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How Much Pharyngeal Exposure Is “Normal”? Normative Data for Laryngopharyngeal Reflux Events Using Hypopharyngeal Multichannel Intraluminal Impedance (HMII)

  • 2011 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Laryngopharyngeal reflux (LPR) can cause atypical symptoms, asthma, and pulmonary fibrosis. The aim of this study was to establish the normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH (HMII).

Methods

Asymptomatic subjects underwent endoscopy followed by 24-h HMII using a specialized impedance catheter configured to detect LPR before and after a 2-week course of proton pump inhibitors (PPI). Subjects were excluded if they had esophageal pathology or a positive DeMeester score. A cohort of 24 LPR patients who had a complete response to treatment was used for comparison with the normative data.

Results

Forty subjects were enrolled. Thirty-four subjects completed one, and 25 completed both HMII testing periods off and on PPI. There was no difference in the total number of reflux events between off and on PPI [22 (8–32) and 24 (10–28), respectively, p = 0.89]. The 95th percentiles of LPR off and on PPI were 0 and 1, respectively. All patients with treatment responsive LPR had pre-treatment HMII values of LPR greater than the 95th percentile.

Conclusion

LPR events are rare in an asymptomatic population. One or more LPR events should be considered abnormal in patients with LPR symptoms regardless of whether there is a positive DeMeester score.

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Author information

Authors and Affiliations

  1. Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Shadyside Medical Center, Suite 715, 5200 Centre Avenue, Pittsburgh, PA, 15232, USA

    Toshitaka Hoppo, Alejandro F. Sanz, Katie S. Nason, James D. Luketich & Blair A. Jobe

  2. Department of Otolaryngology, Tufts Medical Center, Boston, MA, USA

    Thomas L. Carroll

  3. Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Clark Rosen

  4. Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Daniel P. Normolle

  5. Department of Medicine, University of North Carolina, Chapel Hill, NC, USA

    Nicholas J. Shaheen

Authors
  1. Toshitaka Hoppo
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  2. Alejandro F. Sanz
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  3. Katie S. Nason
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  4. Thomas L. Carroll
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  5. Clark Rosen
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  7. Nicholas J. Shaheen
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  9. Blair A. Jobe
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Corresponding author

Correspondence to Blair A. Jobe.

Additional information

Discussant

Dr. John F. Sweeney (Atlanta, GA): Good morning and Happy Mother’s Day. My name is John Sweeney and I am Chief of General and Gastrointestinal Surgery at Emory University in Atlanta. I would like to take the opportunity to thank the Society for the opportunity to discuss this manuscript. Before I begin, I would like to congratulate Dr. Hoppo on a fine presentation. In addition I would like to thank the authors for providing me a copy of their manuscript for review well in advance of the meeting. It is clearly and concisely written. I have three questions:

1. The manuscript states that healthy subjects were recruited through community advertising. How did you incentivize their participation? Were they paid? If so, when did this occur? After each completed test? At the end of the entire experiment? What happened if they completed the tests but the data were not felt to be usable? Were they still paid?

2. The next question is regarding the LPR treatment responsive group. The manuscript states that subjects were selected from a group of patients with atypical symptoms of LPR that had a complete response to medical or surgical therapy. Were there any differences in impedance results for each subgroup of patients?

3. As you clearly state in the discussion of your manuscript, the outcomes for either medical or surgical management of LPR can vary significantly. How will the results of this study lead to better stratification of patients with LPR to the modality that they are most likely to respond? More importantly, do you envision that this modality will help us identify patients that will not respond to a fundoplication and therefore in whom surgery should therefore be avoided?

Again, I would like to thank the Society for the privilege of discussing this paper and congratulate the authors on a well-designed and well-executed study.

Closing Discussant

Dr. Toshitaka Hoppo: Thank you very much for your great comments and questions, Dr. Sweeney.

1. The first question was regarding incentive for participants. All participants were paid twice after each impedance testing. They were paid $125 after the placement of the first impedance catheter and $75 after the placement of the second impedance catheter. They were still paid if the data were not usable.

2. The second question was regarding difference in LPR events in patients who responded to medical therapy and surgical therapy. When looked at the difference in the number of LPR events on impedance testing, there was a trend towards more LPR events observed in surgical therapy responsive patients compared to medical therapy responsive patients (3 vs. 1.2/day). This may be explained by that more LPR events cannot be controlled well by medical therapy.

3. The last question was regarding the stratification with impedance testing. This is a good question. It is important to determine who would benefit from the treatment and what treatment would be the best. The impedance testing can make a diagnosis of LPR but cannot tell us what the best treatment would be for each patient. However, making an accurate diagnosis of LPR should contribute to the better outcomes of treatments.

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Hoppo, T., Sanz, A.F., Nason, K.S. et al. How Much Pharyngeal Exposure Is “Normal”? Normative Data for Laryngopharyngeal Reflux Events Using Hypopharyngeal Multichannel Intraluminal Impedance (HMII). J Gastrointest Surg 16, 16–25 (2012). https://doi.org/10.1007/s11605-011-1741-1

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