Pharyngeal pH Research Articles

Sensitive Pepsin Immunoassay for Detection of Laryngopharyngeal Reflux

To determine whether measurement of pepsin in throat sputum by immunoassay could be used as a sensitive and reliable method for detecting laryngopharyngeal reflux (LPR) compared with 24-hour double-probe (esophageal and pharyngeal) pH monitoring. Patients with clinical LPR undergoing pH monitoring provided throat sputum samples during the reflux-testing period for pepsin measurement using enzyme-linked immunoadsorbent assay. Pepsin assay results from 63 throat sputum samples obtained from 23 study subjects were compared with their pH monitoring data. Twenty-two percent (14/63) of the sputum samples correlated the presence of pepsin with LPR (pH < or = 4 at the pharyngeal probe), of which the median concentration of pepsin was 0.18 microg/mL (range 0.003-22 microg/mL). Seventy-eight percent (49/63) of the samples unassociated with (pharyngeal) reflux contained no detectible pepsin. Mean pH values for pepsin-positive samples were significantly lower than negative samples at both esophageal probe (pH 2.2 vs. pH 5.0) (P < .01) and the pharyngeal probe (pH 4.4 vs. pH 5.8) (P < .01). When the pepsin assay results were compared with the pharyngeal pH data for detecting reflux (events pH < or = 4), the pepsin immunoassay was 100% sensitive and 89% specific for LPR. Detection of pepsin in throat sputum by immunoassay appears to provide a sensitive, noninvasive method to detect LPR.

Pharyngeal pH Probe Findings in Patients with Postnasal Drainage

Patients commonly present with complaints of postnasal drainage (PND). This study reports the pharyngeal pH probe findings in patients without rhinitis/rhinosinusitis who present with complaints of PND. This is a prospective study of patients presenting with PND but no historical or endoscopic evidence of rhinitis/rhinosinusitis. Twenty-four-hour pharyngeal pH probe studies were done on 32 consecutive patients and compared with historical controls. There were a total of 32 patients with PND (mean age, 54 years) and 51 controls (mean age, 49 years). The proportion of patients with positive pH probe studies was higher in PND (28.1%) versus controls (17.6%) but did not reach statistical significance (p = 0.27). However, when comparing the mean number of pharyngeal acid exposure events, patients with PND had significantly more events (1.6) than controls (0.3; p < 0.002). In addition, the mean acid exposure time was significantly higher in PND (0.18%) versus controls (0.01%; p < 0.004). The proportion of patients with PND displaying positive pharyngeal 24 pH probe studies is not significantly greater than controls. However, patients with PND do exhibit a statistically greater degree of pharyngeal acid exposure as compared with controls. Additional research is required to delineate the role of pharyngeal reflux in patients with PND.

Prevalence of gastroesophagopharyngeal acid reflux events: an evidence-based systematic review

Objectives To identify variables contributing to discrepant gastroesophagopharyngeal acid reflux (GEPR) findings and to critically assess the prevalence of GEPR in healthy individuals and patients with reflux laryngitis (RL). Study design Quantitative systematic review. Methods Pharyngeal pH monitoring studies of healthy individuals and patients with RL were identified through a MEDLINE search of publications between 1966 and 2003. Pooled results of the measured pharyngeal acid exposure characteristics and the prevalence of GEPR events were analyzed. Statistical comparisons were performed using a χ 2 test. Results The study included 181 controls and 184 RL patients. Subjects' age ranged from 19 to 85 years. Gastroesophagopharyngeal acid reflux events were detected at 1, 2, and 4 cm above upper esophageal sphincter (UES) and 0.5 cm below arytenoids, with varying rates. The prevalence of GEPR ranged from 0% to 83% in controls and 27% to 86% in RL. After excluding the healthy subjects with abnormal esophageal acid exposure, prevalence of GEPR decreased from 35% to 17% ( P ≤ .002). Gastroesophagopharyngeal acid reflux in RL was significantly more prevalent than in the entire group of controls as well as in controls without abnormal esophageal acid exposure ( P ≤ .001). Conclusions The prevalence of GEPR in controls and patients with RL varies in the studied 4 areas above the UES. The percentage of the subjects with GEPR increased as the probe was located more closely to the UES. Differences in demographic characteristics of the subjects, interventions used to select subjects, and pharyngeal pH monitoring techniques were identified as factors possibly contributing to inconsistent pharyngeal pH monitoring findings. The documented differences in methodology of existing studies make comparison of the studies difficult.

Typical GERD Symptoms and Esophageal pH Monitoring Are Not Enough to Diagnose Pharyngeal Reflux

Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical anti-reflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR. The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR+) if they had >1 episode of PR detected during pH monitoring. One hundred eighty-one patients were PR+ and 337 were PR-. The most common symptoms, namely cough (PR +73%, PR- 68%), hoarseness (PR +64%, PR- 66%), and dyspnea (PR +59%, PR- 59%) were present with similar incidence in PR+ and PR- patients. The incidence of heartburn was 54% in the PR+ and 52% in the PR- patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR+ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR+. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median = 13 cm, 2-20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR+ patients had normal amounts of esophageal acid exposure. Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.

Esophageal Function Testing

During the past 25 years, there has been an evolution in our ability to evaluate esophageal function and to perform shortand long-term monitoring of the patient with symptoms suspected to be due to gastroesophageal reflux disease (GERD). The growing use of laparoscopic antireflux surgery and now endoscopic antireflux therapy mandates a careful evaluation of patients preparing for these procedures. Patients with atypical chest pain, nonobstructive dysphagia, and other extraesophageal symptoms of gastroesophageal reflux disease present a clinical and diagnostic dilemma. Improvements in the methodology of esophageal function testing now allow us to measure intraluminal pressure and coordination of pressure activity of the muscles of the esophagus accurately and provide qualitative and quantitative assessment of these esophageal pressures and their coordination and motility. The availability of multichannel intraluminal impedance testing allows us to measure changes in resistance to alternating current between two electrodes and to evaluate bolus movement with liquid and viscous material in the antegrade and retrograde directions. Ambulatory pH monitoring can be accomplished with singleor multiplechannel intraluminal electrodes to assess intragastric, intraesophageal, and pharyngeal pH and has become the backbone of our understanding of GERD and the antisecretory capability of proton pump inhibitors. The addition of wireless pH monitoring (Bravo capsule) has added to our armamentarium, and the development of combined multichannel intraluminal impedance and pH Gastrointest Endoscopy Clin N Am

T and IgA B lymphocytes of the pharyngeal and palatine tonsils: differential expression of adhesion molecules and chemokines.

The pharyngeal (Ph) and palatine (Pa) tonsils, although located in different regions of the upper aero-digestive tract (UADT), are thought to protect the respiratory tract similarly against infections by inducing and disseminating T and surface IgA(+) (sIgA(+)) B cells. We investigated the factors controlling the migratory properties of T and sIgA(+) B lymphocytes in the UADT of pigs by comparing the expression of vascular addressins, homing receptors and chemokine transcripts in Ph/Pa tonsils, Peyer's patches (PP) and their draining lymph nodes (LN). The vascular addressin PNAd was detected on high endothelial venules in both tonsils, whereas mucosal addressin cell adhesion molecule-1, otherwise present in PP and mesenteric LN, was not detected. More importantly, the vascular cell adhesion molecule-1 (VCAM-1) addressin was present in Ph tonsil and LN but neither in Pa tonsil nor in PP vascular cells, whereas both T and sIgA(+) B lymphocytes displayed similar levels of alpha4beta1(high) integrin, the ligand of VCAM-1. Analysis of transcript levels for several lymphoid (CCL19, CXCL12 and CCL21) and epithelial chemokines also demonstrated opposite chemokine mRNA ratios for Ph tonsil (CCL28 > CCL25) and PP, with Pa tonsil expressing very low levels of CCL28. Collectively, these data indicate that the differential compartmentalization of sIgA(+) lymphocytes between Pa and Ph tonsils may partly result from the differential expression of VCAM-1 and CCL28. They also suggest that tonsillar addressins and epithelial chemokines, rather than the cells intravasating it, control the regionalization of sIgA(+) lymphocytes in the UADT.

Unprecedented Prevalence of Laryngopharyngeal Reflux (LPR) Amongst Gastro-Oesophageal Reflux (GORD) Sufferers. Is Underdiagnosis Leading to Mismanagement of GORD Patients?

Introduction: Laryngopharyngeal Reflux (LPR) exists if there are >3 episodes of pharyngeal pH <5 in a 24 hr period. The larynx is exquisitely sensitive to peptic injury and LPR has been implicated in the aetiology of many conditions including laryngeal carcinoma. LPR has been considered an otolaryngological (ENT) condition as fewer than 10% of patients manifest oesophagitis or Barretts oesophagus. We undertook to assess the prevalence of LPR in a cross-section of ENT and gastro-oesophageal reflux (GORD) patients.

Artefacts in 24‐h pharyngeal and oesophageal pH monitoring: is simplification of pH data analysis feasible?

Background: Ambulatory 24‐h dual‐channel pharyngeal and oesophageal pH monitoring is the standard test for measuring gastro‐oesophageal and gastropharyngeal reflux. Artefacts caused by the intake of food may result in falsely positive gastropharyngeal reflux, which necessitates a manual review of 24‐h pH data. The purpose of the study was to investigate the influence of meals and whether leaving out meals affected the reliability of the test. Methods: Patients referred for otolaryngological complaints, suspected to have been caused by gastro‐oesophageal reflux, underwent 24‐h dual‐channel pH monitoring. The raw unprocessed pH data were corrected by visual inspection of the 24‐h tracings (corrected data), by leaving out meals or meals plus a 2‐h postprandrial period. Results: The raw pH data were substantially influenced by artefacts of food intake and pseudoreflux. Data obtained by leaving out meals agreed best with manually corrected data. Many of the falsely positive reflux episodes could be removed, thereby inducing a 9%–18% chance of undetected reflux. When examining the fraction of time supine, manually corrected data and data leaving out meals were fully concordant and detected 79% of patients with gastropharyngeal reflux. However, leaving out meals plus a 2‐h postprandrial period resulted in 21%–50% falsely negative tests. Conclusion: Leaving out the period of intake of meals and beverages from the raw pH data might be the second best test after the time‐consuming visual correction with a small chance of undetected gastropharyngeal reflux. For scientific purposes and when in doubt, it remains necessary to review the computer‐generated data manually to discover every gastropharyngeal reflux event.

Pharyngoesophageal pH monitoring

Pharyngeal acid reflux events may be significant in the pathogenesis of various supraesophageal manifestations of gastroesophageal reflux disease. Intragroup variation and an extensive overlap among subject groups and normal controls make proximal esophageal 24-hour pH monitoring studies unreliable for the diagnosis of pharyngeal reflux. However, the clinical value of pharyngeal pH monitoring still remains uncertain. A 24-hour pharyngeal pH monitoring study has shown that at least some pharyngeal reflux events occur in most healthy subjects, mainly in the upright position. Based on these data, values for the upper limits of normal for total pharyngeal acid exposure time and pharyngeal acid events have been determined. This study provides clinicians with reference values for physiologic pharyngeal reflux, but the parameters of abnormal pharyngeal reflux events are still unknown. More research is needed before this practice can become part of the routine evaluation of patients with pharyngeal, laryngeal, respiratory, or ear, nose, and throat symptoms or disorders.

Intrapharyngeal distribution of gastric acid refluxate.

Determination of intrapharyngeal distribution of gastric acid refluxate is needed to better understand the pathogenesis of reflux-attributed aerodigestive tract disorders. The aims of the study were to determine intrapharyngeal distribution of gastric acid refluxate and to determine whether this distribution can better differentiate patients from control subjects compared with data obtained from a single hypopharyngeal site. We prospectively studied 10 healthy volunteers, 12 patients with reflux laryngitis, and 15 patients with vasomotor rhinitis using a concurrent dual pharyngeal/dual esophageal pH recording technique. We determined the hypopharyngeal and oropharyngeal pH profile, including number, duration, and distribution of reflux events irrespective of and in correlation with intraesophageal pH profile using four different pH thresholds. Few drops in pharyngeal pH were found to be true reflux events based on their correlation with esophageal pH events. For the pharyngeal pH threshold criterion of a drop to 4.0 or less, 6 of 12 patients with reflux laryngitis, 5 of 15 patients with vasomotor rhinitis, and 2 of 10 normal control subjects exhibited a total of 25 (range, 1-5) distal pharyngeal acid reflux events. Overall, 34% of these events reached the oropharyngeal pH recording site. Between-group comparison for all levels of pH threshold criteria did not show any significant difference of reflux parameters in the hypopharyngeal or in the oropharyngeal sites among the studied groups. Reflux of gastric acid into the pharynx may extend to the region of the oropharynx in both patients and control subjects. Overall distribution of acid refluxate to the oropharynx is low but as groups is similar between healthy individuals and patients with reflux laryngitis and those with vasomotor rhinitis. Parameters of oropharyngeal acid reflux such as number and duration do not differentiate patients from control subjects.

Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.

To report the prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Prospective study of 58 consecutive patients with documented laryngopharyngeal reflux, all of whom underwent transnasal esophagoscopy as part of their reflux evaluations. All patients with a diagnosis of laryngopharyngeal reflux confirmed by abnormal pharyngeal pH monitoring over a 5-month period were included, and all subjects completed a self-administered reflux symptom index and underwent transnasal esophagoscopy with directed biopsy. Of the 58 study patients with pH-documented laryngopharyngeal reflux, the mean age was 49 years (+/- 13 y), and 53% (31 of 58) were women. Of the study group, 40% (23 of 58) had heartburn and 48% (28 of 58) had abnormal esophageal reflux (by pH monitoring criteria); by transnasal esophagoscopy with biopsy, 12% (7 of 58) had esophagitis and another 7% (4 of 58) had Barrett's metaplasia. Thus, 60% of the study cohort had heartburn, and 81% (47 of 58) had normal esophageal epithelium (i.e., esophagitis or Barrett's metaplasia). In the present series of patients with documented laryngopharyngeal reflux the prevalence of esophagitis and Barrett's metaplasia was only 19%. These data confirm the clinical impression that the patterns, mechanisms, and manifestations of laryngopharyngeal reflux differ from those of classic gastroesophageal reflux disease. Unlike gastroesophageal reflux disease, patients with laryngopharyngeal reflux uncommonly have esophagitis. Thus, although esophagoscopy may be an excellent method for screening the esophagus, it is not the method of choice for diagnosing laryngopharyngeal reflux.

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.

Laryngoscopy and Pharyngeal pH Are Complementary in the Diagnosis of Gastroesophageal-Laryngeal Reflux

Pharyngeal pH monitoring and laryngoscopy are routinely used to diagnose gastroesophageal-laryngeal reflux as a cause of respiratory symptoms. Although their use seems intuitive, their ultimate diagnostic value is yet to be defined. We studied 10 asymptomatic (control) subjects and 76 patients with respiratory symptoms. Both patients and control subjects were given a symptom questionnaire. Each underwent direct laryngoscopy using the reflux finding score (RFS) to grade laryngeal injury, esophageal manometry, and 24-hour esophagopharyngeal pH monitoring. The patients were then classified as RFS+, if the score was greater than 7, and pharyngeal reflux (PR)+, if they had more than one episode of PR detected during pH monitoring. The most common symptoms reported by patients were hoarseness (87%), cough (53%), and heartburn (50%). Control subjects had a significantly lower RFS (2.1 vs. 9.6, P < 0.01) and fewer episodes of PR (0.2 vs. 3.4, P < 0.01), than patients. None of the control subjects had more than one episode of PR during a 24-hour period. Fifty patients (66%) were RFS+ and 26 (34%) were RFS−. Thirty-two patients (42%) were PR+ and 44 (58%) were PR−. Fifteen patients had a normal RFS and no PR (group I = RFS−/PR−). Forty patients had discordance between the laryngoscopic findings and the pH monitoring (group II = RFS−/PR+ or RFS+/PR−). Twenty-one patients had both an abnormal RFS and PR (group III = RFS+/PR+). Patients in group III had significantly higher heartburn scores and distal esophageal acid exposure. Eighty-three percent of patients in group III but only 44% in group I improved their respiratory symptoms as a result of antireflux therapy. An abnormal PR or RFS differentiates patients with laryngeal symptoms from control subjects. Agreement between PR and RFS helps establish or refute the diagnosis of gastroesophageal reflux as a cause of laryngeal symptoms. Patients who are RFS+ and PR− may have laryngeal injury from another source, whereas patients who are RFS− and PR+ may not have acid entering the larynx, despite the presence of PR. Patients who are RFS+ and PR+ have more severe gastroesophageal reflux disease and their reflux causes laryngeal damage. Laryngoscopy and pharyngeal pH monitoring should be considered complementary studies in establishing the diagnosis of laryngeal injury induced by gastroesophageal reflux. ( J Gastrointest Surg 2002;6:189–194.)

Esophageal Motor Function in Laryngopharyngeal Reflux is Superior to That in Classic Gastroesophageal Reflux Disease

Laryngopharyngeal reflux (LPR) in otolaryngology patients appears to be different from classic gastroesophageal reflux disease (GERD). In particular, esophagitis and its principal symptom, heartburn, considered the diagnostic sine qua non of GERD, are often absent in LPR. It has therefore been postulated that LPR patients have superior esophageal function. Esophageal acid clearance (EAC) is a measure of the ability of the esophagus to restore neutral pH after reflux events have occurred. It is considered an excellent overall measure of esophageal function. The mean EAC can be calculated from 24-hour pH monitoring data. A comparison of EAC in patients with GERD and LPR has not been previously reported. To compare the EAC of 1) patients with LPR alone, 2) patients with GERD alone, 3) patients with both LPR and GERD, and 4) patients without either LPR or GERD, we studied 200 otolaryngological patients who had undergone 24-hour double-probe (simultaneous pharyngeal and distal esophageal) pH monitoring, 50 in each group. The subgrouping of each patient was determined by previously established pH monitoring criteria. We defined GERD as abnormal esophageal reflux and LPR as abnormal pharyngeal reflux. The patients with GERD had a mean (+/-SD) EAC of 1.44 +/- 1.2 minutes, and those with LPR had a mean EAC of 1.00 +/- 1.00 minutes (p < .05). The patients with both GERD and LPR had a mean EAC of 1.53 +/- 1.01 minutes. The patients without reflux had a mean EAC of 0.53 +/- 0.38 minutes. We conclude that patients with LPR have significantly better EAC than those with GERD. These data suggest that patients with LPR have superior esophageal function. This finding may clarify our understanding of the differences in mechanisms, symptoms, and incidence of esophagitis in patients with LPR and GERD.

Ambulatory 24-hour double-probe pH monitoring: the importance of manometry.

Historically, manometry has been used for sphincter localization before ambulatory 24-hour double-probe pH monitoring to ensure accurate placement of the probes. Recently, direct-vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard. Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry. Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects. For double-probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid-exposure times. Thus, manometry is needed to ensure valid double-probe pH monitoring data.

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.)

Association of laryngopharyngeal reflux disease and subglottic stenosis.

Laryngopharyngeal reflux (LPR) disease and extraesophageal manifestations of gastroesophageal reflux have been recognized to have dramatic effects in the upper airways. Patient-reported symptoms alone underestimate the presence of LPR, making accurate clinical diagnosis difficult. Many previous studies examine populations with only standard dual-probe pH testing that does not include a test probe in the pharynx. Therefore, documentation of acid exposure at the laryngeal inlet is lacking. In adult patients with subglottic stenosis (SGS), whether due to granulomatous disease or presumed idiopathic causes, LPR is often a contributing or causative factor. A retrospective chart review from 1991 to 1999 identified 19 patients with SGS. Ten of the 19 patients had concomitant disease states, including sarcoidosis (3), Wegener's granulomatosis (3), laryngeal trauma (3), and a history of intubation (1). Fourteen patients underwent 24-hour ambulatory pH probe testing with 3- or 4-port probes. The proximal port in either catheter was positioned by manometric guidance directly behind the laryngeal inlet. Measurements of pH of less than 4 were recorded at the level of the larynx in 12 of the 14 patients tested (86%). This finding was noted in half of the patients despite empirical therapy with proton pump inhibitors at the time of the testing. Seven of 10 patients with underlying disease were studied, and all demonstrated acid reflux in the hypopharynx. In 9 patients, the stenosis was presumed to be idiopathic. Five of the 7 patients (71%) with idiopathic SGS tested had positive pH probe studies (pH below 4 in the pharyngeal probe). Our results demonstrate a strong association of LPR and SGS. In the idiopathic group, reflux is the probable cause of their stenosis. In the group of patients with underlying disease states, reflux was involved in all tested patients and likely acts as a synergistic factor that stimulates their granulomatous disease to react and subsequently result in the development of stenosis. Evaluation for LPR with pharyngeal pH testing should be performed in all patients with SGS.

Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy

Background: Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD. Methods: Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy. Results: Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR−). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 ( P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR− patients (75%) had persistent symptoms on medical therapy. Conclusions: Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.

Laryngoscopy and pharyngeal pH are complimentary in the diagnosis of gastroesphageal-iaryngeal reflux

Laryngoscopy and pharyngeal pH are complimentary in the diagnosis of gastroesphageal-iaryngeal reflux

Laryngoscopy and pharyngeal pH are complimentary in the diagnosis of gastroesphageal-iaryngeal reflux

Laryngoscopy and pharyngeal pH are complimentary in the diagnosis of gastroesphageal-iaryngeal reflux