A new diagnostic paradigm for laryngopharyngeal reflux disease: correlation of impedance-pH monitoring and digital reflux scintigraphy results

Abstract

Purpose

No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR.

Methods

Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated.

Results

105 patients with LPR [31 males (29.5%), median age 60 years (range 20–87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002).

Conclusion

Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

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References

  1. 1.

    Koufman JA (1991) The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal. Laryngoscope 101:1–78. https://doi.org/10.1002/lary.1991.101.s53.1

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Khoma O, Falk SE, Burton L, Van der Wall H, Falk GL (2018) Gastro-oesophageal reflux and aspiration: does laparoscopic fundoplication significantly decrease pulmonary aspiration? Lung 196(4):491–496. https://doi.org/10.1007/s00408-018-0128-4

    Article  PubMed  Google Scholar 

  3. 3.

    Lechien JR et al (2019) Evaluation and management of laryngopharyngeal reflux disease: state of the art review. Otolaryngol Head Neck Surg 160(5):762–782. https://doi.org/10.1177/0194599819827488

    Article  PubMed  Google Scholar 

  4. 4.

    Jaspersen D et al (2003) Prevalence of extra-oesophageal manifestations in gastro-oesophageal reflux disease: an analysis based on the ProGERD study. Aliment Pharmacol Ther 17(12):1515–1520. https://doi.org/10.1046/j.1365-2036.2003.01606.x

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group (2006) The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 101(8):1900–1920. https://doi.org/10.1111/j.1572-0241.2006.00630.x (quiz 1943)

    Article  PubMed  Google Scholar 

  6. 6.

    Gyawali CP et al (2018) Modern diagnosis of GERD: the Lyon consensus. Gut 67(7):1351–1362. https://doi.org/10.1136/gutjnl-2017-314722

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Dent J et al (2010) Accuracy of the diagnosis of GORD by questionnaire, physicians and a trial of proton pump inhibitor treatment: the Diamond study. Gut 59(6):714–721. https://doi.org/10.1136/gut.2009.200063

    Article  PubMed  Google Scholar 

  8. 8.

    Anandasabapathy S, Jaffin BW (2006) Multichannel intraluminal impedance in the evaluation of patients with persistent globus on proton pump inhibitor therapy. Ann Otol Rhinol Laryngol Thousand Oaks 115(8):563–570

    Article  Google Scholar 

  9. 9.

    Harrell SP, Koopman J, Woosley S, Wo JM (2007) Exclusion of pH artifacts is essential for hypopharyngeal pH monitoring. Laryngoscope 117(3):470–474. https://doi.org/10.1097/MLG.0b013e31802d344c

    Article  PubMed  Google Scholar 

  10. 10.

    Zerbib F et al (2013) Normal values of pharyngeal and esophageal 24-hour pH impedance in individuals on and off therapy and interobserver reproducibility. Clin Gastroenterol Hepatol 11(4):366–372. https://doi.org/10.1016/j.cgh.2012.10.041

    Article  PubMed  Google Scholar 

  11. 11.

    Falk GL (2015) Scintigraphy in laryngopharyngeal and gastroesophageal reflux disease: a definitive diagnostic test? WJG 21(12):3619. https://doi.org/10.3748/wjg.v21.i12.3619

    Article  PubMed  Google Scholar 

  12. 12.

    Falk M, Van der Wall H, Falk GL (2015) Differences between scintigraphic reflux studies in gastrointestinal reflux disease and laryngopharyngeal reflux disease and correlation with symptoms. Nucl Med Commun 36(6):625–630. https://doi.org/10.1097/MNM.0000000000000289

    Article  PubMed  Google Scholar 

  13. 13.

    Burton L, Falk GL, Beattie J, Novakovic D, Simpson S, Van der Wall H (2020) Findings from a novel scintigraphic gastroesophageal reflux study in asymptomatic volunteers. Am J Nucl Med Mol Imaging 10(6):342–348

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Vance D et al (2020) The validity and reliability of the reflux finding score. J Voice. https://doi.org/10.1016/j.jvoice.2020.11.008

    Article  PubMed  Google Scholar 

  15. 15.

    Hoppo T et al (2012) How much pharyngeal exposure is ‘Normal’? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg 16(1):16–25. https://doi.org/10.1007/s11605-011-1741-1

    Article  PubMed  Google Scholar 

  16. 16.

    Shay S et al (2004) Twenty-four hour ambulatory simultaneous impedance and pH monitoring: a multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol New York 99(6):1037–1043. https://doi.org/10.1111/j.1572-0241.2004.04172.x

    Article  Google Scholar 

  17. 17.

    Johnson LF, Demeester TR (1974) Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62(4):325–332

    CAS  PubMed  Google Scholar 

  18. 18.

    Burton L, Falk GL, Baumgart K, Beattie J, Simpson S, Van der Wall H (2020) Esophageal clearance in laryngopharyngeal reflux disease: correlation of reflux scintigraphy and 24-hour impedance/pH in a cohort of refractory symptomatic patients. Mol Imaging Radionucl Ther 29(1):7–16. https://doi.org/10.4274/mirt.galenos.2019.30085

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Koufman JA, Amin MR, Panetti M (2000) Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg 123(4):385–388. https://doi.org/10.1067/mhn.2000.109935

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    de Bortoli N et al (2012) How many cases of laryngopharyngeal reflux suspected by laryngoscopy are gastroesophageal reflux disease-related? World J Gastroenterol 18(32):4363–4370. https://doi.org/10.3748/wjg.v18.i32.4363

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Lee BE et al (2010) Combined dual channel impedance/pH-metry in patients with suspected laryngopharyngeal reflux. J Neurogastroenterol Motil 16(2):157–165. https://doi.org/10.5056/jnm.2010.16.2.157

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Vaezi MF et al (2006) Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 116(2):254–260. https://doi.org/10.1097/01.mlg.0000192173.00498.ba

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Merati AL, Ulualp SO (2005) Toohill, “Metaanalysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux.” Ann Otol Rhinol Laryngol 114:177–182

    Article  Google Scholar 

  24. 24.

    Ummarino D, Vandermeulen L, Roosens B, Urbain D, Hauser B, Vandenplas Y (2013) Gastroesophageal reflux evaluation in patients affected by chronic cough: restech versus multichannel intraluminal impedance/pH metry. Laryngoscope 123(4):980–984. https://doi.org/10.1002/lary.23738

    Article  PubMed  Google Scholar 

  25. 25.

    Hayat JO et al (2012) Su1056 do patients with hoarseness and endoscopic signs of LPR have abnormal esophago-pharyngeal reflux? A study using simultaneous impedance-phmetry, oro-pharyngeal pH monitoring (restech) and pepsin measurements in saliva. Gastroenterology 142(5):S411–S412. https://doi.org/10.1016/S0016-5085(12)61556-X

    Article  Google Scholar 

  26. 26.

    Bestetti A, Carola F, Carnevali-Ricci P, Sambataro G, Tarolo GL (2000) 99mTc-sulfur colloid gastroesophageal scintigraphy with late lung imaging to evaluate patients with posterior laryngitis. J Nucl Med 41(10):1597–1602

    CAS  PubMed  Google Scholar 

  27. 27.

    Galli J, Volante M, Parrilla C, Rigante M, Valenza V (2005) Oropharyngoesophageal scintigraphy in the diagnostic algorithm of laryngopharyngeal reflux disease: a useful exam? Otolaryngol Head Neck Surg 132(5):717–721. https://doi.org/10.1016/j.otohns.2005.01.043

    Article  PubMed  Google Scholar 

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All authors made substantial contributions to this study, approved the version to be published, and agree to be accountable for all aspects of the work.

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Correspondence to Jin-soo Park.

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Ethics approval as per Sydney Local Health District (Concord Hospital) Human Research Ethics Committee, reference LNR/12/CRGH/248.

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Park, Js., Khoma, O., Burton, L. et al. A new diagnostic paradigm for laryngopharyngeal reflux disease: correlation of impedance-pH monitoring and digital reflux scintigraphy results. Eur Arch Otorhinolaryngol (2021). https://doi.org/10.1007/s00405-021-06658-z

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Keywords

  • Pharyngeal impedance
  • Laryngopharyngeal reflux
  • Pulmonary microaspiration