and solids) causes the impedance to decrease with respect to the baseline level, and boluses with low conductivity (gas) cause an increase in impedance.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> The combination of pressure and impedance studies allows the simultaneous assessment of motility and flow, providing a visual representation of the pressure flow during swallowing, the objective variables of which are analysed by specific software.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> The nadir impedance value during bolus swallowing, or its inverse peak admittance, can be used to determine the maximum extent of luminal opening during the flow of the bolus.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Equipment for high-resolution pharyngoesophageal manometry with impedance, impedance measurement and probesA wide variety of HRPM-I models are currently available on the market; one systematic methodology review reports that the most popular device in published studies is the ManoScan™ HRM (MEDTRONIC, Minneapolis, Minnesota, USA)<a class="elsevierStyleCrossRef" href="#bib0110">22</a> followed by SolarGI™ (SolarGI HRM, Laborie, Orangeburg, New York, USA) and inSIGHT™ (inSIGHT, Diversatek, Milwaukee, Wisconsin, USA). This can be done using solid-state or water perfusion probes, although experts recommend the solid-state systems as they have a larger number of recording channels and can detect pressure changes at a high frequency, which is necessary when studying structures composed of skeletal muscle such as the pharynx and UOS. These probes must have at least 10 pressure sensors spaced 1cm apart, and if impedance is incorporated, these should be spaced every 2cm.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> The morphology of the UOS is narrow and asymmetrical, which makes the use of multiple circumferential sensors (radial orientation) necessary for study due to the anatomical characteristics described; although there is no expert positioning to date, it is the most widely used (61.3%) in the studies<a class="elsevierStyleCrossRef" href="#bib0110">22</a> included in the aforementioned review. Whereas in groups using solid-state probes, the most common number of recording channels used is 36, in the case of impedance probes it is 12.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>Software programmeFor data recording on the HRPM-I, most groups use the original software provided with the device (for example, Matlab™ [MathWorks, Natick]), MMS). However, most of them are designed for the recording of oesophageal body and lower oesophageal sphincter pressures, and to record certain metrics it is necessary to associate other specific software. In the case of incorporating impedance measurement, external software such as Matlab™ or AIMplot is normally used.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The software provided by MathWorks in MATLAB (computer language) is a fee-charging data analysis platform, in this case manometric data, extracted in an automated way by creating algorithms which allow the integrals to be calculated simply.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> However, although this allows the studies to be exported, it does not allow communication between different laboratories to compare studies. SwallowGateway™ (swallowgateway.com) is a currently fee-charging platform created in 2017 by Taher Omari<a class="elsevierStyleCrossRef" href="#bib0120">24</a> which allows automated analysis of data extracted from a manometry study with oesophageal and pharyngeal impedance in such a way that these are stored in a network. It also integrates diagnostic information, allowing communication and discussion between experts, and it has recently published a study that demonstrates its validity compared to other commercially available systems. The platform requires specific software configuration for each type of probe.MethodBefore the HRPM-I is performed, the patient is told about the examination and any discomfort or complications that may arise from it, all of which should be included in an informed consent form.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Also recommended prior to manometry are symptom assessment questionnaires, which can be given out along with the information or during preparation. The method recommended by the International Working Group is set out in their recent publication<a class="elsevierStyleCrossRef" href="#bib0075">15</a>: when performing HRPM-I, both pharyngeal and oesophageal pressures and impedance studies should be performed to assess flow through the UOS and estimate its opening.Probe placement is carried out by trained personnel using lubricating gel and small sips of water with a straw<a class="elsevierStyleCrossRef" href="#bib0075">15</a>; it has recently been shown that the use of nasal topical anaesthetic does not improve patient comfort or well-being, but does improve tolerance of 4.2mm probes, and does not affect the swallowing process.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> An accommodation period of about 5min is recommended, with the patient seated or semi-reclined, with the head in a neutral position. There is still no standardised protocol, although the International Working Group recommends a minimum standardised research protocol which should include both dry and liquid swallows of different volumes, with 5 and 10ml being the most commonly used and 20ml only in selected cases, administered with a 20ml syringe and each repeated at least three times. According to two recent studies, both voluntary and natural swallows should be incorporated: the former since several consecutive swallows increase the variability of pharyngeal pressure and may be an indicator of the compensatory response in patients with Parkinson's<a class="elsevierStyleCrossRef" href="#bib0130">26</a>; and the latter as they are more uniform and present a more efficient swallowing dynamic than structured swallowing.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> In addition, different viscosities are recommended and should be reproducible to assess the effect of volume and viscosity on the behaviour of the pharyngoesophageal segment.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> There is currently no consensus on the terminology used, however, to describe the different viscosity levels for thickened liquids. The European Society for Swallowing Disorders (ESSD) advises viscosity to be referred to in international system measurements (mPa-s) avoiding viscosity ranges and qualitative descriptors, as many classifications, such as the International Dysphagia Diet Standardisation Initiative (IDDSI), do not express viscosity in scientific terms, but based on the subjective behaviour of fluid flow inside a syringe.In a recently published paper by the T. Omari group studying the effect of volume and viscosity change on pharyngeal modulation, the protocol was based on the administration of four different volumes (3, 5, 10 and 20ml) and three different viscosities, which were confirmed using the IDDSI system and for which the shear viscosity rate was calculated by rheometer to establish viscosities of 37.37±5.16mPa-s (IDDSI 2) and 637.49±33.71mPa-s (IDDSI 4) at 50s−1.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> This study highlights the importance of implementing volume and viscosity change in different swallows since the authors report significant changes in pharyngeal metrics, such as an increase in intrabolus pressure in the hypopharynx or in the integrated relaxation pressure of the UOS.MetricsThe recommendation of the International Working Group regarding the metrics for the study of OD by HRPM-I is that any study should describe these three main phenomena: a) relaxation of the UOS; b) resistance to flow through the UOS; and c) the strength of bolus propulsion forces (by tongue and pharynx). Accordingly, the metrics should assess in that order: a) the relaxation pressures of the UOS; b) the intrabolus pressure in the hypopharynx as a measure of resistance to passage through the UOS; and c) the contractile pressures of the pharynx and base of tongue above the UOS. There are different metrics which can define these phenomena; the most important ones for diagnosis are described below.Relaxation and opening of the UOSRelaxation and opening of the UOS is a complex process which depends on the volume and viscosity of the bolus. The relaxation pressure of the UOS, determined manometrically, correlates well with the electromyography of the cricopharyngeus through its activation (rest) and deactivation (relaxation, during swallowing) mediated by the brainstem<a class="elsevierStyleCrossRefs" href="#bib0095">19,29</a>; these increase with bolus volume and with age (intrabolus pressure being an indirect measure of relaxation). The mechanisms determining the opening of the UOS depend on the strength and synchronisation of the supra- and infra-hyoid muscles, the bolus (pharyngeal propulsion), the inhibition of neural tone and the compliance of the cricopharyngeus and can be assessed by impedance measurement. Theoretically, the luminal impedance measured during the flow of a bolus is influenced by the diameter of the lumen through which it passes and, in fact, the nadir impedance corresponds to the moment when the lumen is distended to its maximum during bolus ingestion and has therefore been used as a time reference point for the measurement of pressures using HRPM.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> According to theoretical principles, the impedance of a filled chamber is inversely proportional to its cross-sectional area, a basic principle of the EndoFLIP technique which adapts the principles of impedance planimetry into a functional luminal technique.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Studies comparing manometry and impedance with VFS have demonstrated the effectiveness of impedance in assessing the diameter of the UOS lumen and thus its opening.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> In recent years, the inverse of the nadir impedance has been used, known as admittance, which is the highest value recorded during bolus flow through the UOS as it is more intuitive than impedance and has been shown to be a good marker of UOS opening dysfunction and, compared to UOS-IRP, appears to be better at discriminating between groups of patients with pharyngeal motor impairment.UOS relaxation measurements:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a.The UOS relaxation time (UOS-RT) is the time interval of eSleeve recording at a pressure below 50% of the baseline UOS pressure, measured in seconds.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> The introduction of the eSleeve in HRPM-I has improved UOS analysis as it avoids calculation errors caused by elevation of the UOS during swallowing. It is higher in the supine position and is not affected by gender, height, weight or BMI.<a class="elsevierStyleCrossRef" href="#bib0165">33</a></li><li class="elsevierStyleListItem" id="lsti0010">b.UOS relaxation pressure: two metrics used in the study of UOS relaxation pressure are the minimum relaxation pressure (or nadir pressure) and the integrated relaxation pressure (UOS-IRP). The UOS-IRP is the mean of pressures during the 0.25s of maximum relaxation, reflects the bolus pressure within the sphincter and indicates complete relaxation of the UOS and sphincter compliance.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> It is similar to the IRP-4s used to assess the oesophagogastric junction (OGJ). The UOS-IRP is the current preferred metric, as it is more accurate for being a set of measurements which combines pressure and time collected in 0.25s.</li></ul>UOS opening measurements:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">a.Determination of UOS Max Admitance, the inverse of nadir impedance, is performed by calculating the highest admittance value recorded during bolus flow through the UOS.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> It has been shown to be a marker of UOS opening dysfunction and, compared to UOS-IRP, may be better at discriminating between groups of patients with pharyngeal motor impairment.<a class="elsevierStyleCrossRef" href="#bib0100">20</a></li></ul>Assessment of flow resistance through UOS: hypopharyngeal intrabolus pressureProper bolus flow requires proper propulsion of the tongue and pharynx and proper relaxation and opening of the UOS which confers low resistance to the bolus passing through it. A metric has been developed to assess bolus passage resistance, hypopharyngeal intrabolus pressure (HIBP), which has been shown to be a good manometric marker of flow resistance at the UOS,<a class="elsevierStyleCrossRefs" href="#bib0060">12,35</a> which increases with bolus volume and viscosity. The HIBP gradient reflects the pressure difference between the pharynx and the UOS during bolus passage through the sphincter, and three metrics have been proposed, the first two of which are the most widely used in the literature:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020">a.Mid-hypopharyngeal intrabolus pressure (mid-hypopharyngeal IBP) was most commonly used on its own prior to the introduction of high-resolution manometry and required video-manometry.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> It is defined as the pressure at the midpoint of the bolus as it advances, recorded radiologically.</li><li class="elsevierStyleListItem" id="lsti0025">b.Hypopharyngeal pressure at nadir impedance (PNadImp or PNI): this is the pressure at the time of maximum hypopharyngeal distension (or admittance) determined by the impedance value 1cm above the highest point (or pharyngoesophageal junction) of the UOS.<a class="elsevierStyleCrossRefs" href="#bib0175">35,37</a> This measurement is the mechanical consequence of lingual and pharyngeal propulsive forces together with the diameter of the lumen.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> An abnormally high PNI may therefore be a marker of flow restriction due to structural disease. Previous studies have shown it to be a predictor of stricture of the pharyngoesophageal junction and it loses predictive value when pharyngeal contractile forces are too weak to mobilise the bolus,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> since ineffective propulsion of the bolus (due to sarcopenia, for example) will prevent hypopharyngeal pressure from developing despite the presence of a stricture.</li><li class="elsevierStyleListItem" id="lsti0030">c.Hypopharyngeal pressure increment (HPI), defined by the average of pressures preceding the onset of pharyngeal contraction at a threshold of 20mmHg. As there has only been one study with healthy volunteers, HPI is not used in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0075">15</a></li></ul>The pressure generated by epiglottic inversion<a class="elsevierStyleCrossRef" href="#bib0190">38</a> is an artefact that must be taken into account when performing HRPM-I, and may lead to potentially erroneous intrabolus pressure results, for example, by giving higher HIBP values.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Assessment of pharyngeal propulsive forcesPatients with OD may have sequential and coordinated oropharyngeal motor response (OMR), but weak lingual and pharyngeal propulsive force, leading to bolus residue in the vallecula or pyriform sinuses and being susceptible to post-swallowing aspiration.<a class="elsevierStyleCrossRefs" href="#bib0065">13,15</a> To assess pharyngeal propulsive forces, we can assess the different regions of the pharynx separately (velo-, oro- and hypopharynx) and the UOS, combinations of them or the whole pharynx (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The velopharynx comprises the velus palatini muscle, the tensor veli palatini muscle, the uvula muscle, the palatoglossus muscle, the palatopharyngeus muscle and the superior pharyngeal constrictor. The oropharynx is the most posterior region of the oral cavity. It extends from the soft palate to the hyoid and includes the posterior segment of the tongue, including the upper and middle constrictor, palatoglossus and hyoglossus muscles. On the anterior aspect, it borders the oral cavity by means of the anterior and posterior palatine pillars and on each side by the palatine tonsils. The hypopharynx extends from the imaginary line at the level of the hyoid bone to the lower edge of the cricoid cartilage, where it continues with the UOS. It comprises three regions or sub-sites: the pyriform sinuses, the posterior and lateral pharyngeal wall (middle and inferior pharyngeal constrictor muscles), and the postcricoid region.<a class="elsevierStyleCrossRef" href="#bib0195">39</a>The metrics used for the propulsive assessment of the pharynx are as follows:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035">a.Peak pharyngeal pressure (PeakP) represents the strength of the pharyngeal contraction and averages 140mmHg (107−194mmHg).<a class="elsevierStyleCrossRef" href="#bib0175">35</a> No complex software is required to determine PeakP, but the measurements produce variable results and artefacts are common with the probe. This contractility metric has been shown to be a predictor of aspiration and presence of pyriform sinus bolus residue in a study comparing HRPM-I and VFS,<a class="elsevierStyleCrossRef" href="#bib0200">40</a> where it was the best metric for differentiating patients from controls in the absence of UOS abnormalities.</li><li class="elsevierStyleListItem" id="lsti0040">b.The pharyngeal contractile integral (PhCI), like the distal contractile integral (DCI) in the distal oesophagus, is a good marker of the so-called "vigour" of the pharyngeal swallowing response. Studying the different contractile integrals of the regions described (velo-[VCI], oro-[OCI] and hypopharynx [HCI]), however, is recommended in the case of a patient with an apparently normal PhCI, as this may be the result of compensation with increased pressure in one of the regions (oropharynx) due to the weakness of another (velo or hypopharynx).<a class="elsevierStyleCrossRef" href="#bib0075">15</a> The velopharynx, which is responsible for sealing the nasopharynx when subjected to high volumes, appears to be an important marker of volume modulation.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> In the study of pharyngeal regions, the use of the VCI and OCI is recommended, as in the velopharynx and oropharynx the pressures are sustained or multimodal, meaning they remain stable or vary only for a few milliseconds. This is not so necessary for the hypopharynx, as in this area the response is brief and unimodal, reaching a pressure peak in a few milliseconds and then returning to the resting pressure.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> These pressures tend to be higher with higher volumes and viscosities, age (compensation for increased UOS opening resistance) and with chin-tuck or Mendelsohn manoeuvres. Reporting and interpreting the different regions may therefore be more useful than PhCI for patients with dysphagia as VCI and OCI have been shown to be predictors of aspiration and the presence of bolus residue.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> The problem with this metric is that it does not differentiate as accurately as PeakP between controls and patients, so future studies will need to establish which metric is the most accurate for assessing pharyngeal propulsive capacity.<a class="elsevierStyleCrossRef" href="#bib0200">40</a></li></ul>Other measures associated with impedanceImpedance complements manometry in the study of swallowing as it allows the presence and flow of the bolus through the pharynx to be determined. Two metrics have been implemented that help the study of bolus flow in relation to time and pharyngeal contractile force.The bolus presence time (BPT) is a temporal metric, which indicates the time the bolus remains in the hypopharynx during the time of maximum admittance from the moment of opening to the closure of the UOS.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> An elevated BTP value may indicate either a drop or premature arrival of the bolus in the hypopharynx or the presence of post-swallowing bolus residue.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>The distension-contraction latency is a metric reflecting a temporal relationship between the point of maximum admittance (distension) in the hypopharynx and the peak pharyngeal pressure or PeakP.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> Low values suggest insufficient tongue thrust (if HIBP is low) or resistance to flow (when HIBP is normal).<a class="elsevierStyleCrossRef" href="#bib0095">19</a>Patterns of pharyngoesophageal dysfunction in HRPM-IAt the previous Ascona II meeting (2015), the International Working Group proposed classifying patients into three patterns of dysfunction based on the pattern and metrics discussed above. Since then, however, a study published in 2022 has proposed a new algorithm based on the pattern of pressurisation<a class="elsevierStyleCrossRef" href="#bib0200">40</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Both classifications require further evidence for validation, so we suggest maintaining the classification presented at Ascona II, but with the recommendations regarding the metrics proposed in the new publications and discussed at Ascona III.<a class="elsevierStyleCrossRef" href="#bib0200">40</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Category 1: "UOS flow restriction with normal propulsion"This pattern occurs in patients in whom there is adequate propulsion of the bolus in the pharynx (both by the base of the tongue and by the pharyngeal constrictors), along with restrictive impairment of relaxation at the level of the UOS. According to recent studies, the metric which best defines this category would be a higher than normal UOS IRP, recommending the use of other metrics to support the diagnosis such as increased HIBP or decreased UOS admittance along with some added pressurisation pattern.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> An example of this category can be seen in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>This category includes patients with a pure restrictive pattern with flow obstruction at the level of the UOS, such as those with Zenker’s diverticulum or with cricopharyngeal bar as the only abnormality. This group of patients is characterised by normal OMR with normal bolus propulsion and reduced UOS compliance secondary to UOS fibrosis. <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a> shows a videofluoroscopy image of a patient with abnormal opening of the UOS with a Zenker’s diverticulum. Histological studies<a class="elsevierStyleCrossRef" href="#bib0215">43</a> have clearly established that the pathophysiology of reduced UOS distensibility is due to fibrosis of the sphincter muscle fibres. The preferred treatment choice for this group of patients is endoscopic myotomy of the cricopharyngeus using C-POEM, with excellent results while keeping the OMR intact,<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> rendering surgery obsolete due to potential secondary complications. Dilation is an option for patients who are not candidates for myotomy.<a class="elsevierStyleCrossRef" href="#bib0220">44</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Category 2: "Restricted flow in the UOS with propulsive defect"This category includes patients with propulsive defects at the base of the tongue, or pharyngeal constrictors together with a restrictive pattern at the level of the UOS. The metric which best characterises this case is the relaxation pressure of the UOS, and specifically high values in conjunction with a decrease in pharyngeal propulsion.Two sub-phenotypes can be distinguished according to pharyngeal contractility: a) type I with absent contractility, based on manometrically undetectable contraction; and b) type II with weak contractility, based on peak pressure (PP) below the lower limit of normal. An example is shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>The second category includes patients with spastic neurological diseases, such as Parkinson's, spinal cord injury and patients treated by radiotherapy. This group of patients is characterised by impaired or absent OMR and weak bolus propulsion; they also have impaired or absent UOS relaxation. In this category where propulsive forces are diminished, myotomy does not work well; injection of Botox into the UOS or dilation may be a treatment option in conjunction with C-POEM.<a class="elsevierStyleCrossRefs" href="#bib0220">44,45</a> Neurorehabilitation strategies to improve bolus propulsion forces are also recommended in this pattern.Category 3: "Ineffective pharyngeal contraction" This group includes patients with ineffective pharyngeal contraction pressure (PP<LLN) and normal UOS relaxation and opening (normal UOS-IRP), an example of which can be seen in <a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>. As previously mentioned, PP was the metric that best discriminated between patients and controls in a recent study when there was normal UOS relaxation and opening.<a class="elsevierStyleCrossRef" href="#bib0200">40</a><elsevierMultimedia ident="fig0030"></elsevierMultimedia>In this category we find older adult patients with sarcopenia or those with neurodegenerative diseases with impaired OMR, along with decreased lingual and pharyngeal propulsion and probable ineffective hyoid traction, and normal UOS relaxation. Treatment of these patients is based on rehabilitation programmes to improve tongue strength and hyoid movement, and neurorehabilitation.DiscussionWe have presented here a review of the methodology and metrics used by the main working groups along with a description of the main patterns of dysfunction and specific recommendations according to our experience, in order to highlight the utility of HRPM-I in studying the pathophysiology and selection of a specific treatment in patients with OD. In our opinion, this technique is now essential for selecting specific treatment for patients with alterations in the opening of the upper oesophageal sphincter confirmed by videofluoroscopy.The study of swallowing disorders today involves the implementation of different diagnostic techniques such as VFS and HRPM-I, which complement each other in terms of understanding the functioning and disorders of the pharyngoesophageal junction.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> With a simple protocol, VFS makes it possible to assess the efficiency and safety of swallowing and can also diagnose abnormalities in the opening of the UOS, such as cricopharyngeal bars, Zenker’s diverticula or extrinsic compressions such as cervical osteophytes. HRPM-I, on the other hand, allows us to study the contractile force of the tongue and pharynx, and abnormalities in the relaxation of the UOS. Therefore, when VFS shows a patient to have impaired opening of the UOS, HRPM-I should be performed to measure the contractile forces of the pharynx, the resistance to flow and the relaxation of the UOS. Although some groups perform both techniques together, we believe that keeping the manometry probe in place during VFS may interfere with the study, so our recommendation would be to perform the two techniques separately and analyse the results together. As restrictive abnormalities at the oesophagogastric junction can be revealed by an increase in volume and viscosity,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> our protocol uses different volumes and viscosities, always following the measurements of the international system (mPa-s) and performing two swallows for each category.As previously mentioned, patients are currently divided into three disease patterns<a class="elsevierStyleCrossRef" href="#bib0075">15</a> and, according to each, we define a metric that helps us to categorise them and propose a specific treatment. In our experience, the metrics which are currently enabling us to study these patients is: a) the integrated relaxation pressure (UOS-IRP) of the UOS in cases with restrictive pattern at the UOS, in both patients with normal and decreased pharyngeal propulsive pattern; b) the intrabolus pressure in the hypopharynx, using hypopharyngeal pressure at nadir impedance as a measure to support the restrictive component of the upper oesophageal sphincter in patients with normal pharyngeal motility; and c) the PhCI integral, assessing the contractile integral of each zone separately to obtain more detailed information together with the hypopharyngeal PeakP to assess the propulsive capacity of the pharynx in patients with correct UOS relaxation and suspected pharyngeal propulsive impairment.With regard to patient management, in our experience, HRPM-I has been particularly useful in deciding on therapeutic management in patients with impaired UOS opening with cricopharyngeal bar and Zenker’s diverticulum. For patients with cricopharyngeal bars but with slightly impaired relaxation and no repercussions in terms of hypopharyngeal pressure on nadir impedance, we have applied conservative treatment, with dietary recommendations involving restriction of highly fibrous and hard solids, and prioritising proper chewing. For patients with impaired cricopharyngeal bar opening and impaired UOS relaxation, with significantly increased hypopharyngeal pressure and normal pharyngeal contraction strength, the treatment option has been to perform a myotomy using C-POEM, as the reduction in distensibility is due to fibrosis of the muscle fibres, with very good subsequent outcomes.<a class="elsevierStyleCrossRefs" href="#bib0225">45,46</a>In patients with restricted flow in the UOS with propulsive defect, which includes patients with neurological disorders such as Parkinson's disease, surgical myotomy does not guarantee good results as it could worsen pharyngeal functional reserve. In this phenotype of patients, however, good options are dilation, Botox injection or the more recently proposed C-POEM, combined with neurorehabilitation strategies to improve bolus propulsive forces.<a class="elsevierStyleCrossRefs" href="#bib0225">45,47</a> Even so, this patient phenotype requires an individualised and multidisciplinary approach to indicate the most appropriate therapeutic option.In patients with no restrictive component at the UOS, but who have ineffective pharyngeal contraction, our recommendation would be to improve their fragility status and sarcopenia, in combination with rehabilitation to improve tongue and pharyngeal propulsion and upward movement of the hyoid bone. The Shaker manoeuvre based on isometric and isotonic exercises of the supra-hyoid muscles has been shown to increase the opening of the UOS and decrease post-swallowing bolus residue and posterior aspiration.<a class="elsevierStyleCrossRef" href="#bib0240">48</a>Apart from its diagnostic utility, HRPM-I is being implemented in some centres as part of rehabilitation techniques for HRPM-I-guided biofeedback, to improve swallowing ability in patients with oropharyngeal dysphagia. This therapeutic modality allows the patient to intuitively implement the rehabilitation exercises and manoeuvres, while the rehabilitator can monitor performance and then set and plan the exercises, taking into account the results and tendency to become fatigued, and so improve adherence.<a class="elsevierStyleCrossRef" href="#bib0245">49</a>ConclusionIn recent years, high-resolution pharyngoesophageal impedance manometry has become a necessary tool for the study of patients with oropharyngeal dysphagia, a highly prevalent condition in the older adult population and in those with a neurological history with significant consequences. The International Working Group has published a first revision for the standardisation of the protocol for pharyngeal and UOS examination and metrics which enables classification of the pathophysiological findings in HRPM-I into three broad categories according to restrictive UOS opening versus pharyngeal propulsive patterns. One of the current challenges is to define which metrics and values better discriminate between normal and diseased, and how to integrate the pathophysiological and clinical findings patients present in different categories, in order to make a more targeted therapeutic approach. Multimodal treatment for swallowing disorders should combine compensatory strategies, speech therapy and new neurorehabilitation treatments, including non-invasive brain stimulation. The data available at present still leave unanswered questions, both from a technological and methodological point of view. However, they do provide a first step, so that the working groups can follow the same methodology, while also having computer tools to facilitate their study and the possibility of sharing data between different specialists. The aim of this paper was to review the current literature and summarise the most important points in order to highlight the need for the implementation of this technique and its applications.Ethical considerationsThis work did not involve the use of human subjects.FundingThis study received no specific funding from public, private or non-profit organisations.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2148808" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1823729" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2148807" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1823730" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Oropharyngeal dysphagia. Definition and prevalence in different patient phenotypes" ] 1 => array:3 [ "identificador" => "sec0015" "titulo" => "Biomechanics of oropharyngeal dysphagia in healthy people and in patients" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Biomechanical changes in the oropharyngeal motor response" ] ] ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Anatomical and histological factors of the pharynx and upper oesophageal sphincter" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Pathophysiological mechanisms involved in the opening of the UOS and different pathological patterns" ] ] ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinical and instrument-based diagnosis of oropharyngeal dysphagia" ] ] ] 5 => array:3 [ "identificador" => "sec0040" "titulo" => "How useful is high-resolution oesophageal manometry?" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Background: high-resolution manometry and Chicago Classification (CC)" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Relationship between videofluoroscopy and high-resolution pharyngoesophageal manometry with impedance" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "HRPM and impedance measurement: what is the added value?" ] ] ] 6 => array:3 [ "identificador" => "sec0060" "titulo" => "Equipment for high-resolution pharyngoesophageal manometry with impedance, impedance measurement and probes" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Software programme" ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Method" ] 8 => array:3 [ "identificador" => "sec0075" "titulo" => "Metrics" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Relaxation and opening of the UOS" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "Assessment of flow resistance through UOS: hypopharyngeal intrabolus pressure" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Assessment of pharyngeal propulsive forces" ] 3 => array:2 [ "identificador" => "sec0095" "titulo" => "Other measures associated with impedance" ] ] ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Patterns of pharyngoesophageal dysfunction in HRPM-I" ] 10 => array:2 [ "identificador" => "sec0105" "titulo" => "Discussion" ] 11 => array:2 [ "identificador" => "sec0110" "titulo" => "Conclusion" ] 12 => array:2 [ "identificador" => "sec0115" "titulo" => "Ethical considerations" ] 13 => array:2 [ "identificador" => "sec0120" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0125" "titulo" => "Conflicts of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-11" "fechaAceptado" => "2023-09-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1823729" "palabras" => array:3 [ 0 => "High-resolution esophageal manometry" 1 => "Oropharyngeal dysphagia" 2 => "Upper esophageal sphincter" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1823730" "palabras" => array:3 [ 0 => "Manometría de alta resolución" 1 => "Disfagia orofaringea" 2 => "Esfínter esofágico superior" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Oropharyngeal dysphagia (OD) is a pathology with a high prevalence in different patient phenotypes. High-resolution pharyngoesophageal manometry (HRPM) with impedance (HRPM-I) has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter (UES) dysfunctions in patients with OD. Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardisation of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of three main phenomena: relaxation of the UES, resistance to flow through the UES and propulsion of the bolus through the pharynx into the oesophagus. According to the alterations of these metrics, three patterns of dysfunction are proposed that allow a specific therapeutic approach: a) UES flow restriction with normal pharyngeal propulsion, b) UES flow restriction with ineffective pharyngeal propulsion, and c) ineffective pharyngeal contraction with normal relaxation of the UES. We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La disfagia orofaríngea (DO) es una patología con una alta prevalencia en diferentes fenotipos de pacientes. La manometría de alta resolución faringoesofágica (MARFE) con impedancia (MARFE-I) se ha convertido en los últimos años en una técnica fundamental para el mejor entendimiento de la fisiopatología de las disfunciones de la faringe y del esfínter esofágico superior (EES) en pacientes con DO. Diversos grupos de expertos han propuesto una metodología para la práctica de la MARFE-I y para la estandarización de las diferentes métricas para el estudio de las disfunciones de la motilidad faríngea y del EES basadas en el la cuantificación de tres fenómenos principales: la relajación del EES, la resistencia al flujo a través del EES y la propulsión del bolo a través de la faringe hacia el esófago. De acuerdo a las alteraciones de estas métricas, se proponen tres patrones de disfunción que permiten un abordaje terapéutico específico: a) restricción al flujo del EES con propulsión faríngea normal, b) restricción al flujo del EES con propulsión faríngea inefectiva y, c) contracción faríngea inefectiva con normal relajación del EES. Presentamos una revisión práctica de la metodología y la métrica que emplean los principales grupos de trabajo junto con la descripción de los principales patrones de disfunción de acuerdo a nuestra experiencia para poner de relevancia la utilidad de la MARFE-I en el estudio de la fisiopatología y selección de un tratamiento específico en pacientes con DO." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1140 "Ancho" => 1625 "Tamanyo" => 222518 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Image of a manometry tracing of a normal swallow. This figure shows normal swallowing in which it is possible to differentiate: a) a normal relaxation of the UOS, studied by means of the minimum relaxation pressure (or nadir) and the relaxation integral of the UOS (UOS-IRP); b) resistance to flow through the UOS (in this case absent hypopharyngeal intrabolus pressure), studied by hypopharyngeal intrabolus pressure (HIBP); and c) assessment of tongue and pharyngeal propulsion, shown as a normal propulsive pharyngeal wave, by means of the pharyngeal peak pressure and the pharyngeal contractile integral (PhCI) which can be assessed together or divided into the different anatomical regions (velo-, oro- or hypopharynx)." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4088 "Ancho" => 2500 "Tamanyo" => 572485 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Adaptation of the flow chart proposed by the International Working Group (Ascona-II) for the process of classifying categories of pharyngoesophageal dysfunction. B) Adaptation of the flow chart proposed at the Ascona-III International Working Group meeting for the classification of categories of pharyngoesophageal dysfunction based on the study by Omari et al.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> This diagram proposes to classify patients according to an initial pressurisation pattern. In pressurisation pattern type 1 (number 1) a clear biomechanical pattern of flow obstruction would appear. Patterns 2 or 3 are considered as UOS abnormalities/disorders when observing a combination of incomplete UOS relaxation (type 2), according to UOS IRP, or findings of altered distensibility (maximum UOS admittance) (type 3). To confirm UOS impairment in patients in whom there is no pressurisation pattern, both incomplete UOS relaxation and other distensibility impairments would be required (number 4). In patients where no UOS disorder is demonstrated (numbers 5–7), if pharyngeal propulsion is taken into account and is weak or absent, they would be classified as propulsion disorder (number 5). The remaining cases would be classified as "other disorders" if they have abnormal findings in one or more metrics (number 6), or no alterations if all variables are within normal ranges. HIBP: hypopharyngeal intrabolus pressure; LLN: lower limit of normal; PP: peak pressure; ULN: upper limit of normal; UOS: upper oesophageal sphincter; UOSRP: UOS relaxation pressure.<a class="elsevierStyleCrossRef" href="#bib0200">40</a>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 3034 "Ancho" => 3000 "Tamanyo" => 727581 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Manometry tracing of a 20ml swallow with nectar viscosity (250mPa-s) of a patient with a cricopharyngeal bar is shown. Normal pharyngeal propulsive force (350mmHg-s-cm). An alteration of UOS relaxation according to the UOS-IRP 0.2s of 28mmHg is observed and increases with successive swallows with increasing volume and viscosity, suggesting a restrictive pattern. As a result of the phenomena described above, there is an increase in intrabolus pressure in the hypopharynx and the UOS, which also increases with volume and viscosity during successive swallows." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1384 "Ancho" => 3000 "Tamanyo" => 173217 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Videofluoroscopic image of a patient with abnormal opening of the UOS with a Zenker's diverticulum. This group of patients has a normal OMR and HRPM-I will show normal bolus propulsion but incomplete UOS relaxation, with increasing volume leading to increased intrabolus pressure (HIBP) and increased relaxation pressure (UOS-IRP). The treatment option in these patients is surgical or endoscopic myotomy by POEM, as the reduction in distensibility is due to fibrosis of the muscle fibres, with very good results." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 3003 "Ancho" => 3000 "Tamanyo" => 701111 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "High resolution manometry and impedance tracing of a 20ml nectar viscosity swallow (250mPas), fractionated, in an older adult patient with cricopharyngeal bar showing flow restriction with incomplete UOS relaxation and weak pharyngeal propulsion. Peak pharyngeal pressure, which assesses the strength of pharyngeal contraction, is decreased, as is pharyngeal propulsive force vigour (PhCI) and pharyngeal propulsive force amplitude. The pharyngeal wave is fragmented and has low amplitude mainly in the oropharynx (OCI). It shows an increased UOS-IRP (IRP-0.2s 13mmHg), demonstrating incomplete relaxation of the UOS. Given the impaired relaxation of the UOS, we would expect an increase in pharyngeal intrabolus pressure (HIBP). However, HIBP is normal due to ineffective pharyngeal propulsion." ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 3299 "Ancho" => 3000 "Tamanyo" => 664502 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "High resolution manometry and impedance tracing of a patient with oculopharyngeal muscular dystrophy showing ineffective pharyngeal contraction with correct relaxation of the UOS. Pharyngeal contractile integral (PhCI) or vigour is decreased in this patient (34mmHg-s-cm), with pharyngeal wave virtually absent. With regard to UOS relaxation and bolus resistance we can see that both are normal." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:49 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dysphagia: current reality and scope of the problem" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Clavé" 1 => "R. 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High-resolution manometry with impedance for the study of pharyngeal motility and the upper esophageal sphincter: Keys for its use in the study of the pathophysiology of oropharyngeal dysphagia

Manometría de alta resolución con impedancia para el estudio de la motilidad faríngea y del esfínter esofágico superior: claves para su utilización en el estudio de la fisiopatología de la disfagia orofaríngea

Miguel Martínez-Guilléna, Pere Clavéa,b, Mónica Zavalaa,c, Silvia Carrióna,b,

Corresponding author

scarrion@csdm.cat

Corresponding author.

a Unidad de Pruebas Funcionales Digestivas, Hospital de Mataró, Mataró, Barcelona, Spain

b Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain

c Universidad La Salle México, Mexico City, Mexico

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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; Adaptation of the flow chart proposed by the International Working Group &#40;Ascona-II&#41; for the process of classifying categories of pharyngoesophageal dysfunction&#46; B&#41; Adaptation of the flow chart proposed at the Ascona-III International Working Group meeting for the classification of categories of pharyngoesophageal dysfunction based on the study by Omari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> This diagram proposes to classify patients according to an initial pressurisation pattern&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In pressurisation pattern type 1 &#40;number 1&#41; a clear biomechanical pattern of flow obstruction would appear&#46; Patterns 2 or 3 are considered as UOS abnormalities&#47;disorders when observing a combination of incomplete UOS relaxation &#40;type 2&#41;&#44; according to UOS IRP&#44; or findings of altered distensibility &#40;maximum UOS admittance&#41; &#40;type 3&#41;&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To confirm UOS impairment in patients in whom there is no pressurisation pattern&#44; both incomplete UOS relaxation and other distensibility impairments would be required &#40;number 4&#41;&#46; In patients where no UOS disorder is demonstrated &#40;numbers 5&#8211;7&#41;&#44; if pharyngeal propulsion is taken into account and is weak or absent&#44; they would be classified as propulsion disorder &#40;number 5&#41;&#46; The remaining cases would be classified as &#34;other disorders&#34; if they have abnormal findings in one or more metrics &#40;number 6&#41;&#44; or no alterations if all variables are within normal ranges&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HIBP&#58; hypopharyngeal intrabolus pressure&#59; LLN&#58; lower limit of normal&#59; PP&#58; peak pressure&#59; ULN&#58; upper limit of normal&#59; UOS&#58; upper oesophageal sphincter&#59; UOSRP&#58; UOS relaxation pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Oropharyngeal dysphagia&#46; Definition and prevalence in different patient phenotypes</span><p id="par0005" class="elsevierStylePara elsevierViewall">Oropharyngeal dysphagia &#40;OD&#41; is a gastrointestinal motility disorder recognised by the World Health Organization&#8217;s International Classification of Diseases &#40;ICD&#41; with specific codes 787&#46;2 &#40;ICD-9&#41; and R13&#46;1 &#40;ICD-10&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is caused by physiological disorders affecting the oropharyngeal motor response &#40;OMR&#41;&#44; such as ageing&#44; degenerative and acute neurological diseases&#44; such as cerebral vascular accident&#44; or anatomical changes &#40;head and neck tumours or radiotherapy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> OD is recognised as a geriatric syndrome affecting 27&#37; of older adults living independently and up to 51&#37; of those who living in institutional care&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Biomechanics of oropharyngeal dysphagia in healthy people and in patients</span><p id="par0010" class="elsevierStylePara elsevierViewall">The process of swallowing is a complex phenomenon involving the passage of the bolus from the mouth into the oesophagus and a temporary transformation of the airway into a gastrointestinal tract&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The process involves motor and sensory structures and involves three distinct phases&#58; an oral&#44; voluntary phase in which the bolus is prepared and propelled into the pharynx<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; a pharyngeal involuntary phase in which the temporary transformation of the oropharyngeal structures takes place&#44; allowing the bolus to pass into the oesophagus via the upper oesophageal sphincter &#40;UOS&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#59; and an oesophageal involuntary phase&#44; which accompanies the bolus into the stomach&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Biomechanical changes in the oropharyngeal motor response</span><p id="par0015" class="elsevierStylePara elsevierViewall">The pathophysiology of the impaired safety is related to a delay in the activation of several physiological reflexes aimed at pharyngeal reconfiguration from airway to gastrointestinal tract&#44; resulting in a slow neural swallowing response&#46; Failures to swallow safely in OD patients are associated with an increased risk of aspiration and respiratory penetration with the risk of aspiration pneumonia<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> and failures in efficacy are related to impaired bolus transport due to decreased pharyngeal propulsive force or altered UOS opening&#44; with the presence of residual food in the oropharynx and increased risk of malnutrition and dehydration&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Some of the most common causes are pathophysiological changes associated with ageing and neurodegenerative and pharmacological diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Anatomical and histological factors of the pharynx and upper oesophageal sphincter</span><p id="par0020" class="elsevierStylePara elsevierViewall">The UOS is a high-pressure anatomical region at the pharyngoesophageal junction about 3&#8722;4<span class="elsevierStyleHsp" style=""></span>cm in length&#44; comprising the lower pharyngeal constrictor&#44; cricopharyngeus and cervical oesophageal striated muscles&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The cricopharyngeus is located in the transition zone between the lower pharyngeal constrictor and the cervical oesophageal musculature&#44; and the area of greatest pressure is in the upper region&#44; which is anatomically bound by muscle tissue&#44; cartilage and aponeurosis rather than a simple muscular ring&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologically&#44; the cricopharyngeus is a striated muscle of small&#44; slow-twitch type I fibres&#44; not set in parallel&#44; which allows basal tone to be maintained&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The presence of some fast-twitch fibres allows rapid contraction during swallowing&#44; belching and vomiting&#46; Relative to other skeletal muscles&#44; the cricopharyngeus has a large proportion of connective tissue&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pathophysiological mechanisms involved in the opening of the UOS and different pathological patterns</span><p id="par0030" class="elsevierStylePara elsevierViewall">The UOS is closed in the resting state and the following four phenomena are necessary for it to open&#58; <span class="elsevierStyleItalic">1&#41;</span> interruption of vagal tone over the cricopharyngeus&#44; allowing muscle relaxation&#59; <span class="elsevierStyleItalic">2&#41;</span> anterior sphincter traction caused by hyoid muscle contraction&#59; <span class="elsevierStyleItalic">3&#41;</span> propulsive forces of the tongue and pharynx on the bolus&#59; and <span class="elsevierStyleItalic">4&#41;</span> sphincter compliance allowing complete relaxation&#44; low residual pressures and absence of resistance during swallowing&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The alterations in the mechanisms described above give rise to three major pathophysiological patterns of UOS dysfunction&#58; <span class="elsevierStyleItalic">a&#41;</span> restrictive change in flow at the UOS&#44; where propulsive capacity at the base of the tongue and pharynx will be normal but with altered relaxation of the UOS due to neurological disease &#40;central or spastic&#44; such as Parkinson&#8217;s disease&#41; with inability to interrupt the vagal tone on the cricopharyngeus&#44; or isolated at the UOS with alteration of its compliance&#44; as in the case of cricopharyngeal bars&#59; <span class="elsevierStyleItalic">b&#41;</span> weakness in the contraction of the hyoid musculature or the base of the tongue&#44; secondary to neurodegenerative disease or sarcopenia with normal relaxation of the UOS&#59; and <span class="elsevierStyleItalic">c&#41;</span> mixed processes with both altered relaxation of the UOS and altered propulsive capacity of the tongue and pharynx&#44; for example&#44; in patients with previous radiotherapy treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical and instrument-based diagnosis of oropharyngeal dysphagia</span><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of diagnosis in OD is for a multidisciplinary team to assess swallowing efficiency and safety early&#44; using clinical screening methods&#44; such as medical history&#44; specific questionnaires and validated clinical methods &#40;for example&#44; Volume-Viscosity Swallow Test &#91;V-VST<span class="elsevierStyleSmallCaps">&#93;</span>&#41;&#46; Subsequently&#44; patients in whom abnormalities are detected in the validated clinical methods should have instrument-based assessment with videofluoroscopy &#40;VFS&#41; or assessment of swallowing by laryngoscopy &#40;Fiberoptic Endoscopic Evaluation of Swallowing &#8212; FEES&#41;&#46; Tests may then be supplemented with high-resolution pharyngoesophageal manometry &#40;HRPM&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main aims of this article are to review the current accepted methodology for performing and interpreting HRPM&#59; to provide guidelines for classifying the different patterns of UOS dysfunction using HRPM&#59; and to be able to decide the most appropriate treatment for each patient&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">How useful is high-resolution oesophageal manometry&#63;</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background&#58; high-resolution manometry and Chicago Classification &#40;CC&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">High-resolution pharyngoesophageal manometry with impedance &#40;HRPM-I&#41; is a method for studying the pharyngoesophageal segment by recording the pressures and flow generated by the pharyngeal musculature during swallowing&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The method has undergone major development over the last 10 years following the popularisation of high-resolution oesophageal manometry&#46; UOS disorders account for 3&#37; in manometry reports and are not currently included in the latest classifications of oesophageal motor disorders&#44; such as the Chicago Classification version 4&#46;0&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The High-Resolution Pharyngeal Manometry International Working Group &#40;for the study of the pharynx and the UOS by HRPM-I&#41; has recently published recommendations for the HRPM-I protocol and metrics&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which we will discuss later&#46; The recommendations were revised and updated at the last meeting of the group &#40;the Ascona III Meeting&#41; in May 2023 in line with the latest advances and published studies and are summarised in this review &#40;Ascona III Advances in Clinical Measurement of Gastrointestinal Motility and Function&#41;&#46; As regards the most suitable probe for the study of the pharyngoesophageal segment&#44; the following phenomena should be taken into account&#58; <span class="elsevierStyleItalic">a&#41;</span> the UOS has a radial asymmetry and its major axis is transversely orientated&#44; causing the manometry values to be higher in the anterior&#47;posterior direction &#40;9&#41;&#59; <span class="elsevierStyleItalic">b&#41;</span> during swallowing there is a rapid upward movement of the UOS&#59; and <span class="elsevierStyleItalic">c&#41;</span> all the muscles of the UOS and pharynx are striated and have very fast and intense contractions of up to 600<span class="elsevierStyleHsp" style=""></span>mmHg&#47;s&#46; As such&#44; accurate recording requires a probe with multiple radially and circumferentially orientated recording channels and high-frequency capture of pressure changes&#44; as offered by solid-state probes&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Relationship between videofluoroscopy and high-resolution pharyngoesophageal manometry with impedance</span><p id="par0055" class="elsevierStylePara elsevierViewall">Videofluoroscopy &#40;VFS&#41; is a dynamic radiological test which obtains imaging sequences of the swallowing of different boluses and viscosities in lateral and anterior&#47;posterior profile&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> enabling visualisation of the anatomy and the functioning of the oropharynx and cervical oesophageal phase&#44; assessing the efficacy and safety of swallowing and evaluating the opening of the UOS&#46; With HRPM&#44; it is possible to assess the relaxation of the UOS and to estimate UOS opening by measurement of impedance&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A recent review proposes HRPM-I as a second line of investigation for swallowing disorders in the event that VFS or FEES does not provide a definitive diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This is a conservative recommendation based on the lack of availability of HRPM-I in many centres<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and the current lack of a protocol for its interpretation&#59; in fact&#44; the decision to perform HRPM-I after&#44; during&#44; or as the only technique would have to depend on the patient&#39;s characteristics&#44; the main indication usually being the study of alterations of upper sphincter opening visible on VFS as cricopharyngeal &#34;bars&#34;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">HRPM and impedance measurement&#58; what is the added value&#63;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Impedance is a non-radiological tool enabling the study of fluid flow through the lumen of the pharyngoesophageal segment&#44; which has a direct correlation with the opening area of the UOS&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It also allows the speed and direction of the flow to be assessed&#46; The passage of a bolus with high conductivity &#40;mostly liquids and solids&#41; causes the impedance to decrease with respect to the baseline level&#44; and boluses with low conductivity &#40;gas&#41; cause an increase in impedance&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The combination of pressure and impedance studies allows the simultaneous assessment of motility and flow&#44; providing a visual representation of the pressure flow during swallowing&#44; the objective variables of which are analysed by specific software&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The nadir impedance value during bolus swallowing&#44; or its inverse peak admittance&#44; can be used to determine the maximum extent of luminal opening during the flow of the bolus&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Equipment for high-resolution pharyngoesophageal manometry with impedance&#44; impedance measurement and probes</span><p id="par0070" class="elsevierStylePara elsevierViewall">A wide variety of HRPM-I models are currently available on the market&#59; one systematic methodology review reports that the most popular device in published studies is the ManoScan&#8482; HRM &#40;MEDTRONIC&#44; Minneapolis&#44; Minnesota&#44; USA&#41;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> followed by SolarGI&#8482; &#40;SolarGI HRM&#44; Laborie&#44; Orangeburg&#44; New York&#44; USA&#41; and inSIGHT&#8482; &#40;inSIGHT&#44; Diversatek&#44; Milwaukee&#44; Wisconsin&#44; USA&#41;&#46; This can be done using solid-state or water perfusion probes&#44; although experts recommend the solid-state systems as they have a larger number of recording channels and can detect pressure changes at a high frequency&#44; which is necessary when studying structures composed of skeletal muscle such as the pharynx and UOS&#46; These probes must have at least 10 pressure sensors spaced 1<span class="elsevierStyleHsp" style=""></span>cm apart&#44; and if impedance is incorporated&#44; these should be spaced every 2<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The morphology of the UOS is narrow and asymmetrical&#44; which makes the use of multiple circumferential sensors &#40;radial orientation&#41; necessary for study due to the anatomical characteristics described&#59; although there is no expert positioning to date&#44; it is the most widely used &#40;61&#46;3&#37;&#41; in the studies<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> included in the aforementioned review&#46; Whereas in groups using solid-state probes&#44; the most common number of recording channels used is 36&#44; in the case of impedance probes it is 12&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Software programme</span><p id="par0075" class="elsevierStylePara elsevierViewall">For data recording on the HRPM-I&#44; most groups use the original software provided with the device &#40;for example&#44; Matlab&#8482; &#91;MathWorks&#44; Natick&#93;&#41;&#44; MMS&#41;&#46; However&#44; most of them are designed for the recording of oesophageal body and lower oesophageal sphincter pressures&#44; and to record certain metrics it is necessary to associate other specific software&#46; In the case of incorporating impedance measurement&#44; external software such as Matlab&#8482; or AIMplot is normally used&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The software provided by MathWorks in MATLAB &#40;computer language&#41; is a fee-charging data analysis platform&#44; in this case manometric data&#44; extracted in an automated way by creating algorithms which allow the integrals to be calculated simply&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> However&#44; although this allows the studies to be exported&#44; it does not allow communication between different laboratories to compare studies&#46; SwallowGateway&#8482; &#40;swallowgateway&#46;com&#41; is a currently fee-charging platform created in 2017 by Taher Omari<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> which allows automated analysis of data extracted from a manometry study with oesophageal and pharyngeal impedance in such a way that these are stored in a network&#46; It also integrates diagnostic information&#44; allowing communication and discussion between experts&#44; and it has recently published a study that demonstrates its validity compared to other commercially available systems&#46; The platform requires specific software configuration for each type of probe&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Method</span><p id="par0080" class="elsevierStylePara elsevierViewall">Before the HRPM-I is performed&#44; the patient is told about the examination and any discomfort or complications that may arise from it&#44; all of which should be included in an informed consent form&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Also recommended prior to manometry are symptom assessment questionnaires&#44; which can be given out along with the information or during preparation&#46; The method recommended by the International Working Group is set out in their recent publication<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58; when performing HRPM-I&#44; both pharyngeal and oesophageal pressures and impedance studies should be performed to assess flow through the UOS and estimate its opening&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Probe placement is carried out by trained personnel using lubricating gel and small sips of water with a straw<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#59; it has recently been shown that the use of nasal topical anaesthetic does not improve patient comfort or well-being&#44; but does improve tolerance of 4&#46;2<span class="elsevierStyleHsp" style=""></span>mm probes&#44; and does not affect the swallowing process&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> An accommodation period of about 5<span class="elsevierStyleHsp" style=""></span>min is recommended&#44; with the patient seated or semi-reclined&#44; with the head in a neutral position&#46; There is still no standardised protocol&#44; although the International Working Group recommends a minimum standardised research protocol which should include both dry and liquid swallows of different volumes&#44; with 5 and 10<span class="elsevierStyleHsp" style=""></span>ml being the most commonly used and 20<span class="elsevierStyleHsp" style=""></span>ml only in selected cases&#44; administered with a 20<span class="elsevierStyleHsp" style=""></span>ml syringe and each repeated at least three times&#46; According to two recent studies&#44; both voluntary and natural swallows should be incorporated&#58; the former since several consecutive swallows increase the variability of pharyngeal pressure and may be an indicator of the compensatory response in patients with Parkinson&#39;s<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#59; and the latter as they are more uniform and present a more efficient swallowing dynamic than structured swallowing&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> In addition&#44; different viscosities are recommended and should be reproducible to assess the effect of volume and viscosity on the behaviour of the pharyngoesophageal segment&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> There is currently no consensus on the terminology used&#44; however&#44; to describe the different viscosity levels for thickened liquids&#46; The European Society for Swallowing Disorders &#40;ESSD&#41; advises viscosity to be referred to in international system measurements &#40;mPa-s&#41; avoiding viscosity ranges and qualitative descriptors&#44; as many classifications&#44; such as the International Dysphagia Diet Standardisation Initiative &#40;IDDSI&#41;&#44; do not express viscosity in scientific terms&#44; but based on the subjective behaviour of fluid flow inside a syringe&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In a recently published paper by the T&#46; Omari group studying the effect of volume and viscosity change on pharyngeal modulation&#44; the protocol was based on the administration of four different volumes &#40;3&#44; 5&#44; 10 and 20<span class="elsevierStyleHsp" style=""></span>ml&#41; and three different viscosities&#44; which were confirmed using the IDDSI system and for which the shear viscosity rate was calculated by rheometer to establish viscosities of 37&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;16<span class="elsevierStyleHsp" style=""></span>mPa-s &#40;IDDSI 2&#41; and 637&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;71<span class="elsevierStyleHsp" style=""></span>mPa-s &#40;IDDSI 4&#41; at 50<span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleSup">&#8722;1</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> This study highlights the importance of implementing volume and viscosity change in different swallows since the authors report significant changes in pharyngeal metrics&#44; such as an increase in intrabolus pressure in the hypopharynx or in the integrated relaxation pressure of the UOS&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Metrics</span><p id="par0095" class="elsevierStylePara elsevierViewall">The recommendation of the International Working Group regarding the metrics for the study of OD by HRPM-I is that any study should describe these three main phenomena&#58; <span class="elsevierStyleItalic">a&#41;</span> relaxation of the UOS&#59; <span class="elsevierStyleItalic">b&#41;</span> resistance to flow through the UOS&#59; and <span class="elsevierStyleItalic">c&#41;</span> the strength of bolus propulsion forces &#40;by tongue and pharynx&#41;&#46; Accordingly&#44; the metrics should assess in that order&#58; <span class="elsevierStyleItalic">a&#41;</span> the relaxation pressures of the UOS&#59; <span class="elsevierStyleItalic">b&#41;</span> the intrabolus pressure in the hypopharynx as a measure of resistance to passage through the UOS&#59; and <span class="elsevierStyleItalic">c&#41;</span> the contractile pressures of the pharynx and base of tongue above the UOS&#46; There are different metrics which can define these phenomena&#59; the most important ones for diagnosis are described below&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Relaxation and opening of the UOS</span><p id="par0100" class="elsevierStylePara elsevierViewall">Relaxation and opening of the UOS is a complex process which depends on the volume and viscosity of the bolus&#46; The relaxation pressure of the UOS&#44; determined manometrically&#44; correlates well with the electromyography of the cricopharyngeus through its activation &#40;rest&#41; and deactivation &#40;relaxation&#44; during swallowing&#41; mediated by the brainstem<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;29</span></a>&#59; these increase with bolus volume and with age &#40;intrabolus pressure being an indirect measure of relaxation&#41;&#46; The mechanisms determining the opening of the UOS depend on the strength and synchronisation of the supra- and infra-hyoid muscles&#44; the bolus &#40;pharyngeal propulsion&#41;&#44; the inhibition of neural tone and the compliance of the cricopharyngeus and can be assessed by impedance measurement&#46; Theoretically&#44; the luminal impedance measured during the flow of a bolus is influenced by the diameter of the lumen through which it passes and&#44; in fact&#44; the nadir impedance corresponds to the moment when the lumen is distended to its maximum during bolus ingestion and has therefore been used as a time reference point for the measurement of pressures using HRPM&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> According to theoretical principles&#44; the impedance of a filled chamber is inversely proportional to its cross-sectional area&#44; a basic principle of the EndoFLIP technique which adapts the principles of impedance planimetry into a functional luminal technique&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Studies comparing manometry and impedance with VFS have demonstrated the effectiveness of impedance in assessing the diameter of the UOS lumen and thus its opening&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In recent years&#44; the inverse of the nadir impedance has been used&#44; known as admittance&#44; which is the highest value recorded during bolus flow through the UOS as it is more intuitive than impedance and has been shown to be a good marker of UOS opening dysfunction and&#44; compared to UOS-IRP&#44; appears to be better at discriminating between groups of patients with pharyngeal motor impairment&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">UOS relaxation measurements&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The UOS relaxation time</span> &#40;UOS-RT&#41; is the time interval of <span class="elsevierStyleItalic">eSleeve</span> recording at a pressure below 50&#37; of the baseline UOS pressure&#44; measured in seconds&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The introduction of the <span class="elsevierStyleItalic">eSleeve</span> in HRPM-I has improved UOS analysis as it avoids calculation errors caused by elevation of the UOS during swallowing&#46; It is higher in the supine position and is not affected by gender&#44; height&#44; weight or BMI&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">UOS relaxation pressure</span>&#58; two metrics used in the study of UOS relaxation pressure are the minimum relaxation pressure &#40;or nadir pressure&#41; and the integrated relaxation pressure &#40;UOS-IRP&#41;&#46; The UOS-IRP is the mean of pressures during the 0&#46;25<span class="elsevierStyleHsp" style=""></span>s of maximum relaxation&#44; reflects the bolus pressure <span class="elsevierStyleItalic">within</span> the sphincter and indicates complete relaxation of the UOS and sphincter compliance&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> It is similar to the IRP-4s used to assess the oesophagogastric junction &#40;OGJ&#41;&#46; The UOS-IRP is the current preferred metric&#44; as it is more accurate for being a set of measurements which combines pressure and time collected in 0&#46;25<span class="elsevierStyleHsp" style=""></span>s&#46;</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">UOS opening measurements&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">a&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Determination of <span class="elsevierStyleItalic">UOS Max Admitance&#44;</span> the inverse of nadir impedance&#44; is performed by calculating the highest admittance value recorded during bolus flow through the UOS&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It has been shown to be a marker of UOS opening dysfunction and&#44; compared to UOS-IRP&#44; may be better at discriminating between groups of patients with pharyngeal motor impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Assessment of flow resistance through UOS&#58; hypopharyngeal intrabolus pressure</span><p id="par0130" class="elsevierStylePara elsevierViewall">Proper bolus flow requires proper propulsion of the tongue and pharynx and proper relaxation and opening of the UOS which confers low resistance to the bolus passing through it&#46; A metric has been developed to assess bolus passage resistance&#44; <span class="elsevierStyleItalic">hypopharyngeal intrabolus pressure</span> &#40;HIBP&#41;&#44; which has been shown to be a good manometric marker of flow resistance at the UOS&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;35</span></a> which increases with bolus volume and viscosity&#46; The HIBP gradient reflects the pressure difference between the pharynx and the UOS during bolus passage through the sphincter&#44; and three metrics have been proposed&#44; the first two of which are the most widely used in the literature&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">a&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mid-hypopharyngeal intrabolus pressure &#40;mid-hypopharyngeal IBP</span>&#41; was most commonly used on its own prior to the introduction of high-resolution manometry and required video-manometry&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It is defined as the pressure at the midpoint of the bolus as it advances&#44; recorded radiologically&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">b&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hypopharyngeal pressure at nadir impedance</span> &#40;PNadImp or PNI&#41;&#58; this is the pressure at the time of maximum hypopharyngeal distension &#40;or admittance&#41; determined by the impedance value 1<span class="elsevierStyleHsp" style=""></span>cm above the <span class="elsevierStyleItalic">highest</span> point &#40;or pharyngoesophageal junction&#41; of the UOS&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#44;37</span></a> This measurement is the mechanical consequence of lingual and pharyngeal propulsive forces together with the diameter of the lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> An abnormally high PNI may therefore be a marker of flow restriction due to structural disease&#46; Previous studies have shown it to be a predictor of stricture of the pharyngoesophageal junction and it loses predictive value when pharyngeal contractile forces are too weak to mobilise the bolus&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> since ineffective propulsion of the bolus &#40;due to sarcopenia&#44; for example&#41; will prevent hypopharyngeal pressure from developing despite the presence of a stricture&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">c&#46;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Hypopharyngeal pressure increment &#40;<span class="elsevierStyleItalic">HPI</span>&#41;&#44; defined by the average of pressures preceding the onset of pharyngeal contraction at a threshold of 20<span class="elsevierStyleHsp" style=""></span>mmHg&#46; As there has only been one study with healthy volunteers&#44; HPI is not used in routine clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">The pressure generated by epiglottic inversion<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> is an artefact that must be taken into account when performing HRPM-I&#44; and may lead to potentially erroneous intrabolus pressure results&#44; for example&#44; by giving higher HIBP values&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Assessment of pharyngeal propulsive forces</span><p id="par0155" class="elsevierStylePara elsevierViewall">Patients with OD may have sequential and coordinated oropharyngeal motor response &#40;OMR&#41;&#44; but weak lingual and pharyngeal propulsive force&#44; leading to bolus residue in the vallecula or pyriform sinuses and being susceptible to post-swallowing aspiration&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;15</span></a> To assess pharyngeal propulsive forces&#44; we can assess the different regions of the pharynx separately &#40;velo-&#44; oro- and hypopharynx&#41; and the UOS&#44; combinations of them or the whole pharynx &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The velopharynx comprises the velus palatini muscle&#44; the tensor veli palatini muscle&#44; the uvula muscle&#44; the palatoglossus muscle&#44; the palatopharyngeus muscle and the superior pharyngeal constrictor&#46; The oropharynx is the most posterior region of the oral cavity&#46; It extends from the soft palate to the hyoid and includes the posterior segment of the tongue&#44; including the upper and middle constrictor&#44; palatoglossus and hyoglossus muscles&#46; On the anterior aspect&#44; it borders the oral cavity by means of the anterior and posterior palatine pillars and on each side by the palatine tonsils&#46; The hypopharynx extends from the imaginary line at the level of the hyoid bone to the lower edge of the cricoid cartilage&#44; where it continues with the UOS&#46; It comprises three regions or sub-sites&#58; the pyriform sinuses&#44; the posterior and lateral pharyngeal wall &#40;middle and inferior pharyngeal constrictor muscles&#41;&#44; and the postcricoid region&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The metrics used for the propulsive assessment of the pharynx are as follows&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">a&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Peak pharyngeal pressure &#40;<span class="elsevierStyleItalic">PeakP</span>&#41; represents the strength of the pharyngeal contraction and averages 140<span class="elsevierStyleHsp" style=""></span>mmHg &#40;107&#8722;194<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> No complex <span class="elsevierStyleItalic">software</span> is required to determine PeakP&#44; but the measurements produce variable results and artefacts are common with the probe&#46; This contractility metric has been shown to be a predictor of aspiration and presence of pyriform sinus bolus residue in a study comparing HRPM-I and VFS&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> where it was the best metric for differentiating patients from controls in the absence of UOS abnormalities&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">b&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">The pharyngeal contractile integral &#40;PhCI&#41;&#44; like the distal contractile integral &#40;DCI&#41; in the distal oesophagus&#44; is a good marker of the so-called &#34;vigour&#34; of the pharyngeal swallowing response&#46; Studying the different contractile integrals of the regions described &#40;velo-&#91;VCI&#93;&#44; oro-&#91;OCI&#93; and hypopharynx &#91;HCI&#93;&#41;&#44; however&#44; is recommended in the case of a patient with an apparently normal PhCI&#44; as this may be the result of compensation with increased pressure in one of the regions &#40;oropharynx&#41; due to the weakness of another &#40;velo or hypopharynx&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The velopharynx&#44; which is responsible for sealing the nasopharynx when subjected to high volumes&#44; appears to be an important marker of volume modulation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> In the study of pharyngeal regions&#44; the use of the VCI and OCI is recommended&#44; as in the velopharynx and oropharynx the pressures are sustained or multimodal&#44; meaning they remain stable or vary only for a few milliseconds&#46; This is not so necessary for the hypopharynx&#44; as in this area the response is brief and unimodal&#44; reaching a pressure peak in a few milliseconds and then returning to the resting pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> These pressures tend to be higher with higher volumes and viscosities&#44; age &#40;compensation for increased UOS opening resistance&#41; and with chin-tuck or Mendelsohn manoeuvres&#46; Reporting and interpreting the different regions may therefore be more useful than PhCI for patients with dysphagia as VCI and OCI have been shown to be predictors of aspiration and the presence of bolus residue&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The problem with this metric is that it does not differentiate as accurately as PeakP between controls and patients&#44; so future studies will need to establish which metric is the most accurate for assessing pharyngeal propulsive capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Other measures associated with impedance</span><p id="par0180" class="elsevierStylePara elsevierViewall">Impedance complements manometry in the study of swallowing as it allows the presence and flow of the bolus through the pharynx to be determined&#46; Two metrics have been implemented that help the study of bolus flow in relation to time and pharyngeal contractile force&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The bolus presence time</span> &#40;<span class="elsevierStyleItalic">BPT</span>&#41; is a temporal metric&#44; which indicates the time the bolus remains in the hypopharynx during the time of maximum admittance from the moment of opening to the closure of the UOS&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> An elevated BTP value may indicate either a drop or premature arrival of the bolus in the hypopharynx or the presence of post-swallowing bolus residue&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The distension-contraction latency</span> is a metric reflecting a temporal relationship between the point of maximum admittance &#40;distension&#41; in the hypopharynx and the peak pharyngeal pressure or PeakP&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Low values suggest insufficient tongue thrust &#40;if HIBP is low&#41; or resistance to flow &#40;when HIBP is normal&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Patterns of pharyngoesophageal dysfunction in HRPM-I</span><p id="par0195" class="elsevierStylePara elsevierViewall">At the previous Ascona II meeting &#40;2015&#41;&#44; the International Working Group proposed classifying patients into three patterns of dysfunction based on the pattern and metrics discussed above&#46; Since then&#44; however&#44; a study published in 2022 has proposed a new algorithm based on the pattern of pressurisation<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Both classifications require further evidence for validation&#44; so we suggest maintaining the classification presented at Ascona II&#44; but with the recommendations regarding the metrics proposed in the new publications and discussed at Ascona III&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Category 1&#58;</span> &#34;UOS flow restriction with normal propulsion&#34;</p><p id="par0205" class="elsevierStylePara elsevierViewall">This pattern occurs in patients in whom there is adequate propulsion of the bolus in the pharynx &#40;both by the base of the tongue and by the pharyngeal constrictors&#41;&#44; along with restrictive impairment of relaxation at the level of the UOS&#46; According to recent studies&#44; the metric which best defines this category would be a higher than normal UOS IRP&#44; recommending the use of other metrics to support the diagnosis such as increased HIBP or decreased UOS admittance along with some added pressurisation pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> An example of this category can be seen in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">This category includes patients with a pure restrictive pattern with flow obstruction at the level of the UOS&#44; such as those with Zenker&#8217;s diverticulum or with cricopharyngeal bar as the only abnormality&#46; This group of patients is characterised by normal OMR with normal bolus propulsion and reduced UOS compliance secondary to UOS fibrosis&#46; <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows a videofluoroscopy image of a patient with abnormal opening of the UOS with a Zenker&#8217;s diverticulum&#46; Histological studies<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> have clearly established that the pathophysiology of reduced UOS distensibility is due to fibrosis of the sphincter muscle fibres&#46; The preferred treatment choice for this group of patients is endoscopic myotomy of the cricopharyngeus using C-POEM&#44; with excellent results while keeping the OMR intact&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> rendering surgery obsolete due to potential secondary complications&#46; Dilation is an option for patients who are not candidates for myotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Category 2&#58;</span> &#34;Restricted flow in the UOS with propulsive defect&#34;</p><p id="par0220" class="elsevierStylePara elsevierViewall">This category includes patients with propulsive defects at the base of the tongue&#44; or pharyngeal constrictors together with a restrictive pattern at the level of the UOS&#46; The metric which best characterises this case is the relaxation pressure of the UOS&#44; and specifically high values in conjunction with a decrease in pharyngeal propulsion&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Two sub-phenotypes can be distinguished according to pharyngeal contractility&#58; <span class="elsevierStyleItalic">a&#41;</span> type I with absent contractility&#44; based on manometrically undetectable contraction&#59; and <span class="elsevierStyleItalic">b&#41;</span> type II with weak contractility&#44; based on peak pressure &#40;PP&#41; below the lower limit of normal&#46; An example is shown in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">The second category includes patients with spastic neurological diseases&#44; such as Parkinson&#39;s&#44; spinal cord injury and patients treated by radiotherapy&#46; This group of patients is characterised by impaired or absent OMR and weak bolus propulsion&#59; they also have impaired or absent UOS relaxation&#46; In this category where propulsive forces are diminished&#44; myotomy does not work well&#59; injection of Botox into the UOS or dilation may be a treatment option in conjunction with C-POEM&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a> Neurorehabilitation strategies to improve bolus propulsion forces are also recommended in this pattern&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Category 3&#58;</span> &#34;Ineffective pharyngeal contraction&#34; This group includes patients with ineffective pharyngeal contraction pressure &#40;PP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>LLN&#41; and normal UOS relaxation and opening &#40;normal UOS-IRP&#41;&#44; an example of which can be seen in <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#46; As previously mentioned&#44; PP was the metric that best discriminated between patients and controls in a recent study when there was normal UOS relaxation and opening&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">In this category we find older adult patients with sarcopenia or those with neurodegenerative diseases with impaired OMR&#44; along with decreased lingual and pharyngeal propulsion and probable ineffective hyoid traction&#44; and normal UOS relaxation&#46; Treatment of these patients is based on rehabilitation programmes to improve tongue strength and hyoid movement&#44; and neurorehabilitation&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0245" class="elsevierStylePara elsevierViewall">We have presented here a review of the methodology and metrics used by the main working groups along with a description of the main patterns of dysfunction and specific recommendations according to our experience&#44; in order to highlight the utility of HRPM-I in studying the pathophysiology and selection of a specific treatment in patients with OD&#46; In our opinion&#44; this technique is now essential for selecting specific treatment for patients with alterations in the opening of the upper oesophageal sphincter confirmed by videofluoroscopy&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The study of swallowing disorders today involves the implementation of different diagnostic techniques such as VFS and HRPM-I&#44; which complement each other in terms of understanding the functioning and disorders of the pharyngoesophageal junction&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> With a simple protocol&#44; VFS makes it possible to assess the efficiency and safety of swallowing and can also diagnose abnormalities in the opening of the UOS&#44; such as cricopharyngeal bars&#44; Zenker&#8217;s diverticula or extrinsic compressions such as cervical osteophytes&#46; HRPM-I&#44; on the other hand&#44; allows us to study the contractile force of the tongue and pharynx&#44; and abnormalities in the relaxation of the UOS&#46; Therefore&#44; when VFS shows a patient to have impaired opening of the UOS&#44; HRPM-I should be performed to measure the contractile forces of the pharynx&#44; the resistance to flow and the relaxation of the UOS&#46; Although some groups perform both techniques together&#44; we believe that keeping the manometry probe in place during VFS may interfere with the study&#44; so our recommendation would be to perform the two techniques separately and analyse the results together&#46; As restrictive abnormalities at the oesophagogastric junction can be revealed by an increase in volume and viscosity&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> our protocol uses different volumes and viscosities&#44; always following the measurements of the international system &#40;mPa-s&#41; and performing two swallows for each category&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">As previously mentioned&#44; patients are currently divided into three disease patterns<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and&#44; according to each&#44; we define a metric that helps us to categorise them and propose a specific treatment&#46; In our experience&#44; the metrics which are currently enabling us to study these patients is&#58; <span class="elsevierStyleItalic">a&#41;</span> the integrated relaxation pressure &#40;UOS-IRP&#41; of the UOS in cases with restrictive pattern at the UOS&#44; in both patients with normal and decreased pharyngeal propulsive pattern&#59; <span class="elsevierStyleItalic">b&#41;</span> the intrabolus pressure in the hypopharynx&#44; using hypopharyngeal pressure at nadir impedance as a measure to support the restrictive component of the upper oesophageal sphincter in patients with normal pharyngeal motility&#59; and <span class="elsevierStyleItalic">c&#41;</span> the PhCI integral&#44; assessing the contractile integral of each zone separately to obtain more detailed information together with the hypopharyngeal PeakP to assess the propulsive capacity of the pharynx in patients with correct UOS relaxation and suspected pharyngeal propulsive impairment&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">With regard to patient management&#44; in our experience&#44; HRPM-I has been particularly useful in deciding on therapeutic management in patients with impaired UOS opening with cricopharyngeal bar and Zenker&#8217;s diverticulum&#46; For patients with cricopharyngeal bars but with slightly impaired relaxation and no repercussions in terms of hypopharyngeal pressure on nadir impedance&#44; we have applied conservative treatment&#44; with dietary recommendations involving restriction of highly fibrous and hard solids&#44; and prioritising proper chewing&#46; For patients with impaired cricopharyngeal bar opening and impaired UOS relaxation&#44; with significantly increased hypopharyngeal pressure and normal pharyngeal contraction strength&#44; the treatment option has been to perform a myotomy using C-POEM&#44; as the reduction in distensibility is due to fibrosis of the muscle fibres&#44; with very good subsequent outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">In patients with restricted flow in the UOS with propulsive defect&#44; which includes patients with neurological disorders such as Parkinson&#39;s disease&#44; surgical myotomy does not guarantee good results as it could worsen pharyngeal functional reserve&#46; In this phenotype of patients&#44; however&#44; good options are dilation&#44; Botox injection or the more recently proposed C-POEM&#44; combined with neurorehabilitation strategies to improve bolus propulsive forces&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;47</span></a> Even so&#44; this patient phenotype requires an individualised and multidisciplinary approach to indicate the most appropriate therapeutic option&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">In patients with no restrictive component at the UOS&#44; but who have ineffective pharyngeal contraction&#44; our recommendation would be to improve their fragility status and sarcopenia&#44; in combination with rehabilitation to improve tongue and pharyngeal propulsion and upward movement of the hyoid bone&#46; The Shaker manoeuvre based on isometric and isotonic exercises of the supra-hyoid muscles has been shown to increase the opening of the UOS and decrease post-swallowing bolus residue and posterior aspiration&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Apart from its diagnostic utility&#44; HRPM-I is being implemented in some centres as part of rehabilitation techniques for HRPM-I-guided biofeedback&#44; to improve swallowing ability in patients with oropharyngeal dysphagia&#46; This therapeutic modality allows the patient to intuitively implement the rehabilitation exercises and manoeuvres&#44; while the rehabilitator can monitor performance and then set and plan the exercises&#44; taking into account the results and tendency to become fatigued&#44; and so improve adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0280" class="elsevierStylePara elsevierViewall">In recent years&#44; high-resolution pharyngoesophageal impedance manometry has become a necessary tool for the study of patients with oropharyngeal dysphagia&#44; a highly prevalent condition in the older adult population and in those with a neurological history with significant consequences&#46; The International Working Group has published a first revision for the standardisation of the protocol for pharyngeal and UOS examination and metrics which enables classification of the pathophysiological findings in HRPM-I into three broad categories according to restrictive UOS opening versus pharyngeal propulsive patterns&#46; One of the current challenges is to define which metrics and values better discriminate between normal and diseased&#44; and how to integrate the pathophysiological and clinical findings patients present in different categories&#44; in order to make a more targeted therapeutic approach&#46; Multimodal treatment for swallowing disorders should combine compensatory strategies&#44; speech therapy and new neurorehabilitation treatments&#44; including non-invasive brain stimulation&#46; The data available at present still leave unanswered questions&#44; both from a technological and methodological point of view&#46; However&#44; they do provide a first step&#44; so that the working groups can follow the same methodology&#44; while also having computer tools to facilitate their study and the possibility of sharing data between different specialists&#46; The aim of this paper was to review the current literature and summarise the most important points in order to highlight the need for the implementation of this technique and its applications&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Ethical considerations</span><p id="par0285" class="elsevierStylePara elsevierViewall">This work did not involve the use of human subjects&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0290" class="elsevierStylePara elsevierViewall">This study received no specific funding from public&#44; private or non-profit organisations&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0295" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Oropharyngeal dysphagia&#46; Definition and prevalence in different patient phenotypes"
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              "titulo" => "Biomechanics of oropharyngeal dysphagia in healthy people and in patients"
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              "titulo" => "Anatomical and histological factors of the pharynx and upper oesophageal sphincter"
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              "titulo" => "Clinical and instrument-based diagnosis of oropharyngeal dysphagia"
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              "titulo" => "Background&#58; high-resolution manometry and Chicago Classification &#40;CC&#41;"
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              "titulo" => "Relationship between videofluoroscopy and high-resolution pharyngoesophageal manometry with impedance"
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              "titulo" => "HRPM and impedance measurement&#58; what is the added value&#63;"
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          "titulo" => "Equipment for high-resolution pharyngoesophageal manometry with impedance&#44; impedance measurement and probes"
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              "titulo" => "Assessment of flow resistance through UOS&#58; hypopharyngeal intrabolus pressure"
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              "titulo" => "Assessment of pharyngeal propulsive forces"
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          "titulo" => "Patterns of pharyngoesophageal dysfunction in HRPM-I"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Oropharyngeal dysphagia &#40;OD&#41; is a pathology with a high prevalence in different patient phenotypes&#46; High-resolution pharyngoesophageal manometry &#40;HRPM&#41; with impedance &#40;HRPM-I&#41; has become in recent years a fundamental technique for better understanding the pathophysiology of pharynx and upper oesophageal sphincter &#40;UES&#41; dysfunctions in patients with OD&#46; Various groups of experts have proposed a methodology for the practice of the HRPM-I and for the standardisation of the different metrics for the study of pharyngeal motility and UES dysfunctions based on the quantification of three main phenomena&#58; relaxation of the UES&#44; resistance to flow through the UES and propulsion of the bolus through the pharynx into the oesophagus&#46; According to the alterations of these metrics&#44; three patterns of dysfunction are proposed that allow a specific therapeutic approach&#58; a&#41; UES flow restriction with normal pharyngeal propulsion&#44; b&#41; UES flow restriction with ineffective pharyngeal propulsion&#44; and c&#41; ineffective pharyngeal contraction with normal relaxation of the UES&#46; We present a practical review of the methodology and metrics used by the main working groups together with the description of the main patterns of dysfunction according to our experience to highlight the usefulness of the HRPM-I in the study of the pathophysiology and selection of a specific treatment in patients with OD&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La disfagia orofar&#237;ngea &#40;DO&#41; es una patolog&#237;a con una alta prevalencia en diferentes fenotipos de pacientes&#46; La manometr&#237;a de alta resoluci&#243;n faringoesof&#225;gica &#40;MARFE&#41; con impedancia &#40;MARFE-I&#41; se ha convertido en los &#250;ltimos a&#241;os en una t&#233;cnica fundamental para el mejor entendimiento de la fisiopatolog&#237;a de las disfunciones de la faringe y del esf&#237;nter esof&#225;gico superior &#40;EES&#41; en pacientes con DO&#46; Diversos grupos de expertos han propuesto una metodolog&#237;a para la pr&#225;ctica de la MARFE-I y para la estandarizaci&#243;n de las diferentes m&#233;tricas para el estudio de las disfunciones de la motilidad far&#237;ngea y del EES basadas en el la cuantificaci&#243;n de tres fen&#243;menos principales&#58; la relajaci&#243;n del EES&#44; la resistencia al flujo a trav&#233;s del EES y la propulsi&#243;n del bolo a trav&#233;s de la faringe hacia el es&#243;fago&#46; De acuerdo a las alteraciones de estas m&#233;tricas&#44; se proponen tres patrones de disfunci&#243;n que permiten un abordaje terap&#233;utico espec&#237;fico&#58; <span class="elsevierStyleItalic">a</span>&#41; restricci&#243;n al flujo del EES con propulsi&#243;n far&#237;ngea normal&#44; <span class="elsevierStyleItalic">b</span>&#41; restricci&#243;n al flujo del EES con propulsi&#243;n far&#237;ngea inefectiva y&#44; <span class="elsevierStyleItalic">c</span>&#41; contracci&#243;n far&#237;ngea inefectiva con normal relajaci&#243;n del EES&#46; Presentamos una revisi&#243;n pr&#225;ctica de la metodolog&#237;a y la m&#233;trica que emplean los principales grupos de trabajo junto con la descripci&#243;n de los principales patrones de disfunci&#243;n de acuerdo a nuestra experiencia para poner de relevancia la utilidad de la MARFE-I en el estudio de la fisiopatolog&#237;a y selecci&#243;n de un tratamiento espec&#237;fico en pacientes con DO&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image of a manometry tracing of a normal swallow&#46; This figure shows normal swallowing in which it is possible to differentiate&#58; <span class="elsevierStyleItalic">a&#41;</span> a normal relaxation of the UOS&#44; studied by means of the minimum relaxation pressure &#40;or nadir&#41; and the relaxation integral of the UOS &#40;UOS-IRP&#41;&#59; <span class="elsevierStyleItalic">b&#41;</span> resistance to flow through the UOS &#40;in this case absent hypopharyngeal intrabolus pressure&#41;&#44; studied by hypopharyngeal intrabolus pressure &#40;HIBP&#41;&#59; and <span class="elsevierStyleItalic">c&#41;</span> assessment of tongue and pharyngeal propulsion&#44; shown as a normal propulsive pharyngeal wave&#44; by means of the pharyngeal peak pressure and the pharyngeal contractile integral &#40;PhCI&#41; which can be assessed together or divided into the different anatomical regions &#40;velo-&#44; oro- or hypopharynx&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; Adaptation of the flow chart proposed by the International Working Group &#40;Ascona-II&#41; for the process of classifying categories of pharyngoesophageal dysfunction&#46; B&#41; Adaptation of the flow chart proposed at the Ascona-III International Working Group meeting for the classification of categories of pharyngoesophageal dysfunction based on the study by Omari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> This diagram proposes to classify patients according to an initial pressurisation pattern&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In pressurisation pattern type 1 &#40;number 1&#41; a clear biomechanical pattern of flow obstruction would appear&#46; Patterns 2 or 3 are considered as UOS abnormalities&#47;disorders when observing a combination of incomplete UOS relaxation &#40;type 2&#41;&#44; according to UOS IRP&#44; or findings of altered distensibility &#40;maximum UOS admittance&#41; &#40;type 3&#41;&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To confirm UOS impairment in patients in whom there is no pressurisation pattern&#44; both incomplete UOS relaxation and other distensibility impairments would be required &#40;number 4&#41;&#46; In patients where no UOS disorder is demonstrated &#40;numbers 5&#8211;7&#41;&#44; if pharyngeal propulsion is taken into account and is weak or absent&#44; they would be classified as propulsion disorder &#40;number 5&#41;&#46; The remaining cases would be classified as &#34;other disorders&#34; if they have abnormal findings in one or more metrics &#40;number 6&#41;&#44; or no alterations if all variables are within normal ranges&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HIBP&#58; hypopharyngeal intrabolus pressure&#59; LLN&#58; lower limit of normal&#59; PP&#58; peak pressure&#59; ULN&#58; upper limit of normal&#59; UOS&#58; upper oesophageal sphincter&#59; UOSRP&#58; UOS relaxation pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p>"
        ]
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        "etiqueta" => "Figure 3"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A&#41; Manometry tracing of a 20<span class="elsevierStyleHsp" style=""></span>ml swallow with nectar viscosity &#40;250<span class="elsevierStyleHsp" style=""></span>mPa-s&#41; of a patient with a cricopharyngeal bar is shown&#46; Normal pharyngeal propulsive force &#40;350<span class="elsevierStyleHsp" style=""></span>mmHg-s-cm&#41;&#46; An alteration of UOS relaxation according to the UOS-IRP 0&#46;2<span class="elsevierStyleHsp" style=""></span>s of 28<span class="elsevierStyleHsp" style=""></span>mmHg is observed and increases with successive swallows with increasing volume and viscosity&#44; suggesting a restrictive pattern&#46; As a result of the phenomena described above&#44; there is an increase in intrabolus pressure in the hypopharynx and the UOS&#44; which also increases with volume and viscosity during successive swallows&#46;</p>"
        ]
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      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Videofluoroscopic image of a patient with abnormal opening of the UOS with a Zenker&#39;s diverticulum&#46; This group of patients has a normal OMR and HRPM-I will show normal bolus propulsion but incomplete UOS relaxation&#44; with increasing volume leading to increased intrabolus pressure &#40;HIBP&#41; and increased relaxation pressure &#40;UOS-IRP&#41;&#46; The treatment option in these patients is surgical or endoscopic myotomy by POEM&#44; as the reduction in distensibility is due to fibrosis of the muscle fibres&#44; with very good results&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">High resolution manometry and impedance tracing of a 20<span class="elsevierStyleHsp" style=""></span>ml nectar viscosity swallow &#40;250<span class="elsevierStyleHsp" style=""></span>mPa<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; fractionated&#44; in an older adult patient with cricopharyngeal bar showing flow restriction with incomplete UOS relaxation and weak pharyngeal propulsion&#46; Peak pharyngeal pressure&#44; which assesses the strength of pharyngeal contraction&#44; is decreased&#44; as is pharyngeal propulsive force vigour &#40;PhCI&#41; and pharyngeal propulsive force amplitude&#46; The pharyngeal wave is fragmented and has low amplitude mainly in the oropharynx &#40;OCI&#41;&#46; It shows an increased UOS-IRP &#40;IRP-0&#46;2<span class="elsevierStyleHsp" style=""></span>s 13<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; demonstrating incomplete relaxation of the UOS&#46; Given the impaired relaxation of the UOS&#44; we would expect an increase in pharyngeal intrabolus pressure &#40;HIBP&#41;&#46; However&#44; HIBP is normal due to ineffective pharyngeal propulsion&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
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            "identificador" => "at0055"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">High resolution manometry and impedance tracing of a patient with oculopharyngeal muscular dystrophy showing ineffective pharyngeal contraction with correct relaxation of the UOS&#46; Pharyngeal contractile integral &#40;PhCI&#41; or vigour is decreased in this patient &#40;34<span class="elsevierStyleHsp" style=""></span>mmHg-s-cm&#41;&#44; with pharyngeal wave virtually absent&#46; With regard to UOS relaxation and bolus resistance we can see that both are normal&#46;</p>"
        ]
      ]
    ]
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Article information

ISSN: 24443824
Original language: English

DOI:10.1016/j.gastre.2023.09.003

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