GASTROENTEROLOGY 1992;103:128-136

Pharyngeal Clearance During Swallowing: A

Combined Manometric and Videofluoroscopic
Study

PETER J. KAHRILAS, JERILYN A. LOGEMANN, SHEZHANG LIN,

and GULCHIN A. ERGUN
Departments of Medicine and Communication Sciences and Disorders, Northwestern University and
Veterans Administration Lakeside Medical Center. Chicago, Illinois

The deglutitive pharyngeal contraction was ana- in this way, the swallow response comprises several
lyzed using simultaneous videofluoroscopic and discrete elements including laryngeal closure, UES
manometric studies of eight volunteers. Anterior, opening, nasopharyngeal closure, bolus propulsion,
posterior, and longitudinal movements of the pha- and pharyngeal clearance. Recent investigations
ryngeal surfaces, relative to the cervical vertebrae, have used computer-assisted analysis of videofluor-
were measured during swallows of 5 and 10 mL of oscopy, sometimes synchronized with intraluminal
liquid barium. Profound pharyngeal shortening manometry, to examine the mechanism of UES
during bolus transit through the pharynx elimi- opening,l the volitional modifiability of UES open-
nated access to the larynx and elevated the upper ing, and the mechanism of laryngeal closure.3 The
esophageal sphincter to within 1.5 cm of the retro- present investigation used these same techniques to
lingual pharynx. Bolus head movement through the examine the mechanism of pharyngeal clearance
pharynx preceded the propagated pharyngeal con- during swallowing.
traction and registered manometrically as a slight
intrabolus pressure before the major pressure com- Materials and Methods
plex. Contraction in the horizontal plane began
Concurrent videofluoroscopic and manometric
after bolus head transit and culminated with strip- studies of swallowing were obtained in eight fasted male
ping of the bolus tail through the pharynx. Pro- volunteers, 23-32 years old, without swallowing prob-
longed upper sphincter opening with the larger- lems. The study protocol was approved by the Northwest-
volume swallows resulted from a delayed onset ern University Institutional Review Board. During record-
rather than altered propagation of the horizontal ing sessions, subjects sat upright in a high-backed chair
pharyngeal contraction. It is concluded that the with head support as lateral videofluoroscopic images in-
propagated pharyngeal contraction facilitates pha- cluding the vertebral bodies posteriorly, the hard palate
ryngeal clearance but has a minimal role in the pro- superiorly, and the subglottic air column inferiorly were
obtained. The fluoroscopic image was displayed on a mon-
cess of bolus propulsion during swallowing. The
itor and recorded with a videocassette recorder (Sony
propagated contraction works in concert with pro-
U-matic, model VO-9800). A manometric assembly with
found pharyngeal shortening to minimize hypo- three strain-gauge sensors spaced 1 cm apart in a 2.5-mm
pharyngeal residue after a swallow. by 3-cm radiopaque cylindrical housing (Medical Measure-
ments Inc., Hackensack, NJ) was passed nasally and posi-

S
tioned with the distal sensor facing posteriorly at the level
wallowing is a complex action with a simple re-
of the valleculae. Pressure tracings were displayed on a
sult: transfer of ingested material from the oral
polygraph (model R-611; Beckman Instruments, Oxnard,
cavity to the proximal esophagus. For this action to CA) with the sensitivity set at lo-20 mm Hg/cm and the
be accomplished, the pharynx must be transiently chart speed at 50 mm/s.
altered from its resting state as a respiratory conduit Manometric and videofluoroscopic records were syn-
into a gustatory conduit in which the nasopharynx chronized using a modified videotimer (model VC 436;
and laryngeal inlet are sealed and the oropharynx Thalner Electronics Laboratories, Ann Arbor, MI) that
instead leads to an opened upper esophageal both encoded an analog time signal on the videotape in
sphincter (UES). The ingesta must then be propelled hundredths of a second and sent a 5-millisecond pulse to
through the UES into the esophagus. Finally, before an instrumentation channel of the polygraph at whole-
the resumption of respiration, residual ingesta must
be cleared from the pharynx to prevent subsequent 0 1992 by the American Gastroenterological Association
inhalation of that residue into the trachea. Examined 0016-5085/92/$3.00
July 1992
second intervals. During each swallow sequence, one of
the second marks was labeled from the video display to
facilitate temporal correlation between fluoroscopic and
manometric records. Pressure values corresponding
fractions of seconds were derived by interpolation
tween the second marks. Two swallows each of 5 and 10
mL of liquid barium were obtained. Test boluses were
placed in the mouth with a syringe and subjects were told
to hold the bolus over the tongue until the swallow com-
mand, at which time they should swallow it as a single
bolus.
Videofluoroscopic data were analyzed temporally rela-
tive to UES opening (either barium or air within the UES at
the level 1 cm distal to the subglottic air column), which
was set as time zero to allow for comparison of pharyngeal
events among swallows.45 Spatial analysis of the video-
fluoroscopic swallowing sequences was accomplished
ing an interactive computer program written to enable x-y
coordinate determination of selected structures on each
video frame.6 For each swallow, 40 sequential frames [at
1/3Oth-second intervals) were analyzed such that frame
15 was always the first frame showing UES opening. The
analysis of anterior and posterior pharyngeal wall motion
during swallowing was based on the construction
subject-specific grid that served to normalize size differ-
ences among subjects and permit the same anatomic struc-
ture to be analyzed for each subject (Figure 1). The span of
the pharynx analyzed was from the tongue base superiorly
to the resting position of the uppermost margin of the UES
inferiorly.4 Once constructed on tracing paper, the grid
was placed over each digitized image of each swallow se-
quence for that subject and the data points shown in Fig-
ure 1 were marked using a mouse to position cross-hairs
on the monitor showing the fluoroscopic image. The coor-
dinates of the marked points were then stored as a data
file. The image-based coordinate system was referenced to
the anterior inferior corner of C3, which served as the an-
chor point (coordinate 0,O). Fluoroscopic magnification
was corrected for using the known s-cm length of the
manometric sensor casing positioned within the sagittal
plane. Thus, data coordinates were corrected for magnifi-
cation, head tilt, head movement, and different head sizes
among subjects.
As outlined above, the image data set was comprised of
the coordinates of 29 structures at 40 different times dur-
ing two swallows each of two test boluses in eight subjects.
Data for each structure among swallows of a given condi-
tion were averaged and expressed as mean ? SE. The tim-
ing of events or the extent of movement among test condi-
tions was compared by averaging values for each subject
within a test condition and then comparing values be-
tween conditions using a paired Students t test.
Manometric recordings were analyzed in conjunction
with the fluoroscopy to determine the time of initial bolus
contact with the most orad sensor in the bolus path and the
time of luminal closure at the level of that sensor. Pressure
during this interval was referred to as intrabolus pressure.
After luminal closure, the major pharyngeal contraction
was recorded and the timing and maximal value of this
complex were noted. The accuracy of manometric tracings
interpreted without the aid of fluoroscopy for determining
PHARYNGEAL CLEARANCE DURING SWALLOWING 129
to
be-
_-._ Line 4
Topot UES
us-
Vertical Axis
Figure 1. Subject-specific grid used to normalize anatomic data
among subjects. The vertical axis of the grid was drawn through
the anterior superior corners of C3 and C5. Lines 4 and 9 are
perpendicular to the vertical axis at the levels of the valleculae
and the uppermost margin of the LJES,respectively, in the first
of a digitized image of each swallow. Lines 5-8 are evenly spaced
between lines 4 and 9, and lines l-3 are spaced at the same inter-
val above line 4. The nine grid lines maintain a constant rela-
tionship to the vertebrae from the first digitized image of each
swallow to the last, in which the positions of the anterior pha-
ryngeal wall structure, posterior wall structure, and anterior
vertebral surface were marked at the intersection of each grid
line. The positions of the valleculae and superior aspect of the
arytenoid were marked as indicators of axial pharyngeal short-
ening. In instances of a closed lumen, anterior and posterior
walls were marked as superimposed. The length of the manomet-
ric sensor casing was marked to use as a known s-cm length in
the midline. The three posterior indentations on the manometric
casing correspond to the sites of the pressure sensors; the proxi-
mal sensor is Sl, and the most distal is S3. The anterior inferior
corner of C3 was used as the anchor point among frames.
the timing of the onset and offset of the intrabolus pressure
was determined by comparing values obtained by blinded
inspection of the manometric tracings with those obtained
while cross-referencing the fluoroscopy. The two sets of
values were then compared by linear regression analysis.
Results
Bolus Movement Relative to Pharyngeal
Contraction
Of the three manometric sensors, only the
most distal (3) was within the bolus path during
most swallows as determined by playback of the vi-
deofluoroscopy. The more proximal sensors (Sl and
S2) were usually behind the soft palate and thus re-
moved from the bolus path. Relative to the grid in
Figure 1, S3 was very close to the level of L2 at the
time of luminal closure; repositioning relative to the
rest position was a consequence of soft palate eleva-
tion early in the swallow. Figure 2 illustrates repre-
130 KAHRILAS ET AL.
5 ml
c (Pmax)
120
mmHg
0 !_ Av
b (lumen closed)
(bolus t:sensor)
I i
1 second
Figure 2. Manometric tracings obtained from one of the subjects
during 5- and lo-mL liquid barium swallows. In each panel, the
times of arrival of the bolus head (a) and the bolus tail (b) are
indicated as determined by playback of the videofluoroscopy.
Time b also indicates the timing of luminal closure at the level of
the sensor. Thus, the interval a-b indicates the period during
which the bolus passes the sensor, and pressure recorded during
that period (shaded area) is intrabolus pressure. The major pha-
ryngeal contractile complex occurs after bolus passage; time c
indicates the timing of the maximal pressure recorded.
sentative manometric tracings obtained from S3 dur-
ing 5- and IO-mL swallows showing the relationship
of contractile activity to bolus movement. Table 1
summarizes the values of times a, b, and c relative to
time 0 as well as the peak value of the pharyngeal
contraction (P,,,). Note that the a-b interval but not
b-c interval was significantly prolonged during
IO-mL swallows. The a-b interval reflects the delay
between initial bolus movement and the onset of the
pharyngeal contraction, whereas the b-c interval is a
characteristic of the pharyngeal contraction wave it-
self. Thus, volume-dependent modulation of the pe-
riod of UES opening during swallowing is associated
with a delayed onset of the pharyngeal contraction
wave relative to bolus propulsion, and consequently
UES opening, without significant alteration of the
wave form of the pharyngeal contraction itself.
Inspection of Figure 2 suggests that times a and b
could be estimated without reference to videofluo-
roscopy as the onset and offset of the intrabolus pres-
sure, respectively. In most instances, values obtained
with the aid of fluoroscopy were similar to those ob-
tained by blinded reading of the manometry trac-
ings, but because of a few widely discrepant data
points the overall r values for this correlation were
Table 1. Bolus Position Relative to the Manometric
Time a Time b
5 mL -0.10 f 0.02 0.15 f 0.03
10 mL -0.10 + 0.02 0.23 k 0.03O
NOTE. Times a, b, and c and P,,, are as defined
P < 0.01.
GASTROENTEROLOGY Vol. 103, No. 1
10 ml 0.46 and 0.14 for points a and b, respectively. How-
c
ever, when videofluoroscopy was used as an aid to
interpret the unusual wave forms that occurred in
four swallows, these correlation coefficients im-
proved to 0.82 and 0.86, respectively.
Pharyngeal Conformation During
Bolus Passage
b
Each axial level of the pharyngeal lumen
showed a distinct pattern of closure, as illustrated in
Figure 3. At the extreme ends, the retrolingual pat-
tern was most evident at the level of line 1 (Ll) and
the UES pattern at line 9 (L9). The retrolingual re-
gion was characterized by initial widening before
sphincter opening, rapid sealing after time 0 with
substantial contribution from both the anterior wall
(tongue) and the posterior wall (pharyngeal constric-
tors), and then widening again late in the swallow.
The sphincter zone showed the opposite activity, ini-
tially being narrow, widening at time 0, and then
narrowing again late in the swallow. Understanding
the dynamic behavior of the luminal dimensions be-
tween grid lines 1 and 9 requires consideration of
pharyngeal shortening as discussed below.
Each of the nine grid lines of Figure 1 maintained a
constant relationship to the vertebrae as determined
by the positions of the valleculae (line 4) and the
uppermost margin of the UES (line 9) at rest. As the
pharynx shortened, the points of intersection of the
grid lines with pharyngeal structures shifted. Figure
4 illustrates the pattern of pharyngeal shortening ob-
served during 5-mL liquid swallows and the effect of
this shortening on the anatomic structures inter-
sected by the grid lines. The lower line in Figure 4
depicts the axial level of the valleculae, which ele-
vates an average of imm in the course of swallow-
ing. Thus, line 4 was just above the level of the val-
leculae before initiation of swallowing but distal to
the valleculae at the midpoint of the swallow. Lines
1-3, however, were consistently in the retrolingual
space. Substantially more shortening was evident in
the pharyngeal segment between the superior aspect
of the arytenoid and the valleculae, as indicated in
Figure 4. On average, the arytenoid and UES were
elevated 22 mm by the midpoint of the swallow. Be-
cause the mean distance between grid lines was 6
Sensor and the Pharyngeal Contractile Complex
Time c a-b Interval b-c Interval P,,, (mm Hg)
0.25 f 0.02 0.25 f 0.03 0.10 f 0.01 103 f 7
0.33 k 0.02 0.32 f 0.03 0.10 rtr.
0.01 90 f 7
in Figure 2.
July 1992 PHARYNGEAL CLEARANCE DURING SWALLOWING 131

25 25 25
mm
20 20 20

15 15 15
10 10 10
5 5 5
0 0 0
a0 bL7

25 25 25
20 20 20
15 15 15
10 10 10

5 5 5

0 0 0

25 25 25
20 20 20
15 15 15
10 10 10
5 5 5
0 0 0
a o bL3 a0 bL6 a0 bL9

Figure 3. Anterior-posterior coordinates of the pharyngeal surfaces during 5-mL liquid swallows at the axial levels of grid lines 1-g.
Distances are referenced to the anterior surface of the vertebral bodies, and in each tracing the upper line indicates the position of the
anterior pharyngeal structure while the lower line indicates the position of the posterior pharyngeal wall. The vertical time line a
indicates the timing of the arrival of the bolus head at the manometric sensor and 0 indicates the timing of UES opening. Thus, the
interval from time a to 0 approximates the period of bolus head transit through the pharynx. Time b at each axial level indicates the
time at which luminal closure had been achieved in half of the test swallows (median closure time). Thus, the interval from bL1 to bLg
indicates the period of passage of the tail of the bolus through the pharynx. Time c indicates the timing of P,,, (Figure 2) and is shown
only at the level of L2 because this was very nearly the position of the manometric sensor. Each tick on the time axis is 1/3Oth second.
Although not shown for reasons of clarity, the maximal SE of data points ranged from 0.5 mm to 0.9 mm for posterior wall data points
and from 0.7 mm to 1.4 mm for anterior wall data points among the nine levels.

mm among subjects, this amounts to shifting the up-
per margin of the UES three lines orad from its initial
position (so as to include lines 6-8), thereby position-
ing it within 1.5 cm of the retrolingual pharynx.
Thus, the initial luminal narrowing that occurred
before time 0 at levels 6-8 in Figure 3 was a conse-
quence of sphincter elevation, in essence making
these lines indicators of sphincter opening and clos-
ing during the period of pharyngeal shortening. Ta-
ble 2 quantifies parameters of pharyngeal shortening
during 5- and lo-mL swallows. Although the extent
of shortening achieved during 5- and lo-mL swal-
lows was similar, maximal shortening was main-
tained significantly longer for the larger volume.
Times a and b are marked on Figures 3 and 4 to
show that the pharynx achieves and maintains its
shortened configuration during virtually the entire
period of bolus passage. The bolus head rapidly tra-
verses the pharynx between time a and time 0, and
the bolus tail traverses the pharynx from time bL1 to
bL9. Note that although the pharynx has begun to
lengthen by time bL9, lines 7, 8, and 9 all remain
within the white area of Figure 4 during this onset of
lengthening (0.4-0.5 seconds), showing that the tail
of the bolus is within or below the UES, in essence
having already been engulfed by the sphincter. The
period of sphincter opening for IO-mL swallows was
0.07 + 0.02 seconds longer than for 5-mL swallows,
but maximal pharyngeal shortening was maintained
0.2 seconds longer. Thus, the period of near-maximal
pharyngeal shortening is increased along with the
a-b interval as part of the volume-dependent modu-
lation of the timing of pharyngeal events.
Wall Contributions to Clearance
Figure 5 illustrates the dynamic behavior of
the posterior pharyngeal wall, and Figure 6 shows
the dynamic behavior of the anterior pharyngeal
surface during 5-mL liquid barium swallows. These
two figures contain the same data points as Figure 3
but are presented as surface contour graphs so that
the movement patterns of the nine axial levels are
more easily related to each other. Several aspects of
these figures are notable. Distal propagation of the
132 KAHRILAS ET AL. GASTROENTEROLOGY Vol. 103, No. l

a 0 bL1 b L9 base first moves forward and then begins its posterior
I I I I
L9 thrust while the anterior wall of the sphincter is
L8 pulled forward (L6-L9). Thus, the initial horizontal
motion of the anterior wall occurs before and coin-
cident with passage of the bolus head through the
L6 pharynx whereas only the propagated posterior wall
contraction coincides with movement of the bolus
tail through the pharynx (pharyngeal clearance).
L4
Modulation of the period of sphincter opening is
achieved by a dissociation between the early ante-
rior wall events and the posterior wall events, as sug-
gested by the modifiability of the a-b interval shown
in Table 1. However, the characteristics of the propa-
gated pharyngeal contraction itself are unchanged
Time In Seconds
among swallow volumes, as detailed in Table 3. Al-
Figure 4. Pharyngeal shortening during 5-mL liquid swallows. though there is a systematic shift in time b with in-
Times a, 0, bL1, and bL9, highlighted by vertical lines, are as creased bolus volume, the rapidity of propagation
indicated in the legend of Figure 3. The vertical axis indicates and the maximal amount the posterior wall bulged
the average positions of grid lines l-6 on the right, converted forward are unchanged with the larger-volume
into millimeters on the left (the mean distance between grid
swallow. In fact, a graph of the pharyngeal contrac-
lines among subjects was 6 mm). The functional zones of the
pharynx are indicated by shading on the graph; the very lightly tion during IO-mL swallows (not shown) appears vir-
shaded area on the bottom indicates the retrolingual propulsive tually identical to Figure 5 except for slight prolon-
chamber, the next darkest area indicates the region between the gation of the a-b interval.
valleculae and the superior aspect of the arytenoid, the darkest As is evident in the Figures 3, 5, and 6, the closure
area indicates the zone from the tip of the arytenoid to the top of
pattern in the retrolingual pharynx is different from
the UES, and the white area on top indicates the zone within the
UES. Thus, following any grid line across the graph indicates the that in the more distal zones. In the retrolingual
functional zones of the pharynx encountered by that line in the pharynx, the chamber first widens, then narrows by
course of the swallow. For example, L7 is initially between the the combination of the posterior wall bulging for-
valleculae and the tip of the arytenoid. However, in the interval ward from its resting position and the tongue thrust-
from -6.15 to 0.53 seconds, L6 is within the LJESas a result of
ing back posterior to its resting position, and then
pharyngeal shortening. Applying this information to Figure 3,
panel 7, it becomes apparent that the narrowing observed before widens again after bolus clearance. At the distal lev-
time -0.15 (time a is 0.1 seconds) is a consequence of pharyngeal els the pharynx first narrows in association with ax-
shortening and that the widening after 0.53 seconds (time bL7 is ial shortening, then widens as a result of traction via
0.41 seconds) is a consequence of pharyngeal lengthening. Al- the hyoid axis,l and then narrows again as the propa-
though not shown for clarity, the maximal SE was 1.5 mm for
gated contraction pulls the pharyngeal walls to-
the arytenoid data points and 1.6 mm for the valleculae data
points. gether, achieving closure at very nearly the same
anterior-posterior coordinates occupied in the rest-
ing state. Thus, the horizontal motion of the proxi-
posterior wall contraction coincided exactly with mal pharynx is in essence 180 out of phase with the
passage of the bolus tail through the pharynx but distal pharynx.
began superiorly after the head of the bolus had al-
ready traversed the entire pharynx as demonstrated Discussion
by the positions of lines indicating times a, 0, and b in In this study, computer-assisted analysis of di-
Figure 5. The aboral propagation of the contraction is gitized videofluoroscopic swallowing studies was
evident by the rightward movement of the shaded
stripes, indicating zones of equal distance from the
vertebral surface, in Figure 5. Note that the posterior
Table 2. Pharyngeal Shortening During Swallowing
wall bulged 6 mm forward from its resting position in
the retrolingual region, whereas distally the contrac- 5 mL 10 mL
tion only restored the wall to its initial position after Initial length (mm) 47.5 + 2 48.0 f 2
having been first compressed against the vertebrae. Shortening at time 0 (%) 41.4 k 3.6 43.5 f 4.3
The anterior pharyngeal surface, shown in Figure When shortening achieved (s) -0.06 f 0.01 -0.04 f 0.01
6, showed marked conformational change character- Persistence of shortening (s)~ 0.50 + 0.3 0.70 f 0.03
ized by proximal widening and distal narrowing be- Time 0 is the time of UES opening.
fore time a, coincident with pharyngeal shortening. bShortening greater than or equal to the degree achieved at time 0.
Similarly, between time a and time 0, the tongue P < 0.05.
July 1992 PHARYNGEAL CLEARANCE DURING SWALLOWING 133

10
9
8
7
6
5
4
3
2
1
0

Figure 5. Horizontal posterior pharyngeal wall movement during 5-mL liquid barium swallows. The data shown are the average
values for 16 swallows. The distance from the pharyngeal wall to the anterior surface of the vertebral bodies at each level is shown on
the z axis, the key on the right applying to the shading of the surface graph. Time is on the x axis, time 0 indicating UES opening, time a
indicating bolus head contact with the sensor at the level of L2, and time b indicating the time at which luminal closure had been
achieved in half of the cases (median closure time) at each axial level. Axial levels Ll-L6 correspond to the grid lines of Figure 1,and
line b intersects with Ll-L6 at times bL1-bL6, respectively. Because UES opening corresponds with the arrival of the bolus head at the
sphincter, the interval a-0 (0.1 seconds) approximates the period during which the holus head traverses the pharynx. The holus tail
traverses the pharyngeal grid between the interval from bL1 to bL6 (0.37 seconds). Note that the period of bolus head passage precedes
any significant contractile activity of the pharyngeal constrictors but that the pharyngeal constrictor contraction is intimately
associated with passage of the bolus tail through the pharynx.

used to examine the mechanics of the deglutitive
pharyngeal contraction with relation to UES open-
ing, intraluminal pressure recording from within the
pharynx, and bolus transport through the pharynx.
The analysis emphasized that there are two compo-
nents of the deglutitive pharyngeal contraction:
longitudinal shortening with consequent laryngeal
elevation and an aborally propagated, lumen-obli-
terating horizontal contraction. Although both ele-
ments of the pharyngeal contraction are tightly inte-
grated into the swallow response, each has unique
functional attributes.
Pharyngeal shortening, largely attributable to sty-
lopharyngeus contraction, is a major component of
the conformational change that occurs early in the
swallow as the pharynx is transformed from respira-
tory to gustatory conduit.7 Because the majority of
pharyngeal shortening occurred in the segment be-
tween the valleculae and the superior margin of the
arytenoid, shortening had the effect of closely ap-
proximating the UES to the tongue base, leaving only
a 1.5-cm transition zone between them. Thus, the
laryngeal vestibule and pyriform sinuses were vir-
tually obliterated during the period of bolus transit
through the pharynx, avoiding the problem of
postswallow residue in these areas. Shortening oc-
curred as the bolus head traversed the pharynx and
was maintained at a given axial level until after pas-
sage of the bolus tail at that level. The prolonged
period of bolus transit through the pharynx asso-
ciated with larger-volume swallows was matched by
a proportionately prolonged duration of pharyngeal
shortening. The period of deglutitive pharyngeal
shortening is also subject to some element of voli-
tional control, as shown by its marked prolongation
during use of the Mendelsohn maneuver.
Although the indicators of pharyngeal shortening
used in this study (elevation of the valleculae and
arytenoid relative to the vertebrae) reflect anterior
wall motion, substantial evidence suggests that short-
ening in the anterior pharyngeal wall is paralleled in
the posterior pharyngeal wall. During videofluoros-
topic swallowing studies obtained with radiopaque
suction cups attached to the posterior pharyngeal
wall, Palmer et al. observed degrees of shortening
nearly identical to those measured in the present
134 KAHRILAS ET AL. GASTROENTEROLOGY Vol. 103, No. 1

Figure 6. Anterior pharyngeal wall movement in the horizontal plane during 6-mL liquid barium swallows. All three axes and times
a, b, and 0 are as described in the legend of Figure 5. Interpretation of the contour of the anterior pharyngeal surface is more
complicated than that of the posterior surface because of the effect of pharyngeal shortening. Inspection of Figure 4 suggests that
pharyngeal shortening is fully achieved shortly after time a. In conjunction with anterior tongue ramping, this results in widening of
the pharynx in the retrolingual area (LI-L3) and substantial narrowing at the levels of grid lines L&L9. At the levels of L4 and L5, the
luminal narrowing is a consequence of arytenoid to epiglottic approximation that has the effect of obliterating the laryngeal vestibule.
The pharyngeal lumen narrows to the point of closure at L6-L9 because of the elevation of the UES. At time 0, the retrolingual
pharynx is beginning its posterior thrust while the anterior surface of the UES is being pulled forward; minimal anterior wall
movement is occurring at time b.

study (25 mm at the level of the UES). Detailed fluo- studies by Nilsson et al. have shown that the prever-
roscopic and manometric analyses of the axial mo- tebral space at the level of the larynx and hypophar-
tion of the UES high-pressure zone during swallow ynx is composed of a thin layer of fatty tissue and
support both the degree of elevation observed in this that a distinct slit along the prevertebral fascia
study and the prolongation of elevation associated through this tissue allows for the larynx, trachea,
with larger-volume swallows.4 Finally, cadaveric and attached UES to move up and down in unison

Table 3. Timing, Position, and Propagation ofLumina1 Closure During 5- and IO-mL Swallows

5-mL swallows lo-mL swallows

Time b Velocity (cm/s) PW bulge Time b Velocity (cm/s) PW bulge

Ll 0.12+ 0.01 - 6.5+ 0.4 0.17rtO.Olb 5.8k 0.5

L2 0.14* 0.01 40 +15 5.7+ 0.3 0.22* O.Olb 14 f 1.8 5.5* 0.4
L3 0.22+ 0.02 13 f 2 5.2+ 0.4 0.31f O.Olb 13 f 1.6 4.6f 0.4
L4 0.27f 0.01 17 f 5 4.4f 0.3 0.33+ O.Olb 12 f 1.7 3.1k 0.3
L5 0.32+ 0.01 15 * 2 2.9f 0.3 0.39f 0.02b 12 + 2.0 2.3k 0.3
L6 0.37+ 0.01 15 + 2 1.9+ 0.3 0.42f 0.02b 18 k 2.5 1.4? 0.3
L7 0.41+ 0.02 21 * 7 1.8k 0.3 0.46f O.OZb 17 k 2.6 1.2+ 0.3
LB 0.44+ 0.02 24 k 5 1.7* 0.3 0.50f 0.02b 14 + 2.8 0.6f 0.3
L9 0.48f 0.02 22 * 5 1.5t 0.3 0.55f 0.02b 20 + 5.8 0.6f 0.2

NOTE. Although time b and consequently the timing of luminal closure is systematically delayed with the 10-mL swallows, there was no
difference in the local propagation velocity or in the extent of the posterior wall bulge between swallow volumes. Data are presented as
means f SEM.
Maximal amount the posterior wall bulged forward during the propagated contraction.
bP i 0.05vs.5.mL values.
July 1992 PHARYNGEAL CLEARANCE DURING SWALLOWING 135

during swallowing without oblique forces acting on residue as suggested by clinical observations.~4
the sphincter.g However, impaired shortening and an impaired
In contrast to the longitudinal pharyngeal contrac- clearing wave have different clinical implications. In
tion, the aborally propagated horizontal contraction one case it is possible to train individuals to accentu-
began late in the swallow as the bolus tail traversed ate laryngeal elevation, which is subject to some vo-
the pharynx. The corresponding position of the bolus litional contro1,25 but in the other case present
head at the onset of the horizontal contraction is treatment is limited to compensations such as head
bolus volume dependent,3 but for the 5- and lo-mL turning to exclude the paretic side of the pharynx if
volumes used in this work the bolus head had com- unilateral or a postswallow cough to clear residue if
pletely traversed the pharynx before its onset. Se- it is bilateral.4~ It also becomes apparent that the
quencing of the horizontal contraction coincided pre- clinical assessment of pharyngeal function must in-
cisely with clearance of the bolus tail from the clude determination of effective shortening, timing
pharynx, supporting the suggestion of Cerenko et of shortening relative to bolus transit, and finally the
al. that the propagated contraction is primarily a characteristics of the propagated posterior wall con-
pharyngeal clearance event rather than an element traction itself. Videofluoroscopic study is ideally
of bolus propulsion. Aboral sequencing of the pha- suited to this task, but evaluation of pharyngeal
ryngeal stripping wave is probably entirely a func- function from manometric data alone is inadequate
tion of the posterior wall because no detectable se- and can result in serious informational disparities.
quencing occurs in the electromyographic activity of Pharyngeal manometry recordings reflect only the
the tongue base, and distal to the tongue the ante- horizontal component of the pharyngeal contraction,
rior pharyngeal wall is composed of cartilaginous and the most obvious feature of the manometric re-
structures (i.e., the underside of the epiglottis over- cord, the time and value of maximal pressure, is of
lying the arytenoids superior to the UES and the cri- unclear functional significance. Maximal contractile
coid plate within the sphincter itself). Our findings pressure occurs after luminal closure, and the timing
suggest that the propagated pharyngeal contraction and effectiveness of luminal closure during pharyn-
is a highly stereotyped event within subjects and geal clearance require evaluation because these are
among swallow volumes in terms of propagation ve- of the greatest functional significance.
locity, extent of contraction, and maximal contrac-
tile pressure achieved. Ekberg et al. similarly found References
minimal variability in propagation velocity with
varied bolus volume.3 Iacob P, Kahrilas PJ, Logemann JA, Shah V, Ha T. Upper esoph-
Recent investigations have shown that one mecha- ageal sphincter opening and modulation during swallowing.
Gastroenterology 1989:97:1469-1478.
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UES opening. The present study suggests that this swallowing. Am J Physiol 1991;260:G450-G456.
prolongation is achieved as a result of a modifiable Logemann JA, Kahrilas PJ, Cheng J. Pauloski BR, Gibbons PJ,
linkage between the events associated with the Rademaker AW. Lin S. Closure mechanisms of the laryngeal
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