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laryngitis
SECKIN O. ULUALP, MD, ROBERT J. TOOHILL, MD, RAYMOND HOFFMANN, PhD, and REZA SHAKER, MD, Milwaukee, Wisconsin
OBJECTIVE: To evaluate the diagnostic value of 3site 24-hour ambulatory pH monitoring in patients
with posterior laryngitis (PL) and the prevalence of
esophageal abnormalities in this patient group.
METHODS: Twenty patients with PL and 17 healthy
volunteers were studied as controls. Control subjects
had transnasal esophagogastroduodenoscopy
(T-EGD) and ambulatory pH monitoring. Patients
underwent T-EGD, ambulatory pH monitoring, and
barium esophagram.
RESULTS: T-EGD documented no abnormality in
controls. Esophagitis was present in 2 PL patients,
and hiatal hernia in 3. Ambulatory pH monitoring
showed that 15 PL patients and 2 controls exhibited
pharyngeal acid reflux. Barium esophagram documented gastroesophageal reflux in 5 PL patients.
However, none of these barium reflux events
reached the pharynx. All PL patients with barium
esophagram evidence of gastroesophageal reflux
also showed pharyngeal acid reflux by pH monitoring.
CONCLUSION: Pharyngeal acid reflux is more
prevalent in patients with PL than in healthy controls. Patients with PL infrequently have esophageal
sequelae of reflux disease. Ambulatory 24-hour
simultaneous 3-site pharyngoesophageal pH monitoring detects gastroesophagopharyngeal acid
reflux events in most patients with PL. (Otolaryngol
Head Neck Surg 1999;120:672-7.)
METHODS
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Head and Neck Surgery
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ULUALP et al
673
Videostroboscopy
Barium esophagram
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
PL, VCN
PL
PL, LTS
PL, VCN
PL, LTS
PL, LTS
PL
PL
PL
PL
PL
PL, LTS
PL, VCN
PL
PL, LTS
PL
PL
PL, VFP
PL, VCN
PL
GER()
GER()
GER()
GER()
GER()
GER()
GER()
GER(+), HH
AM
GER()
AM
GER()
GER(+), HH
GER(+), AM, HH
GER(+)
AM
GER(+), HH
GER()
GER()
GER()
No abnormality
No abnormality
No abnormality
No abnormality
No abnormality
No abnormality
No abnormality
HH
No abnormality
No abnormality
No abnormality
HH, Esophagitis
HH
No abnormality
Esophagitis
Positive
Positive
Positive
Negative
Positive
Negative
Negative
Positive
Positive
Negative
Negative
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive
VCN, Vocal cord nodules; LTS, laryngotracheal stenosis; HH, hiatal hernia; AM, abnormal motility; VFP, vocal fold polyp.
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ULUALP et al
Otolaryngology
Head and Neck Surgery
May 1999
nose. Studies were initiated in the morning after the manometric studies and terminated 22 to 24 hours later. Subjects ate
a standard meal that included the following: (1) breakfast, a
total of 504 kcal (78.6% carbohydrate, 12.1% protein, 9.3%
fat); (2) lunch, a total of 822 kcal (67.7% carbohydrate, 11.4%
protein, 20.9% fat); and (3) dinner, a total of 1199 kcal (58.2%
carbohydrate, 16.2% protein, 25.6% fat). Meals were provided through the Medical College of Wisconsin General Clinical
Research Center. All subjects kept a detailed diary indicating
the time of oral intakes and time of going to bed. They also
indicated position (upright or supine) and events such as
heartburn, belching, cough, chest pain, and exercise. For all 3
sites, a decrease in pH below 4, which was not related to
belching or to the time of eating or drinking, was considered
to be an acid reflux episode. To be considered a pharyngeal
reflux event, it had to be simultaneous or preceded by a
decrease in pH of similar or larger magnitude in the proximal
and distal esophageal sites. Earlier studies have shown that the
proximal distribution of refluxate is associated with a decline
in pH activity of refluxed material in the esophagus. Also,
determination of the temporal relationship between the onset
of pH decline among recording sites differentiated pH
declines induced by oral intake (in which pharyngeal decline
precedes distal esophageal pH drops) from true gastroesophagopharyngeal acid reflux episodes (in which pharyngeal pH decline occurs either simultaneously or after the
esophageal pH decline). These strict criteria were applied to
avoid counting in spurious readings induced by pharyngeal
pH probe movement, loss of complete mucosal contact, pH
change caused by aerodigestive tract residue and secretions,
and pH change caused by oral intake.
During the study, signals from pH electrodes were stored
by the portable data logger, and on completion of each study,
they were transferred to a computer for subsequent printing
and analysis. In addition, pH recordings were displayed on the
screen, and a computer program was used to create a smaller
time scale for determination of the temporal relationship
among pH declines registered at various sites. The 2 pH electrodes were calibrated in buffers of pH 1 and pH 7, before and
at the end of each study, and showed no significant drift in the
pH signal during the study. Using these techniques, we determined in the pharyngeal site the number of pH declines below
4, percent of study time that the pH was below 4, and average
acid clearance time of the acid reflux episodes. Percent acid
exposure time was calculated as the percentage of the study
period that the pH sensor was exposed to acid. Average acid
clearance time was derived by dividing the total acid exposure
time in minutes by the number of reflux episodes. We also
determined the presence or absence of hiatal hernia, esophagitis, esophageal dysmotility, reflux of barium, and clearance
during esophagography. Statistical comparison between
groups for acid reflux event exposure time was performed
Otolaryngology
Head and Neck Surgery
Volume 120 Number 5
with the nonparametric test (Wilcoxon rank sum test) and for
prevalence was performed by the 2 test.
RESULTS
Findings of Barium Esophagram
ULUALP et al
675
The association between GER and laryngeal disorders was first reported in patients with contact ulcer of
the larynx by Cherry and Margulies6 in 1968. Since
then GER has been implicated in the pathogenesis of a
large number of aerodigestive tract disorders. However,
the cause-and-effect relationship between the majority
of these disorders and gastric refluxate has not been systematically studied. In practice, to determine the role of
GER in the pathogenesis of these disorders, patients are
evaluated by various modalities such as esophageal
endoscopy, barium esophagram, and 24-hour pH monitoring. Except for pharyngeal pH monitoring, esophageal occurrence of reflux or its sequela is evaluated
by these techniques, and findings are extrapolated to
assess the role of reflux in the pathogenesis of supraesophageal lesions.
In this study we report the combined findings of barium esophagram, 24-hour pH monitoring, and endoscopic evaluation of the esophagus in a group of
patients with objectively documented PL. We also compared the pharyngoesophageal distribution of refluxed
gastric acid between these patients and healthy controls.
GER events have been reported to occur spontaneously or may be provoked during standard barium
esophagography. However, the sensitivity and specificity of this technique for documentation of GERD have
been reported to range from 20% to 70%14-16 and 74%
to 94%,14,16 respectively. Gastroesophagopharyngeal
reflux of acid barium in patients with PL has been
reported in some studies.1,6 In our study, barium
esophagram revealed GER in 25% of patients, but pharyngeal reflux of barium was not observed in any
patients.
Although previous studies using barium have reported a 61%5 to 80%2 incidence of hiatal hernia in patients
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Otolaryngology
Head and Neck Surgery
May 1999
ULUALP et al
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Head and Neck Surgery
Volume 120 Number 5
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