Physical and pH properties of gastroesophagopharyngeal refluxate: a 24-hour simultaneous ambulatory impedance and pH monitoring study

Diagnostic Testing for Laryngopharyngeal Reflux Disease: The Role of 24-hour Hypopharyngeal-Esophageal Multichannel Intraluminal Impedance-pH Monitoring

Laryngopharyngeal reflux disease (LPRD) presents as a constellation of nonspecific upper aerodigestive tract symptoms and signs. Among many objective tools available on the market, hypopharyngeal-esophageal multichannel intraluminal impedance and pH monitoring (HEMII-pH) is considered to date the gold standard technique for diagnosing LPRD, as well as tailoring treatment according to the different LPR profiles. More studies are needed to further validate and standardize diagnostic criteria and evaluate long-term outcomes of patients diagnosed and treated for LPRD using HEMII-pH.

Link between pharyngeal acid reflux episodes and the effectiveness of proton pump inhibitor therapy

BACKGROUND

Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.

AIM

To investigate whether PAR episodes alone predict a positive response to PPI therapy.

METHODS

Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.

RESULTS

A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, n = 11), followed by EAR alone (59%, n = 68), both pH (+) (56%, n = 18), and both pH (-) (33%, n = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold (P = 0.008), 4.2-fold (P = 0.0002), and 3.4-fold (P = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.

CONCLUSION

In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.

Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review

Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.

Increased Sensitivity of Cough Reflex is Not the Mechanism of Cough Attributed to Laryngopharyngeal Reflux

OBJECTIVES

In laryngopharyngeal reflux (LPR) patients acid reaches laryngopharyngeal area and stimulates/sensitizes respiratory nerve terminals mediating cough. We addressed several hypothesis: if stimulation of respiratory nerves is responsible for coughing then acidic LPR should correlate with coughing and proton pump inhibitor (PPI) treatment should reduce both LPR and coughing. If sensitization of respiratory nerves is responsible for coughing then cough sensitivity should correlate with coughing and PPI should reduce both coughing and cough sensitivity.

STUDY DESIGN/METHODS

In this prospective single center study, patients with positive reflux symptom index (RSI > 13) and/or reflux finding score (RFS > 7) and ≥1 LPR episode/24 hours were enrolled. We evaluated LPR by dual channel 24-hour pH/impedance. We determined number of LPR events with pH drop at levels 6.0, 5.5, 5.0, 4.5, and 4.0. Cough reflex sensitivity was determined as lowest capsaicin concentration causing at least 2/5 coughs (C2/C5) by single breath capsaicin inhalation challenge. For statistical analysis C2/C5 values were -log transformed. Troublesome coughing was evaluated on the scale 0-5.

RESULTS

We enrolled 27 LPR patients. The number of LPR events with pH 6.0, 5.5, 5.0, 4.5, and 4.0 was 14[8-23],4[2-6],1[1-3],1[0-2] and 0[0-1], respectively. There was no correlation between number of LPR episodes at any pH level and coughing (Pearson range -0.34 to 0.21, P = NS). There was no correlation between cough reflex sensitivity C2/C5 and coughing (R = -0.29 to 0.34, P = NS). Of patients that completed PPI treatment, 11 had RSI normalized (18.36 ± 2.75 vs. 7 ± 1.35, P < 0.01). There was no change in cough reflex sensitivity in PPI-responders. C2 threshold was 1.41 ± 0.19 vs. 1.2 ± 0.19 (P = 0.11) before and after PPI.

CONCLUSIONS

No correlation between cough sensitivity and coughing and no change in cough sensitivity despite improvement of coughing by PPI argue that an increased cough reflex sensitivity is not mechanism of cough in LPR. We identified no simple relationship between LPR and coughing suggesting that this relationship is more complex.

Validation of Pharyngeal Acid Reflux Episodes Using Hypopharyngeal Multichannel Intraluminal Impedance-pH

Background/Aims

Hypopharyngeal multichannel intraluminal impedance-pH (HMII-pH) technology incorporating 2 trans-upper esophageal sphincter impedance channels has been developed to detect pharyngeal reflux. We used the HMII-pH technique to validate the candidate pharyngeal acid reflux (PAR) episodes based on the dual-pH tracings and determined the interobserver reproducibility.

Methods

We conducted a cross-sectional study in tertiary centers in Taiwan. Ninety patients with suspected laryngopharyngeal reflux and 28 healthy volunteers underwent HMII-pH test when off acid suppressants. Candidate PAR episodes were characterized by pharyngeal pH drops of at least 2 units and reaching a nadir pH of 5 within 30 seconds during esophageal acidification. Two experts manually independently identified candidate PAR episodes based on the dual-pH tracings. By reviewing the HMII-pH tracings, HMII-pH-proven PAR episodes were subsequently confirmed. The consensus reviews of HMII-pH-proven PAR episodes were considered to be the reference standard diagnosis. The interobserver reproducibility was assessed.

Results

A total of 105 candidate PAR episodes were identified. Among them 84 (80.0%; 95% CI, 71.0-87.0%) were HMII-pH-proven PAR episodes (82 in 16 patients and 2 in 1 healthy subject). Patients tended to have more HMII-pH-proven PAR episodes than healthy controls (median and percentile values [25th, 75th, and 95th percentiles]: 0 [0, 0, 3] vs 0 [0, 0, 0], P = 0.067). The concordance rate in diagnosing HMII-pH-proven PAR episodes between 2 independent observers was 92.2%.

Conclusion

Our preliminary data showed that 80.0% (71.0-87.0%) of the proposed candidate PAR episodes were HMII-pH-proven PAR episodes, among which the interobserver reproducibility was good.

The burden of gastroesophageal reflux disease on the cost of managing chronic diseases in Australia. The need for a new diagnostic and management paradigm

INTRODUCTION

Chronic disease poses a major problem for the Australian healthcare system as the leading cost-burden and cause of death. Gastroesophageal reflux disease (GORD) typifies the problems with a growing prevalence and cost. We hypothesise that a scintigraphic test could optimise the diagnosis, especially in problematic extraoesophageal disease.

MATERIALS AND METHODS

Data was collected from 2 groups of patients. Patients undergoing fundoplication for severe GORD (n = 30) and those with atypical symptoms (n = 30) were studied by scintigraphy and 24-hour oesophageal pH, impedance and manometry.

RESULTS

Mean age of cohort was 55.8 years with 40 females and 20 males. Body mass index was a mean of 28.3. DeMeester score was normal in 12/60 with atypical symptoms and abnormal in the rest. Good correlation was shown between scintigraphy and impedance, manometry and distal pH readings. Pulmonary aspiration was shown in 25/60 (15 with atypical symptoms) and LPR in 20/30. Several impedance, manometric and scintigraphic finding were good predictors of lung aspiration of refluxate.

CONCLUSION

Scintigraphy provides a good tool for screening patients with typical and atypical symptoms of GORD. It is well correlated with the standard methods for the diagnosis and provides visual evidence of LPR and lung aspiration.

Clinical practice guidelines for esophageal ambulatory reflux monitoring in Chinese adults

Esophageal ambulatory reflux monitoring is the current gold standard for the diagnosis of gastroesophageal reflux disease (GERD). In order to facilitate standardized procedure and improve diagnostic accuracy, clinical guidelines for ambulatory esophageal reflux monitoring were developed based on thorough literature search and working group conference by experts in gastrointestinal motility. Indications, contraindications, methodology, and reporting of ambulatory esophageal reflux monitoring were discussed in these clinical guidelines.

"Gas" laryngopharyngeal reflux cause unexplained chronic cough

Hypopharyngeal multichannel intraluminal impedance (HMII) that can measure laryngopharyngeal reflux (LPR) events has supported the causal relationship between chronic cough (CC) and LPR containing liquid. However the role of "gas" LPR associated with CC has been poorly understood. We present two cases of patients with CC who had negative LPR containing liquid but had multiple episodes of "gas" LPR on HMII. The majority of "gas" LPR events had a minor pH drop at hypopharynx. Since any etiology of CC was excluded and medical therapy failed, both patients underwent laparoscopic antireflux surgery (LARS). Both of the patients had complete resolution of cough postoperatively. The present cases demonstrated successful outcome of LARS to treat the patients with CC who had documented "gas" LPR on HMII, thus suggesting the causal relationship between CC and "gas" LPR. The number of "gas" LPR events may need to be considered as an important diagnostic parameter.

Laparoscopic Toupet Fundoplication for the Treatment of Laryngopharyngeal Reflux: Results at Medium-Term follow-Up

BACKGROUND

The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up.

MATERIALS AND METHODS

Observational cohort study (2015-2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) validate questionnaires at baseline and during follow-up.

RESULTS

Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR-HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores "voice," "cough," "throat" and "swallow" showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved (p < 0.001).

CONCLUSIONS

LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients' quality of life perception up to 3-year follow-up.

Laryngopharyngeal Reflux Among Patients Undergoing Bariatric Surgery

PURPOSE

The effect of altered subsphincteric gastric volume and pressure after bariatric surgery on laryngopharyngeal reflux (LPR) remains largely unknown. This was a cross-sectional pilot study conducted between January 2018 and January 2019 to identify changes in LPR symptoms and signs in bariatric surgery patients presurgery and postsurgery.

MATERIALS AND METHODS

Thirty-four patients listed for bariatric surgery in a single tertiary referral center were recruited, where 31 (77.4% female, mean age 46.3 ± 8.9 years) fulfilled the eligibility criteria. Of the eligible patients, 54.8% and 45.2% underwent sleeve gastrectomy (SG) and gastric bypass (GB), respectively. LPR symptoms were assessed using the self-reported reflux symptom index (RSI). Video-recorded endolaryngeal signs were scored using the reflux finding score (RFS) by two blinded otolaryngologists. Patients' presurgical and 3-month postsurgical body mass index (BMI), RSI, and RFS were determined. Patients were deemed as having LPR when RSI > 13 or RFS > 7.

RESULTS

There was a significant correlation between the postsurgical RSI and RFS changes (Pearson's r = 0.474, p = 0.007). Of the 31 patients, 12.9% (RSI) and 6.4% (RFS) recovered from preexisting LPR, whereas 22.6% (RSI) and 3.2% (RFS) developed new de novo LPR postsurgery. The postsurgical mean RFS change improved significantly in the GB group compared with that of the SG group (p < 0.05).

CONCLUSION

LPR is best assessed clinically using a multimodal approach (RSI and RFS). Bariatric surgery may worsen or lead to de novo LPR. Recognizing the LPR outcomes in these patients is paramount for optimal voice, speech, and swallowing functions.

Pepsin Promotes Activation of Epidermal Growth Factor Receptor and Downstream Oncogenic Pathways, at Slightly Acidic and Neutral pH, in Exposed Hypopharyngeal Cells

Pepsin refluxate is considered a risk factor for laryngopharyngeal carcinogenesis. Non-acidic pepsin was previously linked to an inflammatory and tumorigenic effect on laryngopharyngeal cells in vitro. Yet there is no clear evidence of the pepsin-effect on a specific oncogenic pathway and the importance of pH in this process. We hypothesized that less acidic pepsin triggers the activation of a specific oncogenic factor and related-signalling pathway. To explore the pepsin-effect in vitro, we performed intermittent exposure of 15 min, once per day, for a 5-day period, of human hypopharyngeal primary cells (HCs) to pepsin (1 mg/mL), at a weakly acidic pH of 5.0, a slightly acidic pH of 6.0, and a neutral pH of 7.0. We have documented that the extracellular environment at pH 6.0, and particularly pH 7.0, vs. pH 5.0, promotes the pepsin-effect on HCs, causing increased internalized pepsin and cell viability, a pronounced activation of EGFR accompanied by NF-κB and STAT3 activation, and a significant upregulation of EGFR, AKT1, mTOR, IL1β, TNF-α, RELA(p65), BCL-2, IL6 and STAT3. We herein provide new evidence of the pepsin-effect on oncogenic EGFR activation and its related-signaling pathway at neutral and slightly acidic pH in HCs, opening a window to further explore the prevention and therapeutic approach of laryngopharyngeal reflux disease.

[Phytotherapeutische Ansätze zur Behandlung des laryngopharyngealen Reflux in der HNO-Praxis]

Der gastroösophageale Reflux, auch GERD genannt (gastroesophageal reflux disease) ist mit einer Prävalenz von 20-30% der erwachsenen Bevölkerung ein weit verbreitetes Problem. Davon abzugrenzen ist der häufig in der HNO-Praxis anzutref-fende laryngopharyngeale Reflux (LPR), bei dem es sich um eine durch den Magensäurereflux bedingte Entzündung der oberen Atemwege handelt. Die Unterschiede im klinischen Bild charakterisieren die widersprüchliche Beziehung der beiden klinischen Entitäten und erschweren die Diagnosestellung. Darüber hinaus muss ein besonderes Augenmerk auf Beschwerden des Magen- und Darmtrakts gelegt und deren Behandlung nicht vernachlässigt werden. Neben diätetischen Ratschlägen zählen einige pflanzliche Arzneimittel zu den Therapieoptionen. Alginate, die ein Aufstossen verhindern, bewähren sich in der Praxis. Kombinationsarzneimittel aus der europäischen und tibetischen Tradition spielen eine wesentliche Rolle in der Behandlung, nicht nur des LPR sondern auch bei Verdauungsproblemen des oberen und unteren Verdauungstrakts, wie Reizmagen und Reizdarm.

The gastroesophageal reflux, also called GERD (gastroesophageal reflux disease), is a widespread problem with 20–30% of the adult population concerned. The laryngopharyngeal reflux (LPR), which is an inflammation of the upper respiratory system due to reflux of gastric acids, is a frequently encountered problem of the gastrointestinal practitioner and should be separated from GERD. The differences in the clinical image characterize the contradictory relationship of both clinical entities and complicate the diagnosis. In addition, the focus should also be turned on eventual disorders of the gastrointestinal tract and, if necessary, they should be treated, too. Besides dietetic advice some herbal medicines belong to the therapeutic options. Alginates, which prevent reflux, have proved a great value in the practice. Multicomponent mixtures originating from the European and Tibetan herbal medicine traditions play a major role in the treatment, not only for LPR, but also for the upper and lower digestive pathologies such as functional dyspepsia and irritable colon.

Adaptation and Validation of Reflux Symptom Index Into Kannada Language

OBJECTIVE

The present study aimed to translate, validate the Reflux Symptom Index in Kannada language and to compare its outcomes between normal individuals and individuals with laryngopharyngeal reflux.

STUDY DESIGN

Cross sectional study design MATERIALS AND METHOD: : The English version of Reflux Symptom Index was translated into Kannada language using standard procedures. A total of 162 participants participated in the study, 81 with laryngopharyngeal reflux and 81 controls. Internal consistency, test-retest reliability, and clinical validity were calculated.

RESULTS

Results revealed that the Kannada Reflux Symptom Index exhibited an excellent internal consistency (α = 0.87). The average intra-class correlation coefficient was 0.90 and 0.92, indicating excellent test-retest reliability. Independent sample t test revealed a statistically significant difference between the total scores of both the groups, thereby exhibiting good clinical validity of RSI-K (t = 42.71, df = 158, P < 0.001).

CONCLUSION

The Kannada Reflux Symptom Index is a reliable and valid tool for use in patients with laryngopharyngeal reflux. It can be used as a quick tool to assess laryngopharyngeal reflux.

Proximal reflux: biochemical mediators, markers, therapeutic targets, and clinical correlations

Airway reflux is implicated in the pathophysiology of a wide range of adult and pediatric upper and lower airway diseases. However, the diagnosis of proximal reflux-associated disease remains challenging due to evolving clinical criteria and institutional and regional variances in diagnostic practices. Evidence suggests that nonacidic contents of reflux may serve as both pathologic mediators of and biomarkers for reflux in the upper airway. Furthermore, they offer potential pharmaceutical and surgical intervention targets and are the focus of novel clinical diagnostic tools currently under investigation.

Comprehensive analysis of acidic pharyngeal reflux before and after proton pump inhibitor treatment in patients with suspected laryngopharyngeal reflux

OBJECTIVES

The usefulness of pharyngeal pH monitoring in patients with symptoms attributed to laryngopharyngeal reflux (LPR) has been questioned. One problem is the uncertainty whether the pharyngeal pH monitoring captures the aspects of LPR which are responsible for symptoms. We aimed to gain more insight into this problem by performing a comprehensive analysis of acidic pharyngeal reflux before and after the treatment with proton pump inhibitors (PPIs) in patients with suspected LPR.

METHODS

We used simultaneous pharyngeal and distal esophageal 24-hour pH/impedance monitoring to establish the gastroesophageal origin of pharyngeal reflux, and an unbiased approach to analysis by evaluating a whole range of pharyngeal reflux acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0).

RESULTS

PPI treatment substantially (by ~50%) improved the symptoms attributed to LPR. In contrast, PPI did not reduce the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level. This was also true in a subgroup of patients considered to be good responders to PPI (symptoms improvement by ~75%). Furthermore, good responders did not have more acidic pharyngeal reflux than the patients who were less responsive to PPI.

CONCLUSIONS

PPI treatment did not reduce acidic pharyngeal reflux despite substantially improving the symptoms attributed to LPR. This may be because pharyngeal pH monitoring does not quantitatively capture the aspects of LPR responsible for symptoms or because acid causes the symptoms also by mechanisms other than LPR. Our results argue against the utility of pharyngeal pH monitoring in patients with suspected LPR.

Laryngopharyngeal Reflux Diagnosis in Obstructive Sleep Apnea Patients Using the Pepsin Salivary Test

Background: To investigate the presence of laryngopharyngeal reflux in patients with obstructive sleep apnea (OSA) employing the salivary pepsin concentration method. To compare the results of pepsin concentration with the severity of the pathology. Methods: Seventy-five OSA patients (44 males, 31 females) were enrolled in the study. For each patient, the AHI (apnea–hypopnea index) and the BMI (body mass index) were initially evaluated. All the patients enrolled were assessed using the reflux symptom index (RSI) and the reflux finding score (RFS) in order to perform a clinical diagnosis of laryngopharyngeal reflux. In all patients a salivary sample was taken to estimate the presence of pepsin and its concentration. Results: The incidence of LPR (laryngopharyngeal reflux) in OSA patients, evaluated using the salivary pepsin concentration test (PEP-test), was found to be 32% of cases. Linear regression testing did not show any correlation between AHI and pepsin concentration in salivary samples (p = 0.1). Conclusion: A high number of patients with OSA seem to show positivity for salivary pepsin, correlated to an LPR. There does not appear to be a correlation between the severity of apnea and the grade of salivary pepsin reflux. On the other hand, direct correlation between BMI and the value of pepsin in salivary specimens was observed.

Acidic Pharyngeal Reflux Does Not Correlate with Symptoms and Laryngeal Injury Attributed to Laryngopharyngeal Reflux

BACKGROUND

Laryngopharyngeal reflux (LPR) is suspected when the symptoms are attributed to the penetration of acidic gastroesophageal reflux (GER) into the larynx. However, the relationships between the intensity of LPR and symptoms and laryngeal injury have not been elucidated. Several factors confound the study of LPR, namely pH is monitored in the pharynx (pharyngeal reflux) but the pharyngeal acidity (pH) required to induce laryngeal injury is unknown, the GER origin of pharyngeal acid is not always established, and a recent treatment with proton pump inhibitors (PPI) confounds the analysis.

AIMS

We aimed to limit these confounding factors to analyze the relationship between LPR and symptoms and laryngeal injury.

METHODS

We used dual pharyngeal and distal esophageal 24-h pH/impedance monitoring to establish GER origin of pharyngeal reflux, we used an unbiased approach to analysis by evaluating a whole range of acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0) in patients with suspected LPR without PPI for  > 30 days.

RESULTS

Pharyngeal reflux was (median[IQR]) 14[8-20.5] and 4[1.5-6.5] pharyngeal reflux episodes with pH < 6.0 and pH < 5.5, respectively. Pharyngeal reflux with pH < 5.0 was rare. Comprehensive analysis did not reveal any correlation between symptoms (reflux symptom index) or laryngeal injury (reflux finding score) and the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level.

CONCLUSION

Unbiased comprehensive approach did not reveal any relationship between acidic pharyngeal reflux and the symptoms or laryngeal injury attributed to LPR. Limited clinical usefulness of pharyngeal monitoring reported by others is unlikely due to confounding factors.

Heat shock protein 70 is induced by pepsin via MAPK signaling in human nasal epithelial cells

BACKGROUND

Recent studies have shown that laryngopharyngeal reflux is associated with chronic rhinosinusitis. Pepsin may be a key factor involved in the injury of nasal mucosal epithelial cells, but the pathogenesis remains unclear. We are to investigate whether a mitogen-activated protein kinase (MAPK) pathway regulates heat shock protein 70 (HSP70) expression in primary cultures of human nasal epithelial cells (HNEpCs) in response to pepsin stimulation.

METHODS

HSP70 protein expression levels in HNEpCs were estimated by Western blot analysis after treatment with pepsin. MAPK pathway activity levels were also evaluated to elucidate the mechanism underlying the effects of pepsin on HSP70 in HNEpCs. Inhibitors of signaling pathways were used to determine the contribution of MAPKs in HSP70 response after pepsin stimulation. Cellular apoptosis and cell viability in HNEpCs after treatment with pepsin were measured.

RESULTS

The expression of HSP70 increased after stimulation with pepsin and decreased after the removal of pepsin. Pepsin induced activation of p38, extracellular signal-regulated kinase 1/2, and c-Jun N-terminal kinase (JNK) 1/2. Inhibition of JNK1/2 reduced HSP70 expression in HNEpCs. The apoptosis in HNEpCs at 12 h after treatment with pepsin at pH 7.0 increased significantly when compared with the control and pH 7.0 groups. Cell viability decreased following exposure to pepsin at pH 7.0.

CONCLUSION

Pepsin, even under neutral pH 7.0, increases the expression of HSP70 in HNEpCs by activating the JNK/MAPK signaling pathway. Increased HSP70 may be the protective mechanism when pepsin presents in the other parts of the body.

Throat Clearing, Frequently Reported, But is it GERD Related?

GOALS

To identify the association of throat clearing (TC) with gastroesophageal reflux disease (GERD) during objective reflux monitoring in a large number of patients studied in our esophageal testing laboratory.

BACKGROUND

TC is frequently reported and considered to be an atypical symptom of GERD. Atypical GERD symptoms have been widely investigated and empirically treated with proton pump inhibitors.

STUDY

We reviewed ambulatory impedance-pH studies of 186 patients referred for evaluation of possible GERD from January 2011 to December 2015 to evaluate the symptom association (SA) of TC with both an abnormal number of reflux episodes and also abnormal esophageal acid exposure (EAE). Patients were divided into 2 groups; group 1: TC is the only reported symptom, group 2: TC is one of the symptoms. All patients were studied off proton pump inhibitors therapy.

RESULTS

Group 1 where TC was the only symptom in 27/186 (14.5%) patients. There was no significant difference in positive SA between this group (6/27; 22%) and group 2 (43/159; 27%) (Z score P=0.59). There was also no significant association between SA and abnormal EAE whether TC was the only presenting symptom (χ, P=0.7) or one of the reported symptoms (χ, P=0.10). None of the 6/27 had abnormal EAE.

CONCLUSION

Although TC is often considered a possible GERD-related symptom, we found a low probability of objective association. TC is not likely to be the only presenting symptom, and if it happens, it is unlikely to be associated with GERD. Perhaps, TC should not be considered as a GERD symptom, even as an atypical one.

Laryngopharyngeal reflux in obstructive sleep apnoea patients: Literature review and meta-analysis

PURPOSE

Laryngopharyngeal reflux (LPR) is a frequent condition in Obstructive Sleep Apnoea (OSA) patients and different studies have been published in the last years about this topic. A review of the published literature regarding LPR in OSA patients has been reported. A meta-analysis to evaluate the incidence of LPR in OSA patients and correlate LPR positivity with OSA patients' characteristics has been performed.

METHODS

A comprehensive review of the English language literature about LPR in OSA patients was performed using the most important electronic databases (PubMed, EMBASE, the Cochrane Library etc.). A total of 10 papers studying LPR in OSA were assessed and considered eligible for the meta-analysis.

RESULTS

The data analysis regarding 870 identified OSA patients showed that 394 patients were LPR +, while 476 were LPR-. The meta-analysis showed no statistical difference regarding the AHI value between LPR + patients and LPR- patients (p = 0,3). Mean BMI was more higher in LPR + patients than in the patients without LPR, showing a significant statistical difference (p = 0.001).

CONCLUSION

Current international literature demonstrates a high incidence of LPR (45.2%) in OSA patients. The severity of AHI in OSA patients would not seem to correlate with the presence of laryngopharyngeal reflux. The OSA patients with LPR showed a higher BMI compared with LPR- patients.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Globus Pharyngeus: A Symptom of Increased Thyroid or Laryngopharyngeal Reflux?

SUMMARY – The aim of this study was to investigate the relationship between globus pharyngeus and laryngopharyngeal reflux, as well as between globus and thyroid volume. A two-year prospective study included 56 patients aged 18-75 with globus symptom. Anthropometric, clinical and laboratory data were collected. All patients filled-out the Glasgow Edinburgh Throat Scale (GETS) and then underwent thyroid ultrasound. Morphological changes of the larynx were detected by direct laryngoscopy and classified by the Reflux Finding Score (RFS). If RFS >7, the diagnosis of laryngopharyngeal reflux was made and therapy with proton pump inhibitors initiated. According to GETS, there was significant difference between patients with normal volume and those with large thyroid volume. There was no statistically significant difference between patients with RFS <7 and RFS >7. In conclusion, the incidence and severity of globus pharyngeus do not definitely indicate laryngopharyngeal reflux. It is more common in patients with normal thyroid volume.

Effect of matrix metalloproteinase inhibitor on disrupted E-cadherin after acid exposure in the human nasal epithelium

OBJECTIVE

Laryngopharyngeal reflux disease (LPRD) is one of potential factors in recalcitrant chronic rhinosinusitis with or without polyps. An increase in junctional permeability in the nasal mucosa in LPRD may be due to disrupted protein bridge formation with cell-to-cell adhesion molecules such as E-cadherin. Despite the relationship between nasal mucosal inflammation and LPRD, the clear mechanism by which acid reflux affects the nasal epithelium remains unclear.

METHODS

The expression levels and distribution patterns of E-cadherin in primary culture of nasal epithelial cells after acid exposure with or without dexamethasone and matrix metalloproteinase (MMP) inhibitor were determined using Western blot and immunocytochemistry. The functional roles of MMP inhibitor in maintaining junctional permeability in the nasal epithelium were elucidated by transepithelial permeability test.

RESULTS

By acid exposure to nasal epithelial cells, mature E-cadherin was decreased and cleaved E-cadherin was increased. This was thought to be caused by cleavage of mature E-cadherin between cells and was confirmed by the increment of E-cadherin inside a cell in immunocytochemical evaluation. Whereas disruption of E-cadherin was not recovered by steroid medication with various treatments of dexamethasone, disrupted E-cadherin was restored to normal by inhibition of MMPs with actinonin, a broad MMP inhibitor. This recovery was functionally demonstrated by transepithelial permeability test.

CONCLUSION

Our results suggest that altered expression of E-cadherin in the nasal epithelium by acid exposure may be a possible mechanism for nasal tissue injury in chronic nasal inflammation with LPRD, and that MMP inhibition is a potential treatment.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:E1-E7, 2018.

Facts and Fantasies on Extraesophageal Reflux: A Gastroenterologist Perspective

Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.

Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: Update of the Porto consensus and recommendations from an international consensus group

BACKGROUND

An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro-esophageal reflux disease (GERD).

METHODS

Literature search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings.

KEY RESULTS

Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter-based or wireless pH-monitoring or pH-impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH-impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom-reflux association in the absence of pathological AET defines hypersensitivity to reflux.

CONCLUSIONS AND INFERENCES

The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.

A study with pharyngeal and esophageal 24-hour pH-impedance monitoring in patients with laryngopharyngeal symptoms refractory to proton pump inhibitors

BACKGROUND

The role of gastroesophageal reflux in chronic laryngeal symptoms is difficult to establish. The aim of this study was to characterize pharyngeal and esophageal pH-impedance reflux patterns in a group of patients with suspected laryngopharyngeal reflux and to determine predictive factors of response to proton pump inhibitors.

METHODS

Patients with chronic pharyngolaryngeal symptoms were evaluated with a symptom score questionnaire, laryngoscopy, and 24-hour pharyngeal and esophageal pH-impedance monitoring at baseline and after 8-week treatment with esomeprazole 40 mg b.i.d. Response to treatment was defined by a diminution of more than 50% of the score for the primary symptom. Reflux patterns and baseline impedance values were compared to those obtained in 46 healthy subjects.

KEY RESULTS

Twenty-four patients were included (17 women, median age 54 years), all previously refractory to antisecretory therapy. Symptom scores were 46 (32-62) and 40 (27-76) off and on therapy, respectively (P=.1). There was no significant difference between patients and controls for pH-impedance reflux parameters and baseline values off and on therapy in distal and proximal esophagus and in the pharynx. Median numbers of pharyngeal reflux were 0 and 0 off and on therapy, respectively. Only two patients were responders to treatment, both with excessive distal reflux but no pharyngeal reflux. Only one patient had abnormal pharyngeal reflux but did not respond to proton pump inhibitors.

CONCLUSIONS

Patients with suspected laryngopharyngeal reflux refractory to therapy do not exhibit abnormal pharyngeal or esophageal pH-impedance reflux. In these patients, laryngopharyngeal reflux is unlikely.

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.

Liquid-containing Refluxes and Acid Refluxes May Be Less Frequent in the Japanese Population Than in Other Populations: Normal Values of 24- hour Esophageal Impedance and pH Monitoring

Background/Aims

Twenty-four-hour esophageal impedance and pH monitoring allows detection of all types of reflux episodes and is considered the best technique for identifying gastroesophageal refluxes. However, normative data for the Japanese population are lacking. This multicenter study aimed to establish the normal range of 24-hour esophageal impedance and pH data both in the distal and the proximal esophagus in Japanese subjects.

Methods

Forty-two healthy volunteers (25 men and 17 women) with a mean ± standard deviation age of 33.3 ± 12.4 years (range: 22–72 years) underwent a combined 24-hour esophageal impedance and pH monitoring. According to the physical and pH properties, distal or proximal esophageal reflux events were categorized.

Results

Median 45 reflux events occurred in 24 hours, and the 95th percentile was 85 events. Unlike previous reports, liquid-containing reflux events are median 25/24 hours with the 95th percentile of 62/24 hours. Acidic reflux events were median 11/24 hours with the 95th percentile of 39/24 hours. Non-acidic gas reflux events were median 15/24 hours with the 95th percentile of 39/24 hours. Proximal reflux events accounted for 80% of the total reflux events and were mainly non-acidic gas refluxes. About 19% of liquid and mixed refluxes reached the proximal esophagus.

Conclusions

Unlike previous studies, liquid-containing and acidic reflux events may be less frequent in the Japanese population. Non-acidic gas reflux events may be frequent and a cause of frequent proximal reflux events. This study provides important normative data for 24-hour impedance and pH monitoring in both the distal and the proximal esophagus in the Japanese population.

Laryngopharyngeal Reflux in Children with Chronic Otitis Media with Effusion

BACKGROUND/AIMS

To evaluate the characteristic properties of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GER) in children with otitis media with effusion (OME) using 24-hour multichannel intraluminal impedance combined with dual-probe (pharyngeal and esophageal) pH-metry.

METHODS

Children aged 7-10 years of age with OME underwent 24-hour multichannel intraluminal impedance pH-metry. The upper pH sensor was situated 1 cm above the upper esophageal sphincter, and the lower pH sensor was placed 3-5 cm above the lower esophageal sphincter. Parents were asked to complete the gastroesophageal reflux assessment of symptoms in a pediatrics questionnaire.

RESULTS

Twenty-eight children were enrolled; LPR was detected in 19 (67.9%) children. The criteria of the LPR diagnosis was the presence of at least one supraesophageal episode with a pH < 5.0 and a change in the pH value measured from the initial level at the upper sensor of > 0.2. In total, 64 episodes were observed. Assessment of all LPR episodes showed the presence of 246 episodes in the entire study. A considerable predominance of weakly acidic episodes (87.8%) was noted; there were 6.5% acidic episodes, and weakly alkaline episodes reached 5.7%. Pathological GER was noted in 10 (35.7%) subjects. Acid GER was detected in 8 children, 2 of whom demonstrated non-acidic reflux. In the LPR-negative patients, no pathological GER was confirmed with the exception of a single case of non-acidic reflux.

CONCLUSIONS

LPR was frequently noted in the group of children with OME, and it might be an important risk factor in this common disease.

Evaluation of proton pump inhibitor-resistant nonerosive reflux disease by esophageal manometry and 24-hour esophageal impedance and pH monitoring

BACKGROUND

Patients with proton pump inhibitor (PPI)-resistant nonerosive reflux disease (NERD) include subgroups that have markedly different pathophysiology. This study aimed to clarify the pathophysiology of NERD by esophageal manometry with 24-hour esophageal impedance and pH monitoring.

METHODS

Eighteen consecutive outpatients referred to our expert center for functional gastrointestinal motility with suspected PPI-resistant NERD were enrolled. Manometry was performed to detect esophageal motility disorders. Subsequently, 24-hour esophageal impedance and pH monitoring was done while patients were on PPI therapy.

RESULTS

Manometry revealed 1 case of achalasia, 1 case of nutcracker esophagus and 3 cases of diffuse esophageal spasm. Three patients had ineffective esophageal motility, with impedance and pH monitoring being performed in 2 of them. Esophageal acid exposure (%time pH <4) was normal in both, but the symptom index (SI) was positive for nonacidic reflux in 1 patient. One of the 10 patients with normal esophageal motility had abnormal esophageal acid exposure. The SI was positive for weakly acidic and nonacidic reflux in 3 of the remaining 9 patients with normal esophageal acid exposure. Five of the other 6 patients seemed to have functional heartburn.

CONCLUSION

A substantial percentage (28%) of patients with suspected PPI-resistant NERD had primary esophageal motility disorders. Both nonacidic reflux and weakly acidic reflux are important contributors to the symptoms of patients with PPI-resistant NERD. Esophageal manometry is required to exclude motility disorders, while 24-hour esophageal impedance and pH monitoring is invaluable for assessing symptom-reflux associations and the indications for fundoplication in patients with suspected PPI-resistant NERD.

[pH values in the pharynx of the patients presenting with compromised nasal breathing of inflammatory and non-inflammatory genesis concomitant with gastroesophageal reflux disease]

The objective of the present study was to estimate the influence of gastroesophageal reflux disease (GERD) on the pH values in the pharynx and nose. It included 87 patients at the age varying from 18 to 81 years admitted to the Irkutsk-based Railway Clinical Hospital and allocated to four groups. Group 1 was comprised of 25 patients presenting with gastroesophageal reflux disease and chronic rhinosinusitis (CRS), group 2 consisted of 29 patients with CRS in the absence of GERD, group 3 included 22 patients with nasal septum deformations (NSD) and GERD, group 4 included 11 patients with NSD and motor rhinitis without GERD. The control group was formed from 10 volunteers. pH was measured by the contact method with the use ofEkokhim indicator paper. Gastroesophageal reflux disease was diagnosed following the recommendations of the Montreal consensus. It was shown that pH values in the pharynx of the patients with compromised nasal breathing of any origin in combination with GERD were lower than in the absence of GERD and in the healthy volunteers. The study groups did not differ in terms of pH values in the nasal cavity. It is concluded that pH values 4 or lower may serve as the criterion for pharyngo-laryngeal reflux (PLR) concomitant with HERD while pH 5 occurs more frequently in the patients with compromised nasal breathing of any etiology, regardless of the presence or absence of GERD.Disordered nasal breathing of any genesis in the patients presenting with gastroesophageal reflux disease was associated with the feeling of the lump in the throat, congestion of the respiratory tract and the nose, pain in the ears, cardialgia, and irregular heartbeat. It isrecommended to use pH measurements as a criterion for diagnostics of pharyngo-laryngeal reflux in the patients presenting with gastroesophageal reflux disease.

Modern medical and surgical management of difficult-to-treat GORD

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.

An oropharyngeal pH monitoring device to evaluate patients with chronic laryngitis

BACKGROUND

Diagnostics for gastro-esophageal reflux disease (GERD) are suboptimal because of limited sensitivity. We performed in vitro and in vivo studies to systematically assess the performance characteristics of an oropharyngeal pH probe.

METHODS

In vitro studies compared the oropharyngeal probe with a standard pH catheter in liquid and aerosolized solutions, pH 1-7. The accuracy of measurements, deviation from target pH, and time to equilibrium pH were determined. Simultaneous distal esophageal pH measurements were obtained in 11 patients with GERD. Oropharyngeal and distal esophageal reflux parameters were measured for controls (n = 20), patients with GERD (n = 17), and patients with chronic laryngitis (n = 10).

KEY RESULTS

In the liquid phase, at pH 4-5, the oropharyngeal probe had less deviation from the target value than the standard catheter; deviation in the vapor phase was similar (0.4 pH units). Median (interquartile) time to reach equilibrium pH was significantly (P < 0.001) faster with the oropharyngeal than the standard probe. In comparing simultaneous distal esophageal pH characteristics, 96% of recordings with the new and standard probes were in agreement to within ± 1.0 pH unit; 71% of recordings were in agreement within ± 0.5 pH units. Patients with chronic laryngitis had significantly higher levels of oropharyngeal acid exposure at pH <4, <5, and <6, in the upright position than patients with GERD or controls (P < .001).

CONCLUSIONS & INFERENCES

Oropharyngeal pH monitoring appears to be more sensitive than traditional pH monitoring in evaluation of patients with extraesophageal reflux. It is a promising tool in evaluation of this difficult group of patients.

Refractory chronic cough, or the need to focus on the relationship between the larynx and the esophagus

In this review we question the current way of handling tackle a problem of chronic cough, especially by the excessive number of patients who can not find complete relief from your cough by anatomical diagnosis of universal use. From the field of Otolaryngology new perspectives arise now considering the larynx as a preferential afferent stimuli cough reflex arc. Also the constitution laryngopharyngeal reflux gas and new approaches to non-acid reflux and the local action of pepsin in laryngeal deserving of a joint review, which can illuminate new ways to handle the problem of chronic refractory cough. We believe that the chronic cough syndrome hpersensitivity as more precise label for chronic cough, should place particular emphasis on laryngeal sensory neuropathy as cough and reflux the influence that may have on their maintenance, and thereby causes definitely wide related to the syndrome if the larynx is incorporated, place greater number of afferent nerves of chronic cough, which are sure to cover much of the case of refractory cough remain without a satisfactory solution. The close collaboration between Otolaryngology, Gastroenterology and Pneumology in a patient with refractory chronic cough seems now an unavoidable necessity.

Normal values of pharyngeal and esophageal 24-hour pH impedance in individuals on and off therapy and interobserver reproducibility

BACKGROUND & AIMS

Combined pH and impedance monitoring can detect all types of reflux episodes within the esophageal lumen and the pharynx. We performed a multicenter study to establish normal values of pharyngeal and esophageal pH-impedance monitoring in individuals on and off therapy and to determine the interobserver reproducibility of this technique.

METHODS

We collected ambulatory 24-hour pH-impedance recordings from 46 healthy subjects by using a bifurcated probe that allowed for detection of reflux events in the distal and proximal esophagus and pharynx. Data were collected when subjects had not received any medicine (off therapy) and after receiving 40 mg esomeprazole twice daily for 14 days (on therapy). The interobserver agreement for the detection of reflux events was determined in 20 subjects off and on therapy. Results were expressed as median (interquartile range).

RESULTS

Off therapy, subjects had a median of 32 reflux events (17-45) in the distal esophagus and 3 (1-6) in the proximal esophagus; they had none in the pharynx. On therapy, subjects had a median number of 21 reflux events (6-37) in the distal esophagus and 2 (0-5) in the proximal esophagus; again, there were none in the pharynx. Interobserver agreement was good for esophageal reflux events but poor for pharyngeal events.

CONCLUSIONS

We determined normal values of pharyngeal and gastroesophageal reflux events by 24-hour pH-impedance monitoring of subjects receiving or not receiving esomeprazole therapy. Analyses of esophageal events were reproducible, but analyses of pharyngeal events were not; this limitation should be taken into account in further studies.

Airway reflux, cough and respiratory disease

It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options.

How many cases of laryngopharyngeal reflux suspected by laryngoscopy are gastroesophageal reflux disease-related?

AIM: To investigate the prevalence of gastroesophageal reflux disease (GERD) in patients with a laryngoscopic diagnosis of laryngopharyngeal reflux (LPR).

METHODS: Between May 2011 and October 2011, 41 consecutive patients with laryngopharyngeal symptoms (LPS) and laryngoscopic diagnosis of LPR were empirically treated with proton pump inhibitors (PPIs) for at least 8 wk, and the therapeutic outcome was assessed through validated questionnaires (GERD impact scale, GIS; visual analogue scale, VAS). LPR diagnosis was performed by ear, nose and throat specialists using the reflux finding score (RFS) and reflux symptom index (RSI). After a 16-d wash-out from PPIs, all patients underwent an upper endoscopy, stationary esophageal manometry, 24-h multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring. A positive correlation between LPR diagnosis and GERD was supposed based on the presence of esophagitis (ERD), pathological acid exposure time (AET) in the absence of esophageal erosions (NERD), and a positive correlation between symptoms and refluxes (hypersensitive esophagus, HE).

RESULTS: The male/female ratio was 0.52 (14/27), the mean age ± SD was 51.5 ± 12.7 years, and the mean body mass index was 25.7 ± 3.4 kg/m². All subjects reported one or more LPS. Twenty-five out of 41 patients also had typical GERD symptoms (heartburn and/or regurgitation). The most frequent laryngoscopic findings were posterior laryngeal hyperemia (38/41), linear indentation in the medial edge of the vocal fold (31/41), vocal fold nodules (6/41) and diffuse infraglottic oedema (25/41). The GIS analysis showed that 10/41 patients reported symptom relief with PPI therapy (P < 0.05); conversely, 23/41 did not report any clinical improvement. At the same time, the VAS analysis showed a significant reduction in typical GERD symptoms after PPI therapy (P < 0.001). A significant reduction in LPS symptoms. On the other hand, such result was not recorded for LPS. Esophagitis was detected in 2/41 patients, and ineffective esophageal motility was found in 3/41 patients. The MII-pH analysis showed an abnormal AET in 5/41 patients (2 ERD and 3 NERD); 11/41 patients had a normal AET and a positive association between symptoms and refluxes (HE), and 25/41 patients had a normal AET and a negative association between symptoms and refluxes (no GERD patients). It is noteworthy that HE patients had a positive association with typical GERD-related symptoms. Gas refluxes were found more frequently in patients with globus (29.7 ± 3.6) and hoarseness (21.5 ± 7.4) than in patients with heartburn or regurgitation (7.8 ± 6.2). Gas refluxes were positively associated with extra-esophageal symptoms (P < 0.05). Overall, no differences were found among the three groups of patients in terms of the frequency of laryngeal signs. The proximal reflux was abnormal in patients with ERD/NERD only. The differences observed by means of MII-pH analysis among the three subgroups of patients (ERD/NERD, HE, no GERD) were not demonstrated with the RSI and RFS. Moreover, only the number of gas refluxes was found to have a significant association with the RFS (P = 0.028 and P = 0.026, nominal and numerical correlation, respectively).

CONCLUSION: MII-pH analysis confirmed GERD diagnosis in less than 40% of patients with previous diagnosis of LPR, most likely because of the low specificity of the laryngoscopic findings.

Impact of laminar flow velocity of different acids on enamel calcium loss

OBJECTIVE

The aim of the study was to evaluate the impact of flow velocity under laminar flow conditions of different acidic solutions on enamel erosion.

MATERIAL AND METHODS

A total of 240 bovine enamel specimens were prepared and allocated to 30 groups (n = 8 each). Samples of 18 groups were superfused in a flow chamber system with laminar flow behavior using 1 ml of citric acid or hydrochloric acid (HCl) of pH 2.0, 2.6 or 3.0. Flow rates in the sample chamber were adjusted to 10, 60 or 100 μl/min. To simulate turbulent flow behavior, samples of six groups were immersed in 1 ml of the respective solution, which was vortexed (15 min, 600 rpm). For simulating non-agitated conditions, specimens of the remaining six groups were immersed in 1 ml of the respective solution without stirring. Calcium in the solutions, released from the enamel samples, was determined using Arsenazo III method.

RESULTS

For acidic solutions of pH 2.6 and 3.0, erosive potential of citric acid was equivalent to that of HCl at a flow of 100 μl/min. The same observation was made for the samples subjected to turbulent conditions at pH 3. At all other conditions, citric acid induced a significantly higher calcium loss than HCl.

CONCLUSION

It is concluded that under slow laminar flow conditions, flow rate variations lead to higher erosive impact of citric acid compared to hydrochloric acid at pH 2.0, but not at pH ≥ 2.6 and increasing laminar flow or turbulent conditions.

CLINICAL RELEVANCE

Erosive enamel dissolution under laminar flow conditions is a complex issue influenced by flow rate and acidic substrate.

Comparison of patients of chronic laryngitis with and without troublesome reflux symptoms

BACKGROUND AND AIM

Little is known about the difference between patients of chronic laryngitis with and without troublesome reflux symptoms. The aim of this study was to compare the clinical characteristics and response to acid suppression between patients of chronic laryngitis with and without troublesome reflux symptoms.

METHODS

Consecutive patients with chronic laryngitis were enrolled. The frequency and severity of reflux and laryngeal symptoms were scored. All the patients underwent laryngoscopy, esophagogastroduodenoscopy and 24-h multichannel intraluminal impedance and pH monitoring before receiving rabeprazole 10 mg b.i.d. for 3 months. Mild typical reflux symptoms (heartburn or regurgitation) occurring ≥ 2 days/week or moderate/severe symptoms occurring ≥ 1 day/week were defined as troublesome reflux symptoms.

RESULTS

Compared to patients without troublesome reflux symptoms, those with troublesome reflux symptoms were older and had more episodes of acid and liquid gastroesophageal reflux (GER) and acid and weakly acidic laryngopharyngeal reflux (LPR). They also had higher percentages of both bolus exposure time and acid exposure time of GER and LPR. Patients with troublesome reflux symptoms responded to acid suppression more often at 12 weeks (67.3% vs 20.9%, P < 0.001) and more rapidly (40.8% vs 14.0%, 3 weeks after the start of acid suppression; P = 0.004) compared to those without.

CONCLUSION

Difference in reflux profile of GER and LPR between patients with and without troublesome reflux symptoms could partly explain the discrepancy of response to acid suppression among patients with chronic laryngitis. Acid suppression therapy may provide limited therapeutic benefits to patients of chronic laryngitis without troublesome reflux symptoms.