Dysphagia in Parkinson's disease: Pharyngeal manometry and fiberoptic endoscopic evaluation

Published:March 31, 2022DOI:



      Dysphagia is a common symptom in Parkinson's disease (PD) and it represents a negative prognostic factor because of its complications. This study is to evaluate pharyngeal dysphagia for boluses of various consistencies with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Pharyngeal High-Resolution Manometry (PHRM) in a group of PD patients, making a comparison between the information provided by the two exams.


      Group of 20 patients affected by PD was selected and initially subjected to a qualitative evaluation of the swallowing performing FEES. Subsequently, they were evaluated by PHRM to identify quantitative measures associated with pressures expressed by pharyngeal organs during swallowing. Values obtained in the study group were compared with those recorded in a group of 20 healthy subjects.


      Study showed that Pmax (the maximum pressure elicited by the single pharyngeal muscle structures involved in swallowing) was significantly lower than the control group (p<0.05) for all the boluses and consistency tested, in particular for the Tongue base and the Cricopharyngeal muscle. Pmean pre-swallowing pressure (represents the mean value of a contraction in which basal and maximal pressure where normally calculated) was significantly higher compared to normal subjects for the Tongue base and the Cricopharyngeal muscle (p<0.05). Mean intra-swallowing pressure was higher for the Velopharynx and the Cricopharyngeal muscle, but lower for the tongue base. Pmax and Pmean at PHRM were altered independently to the degree of dysphagia detected at FEES, and they did not correlate either with the location of the residue or with the type of bolus. Images displayed at the FEES, found the corresponding biomechanical explanations in the PHRM, which also allowed us to quantify the extent of the dysfunction, through the calculation of the pressures generated in the various structures studied.


      PHRM is particularly useful in the early detection of dysphagia, when FEES may still show no evidence of abnormal swallowing.



      PD (Parkinson's Disease), FEES (Fiberoptic Endoscopic Evaluation Swallowing), HRM (High -Resolution Manometry), IDDSI (International Dysphagia Diet Standardisation Initiative), UES (Upper Esophageal Sphincter), VFSS (Videofluoroscopic Swallowing Study)
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      1. Parkinson J. An essay on the shaking palsy. In: Sherwood, Neely and Jones, editors. London Press, 1817.

        • Suttrup I
        • Warnecke T.
        Dysphagia in Parkinson's Disease.
        Dysphagia. 2016; 31: 24-32
        • Kalf JG
        • de Swart BJ
        • Bloem BR
        • Munneke M.
        Prevalence of oropharyngeal dysphagia in Parkinson's disease: a meta-analysis.
        Parkinsonism Relat Disord. 2012; 18: 311-315
        • Warnecke T
        • Hamacher C
        • Oelenberg S
        • Dziewas R.
        Off and on state assessment of swallowing function in Parkinson's disease.
        Parkinsonism Relat Disord. 2014; 20: 1033-1034
        • Plowman-Prine EK
        • Sapienza CM
        • Okun MS
        • Pollock SL
        • Jacobson C
        • Wu SS
        • et al.
        The relationship between quality of life and swallowing in Parkinson's disease.
        Mov Disord. 2009; 24: 1352-1358
        • Miller N
        • Noble E
        • Jones D
        • Burn D.
        Hard to swallow: dysphagia in Parkinson's disease.
        Age Ageing. 2006; 35: 614-618
        • Fasano A
        • Visanji NP
        • Liu LW
        • Lang AE
        • Pfeiffer RF.
        Gastrointestinal dysfunction in Parkinson's disease.
        Lancet Neurol. 2015; 14: 625-639
        • Michou E
        • Hamdy S.
        Dysphagia in Parkinson's disease: a therapeutic challenge?.
        Expert Rev Neurother. 2010; 10: 875-878
        • Suntrup S
        • Teismann I
        • Bejer J
        • Suttrup I
        • Winkels M
        • Mehler D
        • et al.
        Evidence for adaptive cortical changes in swallowing in Parkinson's disease.
        Brain. 2013; 136: 726-738
        • Mu L
        • Sobotka S
        • Chen J
        • Su H
        • Sanders I
        • Adler CH
        • et al.
        Arizona Parkinson's Disease Consortium. Altered pharyngeal muscles in Parkinson disease.
        J Neuropathol Exp Neurol. 2012; 71: 520-530
        • Langmore SE.
        Evaluation of oropharyngeal dysphagia: which diagnostic tool is superior?.
        Curr Opin Otolaryngol Head Neck Surg. 2003; 11: 485-489
        • Nordio S
        • Di Stadio A
        • Koch I
        • Stritoni P
        • Meneghello F
        • Palmer K.
        The correlation between pharyngeal residue, penetration/aspiration and nutritional modality: a cross-sectional study in patients with neurogenic dysphagia.
        Acta Otorhinolaryngol Ital. 2019;
        • Langmore SE.
        History of Fiberoptic Endoscopic Evaluation of Swallowing for Evaluation and Management of Pharyngeal Dysphagia: Changes over the Years.
        Dysphagia. 2017; 32: 27-38
        • Hoffman MR
        • Ciucci MR
        • Mielens JD
        • Jiang JJ
        • McCulloch TM.
        Pharyngeal swallow adaptations to bolus volume measured with high-resolution manometry.
        Laryngoscope. 2010; 120: 2367-2373
        • Ciucci M
        • Jones CA
        • Malandraki GA
        • Hutcheson KA.
        Dysphagia Practice in 2035: Beyond Fluorography, Thickener, and Electrical Stimulation.
        Semin Speech Lang. 2016; 37: 201-218
        • Jones CA
        • Ciucci MR.
        Multimodal Swallowing Evaluation with High-Resolution Manometry Reveals Subtle Swallowing Changes in Early and Mid-Stage Parkinson Disease.
        J Parkinsons Dis. 2016; 6: 197-208
        • Jones CA
        • Hoffman MR
        • Lin L
        • Abdelhalim S
        • Jiang JJ
        • McCulloch TM.
        Identification of swallowing disorders in early and mid-stage Parkinson's disease using pattern recognition of pharyngeal high-resolution manometry data.
        Neurogastroenterol Motil. 2018; 30: e13236
        • Suttrup I
        • Suttrup J
        • Suntrup-Krueger S
        • Siemer ML
        • Bauer J
        • Hamacher C
        • et al.
        Esophageal dysfunction in different stages of Parkinson's disease.
        Neurogastroenterol Motil. 2017; 29
      2. International Dysphagia Diet Standardisation Initiative (IDDSI). Accessed 10 October 2016.

        • Goetz CG
        • Poewe W
        • Rascol O
        • Sampaio C
        • Stebbins GT
        • Counsell C
        • et al.
        Movement Disorder Society Task Force on Rating Scales for Parkinson's Disease. Movement Disorder Society Task Force report on the Hoehn and Yahr staging scale: status and recommendations.
        Mov Disord. 2004; 19: 1020-1028
        • Nacci A
        • Ursino F
        • La Vela R
        • Matteucci F
        • Mallardi V
        • Fattori B
        Fiberoptic endoscopic evaluation of swallowing (FEES): proposal for informed consent.
        Acta Otorhinolaryngol Ital. 2008; 28: 206-211
        • Hiss SG
        • Postma GN.
        Fiberoptic endoscopic evaluation of swallowing.
        Laryngoscope. 2003; 113: 1386-1393
        • Fife TA
        • Butler SG
        • Langmore SE
        • Lester S
        • Wright Jr, SC
        • Kemp S
        • et al.
        Use of topical nasal anesthesia during flexible endoscopic evaluation of swallowing in dysphagic patients.
        Ann Otol Rhinol Laryngol. 2015; 124 (Mar): 206-211
        • Farneti D.
        Pooling score: an endoscopic model for evaluating severity of dysphagia.
        Acta Otorhinolaryngol Ital. 2008; 28: 135-140
        • Farneti D
        • Fattori B
        • Nacci A
        • Mancini V
        • Simonelli M
        • Ruoppolo G
        • et al.
        The Pooling-score (P-score): inter- and intra-rater reliability in endoscopic assessment of the severity of dysphagia.
        Acta Otorhinolaryngol Ital. 2014; 34: 105-110
        • Takasaki K
        • Umeki H
        • Enatsu K
        • Tanaka F
        • Sakihama N
        • Kumagami H
        • et al.
        Investigation of pharyngeal swallowing function using high-resolution manometry.
        Laryngoscope. 2008; 118: 1729-1732
        • Omari TI
        • Ciucci M
        • Gozdzikowska K
        • Hernández E
        • Hutcheson K
        • Jones C
        • et al.
        High-Resolution Pharyngeal Manometry and Impedance: Protocols and Metrics-Recommendations of a High-Resolution Pharyngeal Manometry International Working Group.
        Dysphagia. 2019;
        • Meyer JP
        • Jones CA
        • Walczak CC
        • McCulloch TM.
        Three-dimensional manometry of the upper esophageal sphincter in swallowing and nonswallowing tasks.
        Laryngoscope. 2016; 126: 2539-2545
        • Rosen SP
        • Jones CA
        • McCulloch TM.
        Pharyngeal swallowing pressures in the base-of-tongue and hypopharynx regions identified with three-dimensional manometry.
        Laryngoscope. 2017; 127: 1989-1995
        • Walczak CC
        • Jones CA
        • McCulloch TM.
        Pharyngeal Pressure and Timing During Bolus Transit.
        Dysphagia. 2017; 32: 104-114
        • Umeki H
        • Takasaki K
        • Enatsu K
        • Tanaka F
        • Kumagami H
        • Takahashi H.
        Effects of a tongue-holding maneuver during swallowing evaluated by high-resolution manometry.
        Otolaryngol Head Neck Surg. 2009; 141: 119-122
        • McCulloch TM
        • Hoffman MR
        • Ciucci MR.
        High-resolution manometry of pharyngeal swallow pressure events associated with head turn and chin tuck.
        Ann Otol Rhinol Laryngol. 2010; 119: 369-376
        • Geng Z
        • Hoffman MR
        • Jones CA
        • McCulloch TM
        • Jiang JJ.
        Three-dimensional analysis of pharyngeal high-resolution manometry data.
        Laryngoscope. 2013; 123: 1746-1753
        • Ellerston JK
        • Heller AC
        • Houtz DR
        • Kendall KA.
        Quantitative Measures of Swallowing Deficits in Patients With Parkinson's Disease.
        Ann Otol Rhinol Laryngol. 2016; 125: 385-392