Potential for Volitional Control of Resting Pressure at the Upper Oesophageal Sphincter in Healthy Individuals


Resting pressure at the upper oesophageal sphincter (UOS) has been reported to be susceptible to factors such as emotional stress or respiration. This exploratory study investigated the potential for behavioural modulation of UOS resting pressure in healthy adults to increase our understanding of volitional control of UOS pressure, and the potential development of rehabilitation approaches. Six healthy adults were seen one hour daily for two weeks (10 days) and for one post-training session after a training break of two weeks. Manipulation of UOS resting pressure was practised during a protocol of alternating increased and decreased pressure. A high-resolution manometry contour plot was used as a biofeedback modality. Participants were asked to explore how to achieve warmer and cooler colours (pressure increase and decrease, respectively) at the UOS resting pressure band, without changing head position or manipulating activity of other muscles. Performance was analysed prior to training start and following daily training. Participants were able to increase resting pressure following one week of practice; however, there was no evidence for purposeful pressure decrease. The increased resting pressure achieved by participants indicates a capacity for purposeful pressure modulation given intensive biofeedback training. The lack of volitional reduction in pressure may be explained by sustained pressure generation due to the intrinsic muscular characteristics of the UOS and a flooring effect in healthy subjects, in whom physiology mandates a minimum degree of resting pressure to fulfil the barrier function. Distention caused by the presence of the intraluminal catheter cannot be ruled out.

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  1. 1.

    Lang IM. Development, anatomy, and physiology of the upper esophageal sphincter and pharyngoesophageal junction. In: Shaker R, Belafsky P, Postma G, Easterling C, editors. Principles of deglutition: A multidisciplinary text for swallowing and its disorders. New York: Springer; 2013. p. 235–255. https://doi.org/10.1007/978-1-4614-3794-9.

    Google Scholar 

  2. 2.

    Nilsson ME, Isberg A, Schiratzki H. The location of the upper oesophageal sphincter and its behaviour during bolus propagation-a simultaneous cineradiographic and manometric investigation. Clin Otolaryngol Allied Sci. 1989;14(1):61–5.

    CAS  Article  Google Scholar 

  3. 3.

    Halum SL, Shemirani NL, Merati AL, Jaradeh S, Toohill RJ. Electromyography findings of the cricopharyngeus in association with ipsilateral pharyngeal and laryngeal muscles. Ann Otol Rhinol Laryngol. 2006;115(4):312–6. https://doi.org/10.1177/000348940611500411.

    Article  PubMed  Google Scholar 

  4. 4.

    Singh S, Hamdy S. The upper oesophageal sphincter. Neurogastroenterol Motil. 2005;17:3–12. https://doi.org/10.1111/j.1365-2982.2005.00662.x.

    Article  PubMed  Google Scholar 

  5. 5.

    Kahrilas PJ, Dodds WJ, Dent J, Haebrle B, Hogan WJ, Arndorfer RC. Effect of sleep, spontaneous gastroesophageal reflux, and a meal on upper esophageal sphincter pressure in normal human volunteers. Gastroenterology. 1987;92(2):466–71.

    CAS  Article  Google Scholar 

  6. 6.

    Eastwood PR, Katagiri S, Shepherd KL, Hillman DR. Modulation of upper and lower esophageal sphincter tone during sleep. Sleep Med. 2007;8(2):135–43. https://doi.org/10.1016/j.sleep.2006.08.016.

    Article  PubMed  Google Scholar 

  7. 7.

    Perera L, Kern M, Hofmann C, Tatro L, Chai K, Kuribayashi S, Lawal A, Shaker R. Manometric evidence for a phonation-induced UES contractile reflex. Am J Physiol Gastrointest Liver Physiol. 2008;294(4):G885–891. https://doi.org/10.1152/ajpgi.00470.2007.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    DiRe C, Shi G, Manka M, Kahrilas PJ. Manometric characteristics of the upper esophageal sphincter recorded with a microsleeve. Am J Gastroenterol. 2001;96(5):1383–9. https://doi.org/10.1111/j.1572-0241.2001.03793.x.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Cook IJ, Dent J, Shannon S, Collins SM. Measurement of upper esophageal sphincter pressure. Effect of acute emotional stress. Gastroenterology. 1987;93(3):526–32.

    CAS  Article  Google Scholar 

  10. 10.

    Shaker R, Ren J, Xie P, Lang IM, Bardan E, Sui Z. Characterization of the pharyngo-UES contractile reflex in humans. Am J Physiol. 1997;273(4 Pt 1):G854–858.

    CAS  PubMed  Google Scholar 

  11. 11.

    Lang IM, Shaker R. Anatomy and physiology of the upper esophageal sphincter. Am J Med. 1997;103(5A):50–5.

    Article  Google Scholar 

  12. 12.

    Miller AJ. The neuroscientific principles of swallowing and dysphagia. San Diego: Singular Publishing Group; 1999.

    Google Scholar 

  13. 13.

    Ertekin C, Turman B, Tarlaci S, Celik M, Aydogdu I, Secil Y, Kiylioglu N. Cricopharyngeal sphincter muscle responses to transcranial magnetic stimulation in normal subjects and in patients with dysphagia. Clin Neurophysiol. 2001;112(1):86–94. https://doi.org/10.1016/S1388-2457(00)00504-6.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Ertekin C, Aydogdu I. Electromyography of human cricopharyngeal muscle of the upper esophageal sphincter. Muscle Nerve. 2002;26(6):729–39. https://doi.org/10.1002/mus.10267.

    Article  PubMed  Google Scholar 

  15. 15.

    Nativ-Zeltzer N, Belafsky PC, Bayoumi A, Kuhn MA. Volitional control of the upper esophageal sphincter with high-resolution manometry driven biofeedback. Laryngoscope Investig Otolaryngol. 2019;4(2):264–8. https://doi.org/10.1002/lio2.255.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Peng L, Patel A, Kushnir V, Gyawali CP. Assessment of upper esophageal sphincter function on high-resolution manometry: identification of predictors of globus symptoms. J Clin Gastroenterol. 2015;49(2):95–100. https://doi.org/10.1097/MCG.0000000000000078.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Schindler A, Mozzanica F, Alfonsi E, Ginocchio D, Rieder E, Lenglinger J, Schoppmann SF, Scharitzer M, Pokieser P, Kuribayashi S, Kawamura O, Kusano M, Zelenik K. Upper esophageal sphincter dysfunction: Diverticula-globus pharyngeus. Ann N Y Acad Sci. 2013;1300(1):250–60. https://doi.org/10.1111/nyas.12251.

    Article  PubMed  Google Scholar 

  18. 18.

    Tokashiki R, Funato N, Suzuki M. Globus sensation and increased upper esophageal sphincter pressure with distal esophageal acid perfusion. Eur Arch Otorhinolaryngol. 2010;267(5):737–41. https://doi.org/10.1007/s00405-009-1134-1.

    Article  PubMed  Google Scholar 

  19. 19.

    Kiebles JL, Kwiatek MA, Pandolfino JE, Kahrilas PJ, Keefer L. Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report. Dis Esophagus. 2010;23(7):545–53. https://doi.org/10.1111/j.1442-2050.2010.01064.x.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Lamvik K, Jones R, Sauer S, Erfmann K, Huckabee ML. The capacity for volitional control of pharyngeal swallowing in healthy adults. Physiol Behav. 2015;152(Pt A):257–63. https://doi.org/10.1016/j.physbeh.2015.09.026.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Knigge MA, Thibeault S, McCulloch TM. Implementation of high-resolution manometry in the clinical practice of speech language pathology. Dysphagia. 2014;29(1):2–16. https://doi.org/10.1007/s00455-013-9494-5.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Guiu Hernandez E, Gozdzikowska K, Apperley O, Huckabee M-L. Effect of topical nasal anesthetic on swallowing in healthy adults: a double-blind, high-resolution manometry study. Laryngoscope. 2017;128(6):1335–9. https://doi.org/10.1002/lary.26996.

    Article  PubMed  Google Scholar 

  23. 23.

    Nelson LA. The role of biofeedback in stroke rehabilitation: past and future directions. Top Stroke Rehabil. 2007;14(4):59–66. https://doi.org/10.1310/tsr1404-59.

    Article  PubMed  Google Scholar 

  24. 24.

    Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–40. https://doi.org/10.1002/1098-240X(200008)23:4<334:AID-NUR9>3.0.CO;2-G.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Med Res Methodol. 2009;9(1):52. https://doi.org/10.1186/1471-2288-9-52.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Lamvik K, Guiu Hernandez E, Jones R, Huckabee ML. Characterization and correction of pressure drift in the ManoScan™ high-resolution manometry system: in vitro and in vivo. Neurogastroenterol Motil. 2016;28(5):732–42. https://doi.org/10.1111/nmo.12770.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Core Team R. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2016.

    Google Scholar 

  28. 28.

    Shrout PE, Fleiss JL. Intraclass correlations: Uses in assessing rater reliability. Psychol Bull. 1979;86(2):420–8. https://doi.org/10.1037/0033-2909.86.2.420.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Portney LG, Watkins MP. Foundations of clinical research. Applications to practice. 3rd ed. London: Pearson Education; 2009.

    Google Scholar 

  30. 30.

    Bates D, Mächler M, Bolker B, Walker S. Fitting linear mixed-effects models using {lme4}. J Stat Softw. 2015;67:1–48. https://doi.org/10.18637/jss.v067.i01.

    Article  Google Scholar 

  31. 31.

    Jungheim M, Miller S, Kühn D, Schwemmle C, Schneider JP, Ochs M, Ptok M. Physiology of the upper esophageal sphincter. HNO. 2014;62(6):457–68. https://doi.org/10.1007/s00106-014-2846-0.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Given Imaging (2016) ManoScanTM user manual: Modular cart system A120, A200, A300, and A400 (DOC1963-04)

  33. 33.

    Pope C, Ziebland S, Mays N. Qualitative research in health care: analysing qualitative data. Br Med J. 2000;320(7227):114–6. https://doi.org/10.1136/bmj.320.7227.114.

    CAS  Article  Google Scholar 

  34. 34.

    Jungheim M, Miller S, Kühn D, Schwemmle C, Schneider JP, Ochs M, Ptok M. Anatomy of the upper esophageal sphincter. HNO. 2014;62(5):385–94. https://doi.org/10.1007/s00106-014-2845-1.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Jungheim M, Schubert C, Miller S, Ptok M. Normwerte für die Hochauflösungsmanometrie von Pharynx und oberem Ösophagussphinkter (Normative data of pharyngeal and upper esophageal sphincter high resolution manometry). Laryngorhinootologie. 2015;94(09):601–8. https://doi.org/10.1055/s-0034-1395532.

    CAS  Article  PubMed  Google Scholar 

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Reliability data were extracted by Susanne Ebert.


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Winiker, K., Gozdzikowska, K., Guiu Hernandez, E. et al. Potential for Volitional Control of Resting Pressure at the Upper Oesophageal Sphincter in Healthy Individuals. Dysphagia (2020). https://doi.org/10.1007/s00455-020-10146-7

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  • Deglutition
  • Deglutition disorders
  • Upper oesophageal sphincter
  • Volition
  • Resting pressure
  • High-resolution manometry