The calibrated area of the pharynx can then be measured at rest and then again at maximal constriction and a ratio is calculated (figure 3). A metal ring of known diameter is placed on the patient’s chin during videofluoroscopy. It has been validated as a surrogate measure of strength and is correlated with manometric findings 10,11. Pharyngeal constriction ratio (PCR) is now a well-established tool for measuring and monitoring pharyngeal constriction. Videofluoroscopic – pharyngeal constriction ratio
Rebecca Leonard, Otolaryngology, University California, Davis. Using simultaneous videofluoroscopy and endoscopy, Fuller & colleagues found significant correlations between pharyngeal squeeze and pharyngeal constriction ratio (PCR). The patient is asked to perform a forceful “eee.” The endoscopist observes the pharyngeal wall and documents pharyngeal strength as abnormal if the pharyngeal walls don’t contract medially narrowing the hypopharynx and pyriform fossae (Figure 2). The pharyngeal squeeze is a validated tool for measuring pharyngeal strength during endoscopy 9. Where there is a high-pressure gradient across the UES, there is likely to be a better surgical response to myotomy or dilatation treatments. Key measures from the pharyngeal manometry study include: pharyngeal occlusion pressures, intrabolus pressure gradient and upper esophageal sphincter (UES) pressures. High-resolution manometry is an established, validated assessment for measuring intraluminal pressures throughout the gastrointestinal tract including the pharynx and pharyngoesophageal segment 8. These may provide insight into risk of airway violation and improve surgical decision-making. There are a number of measures of pharyngeal constriction/ strength available. However, they provide little predictive information and therefore have limited value in management decisions: compensatory strategies, decisions regarding enteral feeding, objective monitoring over time or rehabilitation programmes. Residue in the pharynx and penetration-aspiration are associated with pharyngeal weakness. If pharyngeal constriction is reduced, it implies overall pharyngeal weakness and reduces the ability to pass the bolus distally. Primarily produced by sequential constrictor contraction, it impels bolus through the pharynx and pharyngoesophageal inlet in combination with negative pressures generated within the oesophagus and hyolaryngeal distraction. Pharyngeal constriction refers to the three-dimensional contraction that occurs through the pharynx, upper esophageal sphincter and then traverses into the peristaltic oesophageal wave. Pictures extracted from The University of Auckland Dysphagia Database. Pharyngeal constriction impairments across aetiologies. Figure 1 demonstrates impaired pharyngeal constriction across aetiologies. Pharyngeal weakness is seen across many common conditions: Parkinson’s disease 2, brainstem stroke 3, anterior cervical spine surgery 4, head and neck cancer 5, myotonic muscular dystrophy 6 and Zenker’s diverticulum 7. Poor pharyngeal constriction is one of the most common swallowing deficits reported in swallowing clinics 1.
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