Pharyngeal Acid Research Articles

Symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux.

Pharyngeal pH monitoring has recently been used to identify patients with extraesophageal symptoms induced by gastroesophageal reflux. We employed this method of acid detection to evaluate patients with respiratory symptoms prior to and after laparoscopic Nissen fundoplication to further elucidate the relationship between GERD and respiratory symptoms. Twenty-one consecutive patients with extraesophageal symptoms thought to be caused by reflux underwent symptomatic and functional evaluation (esophageal manometry and 24-h pH monitoring with a pharyngeal probe) before and after laparoscopic Nissen fundoplication. Episodes of pharyngeal acid exposure were considered abnormal if the pH dropped below 4, occurred simultaneously with esophageal acidification, and occurred outside meal times. All patients had gastroesophageal reflux disease (GERD) and respiratory symptoms; nine of 15 (60%) had evidence of pharyngeal reflux preoperatively. Antireflux procedures resulted in a significant decrease in pharyngeal reflux (7.9 to 1.6 episodes/24h; p <0.05) and esophageal acid exposure (7.5% to 2.1%; p <0.05). In patients with pharyngeal reflux and complete postoperative testing, three (60%) obtained improvement of respiratory symptoms and resolution of pharyngeal reflux. In two patients with recurrent respiratory symptoms after surgery, persistent pharyngeal reflux was detected. Operative treatment of GERD is effective in controlling extraesophageal reflux, measured subjectively and objectively. Evidence of pharyngeal reflux on pH testing helps to identify which patients with respiratory symptoms will benefit from an antireflux procedure.

Gastroesophagopharyngeal reflux in patients with contact granuloma: a prospective controlled study.

The aim of this study was to compare the incidences of gastroesophagopharyngeal reflux in patients with contact granuloma and healthy controls. A 24-hour ambulatory esophagopharyngeal pH monitoring technique was used to measure reflux parameters in the pharynx and distal esophagus. Pharyngeal acid reflux events occurred in 17 of 26 granuloma patients (1 to 20 episodes per patient) and 5 of 19 controls (1 to 8 episodes per patient). The reflux episodes were typically short and occurred predominantly in an upright position. A comparison between the groups showed a significant difference in the number of pharyngeal reflux episodes (p = .009) and in the total time of pH below 4 (p = .006). On the other hand, we found no significant differences in any esophageal reflux parameters, except for the percentage of distal esophageal reflux episodes that reached the pharynx (p = .006). In this study, pharyngeal acid exposure was significantly more prevalent in patients with contact granuloma than in healthy controls.

Symptoms, Laryngeal Findings, and 24‐Hour pH Monitoring in Patients With Suspected Gastroesophago‐Pharyngeal Reflux

To investigate the laryngeal signs and symptoms associated with gastroesophago-pharyngeal reflux (GEPR). A prospective controlled study. Nineteen healthy control subjects and 43 patients, 26 with posterior laryngitis (PL) and 17 with a normal larynx and suspected GEPR, were examined using videolaryngoscopy and 24-hour ambulatory dual-probe pH monitoring. Pharyngeal acid reflux occurred in 18 (69%) patients with PL, in 9 (53%) patients with a normal larynx, and in 5 (26%) healthy control subjects. Multiple-comparison procedure showed that pharyngeal reflux was significantly more prevalent in patients with PL than in the healthy control subjects (P < .05). The laryngoscopic findings in patients with pharyngeal reflux varied from normal mucosa to thickening or edema of the posterior wall of the glottis, which was the most frequent finding in the PL group. Erythema was uncommon; it was found only in patients with verified pharyngeal reflux. There was no difference in symptom profile between the patients with PL and patients with a normal larynx or patients with or without pharyngeal reflux. Pharyngeal reflux is significantly more prevalent in patients with posterior laryngitis than in healthy control subjects. Moreover, a certain degree of pharyngeal reflux appears to be a normal phenomenon. The most common laryngeal finding in patients with posterior laryngitis is thickening or edema of the posterior wall of the glottis. GEPR does not yield specific laryngeal symptoms. Thus, it is unreliable to base the reflux diagnosis on symptoms alone.

Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux

Objective: To describe the occurrence of relative proton pump inhibitor (PPI) drug resistance in the treatment of laryngopharyngeal reflux (LPR). Study design and setting: A retrospective review was performed for 1053 consecutive adults undergoing double-probe (simultaneous esophageal and pharyngeal) pH testing in our laboratory. Two hundred five patients who had pH studies performed while taking at least a daily dose of PPI therapy were identified; 167 qualified for further analysis. The pH data was reviewed for the presence of abnormalities in either esophageal or pharyngeal acid exposure to evaluate drug efficacy. Results: Forty-four percent (74/167) of the study patients demonstrated abnormal levels of acid exposure. Results were further analyzed to compare failure rates based on different dosage regimens. Patients on once daily doses of PPI failed at a rate of 56%, with lower failure rates for higher-dose regimens. Conclusions: A significant number of LPR patients on PPI therapy demonstrate relative drug resistance. (Otolaryngol Head Neck Surg 2001;125:374-8.)

Outcomes of acid suppressive therapy in patients with posterior laryngitis

Objective: To evaluate the results of acid suppressive therapy (AST) in posterior laryngitis (PL) patients with and without documented pharyngeal acid reflux (PAR). Methods: The charts of all patients with PL who received AST and who had undergone pharyngeal pH monitoring were reviewed. Results of AST in patients with PL with and without documented PAR were evaluated by laryngeal examination, symptom scores, and self-reported overall benefit. Results: Thirty-nine patients with PL had received AST and undergone pharyngeal pH monitoring. Follow-up ranged from 2 to 27 months. Laryngeal findings were improved in patients with and without PAR. Pretreatment total symptom scores were significantly greater than that of posttreatment in patients with and without documented PAR. Overall benefit from AST was reported by the majority of PL patients with and without documented PAR. Conclusion: These findings support the use of AST to reduce or eliminate signs and symptoms in PL regardless of documentation of PAR. (Otolaryngol Head Neck Surg 2001;124:16-22.)

후두 결절에서 후-인두역류 양상

Background and Objectives: Laryngo-pharyngeal reflux (LPR) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. But there have not been well-documented that vocal cord nodules are related with reflux. The purpose of this study is to determine the relationship between vocal cord nodules and LPR as causative factor. Materials and Methods: Prospectively, Fifteen patients with vocal cord nodules and ten healthy volunteers were studied. Prior to therapy including laryngeal microsurgery, each group underwent esophageal manometry and ambulatory 24hour double probe pH monitoring. Pharyngeal acid reflux event was deemed acceptable if a decrease in pH below 4 was recorded in all two esophageal and pharyngeal probe. Total reflux score, percent acid exposure time and average acid clearance time were measured and compared between two groups. Results: Eleven of the 15 patients (73.3%) had the reflux in pharyngeal probe. Three of the 10 controls s (30%) had the reflux. Total reflux score and percent acid exposure time were significantly higher in patients than in control group but average acid clearance time was not significantly different between two groups. Conclusion: Prevalence of pharyngeal acid reflux events is significantly higher in patients with vocal cord nodules. LPR may be a risk factor for the development of vocal cord nodules. (J Clinical Otolaryngol 2000;11:237–240)

24-H Pharyngeal pH Monitoring in Healthy Volunteers: A Normative Study

Background: Gastropharyngeal reflux has been associated with disorders of the upper and lower airways. It may be shown by pharyngeal pH-metry, but reports on normality in healthy volunteers are scarce. No definite consensus has been reached considering the upper limit of normality (ULN). The aim of the present study was therefore to quantify the occurrence of pharyngeal acid exposure (pH < 4) in healthy volunteers and, further, to examine its relation to acid exposure of the oesophagus and oesophageal motility and its occurrence in relation to age, sex, and body position. Methods: Forty healthy volunteers underwent ambulatory 24-h pH-metry, using antimony electrodes positioned 2 cm above the upper oesophageal sphincter and 5 cm above the lower oesophageal sphincter on the basis of manometry. Technical artefacts were excluded before calculation of all results. Results: Gastropharyngeal reflux occurred in most healthy volunteers without any significant relation to age, sex, or body weight. Pharyngeal acid reflux occurred mainly in the upright position. The ULN for pharyngeal acid exposure time was assessed to 0.9% (0.2% after exclusion of mealtimes). The ULN for the number of acid events in the pharynx was 18 (6.1). The corresponding ULNs for the oesophagus were 7% and 84. Conclusion: Gastropharyngeal reflux may be effectively monitored by ambulatory pH-metry. The present study provides reference limits, a prerequisite for evaluating the pathophysiologic importance of the phenomenon.

Pharyngeal acid reflux in patients with single and multiple otolaryngologic disorders

Objective: This study was designed to determine the prevalence and characteristics of pharyngeal acid reflux (PAR) events in single and multiple otolaryngologic disorders. Methods: Sixty-seven patients with otolaryngologic symptoms and objective findings and 34 healthy control subjects were studied with an ambulatory 24-hour, 3-site pharyngoesophageal pH monitoring technique. Otolaryngologic diagnosis included isolated posterior laryngitis (PL) in 28 patients, isolated chronic rhinosinusitis (SIN) in 12, combined PL and SIN (PL+SIN) in 6, PL plus laryngotracheal stenosis (PL+LTS) in 12, and PL plus vocal cord nodules (PL+VCN) in 9. Results: PAR events were documented in 68% of patients with PL, 34% of patients with SIN, 67% of patients with PL+SIN, 67% of patients with PL+LTS, 78% of patients with PL+VCN, and 21% of controls. The prevalence of PAR events in patients with isolated PL as well as those with PL combined with other disorders was significantly higher than that in patients without PL and that in controls. As a group, patients with PL had a greater number of PAR events and acid exposure time than other patients and controls. Distal and proximal esophageal reflux parameters were not significantly different among groups. Conclusions: The prevalence of PAR is significantly higher in patients with isolated PL compared to patients with other isolated otolaryngologic disorders and in controls. The prevalence of PAR in isolated otolaryngologic disorders other than PL is similar to that in healthy controls. The prevalence of PAR is significantly higher in patients with both PL and other otolaryngologic disorders than in controls and in patients with isolated otolaryngologic disorders. (Otolaryngol Head Neck Surg 1999;121:725-30.)

Esophagopharyngeal acid regurgitation: Dual pH monitoring criteria for its detection and insights into mechanisms

Background & Aims: A valid technique for the detection of esophagopharyngeal acid regurgitation would be valuable to evaluate suspected reflux-related otolaryngologic and respiratory disorders. The aim of this study was to derive pH criteria that optimally define esophagopharyngeal acid regurgitation and to examine patterns of regurgitation. Methods: In 19 healthy controls and 15 patients with suspected regurgitation, dual or quadruple pH sensors were used to monitor pharyngeal and esophageal pH. For each combination of the 2 variables, ΔpH and nadir pH, proportions of pH decreases that occurred during or independent of esophageal acidification were calculated to determine the likelihood that an individual pharyngeal pH decrease was a candidate regurgitation event or a definite artifact. Results: Overall, 92% of pharyngeal pH decreases of 1–2 pH units and 66% of pH decreases of this magnitude reaching a nadir pH of <4 were artifactual. Optimal criteria defining a pharyngeal acid regurgitation event were a pH decrease that occurred during esophageal acidification, had a ΔpH of >2 units, and reached a nadir of <4 units in less than 30 seconds. Regurgitation occurred more frequently in subjects in an upright (32 of 35) than in a supine (3 of 35 events; P ≤ 0.0001) position and was more frequently abrupt (synchronous with esophageal acidification) than delayed ( P ≤ 0.05). Conclusions: Accepted criteria for gastroesophageal reflux are not applicable to the detection of esophagopharyngeal acid regurgitation, and most regurgitation occurs abruptly and in upright position. GASTROENTEROLOGY 1999;117:1051-1061

Reflux in infants with laryngomalacia: Results of 24-hour double-probe pH monitoring

Laryngomalacia is the most common cause of stridor in children. Previous studies using barium esophagrams or single-probe esophageal pH testing have indicated that 68% to 80% of infants with laryngomalacia have reflux. A recent study in a large series of pediatric patients has shown that these 2 testing modalities are relatively insensitive in detecting reflux when compared with 24-hour double-probe pH testing. This study was undertaken to determine the incidence and frequency of reflux in children with laryngomalacia by use of 24-hour double-probe pH monitoring. Twenty-four children with endoscopically diagnosed laryngomalacia underwent 24-hour double-probe pH testing. The distal probe was placed in the lower esophagus, and the proximal probe was placed just above the cricopharyngeus immediately posterior to the larynx. All 24 (100%) children had pharyngeal acid exposure as judged by the proximal pH probe. These children had a mean of 15.21 episodes of reflux to the level of the pharynx during the 24-hour study period. In contrast, only 16 (66%) children had abnormal acid exposure as measured by the distal esophageal probe. These results indicate that essentially all children with laryngomalacia have reflux of gastric acid to the pharyngeal level. Multiple authors have documented the detrimental effects of acid and the accompanying pepsin in the larynx and tracheobronchial tree. Persistent laryngeal edema is an almost universal finding in patients with reflux to the pharyngeal level and is a common finding in children with laryngomalacia. In some patients with laryngomalacia, reflux may be the primary cause of their airway compromise, whereas in others it may be a significant cofactor exacerbating a preexisting neurologic or anatomic abnormality. (Otolaryngol Head Neck Surg 1999;120:860-4.)

Pharyngeal pH monitoring in patients with posterior laryngitis

Objective: To evaluate the diagnostic value of 3-site 24-hour ambulatory pH monitoring in patients with posterior laryngitis (PL) and the prevalence of esophageal abnormalities in this patient group. Methods: Twenty patients with PL and 17 healthy volunteers were studied as controls. Control subjects had transnasal esophagogastroduodenoscopy (T-EGD) and ambulatory pH monitoring. Patients underwent T-EGD, ambulatory pH monitoring, and barium esophagram. Results: T-EGD documented no abnormality in controls. Esophagitis was present in 2 PL patients, and hiatal hernia in 3. Ambulatory pH monitoring showed that 15 PL patients and 2 controls exhibited pharyngeal acid reflux. Barium esophagram documented gastroesophageal reflux in 5 PL patients. However, none of these barium reflux events reached the pharynx. All PL patients with barium esophagram evidence of gastroesophageal reflux also showed pharyngeal acid reflux by pH monitoring. Conclusion: Pharyngeal acid reflux is more prevalent in patients with PL than in healthy controls. Patients with PL infrequently have esophageal sequelae of reflux disease. Ambulatory 24-hour simultaneous 3-site pharyngoesophageal pH monitoring detects gastroesophagopharyngeal acid reflux events in most patients with PL. (Otolaryngol Head Neck Surg 1999;120:672-7.)

Evaluation of gastroesophageal reflux in patients with laryngotracheal stenosis.

To report the incidence of pharyngeal acid reflux events in patients with laryngotracheal stenosis (LTS), we studied 12 patients with LTS and 34 healthy volunteers. All patients and controls underwent ambulatory 24-hour 3-site pH monitoring. In ambulatory pH monitoring, pH was recorded at manometrically determined sites of the pharynx, proximal esophagus, and distal esophagus. For all 3 sites, a pH value below 4 that was not related to the time of oral intake or belching was considered an acid reflux event. Eight of the 12 LTS patients exhibited pharyngeal acid reflux events. In the control group, pharyngeal acid reflux events were documented in 7 subjects. In between-group comparison, the number of reflux episodes and the percent acid exposure time in the pharynx were greater in LTS patients than in controls. Reflux parameters of the proximal and distal esophagus in LTS patients were similar to those of controls. The incidence of pharyngeal acid reflux events in LTS patients was higher than that in controls. It is suggested that identification and treatment of gastroesophageal reflux in patients will significantly simplify and improve the results of treatment for LTS.

Pharyngeal acid reflux events in patients with vocal cord nodules.

Gastroesophageal reflux has been implicated in the pathogenesis of vocal cord nodules. However, a cause-and-effect relationship has not been established. Because documentation of pharyngeal acid reflux events makes this correlation more plausible, the aim of the present study was to determine the frequency of pharyngeal acid reflux events in patients with vocal cord nodules. Eleven patients with vocal cord nodules (mean age, 42 +/- 6 years) and eleven healthy volunteers (mean age, 45 +/- 6 years) were studied. Patients underwent barium esophagram and ambulatory 24-hour simultaneous three-site pharyngoesophageal pH monitoring. Controls only had ambulatory 24-hour simultaneous three-site pH monitoring. In the ambulatory pH monitoring studies, pH was recorded from the manometrically determined sites of pharynx (2 cm above upper esophageal sphincter), proximal esophagus (10 cm distal to pharyngeal site), and distal esophagus (5 cm above the lower esophageal sphincter). Pharyngeal acid reflux event was deemed acceptable if all three sites recorded a decrease in pH below 4 which was not related to meal or drinking. Pharyngeal acid reflux events occurred in seven of 11 patients with vocal cord nodules (1-4 episodes) and two of 11 controls (1-2 episodes) (P < .05). In both groups all pharyngeal acid reflux events occurred in upright position and were not associated with belching or coughing. Barium studies documented hiatal hernia in two patients and gastroesophageal reflux in five of 11 patients. However, none of the esophageal reflux events reached the pharynx on barium esophagram. Prevalence of pharyngeal acid reflux events is significantly higher in patients with vocal cord nodules compared with normal controls and suggests a contributory role for gastroesophagopharyngeal acid reflux in the pathogenesis of some vocal cord nodules.