24-hour Dual-probe pH Monitoring Research Articles

Use of flexible transnasal esophagogastroscopy in patients with unclear globus sensation

Globus pharyngeus is acommon symptom with considerable suffering. Globus sensation can be caused by reflux. In many places, endoscopy of the esophagus is recommended for clarification, especially when there is aquestion about the presence of ahiatal hernia as the cause of reflux. Transnasal esophagogastroscopy (TNE) represents an alternative to conventional gastroesophagoscopy. It enables aquick low-complication examination of the upper aerodigestive tract in the sitting, non-sedated patient. The aim of this work was to assess the feasibility of outpatient TNE in patients with globus sensation. Furthermore, the results of dual-probe pH monitoring were compared with the results of TNE in order to assess the value of TNE in the clarification of globus sensation and reflux. In 30patients with globus symptoms, 24-hour dual-probe pH monitoring and TNE were performed. In pH monitoring, reflux number, fraction time, reflux surface area index, and DeMeester score were evaluated as indicators of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD). Abnormalities of the esophageal mucosa and the gastroesophageal junction were recorded in TNE. The results were compared. The TNE could be performed without any complications. Mean examination time was 5.34 ± 0.12 min. Reflux was measured in 80% of the patients (24/30) with pH monitoring. In almost half of these patients (46%), abnormalities were detected in TNE as indirect evidence of reflux. In addition to an axial hiatal hernia, these included mucosal changes such as erosive esophagitis and Barrett's metaplasia. Patients with ahiatal hernia also suffered significantly more often from LPR than patients without ahernia (9:1). TNE is aquick and safe examination method for diagnosing patients with an unclear globus sensation. Detection of ahiatal hernia can be seen as an indication of reflux disease. Lack of evidence of ahernia does not rule out reflux. Thus, TNE is auseful addition to pH monitoring in patients with globus sensation, because reflux-related changes in the mucosa can be recognized early and adequately treated.

Correlation between Ambulatory 24 Hour Dual Probe pH Monitoring and Reflux Finding Score, Reflux Symptom Index in the Laryngopharyngeal Reflux

Received June 25, 2013 Revised August 3, 2013 Accepted August 19, 2013 Address for correspondence Kyung Tae, MD Department of OtolaryngologyHead and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-792, Korea Tel +82-2-2290-8585 Fax +82-2-2293-3335 E-mail kytae@hanyang.ac.kr Background and ObjectivesZZA 24-hour ambulatory dual probe for pH monitoring is the most specific and sensitive test for laryngopharyngeal reflux (LPR) disease. However, the use of this probe is not well tolerated in some patients due to discomfort and the invasive nature of the procedure. Thus, the diagnosis of LPR is usually made according to symptomatic responses to empirical treatment using a proton-pump inhibitor for patients with high score of reflux symptom index (RSI) and reflux finding score (RFS). The aim of this study is to evaluate the relationship between the RSI and RFS and pH monitoring using a 24-hour ambulatory dual probe, and determine the role of RSI and RFS in the diagnosis of LPR. Subjects and MethodZZWe studied 100 patients who underwent pH monitoring using a 24hour dual probe because of laryngopharyngeal reflux related symptoms or laryngoscopic findings. The various parameters of the 24-hour dual probe pH monitoring were compared with the scores of RSI and RFS. ResultsZZIn 24-hour dual probe pH monitoring, 64 of 100 patients tested positive for LPR. The mean of RSI score was significantly higher in the positive LPR group than in the negative group. However, RFS did not differ between the two groups. RSI scores were significantly associated with the reflux number in the upright position of the 24-hour dual probe pH monitoring. There was no correlation between RFS and the parameters of the 24-hour dual probe pH monitoring. ConclusionZZRSI can be a reliable diagnostic tool for laryngopharyngeal reflux disease instead of the 24-hour ambulatory dual probe pH monitoring. Korean J Otorhinolaryngol-Head Neck Surg 2013;56:706-10

Role of Reflux in Tracheoesophageal Fistula Problems after Laryngectomy

The purpose of this 2-year prospective nonrandomized study was to investigate the relationship between pathological supraesophageal reflux and the occurrence of speech fistula complications, especially severe fistula enlargement, in patients who underwent total laryngectomy and prosthetic voice restoration. We objectively assessed the presence of reflux disease using 24-hour dual-probe pH monitoring in 60 laryngectomized patients, correlated the incidence of tracheoesophageal fistula complications with the severity of reflux, and assessed the risk of problems by determining the absolute number of reflux events at the level of the speech fistula, the reflux area index score, and the DeMeester score. All patients with fistula enlargement showed highly pathological results in the diagnostic tests for reflux disease. Depending on reflux severity, the relative risk of developing fistula complications was up to 10 times higher for these patients. We found a significant correlation between the occurrence of tracheoesophageal fistula complications and the severity of supraesophageal reflux. Potential chronic irritation of the esophageal and tracheal mucosa can possibly contribute to the development of these problems. If the presence of reflux disease has been confirmed by 24-hour dual-probe pH monitoring, patients with fistula complications should be treated with proton pump inhibitors.

Koinzidenz von Stimmfistelerweiterungen und supraösophagealem Reflux nach stimmprothetischer Versorgung bei Laryngektomie

In a prospective study on patients who developed recurrent periprosthetic leakage in the region of the fistula after laryngectomy and prosthetic voice restoration, we investigated whether there was an increased incidence of supra-oesophageal reflux. A total of 48 patients included 16 patients with recurrent periprosthetic leakage (group A) and 32 patients without periprosthetic leakage (group B). The presence of reflux was objectively assessed using 24-hour dual-probe pH monitoring. The number of supra-oesophageal reflux events, the reflux area index (RAI 4) and the DeMeester score were determined as well as the relative risk of fistula enlargement in relation to the presence of reflux and postoperative radiotherapy. In group A pathological reflux events were detected in 100% of the cases. The mean number of supra-oesophageal reflux episodes was 414.8, the RAI was 419.5 (+/-212.45) and the DeMeester score was 104.4 (+/-21.3). In group B pathological reflux events were found in only 50% of the cases. The mean number of supra-oesophageal reflux episodes was 11.8, the RAI was 146.9 (+/-40.4) and the DeMeester score was 42.9 (+/-11.8). All reflux parameter results for group A patients were significantly higher than those obtained for group B patients. The relative risk of fistula enlargement was 1.8-2.3 times higher in the presence of reflux. Postoperative radiotherapy did not increase the risk of fistula enlargement (relative risk 0.75-0.93). A significantly higher number of supra-oesophageal reflux episodes occurred in patients with recurrent periprosthetic leakage in the region of the fistula. As reflux events may cause problems in the region of the fistula, prophylactic treatment with proton pump inhibitors is recommended.

Nasal Pepsin Assay and pH Monitoring in Chronic Rhinosinusitis

The primary objective of this study was to determine the relationship between chronic rhinosinusitis (CRS) and laryngopharyngeal reflux (LPR). We also investigated the diagnostic value of pepsin in nasal lavage by means of fluorometric assay as compared with 24-hour dual-probe pH monitoring. This is a controlled, prospective study from a retrospective dataset of 33 patients recruited for endoscopic sinus surgery between 2005 and 2006 in a tertiary care referral center (Hacettepe University Medical Center). All patients underwent 24-hour dual-probe pH monitoring and nasal lavage fluid investigation for pepsin. A fluorometric pepsin assay using casein-fluorescein isothiocyanate in nasal lavage fluid was used to detect LPR. The control group included 20 patients who were proven not to have sinusitis. A higher incidence of pharyngeal acid reflux events was found in patients with CRS (29 of 33, 88%) compared with the control patients (11 of 20, 55%). The difference was statistically significant (P = .01). The fluorometric pepsin assay was correlated to the results of 24-hour dual-probe monitoring for LPR diagnosis with a 100% sensitivity and 92.5% specificity. These data suggest that an association between CRS and LPR is present and that the detection of pepsin in nasal lavage fluid may provide a noninvasive and feasible method of LPR screening.

Impact of different pH thresholds for 24-hour dual probe pH monitoring in patients with suspected laryngopharyngeal reflux

The gold standard test for laryngopharyngeal reflux is 24-hour pH monitoring, which determines the reflux area index with a pH threshold of less than four (i.e. the reflux area index four). However, refluxed pepsin is able to cause laryngeal injury at pH levels above five. Prospective study. In order to establish normative values for a reflux area index with a pH threshold of less than five (i.e. the reflux area index five), 29 healthy volunteers underwent pH monitoring. In 45 patients with suspected laryngopharyngeal reflux, reflux area index four and reflux area index five were determined by pH study. In healthy volunteers, the reflux area index five was 72.6 (95th percentile). In 29 of 44 patients, laryngopharyngeal reflux was diagnosed due to a reflux area index four of greater than 6.3. However, the reflux area index five revealed laryngopharyngeal reflux in six more patients. For exact analysis of pH monitoring results, two pH thresholds (less than four and less than five) must be considered. Further studies with a larger number of healthy volunteers are necessary in order to reveal normative values for the reflux area index five parameter.

Gastroesophageal Flap Valve Is Associated with Gastroesophageal and Gastropharyngeal Reflux

Background: The endoscopic grading of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of the reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux. Methods: A total of 364 patients (151 men and 233 women; mean age 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-hour dual probe pH monitoring were included. GEFV was graded I through IV using Hill's classification: the GEFV was largely classified into 2 groups: the normal GEFV group (grade I and II) and the abnormal GEFV group (grade III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared among the groups. Results: Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (p < 0.001). LES pressure was significantly lower in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). In addition, all variables, except the supine time of pH below 4, showing the gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). Conclusions: Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastrophryngeal reflux.

Pepsin assay: A marker for reflux in pediatric glue ear

To evaluate if analysis of pepsin/pepsinogen in middle ear effusions can be considered a diagnostic marker for laryngopharyngeal reflux (LPR) in children with otitis media with effusion (OME). Ambulatory 24-hour dual-probe pH monitoring was carried out on 31 children with OME. Middle ear effusions were collected from 17 children during myringotomy. Total pepsin/pepsinogen concentrations in effusions were measured by ELISA using antipepsin antibody. Dual-probe pH monitoring showed that 22/31 (71%) of the studied children had significant LPR. The concentrations of pepsin/pepsinogen in middle ear effusions, ranged from 0.085 to 5.02 microg/ml, were found to be up to 4.5 to 231.44 times higher than the serum levels. There was a significant positive correlation between the level of pepsin/pepsinogen assayed in the effusions of the 17 children and the number of pharyngeal reflux episodes measured by pH monitoring. Control of LPR may be an essential component in the successful management of OME in pediatric patients. Pepsin/pepsinogen analysis in effusions of children, using ELISA, can be considered a reliable marker for assessment of reflux in children with OME.

Endoscopic Grading of Atrophic Gastritis is Inversely Associated with Gastroesophageal Reflux and Gastropharyngeal Reflux

BackgroundReflux esophagitis is inversely associated with the presence of atrophic gastritis, and endoscopic grading of atrophic gastritis correlates with histological evaluation. The aim of this study was to investigate the association of the endoscopic grade of atrophic gastritis with gastroesophageal and gastropharyngeal reflux.MethodsA total of 627 patients, who underwent endoscopy and ambulatory 24-hour dual-probe pH monitoring, were included in this study. The grade of atrophic gastritis was endoscopically classified into 2 types with the atrophic pattern system: the closed-type (C-type) and the open-type (O-type). We compared the findings from endoscopy and ambulatory pH monitoring for these 2 types.ResultsThe O-type was significantly associated with a lower prevalence of reflux esophagitis (p=0.001). All variables showing gastroesophageal reflux in the distal probe were significantly lower in the O-type than in the C-type (p<0.05). Similarly for the proximal probe, all variables, except the supine time of pH<4, were significantly lower in the O-type than in the C-type (p<0.05). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was in significantly lower in the O-type than in the C-type (p<0.001, p=0.012, respectively).ConclusionsEndoscopic grading of atrophic gastritis is easy and is inversely associated with gastroesophageal and gastropharyngeal reflux.

Diagnostik und Therapie des laryngopharyngealen Reflux

During the last decades an increased prevalence of reflux disease can be observed. Otolaryngologists play an increasing role in the treatment of patients suffering from laryngopharyngeal reflux (LPR). Typical symptoms for LPR are globus sensation, dysphagia, throat clearing, chronic cough and hoarseness. The most frequent laryngoscopic finding in patients suffering from LPR is a posterior commissure hypertrophy. LPR is confirmed by laryngoscopy, LPR-related laryngoscopy scoring, 24-hour dual-probe pH-monitoring, and by empiric trial with proton pump inhibitors (PPI). For therapy PPI-medication in a dosage of 40 mg BID for at least 3 months is successful in many patients. Additional lifestyle modifications can also have a positive effect. When medical management fails, further diagnostic procedures should be initiated. In patients suffering from unspecific laryngeal and respiratory symptoms LPR is an important differential diagnosis.

Diagnosis and management of laryngopharyngeal reflux disease

Laryngopharyngeal reflux has shown high prevalence and it is an interesting issue for otorhinolaryngologists, head and neck surgeons, and gastroenterologists. The present paper presents the most recent findings in diagnosis and management of laryngopharyngeal reflux. Clinical presentation of laryngopharyngeal reflux is widely varied and it may be manifested by a wide range of signs and symptoms. Other diseases that affect the larynx may also show the same signs and symptoms, such as, for example, vocal abuse, allergy, asthma, sinusitis, and smoking. Overvaluation of signs and symptoms related to reflux may be responsible for overdiagnosis of laryngopharyngeal reflux disease. The 24-hour dual-probe pH monitoring is considered the gold standard for the diagnosis of laryngopharyngeal reflux disease, and is essential in cases of pharyngolaryngeal complaints. The management of laryngopharyngeal reflux cases should be based on severity of symptoms, laryngoscopic findings, and frequency of reflux episodes. Proton-pump inhibitors are the preferred drugs for managing patients with laryngopharyngeal reflux and the best control can be achieved by prescribing high doses, twice a day. Patients that do not respond satisfactorily to clinical management are candidates for surgical fundoplication. Laryngopharyngeal reflux is characterized by a set of signs and symptoms resulting from extraesophageal manifestations of gastroesophageal reflux disease; however, this set of signs and symptoms may be related to other causes and the results of management, based on clinical presentation, vary widely and have low cure index.

Prevalence of extraesophageal reflux in patients with symptoms of gastroesophageal reflux

Objectives To compare the prevalence of extraesophageal reflux (EER) in patients with heartburn, posterior laryngitis (PL), and in healthy controls. Study design and setting A retrospective and prospective study including a total of 101 subjects who underwent 24-hour dual-probe pH monitoring. Results 52% of the subjects with heartburn had EER. No significant differences were found between the PL and heartburn groups for any pharyngeal reflux parameters. However, supine pharyngeal reflux was significantly more prevalent in heartburn patients with GERD than in PL patients and healthy controls ( P < 0.05). Significant positive correlation ( P < 0.01) was found between the percentage of time pH <4 in the pharynx and in the distal esophagus. Conclusion EER occurs in the majority of heartburn patients who are lacking laryngeal symptoms. Abnormal distal esophageal acid exposure makes the occurrence of EER more likely. Significance EER appears to be a continuum without clear-cut differences between the groups.