24-h Dual-probe pH Monitoring Research Articles

Laryngopharyngeal reflux disease (LPRD) –Review article-

Laryngopharyngeal reflux disease (LPRD) is caused by the back-flow of stomach contents and/or gastric acid into the laryngopharynx. Symptoms of laryngopharyngeal reflux (LPR) include hoarseness, sore throat, throat-clearing, chronic cough, globus sensation, dysphagia, and postnasal drip. LPRD is diagnosed in approximately 10% of patients presenting to outpatient otolaryngology clinics and in more than 50% of patients presenting with voice complaints. Gastroesophageal reflux disease (GERD) and LPRD may be associated with periodontitis, sleep disorders, and otolaryngology disease.Gastric acid reflux with LPRD is thought to cause laryngeal granulomas.The most useful endolaryngeal signs for diagnosing LPRD are erythema, edema, and interarytenoid hypertrophy. Ambulatory 24-h dual-probe pH monitoring can be misleading; false-positive outcomes may occur due to artifacts in the upper probe, and false-negative outcomes can occur as a result of the intermittent character of reflux episodes. In patients with LPRD, proton pump inhibitors (PPIs) have been shown to significantly improve reflux laryngitis. However, some patients are resistant to antacid therapy. Nocturnal acid breakthrough (NAB) on PPI has been suggested as one reason for resistance to PPI therapy. Administration of a PPI with the additional bedtime administration of a histamine-2 receptor antagonist has been shown to be an effective treatment of LPRD with NAB. Recently, potassium-competitive acid blockers have been proposed as an effective treatment of antacid-resistant disease.

Clinical evaluation of pepsin for laryngopharyngeal reflux in children with otitis media with effusion

ObjectiveWe sought to evaluate the clinical role of pepsin for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME). MethodsPepsin/pepsinogen and fibrinogen were analyzed in fifty effusion and blood samples of children with OME using enzyme linked immunosorbent assay (ELISA). Ambulatory 24-h dual-probe pH monitoring was additionally performed in 31 children divided into two groups according to response of medical treatment. ResultsThe effusion levels of pepsin/pepsinogen ranged from 8.5 to 1512μg/dl and were up to 4–540 times higher than the concentrations found in plasma samples. The effusion levels of fibrinogen ranged from 0.05 to 4.1g/dl. Some effusion samples showed fibrinogen concentrations did not exceed 10 times higher than the concentrations found in plasma samples and others showed lower concentrations. The pH of effusion samples was 7.13 to 8.72. Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant acid reflux documented by either the esophageal probe or the pharyngeal probe and all of them had LPR. There is a significant positive correlation between the level of pepsin assayed in the effusions and the number of pharyngeal reflux episodes measured by pH monitoring. ConclusionsAnalysis of pepsin/pepsinogen in effusion samples of children with OME, using ELISA, can be considered as a reliable biochemical marker for assessment of laryngopharyngeal reflux.

Laryngektomierte Stimmprothesenträger

We conducted a prospective study to assess the influence of supra-esophageal reflux on voice quality and quality of life in patients who had undergone laryngectomy and prosthetic voice rehabilitation. We investigated 60 laryngectomised patients using 24-h dual-probe pH monitoring before and 6 months after oral anti-reflux treatment with proton pump inhibitors (PPIs). Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30. Voice quality was quantified using the voice handicap index (VHI10). Quality of life and voice quality parameters were then correlated with the severity of reflux disease. Patients with physiological reflux area index (RAI) scores had a mean VHI10 score of 46.4 (±11.4). VHI scores were found to increase to up to 64.1 (±9.6) with reflux severity (p=0.025). Total quality of life scores ranged from 115.8 (±24.7) in patients with physiological RAI scores to 131.0 (±33.1) in patients with highly pathological RAI scores (p=0.007). After 6 months of treatment with PPIs, VHI scores improved to a total score of 57.5 (±20.6, p=0.003). Quality of life scores improved to 123.3 (±29.0, p=0.045). Supra-esophageal reflux influences voice quality and quality of life in laryngectomised patients with voice prostheses. This can be explained, for example, by an increased incidence of periprosthetic leakage, the presence of edema in the pharyngo-esophageal segment (where speech is produced), and general reflux symptoms. Rigorous treatment with anti-reflux medications leads to an improvement in reflux parameters that can be assessed objectively (RAI) and in correlated quality of life and voice quality parameters. For this reason, we recommend rigorous oral treatment with PPIs in laryngectomised patients with a confirmed diagnosis of supra-esophageal reflux.

The management of periprosthetic leakage in the presence of supra-oesophageal reflux after prosthetic voice rehabilitation

The objective of the study was to investigate the influence of anti-reflux medications on the management of periprosthetic leakage in laryngectomised patients with prosthetic voice rehabilitation. Sixty patients underwent laryngectomy and prosthetic voice rehabilitation. In a prospective non-randomised study, we examined the patients clinically and assessed the presence of reflux disease using 24-h dual-probe pH monitoring before and 6 months after oral anti-reflux treatment with proton pump inhibitors (PPIs). The severity of reflux, the effectiveness of anti-reflux therapy, and the clinical success of treatment were evaluated. Reflux parameters before and after anti-reflux therapy as well as the severity and incidence of periprosthetic leakage before and after PPI therapy were the main outcome measures. The absolute number of reflux events was 162.2 (±144.3) before treatment and 63.1 (±87.9) after treatment with PPIs (p = 0.031). The reflex area index score decreased from 327.1 (±419.3) without PPIs to 123.8 (±249.7) with PPIs (p = 0.0228). The mean DeMeester score was 108.3 (±85.4) before treatment and 47.4 (±61.7) after 6 months of treatment (p = 0.0557). The relative risk of periprosthetic leakage decreased to 0.5 after anti-reflux treatment. In 19 patients, leakage problems were successfully managed by rigorous treatment with PPIs. No further surgical procedures were required in these cases. Rigorous anti-reflux treatment leads to an improvement in parameters that can be assessed objectively by 24-h dual-probe pH monitoring. In the majority of patients, the symptoms associated with periprosthetic leakage can be improved or cured.

Omeprazole reduces the response to capsaicin but not to methacholine in asthmatic patients with proximal reflux

Objective. To study the relationships between airway responsiveness to methacholine and capsaicin, proximal or distal reflux and the effects of short-term acid inhibition. Material and methods. Twenty-nine asthmatics, not taking steroids regularly, underwent respiratory symptom measurements, 24-h dual-probe pH monitoring, and challenges with methacholine and capsaicin. Challenges and symptom measurements were repeated after 12 days’ omeprazole treatment (20 mg b.i.d.). The results (median and range) were expressed as PD20 methacholine (mg) and PD5 capsaicin (dose causing five coughs, nmol). Results. Seventeen patients presented pathological reflux in the distal esophagus, and 17 in the proximal esophagus. At baseline no correlation was found between PD20 or PD5 and reflux. Treatment with omeprazole did not change bronchial responsiveness to methacholine (basal: 0.16 mg, 0.02–1.27; omeprazole: 0.15 mg, 0.02–1.60); omeprazole decreased the tussive response to capsaicin (basal: 0.08 nmol, 0.08–2.46; omeprazole: 0.61 nmol, 0.08–9.84, p<0.001) only in patients with pathological reflux. The decrease was positively correlated with proximal acid exposure (r2=0.70, p<0.001). Omeprazole reduced asthma symptoms in patients with proximal reflux, cough in those with proximal or distal reflux. Conclusions. In asthmatics, inhibition of gastric acid secretion does not influence bronchial hyperresponsiveness but decreases tussive sensitivity and this effect is related to proximal reflux.

Gastroesophageal flap valve is associated with gastroesophageal and gastropharyngeal reflux

The endoscopic grade of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux. A total of 364 patients (151 men and 233 women; mean age, 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-h dual-probe pH monitoring were included. GEFV was graded I through IV using Hill's classification; then, GEFV was classified into two groups: a normal GEFV group (grades I and II) and an abnormal GEFV group (grades III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared between the groups. Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (P < 0.001). Lower esophageal sphincter pressure was significantly lower in the abnormal GEFV group than in the normal GEFV group (P < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). In addition, all variables, except the supine time of pH < 4, showing gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). The frequency of gastroesophageal reflux disease and of gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux.

Prevalence of Gastroesophageal Reflux in Difficult Asthma

Study objectives To determine the prevalence of gastroesophageal reflux disease (GERD)—both symptoms and objective evidence—using 24-h dual-probe pH monitoring in difficult asthma, and the relationship between the presence and treatment of GERD to clinical outcome Design and setting As part of a systematic evaluation protocol, 68 subjects with difficult-to-control asthma attending a difficult asthma clinic were referred for dual-probe ambulatory pH esophageal monitoring Results Esophageal probe data were available in 52 patients (76%) with difficult asthma. The prevalence of GERD/GERD-associated asthma symptoms was 75% (39 of 52 patients; 95% confidence interval [CI], 63 to 84.7%). The prevalence of GERD as evidenced by an abnormal pH profile at the distal esophageal probe was 55% (29 of 52 patients; 95% CI, 40 to 69%). The prevalence of GERD at the proximal probe was 34.6% (18 of 52 patients; 95% CI, 23.6 to 51%). The prevalence of GERD was similar in asthmatic subjects who responded to intervention and those who remained difficult to control (therapy resistant). Asymptomatic GERD was present in 9.6% (5 of 52 patients); 16% of cough episodes correlated with acid reflux Conclusions In difficult-to-control asthma, GERD is common, but identification and treatment of GERD do not appear to relate to improvement in asthma control in this population

Prevalence of Gastroesophageal Reflux in Difficult Asthma*

To determine the prevalence of gastroesophageal reflux disease (GERD)-both symptoms and objective evidence-using 24-h dual-probe pH monitoring in difficult asthma, and the relationship between the presence and treatment of GERD to clinical outcome. As part of a systematic evaluation protocol, 68 subjects with difficult-to-control asthma attending a difficult asthma clinic were referred for dual-probe ambulatory pH esophageal monitoring. Esophageal probe data were available in 52 patients (76%) with difficult asthma. The prevalence of GERD/GERD-associated asthma symptoms was 75% (39 of 52 patients; 95% confidence interval [CI], 63 to 84.7%). The prevalence of GERD as evidenced by an abnormal pH profile at the distal esophageal probe was 55% (29 of 52 patients; 95% CI, 40 to 69%). The prevalence of GERD at the proximal probe was 34.6% (18 of 52 patients; 95% CI, 23.6 to 51%). The prevalence of GERD was similar in asthmatic subjects who responded to intervention and those who remained difficult to control (therapy resistant). Asymptomatic GERD was present in 9.6% (5 of 52 patients); 16% of cough episodes correlated with acid reflux. In difficult-to-control asthma, GERD is common, but identification and treatment of GERD do not appear to relate to improvement in asthma control in this population.

Is ambulatory 24-h dual-probe pH monitoring useful in suspected ENT manifestations of GERD?

Background and aims. The present study is aimed at assessing the relationship between ear, nose and throat manifestations and proximal reflux in gastro-oesophageal reflux disease by using 24-h dual-probe pH monitoring. Patients and methods. Fifty-eight patients were included: (i) 28 patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease; (ii) 18 patients with typical symptoms of gastro-oesophageal reflux disease without extraoesophageal manifestations of gastro-oesophageal reflux disease; (iii) 12 healthy volunteers. Ambulatory 24-h dual-probe pH monitoring was performed in all patients. Oesophagogastroscopy was performed in all patients of groups I and II. Ear, nose and throat examination was performed in all patients with ear, nose and throat complaints. Results. At the upper oesophageal sphincter, results of pH monitoring were significantly different between groups I and III (0.009< P<0.02) and between groups I and II (0.008< P<0.03). When comparing data at the lower oesophageal sphincter, we found a significant difference between groups II and III (0.002< P<0.009) and between groups I and III (0.001< P<0.002). Endoscopic examination of the oesophagus did not show any significant difference between groups I and II. Laryngoscopy was abnormal in 86% of the patients with ear, nose and throat symptoms. Conclusions. Ambulatory 24-h dual-probe pH monitoring is useful in the assessment of patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease, especially in the case of abnormal laryngoscopy.