Implementation of High-resolution Manometry in the Clinical Practice of Speech Language Pathology

Abstract

Visual imaging modalities, videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallow, for assessment of oropharyngeal dysphagia have been part of the speech language pathologist’s (SLPs) armamentarium for the diagnosis and treatment of dysphagia for decades. Recently, the addition of high-resolution manometry (HRM) has enabled the SLP to evaluate pharyngeal pressures and upper esophageal sphincter relaxation. Taken together, the use of visual imaging modalities with HRM can improve interpretation of swallowing physiology and facilitate more effective treatment planning. The goal of this article is to describe a clinical paradigm using HRM as an adjunct to VFSS, by the SLP, in the assessment of complex dysphagia. Moreover, in three cases described, the value of manometric measurements in elucidating swallowing imaging studies and documenting physiologic change in response to treatment is highlighted. As technology in this area is evolving, so will the clinical use of HRM by the SLP. Limitations of current HRM systems and applications are discussed.

Methods for Measuring Swallowing Pressure Variability Using High-Resolution Manometry

“…Typical clinical and research protocols involve 3-5 swallows of each bolus type [e.g., [72,108,109]]. Using our dataset of 10 swallows, we calculated pressure variability from subsets containing 2-10 swallows.…”

Expanding Instrumental Options for Dysphagia Diagnosis and Research: Ultrasound and Manometry

“…Despite this, pharyngeal manometry has been very slow to emerge into routine clinical practice [51]. In a recent survey of 206 speech-language pathologists, only 3.5% of respondents reported having access to manometry in their workplace [52]. This is compounded by the finding that of those who had access to manometry, only half reported they would pursue further manometric evaluation in a case study of a patient presenting with UES dysfunction [52].…”

“…Pharyngeal HRM is limited by a seldom-reported measurement error in the ManoScan™ system, used widely in research [52,73,81,82,88,92,93,94,95]. A pressure drift has been found to refute the manufacturer's report that pressure uniformity remains within 2 mm Hg for 4 h or less of recording [93,96].…”

“…The locations were selected due to reported ease in identification of each region: the UES has a clear band of pressure at rest, and the velopharynx can be identified by non-swallow speech tasks such as production of /kaka/ [77]. These anatomic definitions have been used for measurement in numerous subsequent publications [18,52,63,78,84], and this framework has been adapted in automated analysis programmes described in the literature [91]. …”

“…In a recent survey of 206 speech-language pathologists, only 3.5% of respondents reported having access to manometry in their workplace [52]. This is compounded by the finding that of those who had access to manometry, only half reported they would pursue further manometric evaluation in a case study of a patient presenting with UES dysfunction [52]. This highlights the need for continued education regarding the utility of this technique and increased inter-disciplinary access, as it is one of the few tools in the diagnostic armamentarium that can provide objective assessment with high temporal resolution.…”