Software improvement for evaluation of laryngopharyngeal pH testing (Restech) – a comparison between DataView 3 and 4

Association between oropharyngeal ph-monitoring, pepsin saliva concentration and degree of apnea-hypopnea index of obstructive sleep apnea

OBJECTIVE

To investigate the association between obstructive sleep apnea (OSA) and laryngopharyngeal reflux (LPR) through oropharyngeal pH-monitoring and pepsin saliva measurements.

DESIGN

Prospective uncontrolled study.

METHODS

Patients with sleep disturbances and reflux symptoms underwent polysomnography, 24-h oropharyngeal pH-monitoring and saliva pepsin collections. The prevalence of LPR was investigated in OSA patients according to oropharyngeal pH-monitoring and pepsin measurements. A correlation analysis was performed between pH-monitoring findings, pepsin saliva levels, reflux symptom score-12 (RSS-12), reflux sign assessment (RSA), Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale, Pichot and arousal findings.

RESULTS

Thirty-seven patients completed the evaluations. LPR was detected in 34/37 (92%) and 29/34 (85%) patients at the oropharyngeal-pH monitoring and pepsin test, respectively. OSA was detected in 30 patients (81%). Among them, LPR was detected in 28/30 (93%) cases. Pharyngeal reflux events mainly occurred nighttime/supine in OSA patients. Both Ryan score and supine reflux time at pH < 6.5 were significantly associated with BMI and the RSA sub- and total scores (p < 0.02). Tongue-base hypertrophy score was positively associated with the number of micro-arousals (p = 0.027); the supine percent of pH < 6.5 (p = 0.030); morning (p = 0.030) and bedtime pepsin saliva measurements (p = 0.037). The bedtime pepsin saliva level was significantly associated with Ryan Score (p = 0.047); AHI (p = 0.017) and the sleep saturation < 90% time (p = 0.040). The saliva level of the morning pepsin was associated with a shortest paradoxical sleep phase (p = 0.013).

CONCLUSION

OSA patients may have high prevalence of pharyngeal reflux events at the oropharyngeal pH-monitoring and high pepsin saliva measurements. Oropharyngeal pH-monitoring should be useful for the correlation between reflux and sleep findings in OSA patients. Future large cohort controlled studies are needed to determine the prevalence of LPR in OSA and healthy individuals.

Reflux Finding Score Using HD Video Chromoendoscopy: A Diagnostic Adjunct in Suspected Laryngopharyngeal Reflux?

OBJECTIVE

To explore the use of real-time virtual chromoendoscopy (i-scan) in characterizing the mucosal changes present in subjects with suspected laryngopharyngeal reflux (LPR) and to compare the inter-rater and intra-rater agreement of Reflux Finding Scores (RFS) from both laryngologists and general otolaryngologists (ORL) observing exams using both white light endoscopy (WLE) and i-scan.

METHODS

This is a cross-sectional study that included 66 subjects: 46 symptomatic and 20 asymptomatic of suspected LPR based on the reflux symptom index (RSI). Subjects underwent flexible video laryngoscopic evaluation of the larynx utilising both WLE and i-scan during one continuous exam. Subjects also underwent 24-hour oropharyngeal pH-monitoring (Dx-pH). Two laryngologists and two general otolaryngologists evaluated the anonymized videos independently using RFS. Dx-pH results were interpreted using the pH graph, report and RYAN score. Subjects were then designated into one of three groups: no reflux, acid reflux and alkaline reflux.

RESULTS

For the symptomatic group, no mucosal irregularities or early mucosal lesions were observed except in one subject who had granulation tissue. The mean RFS using WLE and i-scan were, respectively: 11.8 (SD 6.1) and 11.3 (SD 5.6) in symptomatic and 7.3 (SD 5.7) and 7.3 (SD 5.2) in asymptomatic group. The inter-rater agreement of RFS using WLE and i-scan for both groups were good with intraclass correlation, ICC of 0.84 and 0.88 (laryngologists); and 0.85 and 0.81 (ORL). The intra-rater agreement among all four raters were good to excellent and similar for both WLE and i-scan (ICC of 0.80 to 0.99). 47 of 66 subjects had evidence of LPR on Dx-pH results which more specifically showed 39 subjects had "acid reflux" and 8 had "alkaline reflux". Sixteen subjects demonstrated a positive RYAN score but showed none were significantly correlated with their RFS.

CONCLUSIONS

This study reports the first utilization of real-time video chromoendoscopy with i-scan technology through high-definition flexible endoscopes to attempt to characterize laryngopharyngeal findings in patients suspected of having LPR. Both general otolaryngologists and laryngologists were equally capable of reliably calculating the RFS using both WLE and i-scan, however no significant improvement in agreement or change in RFS was found when i-scan technology was employed.

LEVEL OF EVIDENCE

Level 2.

Gastrointestinal function testing model using a new laryngopharyngeal pH probe (Restech) in patients after Ivor-Lewis esophagectomy

BACKGROUND

There is no established correlation between 24-h esophageal pH-metry (Eso-pH) and the new laryngopharyngeal pH-monitoring system (Restech) as only small case series exist. Eso-pH was not designed to detect laryngopharyngeal reflux (LPR) and Restech may detect LPR better. We have previously published a dataset using the two techniques in a large patient collective with gastroesophageal reflux disease. Anatomically, patients after esophagectomy were reported to represent an ideal human reflux model as no reflux barrier exists.

AIM

To use a human reflux model to examine our previously published correlation in these patients.

METHODS

Patients after Ivor Lewis esophagectomy underwent our routine follow-up program with surveillance endoscopies, computed tomography scans and further exams following surgery. Only patients with a complete check-up program and reflux symptoms were offered inclusion into this prospective study and evaluated using Restech and simultaneous Eso-pH. Subsequently, the relationship between the two techniques was evaluated.

RESULTS

A total of 43 patients from May 2016 - November 2018 were included. All patients presented with mainly typical reflux symptoms such as heartburn (74%), regurgitation (84%), chest pain (58%), and dysphagia (47%). Extraesophageal symptoms such as cough, hoarseness, asthma symptoms, and globus sensation were also present. Esophageal 24-hour pH-metry was abnormal in 88% of patients with a mean DeMeester Score of 229.45 [range 26.4-319.5]. Restech evaluation was abnormal in 61% of cases in this highly selective patient cohort. All patients with abnormal supine LPR were also abnormal for supine esophageal reflux measured by conventional Eso-pH.

CONCLUSION

Patients following esophagectomy and reconstruction with gastric interposition can ideally serve as a human reflux model. Interestingly, laryngopharyngeal reflux phases occur mainly in the upright position. In this human volume-reflux model, results of simultaneous esophageal and laryngopharyngeal (Restech) pH-metry showed 100% correlation as being explicable by one of our reflux scenarios.