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

Abstract

Objectives/hypothesis: Incompetence of the upper esophageal sphincter (UES) is fundamental to the occurrence of esophagopharyngeal reflux (EPR), and development of supraesophageal manifestations of reflux disease (SERD). However, therapeutic approaches to SERD have not been directed to strengthening of the UES barrier function. Our aims were to demonstrate that EPR events can be experimentally induced in SERD patients and not in healthy controls, and ascertain if these events can be prevented by application of a modest external cricoid pressure.

Study design: Individual case control study.

Methods: We studied 14 SERD patients (57 ± 13 years, 8 females) and 12 healthy controls (26 ± 3 years, 7 females) by concurrent intraesophageal slow infusion and pharyngoscopic and manometric technique without and with the application of a sustained predetermined cricoid pressure to induce, detect, and prevent EPR, respectively.

Results: Slow esophageal infusion (1 mL/s) of 60 mL of HCl resulted in a total of 16 objectively confirmed EPR events in none patients and none in healthy controls. All patients developed subjective sensation of regurgitation. Sustained cricoid pressure resulted in a significant UES pressure augmentation in all participants. During application of sustained cricoid pressure, slow intraesophageal infusion resulted in only one EPR event (P < .01).

Conclusions: Slow esophageal liquid infusion unmasks UES incompetence evidenced as the occurrence of EPR. Application of 20 to 30 mm Hg cricoid pressure significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion. These techniques can be useful in diagnosis and management of UES incompetence in patients suffering from supraesophageal manifestations of reflux disease.

Keywords: Regurgitation; cricoid pressure; extraesophageal reflux disease; gastroesophageal reflux disease; laryngopharyngeal reflux; supraesophageal reflux disease.

Fig. 1

Handmade upper esophageal sphincter assist device (UESAD) comprised of two components: an elastic band and a cushion. The prototype cushion was made of multiple sheets of facial tissue paper wrapped by adhesive tape and was 8-cm long, 3-cm wide, and 2.5-cm thick. The elastic band was 45-cm long and 2-cm wide, and was secured around the neck using an 8-cm piece of Velcro. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Fig. 2

Correlation of externally applied cricoid pressure with internally recorded upper esophageal sphincter (UES) pressure in healthy controls and supraesophageal reflux disease (SERD) patients. There was a direct relationship between the increase in cricoid pressure and that of UES in both healthy controls and SERD patients. In both groups, application of cricoid pressure resulted in significant increase in intraluminal UES pressure (*P<.01), but the magnitude of pressure augmentation between the two groups was not statistically diferent.

Fig. 3

Upper esophageal sphincter (UES) intraluminal pressure with and without the application of a UES assist device (UESAD) in healthy controls and patients. As seen in both groups, application of the UESAD resulted in significant increase in intraluminal UES pressure (*P<.001).

Fig. 4

Effect of the upper esophageal sphincter assist device (UESAD) on nadir relaxation pressure during swallowing and belching in supraesophageal reflux disease (SERD) patients and healthy controls. Application of the UESAD resulted in significant increase in nadir relaxation pressure during dry and 10-mL water swallow in both controls and patients (*P<.05). Similarly, the presence of the UESAD was accompanied by a significant increase in UES relaxation nadir pressure during esophageal belch in both groups (#P<.001).

Fig. 5

Frequency of occurrence of objectively verified esophagopharyngeal reflux (EPR) (A) and subjective sensation of regurgitation (B) during esophageal slow infusions in 13 supraesophageal reflux disease patients. (A) Nine of 13 patients developed at least one EPR during their three esophageal infusions. This number was reduced to 1/13 with application of the upper esophageal sphincter assist device (UESAD) (*P<.01). On the other hand, 16 of 39 infusions resulted in endoscopically detected EPR without the application of the UESAD. This number decreased to 1 out of 39 with the application of the UESAD (#P<.0001). (B) All 13 patients developed a sensation of regurgitation during their infusions. This number was decreased to five of 13 after the application of the UESAD (*P<.01). Similarly, 36 of 39 infusions were accompanied by the development of sensation of regurgitation. After the application of the UESAD, the frequency occurrence of this sensation decreased to 11 of 39 infusions (#P<.0001).

Fig. 6

Four examples of still frames of esophagopharyngeal reflux (EPR) detected by videopharyngoscopy and the color contour topographic representation of the pharyngeal, upper esophageal sphincter, and esophageal pressures (A–D). In each image, the exact time that the EPR occurred based on videopharyngoscopic image is indicated by an arrow. The corresponding endoscopic image of EPR is shown in the inset at the right lower corner of each figure. EPR events are evidenced by the presence of green-colored fluid in the hypopharynx of (A) and (B). In C and D the infusate has come in contact with the lens of the endoscope obscuring the hypopharyngeal view. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]