Esophagopharyngeal distribution of refluxed gastric acid in patients with reflux laryngitis

Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023)

Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.

Laryngopharyngeal Reflux Disease and Gastroesophageal Reflux Disease Can Mutually Influence

OBJECTIVE

To investigate the mutually relationship between gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPRD).

METHODS

All included patients completed simultaneous 24-hour hypopharyngeal intraluminal multichannel impedance pH monitoring (24h-MII-pH), Reflux Symptom Index (RSI), and Reflux Finding Score (RFS). The LPRD diagnosis was based on the occurrence of ≥1 acid or non-acid hypopharyngeal proximal reflux episode(HRE), GERD was defined as a length of time >4.0% of the 24-hour recording spent below pH 4.0 or a DeMeester score >14.72. Patients with both positive LPRD and GERD were classified as LPRD & GERD group, patients with positive LPRD and negative GERD were classified as ILPRD group, patients with negative LPRD and positive GERD were classified as IGERD group, and patients with both negative LPRD and GERD were classified as N group. The differences in clinical characteristics of reflux between the groups were statistically analyzed.

RESULTS

A total of 437 patients were included, including 248 (56.75%) in the ILPRD group, 98 (22.43%) in the LPRD & GERD group, 23 (5.26%) in the IGERD group, and 68 (15.56%) in the N group. There was no significant difference between the types of gastroesophageal reflux in patients with GERD. The number of weak acid/acid/gas/liquid HREs was significantly more in LPRD & GERD patients than in ILPRD patients (P < 0.01), and the number of distal acid reflux events and Longest distal acid clearance time were significantly higher in LPRD & GERD patients than in IGERD patients (P > 0.01).

CONCLUSION

GERD and LPRD are not the same disease but can mutually influence. Combined GERD increased all types of laryngopharyngeal reflux events in patients with LPRD, whereas combined LPRD only increased acidic distal reflux events and acid clearance time in patients with GERD.

The application of 24-hour pharyngeal pH-monitoring and Reflux Finding Score and Reflux Symptom Index questionnaires in the diagnostics of laryngopharyngeal reflux

Introduction

Twenty-four-hour oesophageal pH-monitoring is a gold standard in the diagnostics of gastroesophageal reflux (GERD); however, this examination does not always perform well in patients in whom laryngeal symptoms of reflux are observed.

Aim

To test the effectiveness of Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) in confirming the occurrence of laryngopharyngeal reflux (LPR).

Material and methods

Eighty-two patients with symptoms suggesting the occurrence of LPR were studied. The mean age of the participants amounted to 48.79 ±12.02. The patients were asked to fill in the RSI. The pharynx was assessed using videolaryngostroboscopy and then the RSF was filled in. Next, 24-hour pharyngeal pH-monitoring was performed with the use of a Dx pH – Restech System device. All the statistical analyses were conducted with the use of the R computational environment.

Results

The authors attempted to determine the reference values of the RSI and RFS questionnaires for the Polish population. For a very general approximation, normality of the distributions of the results in the RSI and RFS questionnaire can be done and an approximation mean + 2 SD can be used as a reference value. Then, for RSI the recommended cut-off limit of LPR would fluctuate, depending on the study, between 8 and 17, whereas for RFS it would be between 8 and 14.

Conclusions

When used alone, RSI/RFS questionnaires do not allow an unambiguous diagnosis of LPR assessed by 24-hour pharyngeal pH-monitoring.

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

BACKGROUND

Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging.

CASE PRESENTATION

A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough.

CONCLUSION

Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

Association of Nasopharyngeal and Laryngopharyngeal Reflux with Postnasal Drip Symptomatology in Patients with and without Rhinosinusitis

Background

Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux.

Methods

Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3).

Results

Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055).

Conclusion

Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Oropharyngeal Reflux Monitoring and Atypical Gastroesophageal Reflux Disease

The prevalence of gastroesophageal reflux disease (GERD) has been increasing since the 1990 s, with up to 27.8 % of people in North America affected by this disorder. The healthcare burden of patients who primarily have extra-esophageal manifestations of GERD (atypical GERD) is estimated to be 5 times that of patients with primarily heartburn and regurgitation due to lack of a gold standard diagnostic test, poor responsiveness to PPI therapy, and delay in recognition. Empiric twice daily PPI therapy for 1-2 months is currently considered the best diagnostic test, but due to poor responsiveness to PPIs in patients with atypical GERD in multiple randomized controlled trials, newer modes of diagnostic procedures such as oropharyngeal pH monitoring have gained significantly more traction. The utility of oropharyngeal pH monitoring systems such as Restech Dx-pH is currently limited due to lack of consensus on normal and abnormal cutoff values. Recent studies suggest its utility as a prognostic tool and its ability to predict responsiveness to medical and surgical therapy. However, routine use of oropharyngeal pH monitoring is still not widespread due to the lack of well-controlled prospective studies.

Symptoms, Quality of Life, Videolaryngoscopy, and Twenty-Four-Hour Triple-Probe Ph Monitoring in Patients with Typical and Extraesophageal Reflux

A prospective study was designed to characterize patients with typical and extraesophageal reflux (EER) symptoms and seek predictive patterns for each group. Fifteen subjects without symptoms, 16 patients with symptomatic gastroesophageal reflux disease (GERD), and 37 patients with symptomatic EER were evaluated with outcomes tools, videolaryngoscopy, and 24-hour triple-probe pH monitoring. Higher symptom scores, Voice Handicap Index scores, and Gastrointestinal Symptom Rating Scale scores, as well as similarly decreased quality of life as measured by the Short Form 36, were noted among the two symptomatic groups. Patients with clinically diagnosed EER were more likely to have multiple abnormalities on laryngoscopy. There was a trend toward more pharyngeal reflux episodes in EER patients (6.9 ± 8.9) as compared to GERD patients (6.0 ± 9) and asymptomatic subjects (1.1 ± 1.9). On the basis of the pH monitoring of asymptomatic subjects, we define pathological pharyngeal reflux as more than 5 episodes in 24 hours. Pharyngeal acid exposure is more common in patients presumed to have EER, but some pharyngeal reflux does occur in asymptomatic subjects. Neither symptom scores nor videolaryngoscopic findings were predictive of pathological EER as indicated by pH monitoring.

Effect of Acid and Pepsin on Gene Expression in Laryngeal Fibroblasts

The aim of this study was to determine changes that momentary low pH with or without pepsin causes in gene expression in laryngeal fibroblasts. Cell cultures were established from human false vocal fold (FVF) and postcricoidal (PC) mucosae. Using a real-time polymerase chain reaction, we analyzed messenger RNA gene expression of growth factors (transforming growth factor β1, vascular endothelial growth factor, fibroblast growth factor 2), matrix metalloproteinases (MMP-1, MMP-2), and decorin in normal media, pH 4 media, and pH 5 media with and without pepsin. The FVF fibroblast gene expression differed substantially from the PC fibroblast gene expression. No significant interaction effects for acid and pepsin were found in the FVF culture, but in PC cultures we found a significant overexpression interaction effect for vascular endothelial growth factor, fibroblast growth factor 2, MMP-1, MMP-2, and decorin. These results imply that PC tissue is more sensitive than FVF tissue to the noxious effects of gastric contents. Furthermore, there appears to be a synergistic effect for acid and pepsin exposure in the posterior larynx.

Pharyngeal pH monitoring in infants with laryngitis

Objective

To assess pharyngeal acid reflux (PAR) exposure with flexible laryngoscopy-guided pharyngeal pH monitoring in infants with laryngitis.

Study Design

Tertiary care children's hospital.

Subjects and Methods

Charts of 10 infants with laryngitis who underwent pharyngoesophageal pH monitoring were reviewed. Data included history, physical examination, and pharyngoesophageal pH monitoring findings.

Results

Six infants had PAR. Two patients were on acid suppressive therapy and exhibited PAR. The number of PAR observed in six infants ranged between 1 and 81. The percent acid exposure time (AET) in the pharynx was between 0.1% and 1.2%. Esophageal acid reflux documented in nine infants ranged between 5 and 173. The percent AET in the esophagus was between 0.1% and 4.8%.

Conclusions

The majority of the studied infants with laryngitis had PAR. Not all esophageal acid reflux reached the pharynx. Pharyngeal pH monitoring provides additional information that cannot be obtained with esophageal pH monitoring in infants with laryngitis.

Unmet Needs in the Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder. Proton pump inhibitors have profoundly revolutionized the treatment of GERD. However, several areas of unmet need persist despite marked improvements in the ther-apeutic management of GERD. These include the advanced grades of erosive esophagitis, nonerosive reflux disease, main-tenance treatment of erosive esophagitis, refractory GERD, postprandial heartburn, atypical and extraesophageal manifestations of GERD, Barrett's esophagus, chronic protein pump inhibitor treatment, and post-bariatric surgery GERD. Consequently, any fu-ture development of novel therapeutic modalities for GERD (medical, endoscopic, or surgical), would likely focus on the afore-mentioned areas of unmet need.

WITHDRAWN: Acid reflux treatment for hoarseness

Review withdrawn from Issue 4, 2015 as it is out of date.

The editorial group responsible for this previously published document have withdrawn it from publication.

Correlation between oropharyngeal pH-monitoring and esophageal pH-impedance monitoring in patients with suspected GERD-related extra-esophageal symptoms

BACKGROUND

24-hour esophageal pH-impedance (pH-MII) is not totally reliable for laryngopharyngeal reflux (LPR). Oropharyngeal (OP) pH-monitoring with the Dx-pH probe may detect LPR better. The correlation between these two techniques is not thoroughly established. Aim of this study is to examine the correlation between OP pH-metry and esophageal pH-MII monitoring.

METHODS

Thirty-six consecutive patients with suspected gastroesophageal reflux disease-related extra-esophageal symptoms were evaluated using 24-h OP-pH and concomitant esophageal pH-MII monitoring. OP events were defined as: drop in pH below thresholds of 5.5, 5.0, 4.5, 4.0 or drop in pH of at least 10% from a running baseline. Temporal relationship between OP and esophageal reflux events and outcomes of the two tests were evaluated.

KEY RESULTS

2394 refluxes were detected by pH-MII; of these only 120 were detected also by OP Dx-probe. On the other hand, the proportion of OP-pH events which were temporally related to an episode of distal reflux ranged from 0% to 17%, depending on the proximal pH criteria used. In 8/36 patients both tests were pathological, while in 10/36 they were both normal; 14/36 patients had pathological OP reflux, but a normal pH-MII test; 4/36 patients had pathological pH-MII, but a normal OP reflux.

CONCLUSIONS & INFERENCES

The correlation between OP pH-metry and pH-MII was weak. At present, the absence of a reliable gold standard for the diagnosis of LPR and the uncertain etiology of the pharyngeal pH alterations make it difficult to decide which is the most reliable technique for the diagnosis of true LPR.

Modulation of esophageal afferent pathways by 5-HT3 receptor inhibition

BACKGROUND

The study aims were to investigate whether neural pathways involving 5-HT3 receptors mediate: (i) distension-induced upper esophageal sphincter (UES) relaxation reflex, (ii) esophageal sensitivity to acid and electrical stimuli, and (iii) viserosomatic sensitization following acid exposure.

METHODS

In Study I, in a double-blind crossover trial (n = 9) esophageal sensory and pain thresholds to electrical stimulation were measured in the esophagus, midsternum, and the foot, before subjects were randomized to receive either Ondansetron (8 mg i.v.) or NaCl (0.9% w/v). HCl (0.15 mol L(-1)) was then infused into distal esophagus and electrical thresholds were reassessed. Following electrical sensory threshold testing, subjects received a second esophageal infusion of HCl to evaluate esophageal sensitivity to acid. In Study II (N = 10), frequencies of distension-induced UES relaxation responses were scored before and after treatment with Ondansetron and NaCl in a double-blind crossover trial.

KEY RESULTS

In Study I, ondansetron had no effect on esophageal sensitivity to HCl or acid-induced sensitization. However, blockade of 5-HT3 receptors did reduce midsternum somatic pain thresholds. Sixty minutes after esophageal acid exposure, pain thresholds were significantly lower in the ondansetron arm (mean Δ-1.36 ± 0.4 mA) when compared with NaCl (mean Δ-0.14 ± 0.58 mA) (P < 0.05). In Study II, 5-HT3 receptor blockade had no significant effect on UES relaxation reflex.

CONCLUSIONS & INFERENCES

This study does not support the hypothesis that in health, 5-HT3 receptors play a significant role in esophago-UES distention-induced relaxation reflex and esophageal sensitivity to acid or electrical stimulation. It does provide new evidence for involvement of 5-HT3 receptors in viscerosomatic sensitization.

Characterization of the upper esophageal sphincter response during cough

BACKGROUND

Vagal reflex initiated by esophageal stimulation and microaspiration can cause chronic cough in patients with gastroesophageal reflux disease (GERD). By raising intraabdominal pressure,cough can, in turn, predispose to GERD. The role of the upper esophageal sphincter (UES)in preventing esophagopharyngeal reflux during coughing is not well known. The aim of this study was to evaluate the UES response during coughing.

METHODS

We studied 20 healthy young (10 women; age, 27 ± 5 years) and 15 healthy elderly(nine women; age, 73 ± 4 years) subjects. Hard and soft cough-induced pressure changes in the UES, distal esophagus, lower esophageal sphincter, and stomach were determined simultaneously using high-resolution manometry and concurrent acoustic cough recordings.

RESULTS

Resting UES pressure was significantly higher in the young compared with the elderly subjects (42 ± 14 mm Hg vs 24 ± 9 mm Hg; P < .001). Cough induced a UES contractile response in all subjects. Despite lower UES resting pressures in the elderly subjects, the maximum UES pressure during cough was similar between the young and the elderly subjects (hard cough, 230 ± 107 mm Hg vs 278 ± 125 mm Hg, respectively; soft cough, 156 ± 85 mm Hg vs 164 ± 119 mm Hg, respectively; P not significant for both). The UES pressure increase over baseline during cough was significantly higher than that in the esophagus, lower esophageal sphincter, and stomach for both groups ( P < .001).

CONCLUSIONS

Cough induces a rise in UES pressure, and this response is preserved in elderly people. A cough-induced rise in UES pressure is significantly higher than that in the esophagus and stomach,thereby providing a barrier against retrograde entry of gastric contents into the pharynx.

Esophageal motility, vagal function and gastroesophageal reflux in a cohort of adult asthmatics

BACKGROUND

Asthmatics are known to have esophageal hypomotility. Vagal hypofunction and prolonged intra-esophageal acidification cause esophageal hypomotility. The contribution of gastroesophageal reflux (GER) and vagal function to esophageal motility in asthmatics is unclear. We studied the relationship between esophageal motility, GER and vagal function in a cohort of adult asthmatics.

METHODS

Thirty mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory esophageal monitoring, manometry, autonomic function testing and GER symptom assessment. 27 asthmatics underwent gastroscopy. A vagal function score calculated from 3 tests (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) was correlated with esophageal function parameters.

RESULTS

Asthmatics (mean age 34.8 (SD 8.4), 60% female) had more frequent GERD symptoms than controls (mean age 30.9 (SD 7.7), 50% female). 10/27 asthmatics had esophageal mucosal damage, 22 showed hypervagal response, none had a hyperadrenergic response. 14 asthmatics had ineffective esophageal motility. Higher GERD-score asthmatics had significantly fewer peristaltic and more simultaneous contractions than controls, and higher esophageal acid contact times than those with lower scores. All reflux parameters were significantly higher and acid clearance time prolonged in asthmatics than controls (p < 0.001, Mann-Whitney U test). There was no correlation between vagal function score and esophageal function parameters.

CONCLUSIONS

A cohort of adult asthmatics was found to have peristaltic dysfunction and pathological GER, but otherwise normal esophageal motility. The peristaltic dysfunction seems to be associated with vagal hyperreactivity rather than vagal hypofunction.

The Role of Helicobacter pylori in Upper Respiratory System Infections: Is it More Than Colonization?

Helicobacter pylori (HP) is recognized as a common chronic human bacterial infection and is the most common cause of gastritis. Recent studies suggest an increased HP prevalence in patients with various extra-digestive inflammatory diseases. Since many respiratory diseases are characterized by chronic inflammation as well as increased immune response, and HP may enter the nasopharyngeal cavity by gastroesophageal reflux, an association between respiratory disorders and HP infection has been suggested. Several studies discover HP in clinical samples from the patients with upper respiratory system infections. Even some of them revealed a relief after the treatment directed to HP eradication. However some studies do not support this theory and whether this association means a definite proof of a causal relationship between HP and respiratory diseases needs to be clarified. In this study, we aimed to review the reports about the role of HP in upper respiratory system infections.

Gastroesophageal reflux disease and tympanoplasty surgical outcome: is there a relationship?

Objective:

To investigate the possible clinical relationship between gastroesophageal reflux disease and the type one tympanoplasty surgical outcomes of adults with chronic otitis media, by using a simple, cost-effective, reliable questionnaire and physical findings.

Methods:

Fifty-two of 147 patients undergoing type one tympanoplasty were studied. Gastroesophageal reflux disease symptoms were evaluated using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease questionnaire. Laryngoscopic physical findings of laryngopharyngeal reflux were evaluated using the Reflux Finding Score. A successful outcome was defined as an intact tympanic membrane. Correlations between the two assessment tool results and the patient's surgical success were calculated.

Results:

The gastroesophageal reflux disease questionnaire score was significantly higher in patients with unsuccessful tympanic membrane closure (group one) than in patients with successful closure (group two) (p < 0.05). The Reflux Finding Score was also significantly higher in group one than group two (p < 0.05). There was a significant positive relationship between the gastroesophageal reflux disease questionnaire score and the Reflux Finding Score (p < 0.01).

Conclusion:

Gastroesophageal reflux disease may be a significant prognostic factor for tympanoplasty failure. Therefore, reflux investigation may be important during the treatment of chronic otitis media, and positive cases may need reflux treatment as well as ear disease treatment.

Gastroesophageal reflux disease and vocal disturbances

CONTEXT

Gastroesophageal reflux disease is a chronic disease in which gastroduodenal contents reflux into the esophagus. The clinical picture of gastroesophageal reflux disease is usually composed by heartburn and regurgitation (typical manifestations). Atypical manifestations (vocal disturbances and asthma) may also be complaint.

OBJECTIVE

To analyse the clinical, endoscopic, manometric and pHmetric aspects of patients suffering from gastroesophageal reflux disease associated with vocal disturbances.

METHODS

Fifty patients with gastroesophageal reflux disease were studied, including 25 with vocal disturbances (group 1 - G1) and 25 without these symptoms (group 2 - G2). All patients were submitted to endoscopy, manometry and esophageal pHmetry (2 probes). The group 1 patients were submitted to videolaryngoscopy.

RESULTS

Endoscopic findings: non-erosive reflux disease was observed in 95% of G1 patients and 88% of G2. Videolaryngoscopy: vocal fold congestion, asymmetry, nodules and polyps were observed in G1 patients. Manometric findings: pressure in the lower esophageal sphincter (mm Hg): 11.6 ± 5.2 in G1 and 14.0 ± 6.2 in G2 (P = 0.14); pressure in the upper esophageal sphincter (mm Hg): 58.4 ± 15.9 in G1 and 69.5 ± 30.7 in the controls. pHmetric findings: De Meester index: 34.0 ± 20.9 in G1 and 15.4 ± 9.4 in G2 (P<0.001); number of reflux episodes in distal probe: 43.0 ± 20.4 in G1 and 26.4 ± 17.2 in G2 (P = 0.003); percentage of time with esophageal pH value lower than 4 units (distal sensor): 9.0% ± 6.4% in G1 and 3.4% ± 2.1% in G2 (P<0.001); number of reflux episodes in proximal probe: 7.5 ± 10.9 in G1 and 5.3 ± 5.7 in G2 (P = 0.38); percentage of time with esophageal pH values lower than 4 units (Proximal probe): 1.2 ± 2.7 in G1 and 0.5 ± 0.7 in G2 (P = 0.21).

CONCLUSIONS

1) The clinical, endoscopic, and manometric findings observed in patients with vocal disturbance do not differ from those without these symptoms; 2) gastroesophageal reflux intensity is higher in patients with vocal disturbance; 3) patients without vocal disturbance can also present reflux episodes in the proximal probe.

Extraesophageal gastroesophageal reflux disease (GERD) symptoms are not more frequently associated with proximal esophageal reflux than typical GERD symptoms

Extraesophageal (EE) symptoms such as cough and throat clearing are common in patients referred for reflux testing, but are less commonly associated with gastroesophageal reflux disease (GERD). Patients with reflux associated EE symptoms often lack typical GERD symptoms of heartburn and regurgitation. Our aim was to compare the frequency of proximal esophageal reflux between esophageal (typical) symptoms and EE (atypical) symptoms. Combined multichannel intraluminal impedance-pH (MII-pH) tracings were blinded by an investigator so that symptom markers were relabeled with a number without disclosure of symptom type. We selected 40 patients with at least five reflux-related symptom events for one of four symptoms (heartburn, regurgitation, cough, or throat clearing). A blinded investigator analyzed all 200 reflux episodes, reporting the proximal esophageal extent of the reflux for all symptoms. The percentage of symptom-related reflux extending proximally to 17 cm above the LES was similar among all four symptom types. At least 50% of all symptoms were associated with proximal esophageal reflux to 17 cm, with regurgitation having the highest frequency at 60%. Our data indicate that EE symptoms are not more frequently associated with proximal esophageal reflux than typical esophageal symptoms.

Impedance nadir values correlate with barium bolus amount

We examined the value of impedance monitoring in measuring bolus volume compared with videoesophagram. Eighty consecutive subjects were studied with simultaneous impedance-manometry-videoesophagram. A catheter with both an impedance electrode pair and a pressure transducer at four sites (5, 10, 15, 20 cm above lower esophageal sphincter) was passed per nares. Six 10-cc boluses of 45% barium mixed with 0.9% NaCl were swallowed at 20- to 30-second intervals. When impedance fell to below 1000 ohms, other than that occurring during administered swallows, the videofluoroscopic image corresponding to the time of impedance nadir was reviewed. If barium was present at the impedance site, barium area was calculated. The video was reviewed for the cause of abnormal barium transit causing barium presence. We found 38/80 subjects had a total of 169 impedance falls to below 1000 ohms. Ninety-seven percent (164/169) of impedance falls had barium present at the impedance site, and there was good correlation (r = 0.83, P < 0.001) between impedance nadir value and barium area. The impedance nadir value : barium area relationship was similar for the three causes of barium presence identified by video: failed bolus clearing; gastroesophageal reflux; and esophageal escape. Impedance nadir values 700-999 ohms usually had a small barium area. In contrast, nadir values <400 ohms had a large barium area covering all or most of the catheter and filling the esophagus at the impedance site. Impedance falls from >1000 ohms to a low nadir value from all forms of abnormal esophageal bolus transit imply a large bolus amount.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

Diagnosis of supra-esophageal gastric reflux: correlation of oropharyngeal pH with esophageal impedance monitoring for gastro-esophageal reflux

BACKGROUND

Oropharyngeal (OP) pH monitoring has been developed as a new way to diagnose supra-esophageal gastric reflux (SEGR), but has not been well validated. Our aim was to determine the correlation between OP pH and gastro-esophageal reflux (GER) events detected by multichannel intraluminal impedance-pH (MII-pH).

METHODS

Fifteen patients (11 males, median age 10.8 years) with suspected GER were prospectively evaluated with ambulatory 24-h OP pH monitoring (positioned at the level of the uvula) and concomitant esophageal MII-pH monitoring. Potential OP events were identified by the conventional pH threshold of <4 and by the following alternative criteria: (i) relative pH drop >10% from 15-min baseline and (ii) absolute pH drop below thresholds of <5.5, 5.0, and 4.5. The 2-min window preceding each OP event was analyzed for correlation with an episode of GER detected by MII-pH.

KEY RESULTS

A total of 926 GER events were detected by MII-pH. Application of alternative pH criteria increased the identification of potential OP pH events; however, a higher proportion of OP events had no temporal correlation with GER (45-81%), compared with the conventional definition of pH < 4 (40%). A total of 306 full-column acid reflux episodes were detected by MII-pH, of which 10 (3.3%) were also identified by OP pH monitoring.

CONCLUSIONS & INFERENCES

Use of extended pH criteria increased the detection of potential SEGR events, but the majority of decreases in OP pH were not temporally correlated with GER. Oropharyngeal pH monitoring without concurrent esophageal measurements may overestimate the presence of SEGR in children.

Mechanisms of esophago-pharyngeal acid regurgitation in human subjects

Esophago-pharyngeal regurgitation is implicated in various otolaryngologic and respiratory disorders. The pathophysiological mechanisms causing regurgitation are still largely unknown.

Establishment of a reflux esophago-laryngitis model in rats

BACKGROUND

To investigate the pathophysiology of reflux laryngitis, an experimental model is required.

AIM

The aim of this study is to establish an animal model of reflux esophago-laryngitis, modifying our previously reported model of chronic acid reflux esophagitis.

METHODS

The modified chronic acid reflux esophagitis (m-RE) group (n = 10), in which the duodenum was wrapped with 2.5 mm of Nelaton catheter, was not treated with any drugs. Also postoperatively, two treatment groups (n = 10 in each) received different dosages of rabeprazole (RPZ): 1.0 mg/kg/day (RPZ 1.0 group) or 10.0 mg/kg/day (RPZ 10.0 group). As a control group (n = 5), other rats underwent sham operation. The esophagus and larynx were resected on day 14 after the operation, and ulcer score of the esophagus was assessed. The epithelial thickness and leukocyte infiltration of the supraglottic and subglottic laryngeal mucosae were investigated. The number of interleukin (IL)-1β-positive cells was also counted and defined as the IL-1β labeling index.

RESULTS

In the m-RE group, the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of the supraglottic and subglottic laryngeal mucosae were increased compared with controls (P < 0.01). In the RPZ groups, not only the ulcer score of esophagus but also the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of both the supraglottic and subglottic laryngeal mucosae were decreased dose-dependently relative to the m-RE group (P < 0.05).

CONCLUSIONS

Our modified chronic acid reflux esophagitis model proved useful in establishing a rat reflux esophago-laryngitis model, with both pathological laryngeal findings and reflux esophagitis shown to be improved by administration of a proton pump inhibitor.

Increase of weakly acidic gas esophagopharyngeal reflux (EPR) and swallowing-induced acidic/weakly acidic EPR in patients with chronic cough responding to proton pump inhibitors

BACKGROUND

Gastro-esophageal reflux disease (GERD)-related chronic cough (CC) may have multifactorial causes. To clarify the characteristics of esophagopharyngeal reflux (EPR) events in CC patients whose cough was apparently influenced by gastro-esophageal reflux (GER), we studied patients with CC clearly responding to full-dose proton pump inhibitor (PPI) therapy (CC patients).

METHODS

Ten CC patients, 10 GERD patients, and 10 healthy controls underwent 24-h ambulatory pharyngo-esophageal impedance and pH monitoring. Weakly acidic reflux was defined as a decrease of pH by >1 unit with a nadir pH >4. In six CC patients, monitoring was repeated after 8 weeks of PPI therapy. The number of each EPR event and the symptom association probability (SAP) were calculated. Symptoms were evaluated by a validated GERD symptom questionnaire.

KEY RESULTS

Weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR only occurred in CC patients, and the numbers of such events was significantly higher in the CC group than in the other two groups (P < 0.05, respectively). Symptom association probability analysis revealed a positive association between GER and cough in three CC patients. Proton pump inhibitor therapy abolished swallowing-induced acidic/weakly acidic EPR, reduced weakly acidic gas EPR, and improved symptoms (all P < 0.05).

CONCLUSIONS & INFERENCES

Most patients with CC responding to PPI therapy had weakly acidic gas EPR and swallowing-induced acidic/weakly acidic EPR. A direct effect of acidic mist or liquid refluxing into the pharynx may contribute to chronic cough, while cough may also arise indirectly from reflux via a vago-vagal reflex in some patients.

Effect of different pH criteria on dual-sensor pH monitoring in the evaluation of supraesophageal gastric reflux in children

BACKGROUND AND AIM

Existing tests for supraesophageal gastric reflux (SEGR) that focus on pH drops <4 in the proximal esophagus have had limited sensitivity and specificity. The aim of the present study was to evaluate the effect of newly proposed pH criteria on SEGR detection.

PATIENTS AND METHODS

Twenty-four-hour dual-sensor pH tracings of 32 patients were reviewed. Proximal esophageal pH data were evaluated according to the conventional definition of pH drop <4 and 2 proposed definitions: pH drop <5.5 while upright and <5.0 while supine and pH drop of >10% from a running baseline. For each potential SEGR event, the preceding 1-minute window was examined for corresponding distal acid reflux.

RESULTS

Of the 542 distal acid reflux events detected, 200 were associated with a proximal pH drop <4; this number increased to 295 using the definition of proximal pH drop <5.5 (upright)/<5.0 (supine) and 301 using the definition of proximal pH drop >10%. A proportion of proximal events, however, was not associated with distal acid reflux: 21 of 200 (10.5%) proximal pH <4 events, 119 of 414 (29%) proximal pH <5.5 (upright)/<5.0 (supine) events, and 272 of 573 (47%) proximal pH drop >10% events lacked a preceding or simultaneous drop in distal pH <4.

CONCLUSIONS

Although the use of more liberal pH criteria increased the diagnostic yield for SEGR events with dual-sensor monitoring, a significant proportion of proximal pH events did not correlate with distal acid reflux. These events could represent either false-positive measurements or association with weakly acid reflux.

Cardiovascular compression of the esophagus and spread of gastro-esophageal reflux

BACKGROUND

Factors that determine the spread of gastro-esophageal reflux (GER) along the length of the esophagus are not known. We investigated if cardiovascular (CV) compressions on the esophagus may determine the spread of refluxate into the proximal esophagus.

METHODS

High-resolution manometry (HRM) and multi-channel intra-luminal impedance recording (MIIR) were performed simultaneously in 10 normal subjects in the recumbent and upright positions. Pulsatile pressure increases on the esophagus (marker of CV compression) were identified on the HRM. Spread of refluxate into the esophagus was determined by the MIIR.

KEY RESULTS

Cardiovascular compression zones were observed in the esophagus in 9 out of 10 subjects in recumbent position. Forty percent of GER episodes were limited to the distal esophagus in the recumbent position and CV compression pressure was greater than distal esophageal pressure at the time of GER in all such cases. On the other hand, distal esophageal pressure was greater than CV compression pressure when the refluxate extended into the proximal esophagus. In the upright position, CV compression was less frequent than recumbent position and only 12% of GER episodes were limited to the distal esophagus.

CONCLUSIONS & INFERENCES

Cardiovascular compression of the esophagus is frequently observed in normal healthy subject and restricts the spread of refluxate into the proximal esophagus.

[Diagnosis of gastroesophageal reflux disease: a systematic review]

The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.

Loss of alkalization in proximal esophagus: a new diagnostic paradigm for patients with laryngopharyngeal reflux

INTRODUCTION

Cervical esophageal pH monitoring using a pH threshold of <4 in the diagnosis of laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of cervical esophageal exposure to gastric juice. The aim of this study was to define normal values for the percent time the cervical esophagus is exposed to a pH ≥7 and to use the inability to maintain this as an indicator for diagnosis of LPR.

MATERIAL AND METHODS

Fifty-nine asymptomatic volunteers had a complete foregut evaluation including pH monitoring of the cervical esophagus. Cervical esophageal exposure to a pH <4 was calculated, and the records were reanalyzed using the threshold pH ≥7. The sensitivity of these two pH thresholds was compared in a group of 51 patients with LPR symptoms that were completely relieved after an antireflux operation.

RESULTS

Compared to normal subjects, patients with LPR were less able to maintain an alkaline pH in the cervical esophagus, as expressed by a lower median percent time pH ≥ 7 (10.4 vs. 38.2, p < 0.0001). In normal subjects, the fifth percentile value for percent time pH ≥ 7 in the cervical esophagus was 19.6%. In 84% of the LPR patients (43/51), the percent time pH ≥ 7 were below the threshold of 19.6%. In contrast, 69% (35/51) had an abnormal test when the pH records were analyzed using the percent time pH < 4. Of the 16 patients with a false negative test using pH < 4, 11 (69%) were identified as having an abnormal study when the threshold of pH ≥ 7 was used.

CONCLUSION

Normal subjects should have a pH ≥7 in cervical esophagus for at least 19.6% of the monitored period. Failure to maintain this alkaline environment is a more sensitive indicator in the diagnosis of the LPR and identifies two thirds of the patients with a false negative test using pH <4.

Relationship between dental erosion and respiratory symptoms in patients with gastro-oesophageal reflux disease

OBJECTIVES

Both dental erosion and respiratory symptoms are extra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD). The aim of this study was to determine whether dental erosion was correlated with respiratory symptoms in GERD patients.

METHODS

88 GERD patients were recruited and assigned to three groups mainly according to the frequency of respiratory symptoms: Group I: never; Group II: occasional (1-2 days a week or less); Group III: frequent (3-5 days a week or more). All patients underwent medical evaluations, including medical history, questionnaire answering and alimentary tract examinations. Dental examinations were carried out on these patients and 36 healthy controls. Dental erosions were measured by modified method of Smith and Knight Tooth Wear Index (TWI). Location and severity of dental erosion were recorded.

RESULTS

The prevalence of dental erosion in Group III (64.52%) was higher (p<0.05) than that in Groups I (36.67%) and II (44.44%). GERD patients were presented with dental erosion with TWI scores ranging from 1 to 4. Though proportion of dental erosion with Score 2 (7/20) in Group III was higher than that in Group I (2/11) and Group II (3/12), there was no statistical significance in the proportions of erosion scores among three patient groups. Correlation coefficient between airway symptoms and scores of dental erosion was 0.231 (p<0.05). Palatal erosion of upper incisor was seen in 8 persons (72.7%) in Group I, 9 persons (75%) in Group II and 16 persons (80%) in Group III (p>0.05). Labial erosion of upper incisors was found in 1 person in Groups I and II respectively and 4 persons in Group III. All patients with labial erosion on upper incisors had palatal erosion, except 1 patient in Group III.

CONCLUSIONS

In GERD patients, dental erosions are more prevalent in patients with frequent respiratory symptoms than those in patients with occasional and without respiratory symptoms. Palatal erosion of upper incisor is the main manifestation in patients. Acid reflux is the main causative factor of dental erosion in GERD patients with airway symptoms.

The differential effect of gastroesophageal reflux disease on mechanostimulation and chemostimulation of the laryngopharynx

OBJECTIVES

Laryngo-hypopharyngeal sensitivity (LPS) as measured by thresholds to mechanostimulation and chemostimulation is important in the prevention of pulmonary aspiration. The presence of gastroesophageal reflux disease (GERD) increases thresholds to mechanostimulation. However, the effect of GERD on thresholds to chemostimulation remains unknown. The aim of this study was to compare laryngo-hypopharyngeal thresholds to chemostimulation in subjects with GERD with those of healthy subjects and to determine the relationship between thresholds to mechanostimulation and chemostimulation.

METHODS

Forty-eight patients with GERD and 18 control subjects without GERD underwent LPS testing using the Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing technique. All 48 patients and 10 of the control subjects also underwent threshold testing for chemostimulation via hypopharyngeal infusions of normal saline and 0.1 N hydrochloric acid performed in a randomized, blinded manner. Thresholds to mechanical stimulation, as measured by the lowest air pressure level required to elicit the laryngeal adductor reflex (LAR), were determined before and after laryngo-hypopharyngeal infusions. Thresholds to chemical stimulation were measured by determining the infusion volume of acid or saline required to trigger an airway protection response.

RESULTS

The mean LAR threshold of the patient group was significantly higher compared with that of control subjects (9.5 mm Hg vs 3.9 mm Hg, P < .01). Compared with control subjects, significantly less acid (0.13 mL vs 0.21 mL, P < .01) was required to trigger airway protective responses in GERD subjects. There is a strong negative correlation between the volume of acid infused and the LAR thresholds in the control subjects (r = -0.69, P < .05).

CONCLUSIONS

Compared with the control subjects, subjects with GERD have significantly increased thresholds to mechanical stimulation, suggesting reduced mechanosensitivity, but significantly reduced thresholds to chemical stimulation, suggesting heightened chemosensitivity. There is an inverse relationship between mechanosensitivity and chemosensitivity. This relationship may be integral in maintaining airway protection.

Effect of pantoprazole in patients with chronic laryngitis and pharyngitis related to gastroesophageal reflux disease: clinical, proximal, and distal pH monitoring results

Few studies had evaluated the results of proton pump inhibitors on distal and proximal pH recording using a dual-channel probe. The aim of this study was to determine the clinical and pH-metric effect of treatment with pantoprazole 80 mg for 8 weeks in patients with ear, nose, and throat (ENT) manifestations of gastroesophageal reflux disease associated with pathological proximal acid exposure. We conducted a prospective open study. Patients included had to have chronic pharyngitis or laryngitis, and a pathological gastroesophagopharyngeal reflux. All patients received treatment with pantoprazole 80 mg daily for 8 weeks. One week after the end treatment, patients had a second ENT examination and a 24-hour pH monitoring using dual-channel probe. We included 33 patients (11 men, 22 women). A pathological distal acid reflux was found in 30 patients (91%). After treatment, the improvement of ENT symptoms was found in 51.5% of patients. Normalization of 24-hour proximal esophageal pH monitoring was observed in 22 patients (66%). After treatment, the overall distal acid exposure, the number of distal reflux events, and the number of reflux during more than 5 minutes were significantly decreased (respectively: 19.4% vs 7.2% [P < 0.0001], 62.7 vs 28.4 [P < 0.0001], and 10.4 vs 3.9 [P < 0.0001] ). Similarly, in proximal level, the same parameters were significantly decreased after treatment (respectively: 6.8% vs 1.6% [P < 0.0001], 32.6 vs 8.1 [P < 0.0001], and 3.4 vs 0.6 [P= 0.005] ). Treatment with pantoprazole reduced the frequency and severity of gastroesophagopharyngeal acid reflux in patients with chronic pharyngitis and laryngitis.

Combined Dual Channel Impedance/pH-metry in Patients With Suspected Laryngopharyngeal Reflux

BACKGROUND/AIMS

Laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) such as globus sensation, hoarseness and chronic cough are becoming increasingly recognized. This study was aimed to investigate the diagnostic usefulness of combined dual channel multichannel intraluminal impedance (MII)/pH-metry in 'off-proton pump inhibitor (PPI)' patients with suspected laryngopharyngeal reflux.

METHODS

Ninety-eight patients with laryngopharyngeal symptoms of GERD were included. All patients were 'off-PPI' state for at least 2 weeks prior to the study, and underwent endoscopy and dual channel combined MII/pH-metry.

RESULTS

The mean age of the patients was 49.8 +/- 10.9 years and there were 44 males (44.9%). Fifty-three patients (54.1%) showed pathologic gastroesophageal reflux (GER). Combined dual channel MII/pH-metry achieved highest diagnostic yield of 49.0% and diagnostic yield of single channel combined MII/pH-metry was 37.8%. Addition of MII to standard pH-metry increased twofold of the diagnostic yield for detecting GER. Among 37 patients (37.8%) who had pathologic GER being detected by MII/pH-metry, 19 patients (19.4%) had nonacid GER (nonacid GER group) while 18 patients (18.4%) had acid GER (acid GER group). Pathologic GER group, as classified by MII/pH-metry showed more frequent globus sensation than nonpathologic GER group. Acid GER group had more proximal reflux than nonacid GER group, especially in the upright position.

CONCLUSIONS

In this study, combined dual channel MII/pH-metry showed the highest diagnostic yield for detecting GER. This technique can be performed primarily to accurately diagnose laryngopharyngeal reflux disease and exclude other causes of laryngopharyngeal symptoms.

Upregulation of the esophago-UES relaxation response: a possible pathophysiological mechanism in suspected reflux laryngitis

BACKGROUND

Inappropriate or excessive, non-swallow related, reflexive relaxation of the upper esophageal sphincter (UES) in response to esophageal distension may be the principal mechanism permitting retrograde trans-sphincteric flow during acid regurgitation. The neural pathways mediating reflexive UES relaxation in the human have received little attention. Patients with laryngitis demonstrate an increased acid reflux in the proximal esophagus. Such events, combined with an increased tendency for UES relaxation, might precipitate regurgitation into the pharynx. The aim was to determine whether the esophago-UES relaxation reflex induced by rapid esophageal distension is upregulated in patients with posterior laryngitis.

METHODS

In 21 healthy volunteers and 14 patients with posterior laryngitis, UES responses to rapid air insufflation were examined. UES responses were monitored with perfused manometry catheter with a oval sleeve sensor.

KEY RESULTS

The probability of triggering UES relaxation in response to the rapid esophageal air distension, for all volumes of insufflation, was higher in laryngitis (45%) than in health (17%). The minimum distension volume required to elicit an UES relaxation response was significantly lower in laryngitis patients when compared with controls. Patients who demonstrated a laryngoscopic response to a trial of omeprazole, were less likely to generate a distension-induced UES contractile response (5%) than patients who did not respond (23%).

CONCLUSIONS & INFERENCES

The threshold for esophageal distension-induced UES relaxation is reduced in patients with laryngitis when compared with controls. This finding supports the hypothesis that in this population, a hypersensitive belch-like response may be one contributory mechanism of regurgitation when triggered by an abrupt spontaneous gastro-esophageal reflux event.

Ambulatory 24-hour pharyngeal pH monitoring in healthy Korean volunteers

Pharyngeal pH monitoring is the standard diagnostic approach for laryngopharyngeal reflux (LPR). However, the normal values for Asian populations are still unknown. We evaluated the results of ambulatory 24-h pharyngeal pH monitoring in healthy volunteers to determine the normal reference values in the Korean population. Thirty healthy subjects underwent ambulatory 24-h pharyngeal pH monitoring with glass electrodes positioned 1 cm above the upper esophageal sphincter and 5 cm above the lower esophageal sphincter, based on esophageal manometry after upper gastrointestinal endoscopy. LPR occurred in about one half of the healthy volunteers without any significant association with age, gender and body mass index. Pharyngeal acid reflux occurred mainly in the upright position. At the 95th and 90th percentile, after the exclusion of mealtimes, the upper limits of normal (ULN) for pharyngeal acid exposure were 0.41% and 0.18%. The ULNs for the number of pharyngeal acid events were 12.8 and 5.0. The corresponding ULNs for the esophagus were 5.1% and 3.8% and 62.7 and 32.6. The findings of this study help establish the reference standards for LPR in Korean patients.

Proximal oesophagus: the added value in understanding GORD symptoms

Over the past decade, the approach to the understanding of the mechanisms involved in the aetiology of gastro-oesophageal reflux disease (GORD) symptoms has changed, and growing evidence now supports the concept that visceral hyper-sensitivity to intra-oesophageal stimuli plays a major role. Among the recent advances, one of the more consistent findings is that the contact of the refluxate, either acidic or weakly acidic, with the proximal oesophageal mucosa, is a main determinant of GORD symptoms, particularly in the large majority of patients affected by non-erosive reflux disease. The data reported in the current issue of Neurogastroenterology and Motility by Bredenoord et al., showing only a small proportion of proximal reflux in patients with Barrett's oesophagus, who are less sensitive to gastro-oesophageal reflux, further support the consistency of this finding in the pathogenesis of symptoms. In the light of these results, we shall look forward, in the management of patients, to approaches aimed at restoring the antireflux barrier, hopefully decreasing the amount of reflux and, in turn, its proximal extent.

Gastroesophageal reflux monitoring: pH (catheter and capsule) and impedance

Diagnostic testing for GERD has evolved to include multi esophageal sites (distal, proximal and hypopharyngeal monitoring), wireless pH, and oropharyngeal devices. The versatility of the devices has increased our ability to better understand the role of acid reflux in various disorders involving reflux of acid. Wireless pH monitoring improves patient comfort and allows monitoring for gastroesophageal reflux events over several days. Ambulatory MII-pH monitoring is another exciting diagnostic tool, which is capable of detecting more than one type of reflux and achieves higher sensitivity and specificity to detect GERD than endoscopy or pH-metry. It is useful in patients with either typical or atypical reflux symptoms who are refractory to proton pump inhibitor (PPI) therapy. In this setting, MII-pH can be performed on PPI therapy to assess the efficacy of PPIs and the role of nonacid or acid reflux in persistent symptoms.

Laryngeal manifestations of gastroesophageal reflux disease

Chronic laryngeal signs and symptoms associated with gastroesophageal reflux disease (GERD) are often referred to as reflux laryngitis or laryngopharyngeal reflux (LPR). It is estimated that up to 15% of all visits to otolaryngology offices are because of manifestations of LPR. Damage to laryngeal mucosa may be the result of reflux of gastroduodenal contents, whether chronic or a single incident. The most common presenting symptoms of LPR include hoarseness, sore throat, throat clearing, and chronic cough. The diagnosis of LPR is usually made on the basis of presenting symptoms and associated laryngeal signs, including laryngeal edema and erythema. The current recommendation for managing these patients is empiric therapy with twice-daily proton pump inhibitors for 1 to 2 months. Other causes of laryngeal irritation are considered in most of those who are unresponsive to such therapy. Surgical fundoplication is most effective in those who are responsive to acid-suppressive therapy.

Laryngeal carcinoma in nonsmoking patients

OBJECTIVES

Smoking is a known risk factor for laryngeal carcinoma. We sought to describe the clinicopathologic characteristics and outcomes of nonsmoking patients with laryngeal carcinoma.

METHODS

Of 1,443 patients treated for laryngeal carcinoma between 1960 and 2006, 55 (3.8%) were nonsmokers: 40 (73%) had never smoked and 15 (27%) had stopped smoking 12 years or more before diagnosis. Patient characteristics and outcomes were reviewed.

RESULTS

The study group consisted of 87% men; the mean age at diagnosis was 67 years. All lesions but one were located in the glottis. The 5-year survival rate for the whole group was 85%. Most tumors were detected early. Of 38 patients (69%) with stage T1 disease, there was no significant difference in prognostic features between those who had never smoked and those who had smoked in the past.

CONCLUSIONS

Fewer than 5% of patients with laryngeal carcinoma were nonsmokers. Like smokers, this subgroup was characterized by a male predominance and an approximate age at diagnosis in the seventh decade. Unlike smokers, nonsmokers show a greater predilection for glottic rather than supraglottic disease. There was no difference in prognosis between smokers and nonsmokers, regardless of whether they had smoked in the past.

Association of extraesophageal reflux disease and sinonasal symptoms: prevalence and impact on quality of life

OBJECTIVES

The purpose of this study was to investigate the prevalence of extraesophageal reflux disease symptoms and their association with sinonasal disorders within a general sample of adults in our community and to determine how these conditions affect perception of general health, sinus-related quality of life (QOL), and perception of reflux and digestive function.

STUDY DESIGN/METHODS

A community-dwelling sample of 1,878 adults completed symptom and QOL surveys in a two-stage prospective design: an initial screening questionnaire (n = 1,878) and disease-specific (sinus and reflux/digestion) and general health-related QOL instruments (n = 1,073). Demographic and response data were summarized and analyzed for prevalence and correlations among data sets.

RESULTS

Sinonasal symptoms were reported in 71% of subjects who completed the initial screening questionnaire, and reflux-related symptoms were reported by 59% of respondents. The co-occurrence of sinonasal and reflux symptoms was reported by 45% of respondents. Subjects with both sinonasal and reflux symptoms scored significantly worse on the disease-specific and general physical and mental QOL scales than subjects with only reflux or sinonasal symptoms or no symptoms.

CONCLUSIONS

Symptoms associated with inflammatory sinonasal disorders and gastroesophageal reflux disease are common in the general U.S. adult population and co-occur in the same individuals to a greater degree than can be attributed to chance alone. Co-occurrence was found to be associated with significant declines in both disease-specific and general physical and mental QOL. This finding has implications with regard to pathogenesis and treatment of these disorders.

Oropharyngeal pH monitoring for the detection of liquid and aerosolized supraesophageal gastric reflux

The association between gastroesophageal reflux disease (GERD) and extraesophageal symptoms is poorly understood and difficult to document. pH monitoring in this group of patients has resulted in conflicting data due to lack of diagnostic sensitivity. Recently, a new sensitive pH device for detection of liquid and aerosolized droplets in the oropharynx (The Dx-pH Measurement System [Dx-pH]) has become available. Our hypothesis is that we will be able to improve our ability to identify and understand this group of patients with this device. The aim of this preliminary observation study was to compare the results of this new device to the standard esophageal and pharyngeal pH probes in a small group of patients with extraesophageal symptoms. Patients with suspected extraesophageal GER symptoms underwent traditional 24-hour esophago-pharyngeal pH monitoring (24pH) simultaneous with Dx-pH monitoring in the oropharynx. Tracings were reviewed for comparison and correlation between the two probes, with an event in the Dx-pH Probe being defined as a rapid drop >3 standard deviation from baseline. Fifteen patients (10 females, 5 males) with mean age of 57.5 years (range, 25-75) were studied. The predominant chief complaint included 12/15 chronic cough, 2/15 asthma; and 1/15 throat clearing. All Dx-pH events were preceded and associated with distal esophageal pH drops in a progressive ante grade manner. Ten patients had 1-13 abnormal oropharyngeal pH events as measured by Dx-pH monitoring with a total of 48 events. The median pH of reflux events had a statistically significant increase from 3.1 at the distal esophageal probe to 5.2 at the pharynx and 5.6 at the oropharynx, the latter being 80% higher than the distal esophageal probe (P<0.001). The percentage of acid events decreased in a cephalad manner from 66.7% at distal esophagus to 25% at the pharynx and only 6.25% at the oropharyngeal Dx-pH Probe, with the remaining events being weakly acidic. Dx-pH Probe is a new sensitive oropharyngeal pH device whose values correlate well with the gold-standard 24-hour pH device, and appears to accurately detect pH events that begin at the distal esophagus and travel upward to the oropharynx. This device suggests that supraesophageal events manifest themselves as rapid pH drops (>10%), which are likely not to be identified using the standard criteria of pH <4 due to the gradient of increasing pH from the lower esophagus to the oropharynx.