Performance and optimal technique for pharyngeal impedance recording: A simulated pharyngeal reflux study

BACKGROUND AND AIMS: Detection rate, influence of recording site, and subject posture for impedance monitoring of pharyngeal reflux of gastric contents remain unknown. We evaluated the ability of the impedance sensor for detection of various volumes of intrapharyngeal infusate at two sites and in two subject positions. METHODS: Nineteen healthy subjects were studied using concurrent videoendoscopic, manometric, impedance, and pH recording. RESULTS: Detection rate of simulated pharyngeal reflux events ranged between 87% and 100% for 1-4 mL. Detection rate for 0.1-1 mL volumes in the upright position was significantly higher (78-85%) when the impedance sensor was located at the proximal margin of the upper esophageal sphincter (UES) compared to 2 cm proximally (38-68%) (P < 0.001). With the sensor at 2 cm above the UES, the average detection rate for all volumes in the upright position was significantly less (P < 0.001) compared to the supine position (48%vs 84%). There was substantial variability in the magnitude of impedance changes induced by different infusates. CONCLUSIONS: Impedance sensors can detect as small a volume as 0.1 mL and combined with a pH sensor can detect acidic and nonacidic liquid and mist reflux events. Sensor placement at the proximal margin of the UES yields the highest detection rate irrespective of subject posture compared to placement 2 cm proximally. Depending on the volume of refluxate and location of the impedance sensor, a substantial minority of simulated reflux events can be missed.     

咽喉反流病与胃食管反流病关系的研究进展

咽喉反流病与胃食管反流病是耳鼻喉及消化系统的常见疾病,因为患病率的不断增高,二者的诊断与治疗不断受到重视。但因其二者的发病机制仍不完全明确,目前的诊疗仍存在争议。本文结合国内外有关咽喉反流病与胃食管反流病的文献,通过二者发病机制、诊疗现状的特点,阐述其关系,以为后续的研究和临床实践提供参考。     

Impedance baseline and reflux perception in responder and non-responder non-erosive reflux disease patients

Abstract

Background. It was recently shown that GERD patients have lower impedance baseline (IB) values than healthy controls and, that the esophageal acid exposure time (AET) correlates with IB levels. Goals. To explore the sensitivity of IB measurements in NERD patients, responders and non-responders to PPIs, when compared with pH-impedance (MII-pH) variables, and to evaluate whether this variable could represent a marker of GERD symptoms. Reproducibility and inter-observer agreement of IB measurement were also assessed. Study. MII-pH tracings from 44 NERD responders and 22 non-responders were analysed. Ten healthy volunteers underwent the same protocol. IB values were measured at the distal and proximal esophagus. IB was also analysed in a subgroup of patients and in controls with two methods and by two blinded operators. Results. Mean IB values at the distal esophagus were significantly lower in NERD patients than in controls. IB values did not differ between responders and non-responders. Of the 8 responders with negative AET and symptom association probability (SAP), 3 (37.5%) showed IB values lower than controls. IB values in responders with positive and negative SAP were similar (1832 (1596–2068) Ω vs 1667 (1361–1973) Ω, p: n.s.). No differences were found between the IB values measured with the two methods and the inter-observer agreement was good. Conclusions. IB is a promising and easy to calculate MII-pH variable and appears to increase the sensitivity of MII-pH monitoring. IB values cannot predict PPI response and are not associated with reflux perception in NERD patients.     

Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer

OBJECTIVE: Gastroesophageal reflux disease (GERD) is a proposed risk factor for developing laryngeal and pharyngeal cancers. No controlled study has examined this association. METHODS: A case-control-study was performed using the computerized hospitalization and outpatient databases of the US Department of Veterans Affairs. All patients, who were veterans, had been identified as being hospitalized with laryngeal or pharyngeal during 1991 to 1997. In addition, all persons diagnosed with laryngeal or pharyngeal cancer in 1999 in the outpatient files were identified. From the same patient populations, four nonmatched control subjects were randomly assigned for each case. The medical history for cases and controls was retrospectively searched for GERD diagnoses, tobacco use, and alcohol dependence. Multivariable logistic regression analyses were performed to assess the risk factors for laryngeal and pharyngeal cancers. RESULTS: A total of 8,228 hospitalized patients with laryngeal cancers and 1,912 with pharyngeal cancers were compared to 32,912 and 7,648 hospitalized controls, while 9,292 outpatients with laryngeal cancer and 2,769 outpatients with pharyngeal cancer were compared with 37,168 and 11,076 outpatient controls without cancer. Among hospitalized persons, the prevalence of GERD was higher among patients with laryngeal cancer (8.9 vs 4.0%, p < 0.0001) and pharyngeal cancer (6.2 vs 3.8%, p < 0.0001). In a multivariable logistic regression analysis that was controlled for age, gender, ethnicity, smoking, and alcohol, GERD was associated with an adjusted odds ratio (OR) of 2.40 for laryngeal cancer among hospitalized patients (95% CI 2.15-2.69, p < 0.0001) and an adjusted OR of 2.38 (95% CI 1.87-3.02, p < 0.0001) for pharyngeal cancer. For outpatients, GERD was associated with an adjusted OR = 2.31 (95% CI 2.10-2.53) for laryngeal cancer and adjusted OR = 1.92 (95% CI 1.72-2.15). CONCLUSIONS: Among US veterans, the risk for laryngeal or pharyngeal cancers is modestly increased in the presence of GERD. This effect seems to be independent of age, gender, smoking, and alcohol intake.     

表现为咽异感症的反流性食道炎63例临床误诊分析

目的探讨反流性食管炎伴咽异感症的临床特点及治疗方法。方法对反流性食管炎伴慢性咽炎63例患者给予抑酸剂、促动力药治疗。结果显效29例,有效26例,无效6例,失访2例。总有效率为87.30%。结论对反流性食管炎伴慢性咽炎的患者进行抑酸剂、促动力药治疗,效果明显(但应注意饮食控制,坚持按疗程服药)。     

咽白喉1例

白喉是由白喉杆菌引起的急性呼吸道传染病,以咽、喉和鼻部黏膜充血及肿胀,并伴有不易脱落的灰白色假膜为特征。白喉杆菌产生的外毒素可致全身中毒症状,严重者可并发心肌炎和末梢神经麻痹。近年来,由于抗生素广泛应用,临床上已很难见到典型的白喉病例。我科曾收治1例,现报告如下。     

Considerations about pharyngeal manometry

Intraluminal manometry has the potential to provide relevant information for clinical or research studies of pharyngeal motor function. The usefulness of this information, however, depends on appropriate manometric instrumentation and technique. In this report, we discuss the instrumentation and techniques that are currently available for meaningful acquisition and interpretation of pharyngeal pressure phenomena. Sponsored in part by USPHS Grants AM 25731 and AM 07572.     

Duodenogastral reflux burden gastroesophageal reflux disease

The article presents research data of duodenogastral reflux (DGR) role in patients with gastroesophageal reflux disease. It is shown that in the presence DGR, the reflux esophagitis is detected at a higher frequency and outside of esophageal manifestations of the disease. The comorbidities of hepatobiliary zone and pancreas contributes to the DGR development, as well as the syndrome of bacterial overgrowth in the small intestine.     

反流性咽喉炎的研究进展

随着对胃食管反流病认识的深入,其对咽喉部的影响越来越受到临床的关注,研究证明它是导致咽喉部疾病的重要致病因素之一。胃食管反流对消化系统影响的研究很多,但其与咽喉反流性疾病的相关研究甚少,很多基层医生对该病还不甚了解。本文主要对反流性咽喉炎的发病机制、临床表现、诊断方法和治疗作一综述。     

Evaluation of pharyngeal dysphagia with manofluorography

The purpose of this paper is to analyze cervical dysphagia with a two-modality method using simultaneous fluoroscopy and solid-state computerized manometry (manofluorography). Manofluorography provides functional data that are not obtainable using barium swallow or standard manometry. Six examples of pharyngeal dysphagia are presented. They show that pharyngeal bolus transit is due to a pressure gradient. Two major generators of this gradient are tongue-driving pressure and the pharyngeal-esophageal segment negative pressure. Dysphagia is analyzed in terms of alteration of the pharyngeal pressure gradient.     

Laryngopharyngeal reflux in patients with reflux esophagitis

AIM： To assess the prevalence of laryngopharyngeal reflux （LPR） in patients with reflux esophagitis and disclose factors contributing to the development of LPR.
METHODS： A total of 167 patients who proved to have reflux esophagitis by endoscopy were enrolled. They received laryngoscopy to grade the reflux findings for the diagnosis of LPR. We used validated questionnaires to identify the presence of laryngopharyngeal symptoms, and stringent criteria of inclusion to increase the specificity of laryngoscopic findings. The data of patients were analyzed statistically to find out factors related to LPR.
RESULTS： The prevalence rate of LPR in studied subjects with reflux esophagitis was 23.9%. Age, hoarseness and hiatus hernia were factors significantly associated with LPR. In 23 patients with a hiatus hernia, the group with LPR was found to have a lower trend of esophagitis grading.
CONCLUSION： Laryngopharyngeal reflux is present in patients with reflux esophagitis, and three predicting factors were identified. However, the development of LPR might be different from that of reflux esophagitis. The importance of hiatus hernia deserves further study.     

New aspects in the pathomechanism and diagnosis of the laryngopharyngeal reflux-clinical impact of laryngeal proton pumps and pharyngeal p H metry in extraesophageal gastroesophageal reflux disease

AIM:To determine the laryngeal H+K+-ATPase and pharyngeal p H in patients with laryngopharyngeal reflux(LPR)-symptoms as well as to assess the symptom scores during PPI therapy.METHODS:Endoscopy was performed to exclude neoplasia and to collect biopsies from the posterior cricoid area(immunohistochemistry and PCR analysis).Immunohistochemical staining was performed with monoclonal mouse antibodies against human H+K+-ATPase.Quantitative real-time RT-PCR for each of the H+K+-ATPase subunits was performed.The p H values were assessed in the aerosolized environment of the oropharynx(Dxp H Catheter) and compared to a subsequently applied combined p H/MII measurement.RESULTS:Twenty patients with LPR symptoms were included.In only one patient,the laryngeal H+K+-ATPase was verified by immunohistochemical staining.In another patient,real-time RT-PCR for each H+K+-ATPase subunit was positive.Fourteen out of twenty patients had pathological results in Dxp H,and 6/20 patients had pathological results in p H/MII.Four patients had pathological results in both functional tests.Nine out of twenty patients responded to PPIs.CONCLUSION:The laryngeal H+K+-ATPase can only be sporadically detected in patients with LPR symptoms and is unlikely to cause the LPR symptoms.Alternative hypotheses for the pathomechanism are needed.The role of pharyngeal p H-metry remains unclearand its use can only be recommended for patients in a research study setting.     

Videomanometric aspects of pharyngeal constrictor activity

Pressure changes were registered with videomanometry (simultaneous manometry and barium swallow) in the pharynx and in the pharyngoesophageal segment (PES) during swallowing. A considerable longitudinal asymmetry was found. Peak pressure was highest in the PES, lower in the inferior constrictor area, and lowest at the level of the tongue base. The rate of pressure rise was highest at the level of the PES. The speed of propagation of the contraction wave was 13 (±2) cm/sec. There was no correlation between the measured variables (i.e., peak pressure, rate of pressure rise, and speed of contracting wave). Our findings can partly be explained by different mechanical constraints at different levels of the pharynx but may also reflect the organization of neural control of swallowing in the brainstem. Knowledge of transducer position and orientation is essential for the evaluation of pharyngeal pressure during swallowing. Such knowledge is best achieved by performing manometry simultaneously with fluoroscopy, i.e., videomanometry.