Lechien JR, Bobin F, Dapri G, Eisendrath P, Salem C, Mouawad F, Horoi M, Thill MP, Dequanter D, Rodriguez A, Muls V, Saussez S. Hypopharyngeal-Esophageal Impedance-pH Monitoring Profiles of Laryngopharyngeal Reflux Patients. Laryngoscope, 2021,131:268-276
Hypopharyngeal-Esophageal Impedance-pH Monitoring Profiles of Laryngopharyngeal Reflux Patient
Jerome R. Lechien, MD, PhD, MSc†; Francois Bobin, MD†; Giovanni Dapri, MD, PhD, FACS; Pierre Eisendrath, MD, PhD; Charelle Salem, MD; Francois Mouawad, MD, PhD, MSc; Mihaela Horoi, MD; Marie-Paule Thill, MD; Didier Dequanter, MD, PhD; Alexandra Rodriguez, MD; Vinciane Muls, MD#; Sven Saussez, MD, PhD#
Краткое изложение на русском языке
AbstractObjectives/Hypothesis: To investigate the profile of patients with laryngopharyngeal reflux (LPR) at hypopharyngeal–esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring and the relationship between hypopharyngealproximal reflux episodes (HREs) and saliva pepsin concentration.
Study Design: Prospective non-controlled.
Methods: Patients were recruited from three European hospitals from January 2018 to October 2019. Patients benefited from HEMII-pH monitoring and saliva collections to measure saliva pepsin concentration in the same time. Saliva pepsin concentration was measured in the morning (fasting), after lunch, and after dinner. The LPR profile of patients was studied through a breakdown of the HEMII-pH findings over the 24 hours of testing. The relationship between the concentrations of saliva pepsin and 24-hour HREs was studied through linear multiple regression.
Results: One hundred twenty-six patients completed the study. The HEMII-pH analyses revealed that 73.99% of HREs occurred outside 1-hour postmeal times, whereas 20.49% and 5.52% of HREs occurred during the 1-hour postmeal and nighttime, respectively. Seventy-four patients (58.73%) did not have nighttime HREs. Patients with both daytime and nighttime HREs had more severe HEMII-pH parameters and reflux symptom score compared with patients with only daytime HREs. There were no significant associations between HREs and saliva pepsin concentration.
Conclusions: Unlike gastroesophageal reflux disease, HREs occur less frequently after meals and nighttime. The analysis of the HEMII-pH profile of the LPR patients has to be considered to develop future personalized therapeutic strategies.
Key Words: Laryngopharyngeal, reflux, laryngitis, pH monitoring, impedance, reflux episode, pharyngeal, pepsin, profile, treatment.
Level of Evidence: 4
Laryngoscope, 131:268–276, 2021, doi.org/10.1002/lary.28736
INTRODUCTIONLaryngopharyngeal reflux (LPR) is an inflammatory condition of the upper aerodigestive tract tissues related to direct and indirect effect of gastroduodenal content reflux, which induces morphological changes in the upper aerodigestive tract.1 The development of LPR symptoms and signs is related to hypopharyngeal–esophageal reflux episodes (HREs), which are detected by hypopharyngeal–esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring. HEMII-pH monitoring is the best way to diagnose LPR, but this approach is still little used by the majority of American and European otolaryngologists.2,3 Nowadays, the majority of otolaryngologists use an empirical therapeutic trial to confirm the diagnosis.4,5 Physicians usually prescribe proton pump inhibitors (PPIs), twice daily, to ensure an antireflux effect for 24 hours,6 and two or three times daily alginate just after the meals.5,7 PPI and alginate therapeutic regimens were initially based on the profile of the occurrence of the reflux episodes at the pH monitoring of patients with gastroesophageal reflux disease (GERD). In GERD, reflux episodes mainly occur after the meals through transient relaxations of lower esophageal sphincter (LES), daytime and nighttime.8,9 However, there are no clinical studies that precisely reported the profile of reflux episodes of LPR patients at HEMII-pH monitoring.
The aim of this study was to investigate the profile of patients with LPR at HEMII-pH monitoring and the relationship between HREs and the pepsin saliva concentration.
MATERIALS AND METHODSEthical Consideration
The local ethics committee approved the study protocol (no. BE076201837630). Patients were invited to participate and the informed consent was obtained.
Subjects and Setting
Patients with LPR symptoms and findings were recruited from three European hospitals (University Hospital Centers Saint-Pierre and Cesar De Pape Hospital, Brussels, Belgium; and Polyclinic of Poitiers–Elsan, Poitiers, France) from January 2018 to October 2019. The diagnosis was confirmed through positive HEMII-pH. Gastrointestinal (GI) endoscopy was proposed to elderly patients and those with GERD symptoms. The exclusion criteria were similar to those described in a previous publication.10
The characteristics of a HEMII-pH monitoring device, placement, and analyses have been described in previous publications.10 Briefly, the HEMII-pH probe was placed in the morning before breakfast (8:00 am). HEMII-pH probe was composed of eight impedance segments and two pH electrodes (Versaflex Z, Digitrapper pH‐Z testing system; Medtronic, Minneapolis, MN). Six impedance segments were placed along the esophagus zones (Z1 to Z6), and they were centered at 19, 17, 11, 9, 7, and 5 cm above the LES. Two additional impedance segments were placed 1 and 2 cm above the cricopharyngeal sphincter in the hypopharynx. The pH electrodes were placed 2 cm above the LES and 1 to 2 cm below the cricopharyngeal sphincter, respectively
The proximal (hypopharyngeal) reflux event was defined as an episode that reached two impedance sensors in the hypopharynx. The LPR diagnosis was based on the occurrence of ≥1 acid or nonacid HRE.11 The acid reflux episode consisted of an episode with pH ≤ 4.0. The nonacid reflux episode consisted of an episode with pH > 4.0.
Respecting the type of reflux episodes (acid and nonacid), three physicians (f.b., v.m., and c.s.) analyzed the HEMII-pH form to isolate the reflux episodes regarding the following periods of the 24-hour testing: 60 minutes after breakfast; the time between the 60 minutes after breakfast and lunch; the 60 minutes after lunch; the time between the 60 minutes after lunch and dinner; the 60 minutes after dinner; the time between the 60 minutes after dinner and bedtime and nighttime.
Patients were off of PPIs during the HEMII-pH testing.
Saliva Pepsin Measurement
Simultaneously to HEMII-pH monitoring, patients were invited to collect saliva samples (1 to 5 mL; throat sputum) 1 to 2 hours after the meals (lunch and dinner) and in the morning (fasting) to study the relationship between HEMII-pH episodes and the saliva pepsin concentrations. The saliva samples were collected into a 30-mL universal sample collection tube containing a pre-established concentration of citric acid to preserve the action of any pepsin present (Peptest kit; RDBiomed, Cottingham, United Kingdom). The pepsin sample collections were stored in the refrigerator. The measurement of pepsin concentration in the saliva samples was performed through the Peptest device (RDBiomed). A trained lab technician received the samples the day following the collection. The steps for pepsin measurement were performed in a standardized procedure, which has been previously described.12 The saliva pepsin concentration was measured using the Cube Reader (opTricon, Berlin, Germany), which detects pepsin down to 16 ng/mL. If the results did not reach that level, the test was considered negative.
Symptoms and findings were assessed with Reflux Symptom Score (RSS)13 and Reflux Sign Assessment (RSA),14 respectively. RSS is a self-administered, validated 22-item reported-outcome questionnaire assessing frequency and severity of ear, nose, throat, digestive, and respiratory complaints (Fig. 1). RSA is a validated 61-point LPR physical finding score documenting laryngeal and extralaryngeal findings (Fig. 2).
Fig. 1. Reflux Symptom Score (RSS). The questionnaire is subdivided into three parts according to the complaints: ear, nose, and throat (part 1, nine items), digestive (part 2, nine items), and respiratory (part 3, four items) symptoms. The frequency and severity of each symptom are rated with a five‐point scale. Regarding the frequency, 0 = patient did not have the complaint over the past month; 1, 2, 3, or 4 = patient had the complaint 1 to 2, 2 to 3, 3 to 4, or 4 to 5 times weekly over the past month, respectively; 5 = patient had the complaint daily over the past month. Regarding the severity, 0 = the complaint is absent, 5 = the complaint is very troublesome when it occurs. For each item, the severity score is multiplied by the frequency score to obtain a symptom score ranging from 0 to 25. The sum of these symptom scores is calculated to obtain the RSS final score (ranging from 0–550, with the possibility for the physician and the patient to add three symptoms not identified in the RSS, leading to a maximal possible score of 625). The RSS also assesses the symptom impact on quality of life. The total quality of life score is calculated by the sum of each item score.
Fig. 2. Short version of the Reflux Sign Assessment (RSA). The tool is subdivided into three parts according to the sign localization: oral cavity, pharynx, and larynx. The occurrence of vocal fold granuloma (+2), keratosis (+2), or ulceration (+2) may be considered in the last item of the score. Because of low prevalence, the following items were removed from the initial version of the RSA: edema/erythema of the vocal folds, nasopharyngeal erythema, and subglottic edema/erythema. The total score is calculated by the sum of each item score. The maximum score is 61.
Statistical analyses were performed using the Statistical Package for the Social Sciences for Windows (SPSS version 22,0; IBM, Armonk, NY). The relationships between the HEMII-pH data, the pepsin saliva concentration, and the clinical features were investigated through multiple linear regression. The potential comparison between patient groups with different HEMII-pH profiles was made through Mann-Whitney U test. A level of significance of P < .05 was used.
RESULTSA total of 126 patients completed the study. The characteristics of patients are described in Table 1. Ninety-four patients benefited from gastrointestinal (GI) endoscopy (74.6%). The GI endoscopy was normal in 40.4% of cases. Regarding Montreal criteria,15 38.9% of patients had both LPR and GERD. There were 40 acid, 26 mixed, and 60 nonacid LPR patients.
TABLE 1. Characteristics of Patients.
Patient Profiles at HEMII-pH Monitoring
The average numbers (± standard deviation) of acid and nonacid HREs occurring throughout the 24-hour testing day are reported in Table 1. The majority of HREs (73.99%) occurred outside 1-hour postmeal times (Table 2). Of the HREs, 20.49% occurred in the 60 minutes postmeal, whereas 5.52% of HREs occurred at nighttime and with the patient recumbent. There were no significant differences in the occurrence of HREs regarding the type of reflux episodes (acid vs. nonacid). A small number of patients took a coffee break, leading to nonconsideration of the 60 minutes after the coffee break in the analyses.
TABLE 2. Percentages of Occurrence of Hypopharyngeal Reflux Episodes Throughout the 24-Hour Testing According to the Type of Reflux Episodes.
Seventy-four patients (58.73%) had no nighttime HREs. Overall, there were two main patient profiles regarding HEMII-pH: patients with upright and daytime HREs and those with upright and recumbent HREs during both day and night (Fig. 3). The characteristics of these two patient profiles are available in Table 3. Both groups were comparable regarding age, gender ratio, body mass index, saliva pepsin concentration, and GI/esophageal endoscopy. The occurrence of nighttime HREs was associated with a higher number of both distal and HREs, as well as more severe parameters of GERD (DeMeester score and percentage of pH < 4). Patients with both upright and recumbent HREs had higher ear, nose, and throat and total RSS scores compared with patients with only upright and daytime HREs (Table 4).
Fig. 3. Typical profile of laryngopharyngeal reflux (LPR) patients at hypopharyngeal esophageal multichannel intraluminal impedance‐pH (HEMII‐pH) monitoring. We observed two main profiles of LPR patients at the HEMII‐pH monitoring: patients with daytime hypopharyngeal reflux episodes (A) and patients with daytime and nighttime hypopharyngeal reflux episodes (B).
TABLE 3. Characteristics of Patients According to the Reflux Profiles.
BMI = body mass index; GERD = gastroesophageal reflux disease; HEMII-pH = hypopharyngeal–esophageal multichannel intraluminal impedance-pH; LES = lower esophageal sphincter; NS = not significant; SD = standard deviation.
TABLE 4. Symptom Differences in Reflux Patient Regarding the Reflux Profile.
Saliva Pepsin Concentration
The mean level of saliva pepsin is reported in Table 1. Twenty-one patients had LPR at HEMII-pH monitoring and a negative Peptest (16.67%). The clinical and HEMII-pH profiles of patients with a positive Peptest were similar to the profiles of patients with a negative Peptest. The linear regression analysis did not reveal significant positive association between the level of saliva pepsin and the occurrence of HREs before the samples. There were no significant associations between the mean level of saliva pepsin (24-hour testing) and the number and duration of HREs. Similarly, we did not find significant association between the pepsin level and the total acid exposure time at the proximal and distal pH sensors. The mean level of saliva pepsin (24 hours) was associated with the severity of tongue burning (rs: 0.177; P = .025). The saliva pepsin concentration in the morning (fasting) was positively associated with the following findings: throat clearing score (rs = 0.340, P = .020), globus sensation (rs = 0.023, P = .023), endolaryngeal sticky mucus score (rs = 0.466, P = .026), RSA laryngeal subscore (rs = 506, P = .027), and RSA total score (rs = 0.503, P = .028). There was no significant association between the nighttime HREs and the pepsin saliva concentration in the morning in patients with nighttime reflux.
DISCUSSIONIn 1991, Koufman observed that LPR disease was mainly characterized by gaseous, upright, and daytime hypopharyngeal reflux episodes at the dua-probe pH-metry.15 Since then, to our knowledge, there have not been any studies investigating the profile of LPR patients at 24-hour HEMII-pH monitoring. The identification of the times of occurrence of HREs makes particular sense for improving the therapeutic schemes, which are based on drugs with duration of action <24 hours.
In this study, we observed that the high majority of both acid and nonacid HREs occurred while upright and in the daytime. These findings corroborate the results of previous studies exhibiting that pharyngeal reflux episodes occurred in the daytime and were worse in the upright position of patients with chronic laryngitis.15,16
Regarding our data, three-quarters of HREs occurred in the daytime, while upright, and outside postmeal times, which is different from the typical profile of GERD patients. In GERD patients, the distal reflux episodes mainly occur in the 60 minutes postmeal through many mechanisms involving the lowest LES pressure after eating, transient relaxations of the LES, and high pressure of the gastric content on the esophagogastric junction.17 Transient relaxations of the LES allow the movement of gas from the proximal stomach to the distal esophagus while preventing reflux of gastric contents. However, it has been demonstrated that transient relaxations of LES frequently occur in reflux patients, leading to an escape of gastric contents into the esophagus, especially within 15 minutes after eating in patients with an acid pocket.17 Thus, the gastric juice near the cardia may leak backward into the esophagus, which increases the incidence of postprandial reflux events.17,18 The incidence of transient LES relaxations in GERD patients would be more than two times that of healthy people,19 and would be associated with a high probability to develop acid reflux.20,21 In the same vein, the pressure of the gastric content on the esophagogastric junction may be increased in the 60 minutes postmeal, leading to a higher probability of LES relaxations and distal reflux episodes.17 In practice, many studies reported that distal reflux episodes mainly occurred during postmeal times or nighttime when patient is lying down.8,9
A close analysis performed in the present study supports that there would be two main profiles of LPR patients regarding the occurrence of nighttime and recumbent HREs. Patients with both daytime and nighttime HREs would have more severe parameters at HEMII-pH monitoring compared with patients without nighttime/recumbent HREs. The patients without nighttime/recumbent HREs had fewer regurgitations, burp, ear, nose, and throat complaints and overall LPR-related symptoms (RSS) compared with those with nighttime HREs. As expected, the occurrence of nighttime and recumbent HREs was more commonly associated with a GERD pattern. The identification of these two types of profiles of LPR patients may lead to an improvement of the therapeutic schemes according to the characteristics of the patient at HEMII-pH monitoring. Regarding the duration of the effect of PPIs (varying from 6 to 18 hours),22 the use of twice daily PPIs had been originally recommended for ensuring an antireflux effect for 24 hours.6 This recommendation was based on only one study conducted on suspected LPR patients without diagnostic confirmation.6 According to the data of the present study, HEMII-pH monitoring would be used as a therapeutic tool to deliver a personalized treatment (with reduced medication doses) considering the times of occurrence of HREs and the duration of the effect of the different drugs. In that way, it would be conceivable to reduce the PPI doses from twice to once daily in patients without nighttime HREs. Similarly, alginate or magaldrate, which are usually taken after meals and at bedtime, would be taken at the times characterized by a large number of HREs. Physicians should bear in mind that the duration of the effect of alginate and magaldrate ranges from 30 minutes to 4 hours. Naturally, future studies are needed to refine the identification of several LPR patient profiles at HEMII-pH monitoring and to investigate the usefulness of different therapeutic schemes based on the patient profiles.
The last finding of this study is the lack of significant positive association between the occurrence of HREs and the saliva pepsin concentration. These results are not surprising, as a previous study reported no significant associations between saliva pepsin concentration and the HREs preceding the saliva samples.12 Through more precise and detailed analyses, the findings of the present study may suggest that the measured saliva pepsin concentration does not reflect the quantity of deposited pepsin in the upper aerodigestive tract mucosa. The internalization of pepsin in the epithelial cells23 may be a mechanism explaining the lack of significant association between saliva pepsin level and HEMII-pH findings. In practice, the best time to collect the saliva would be the morning (fasting) regarding the predictive value of saliva pepsin level on the severity of some inflammatory signs (endolaryngeal sticky mucus, RSA laryngeal and total scores) and related symptoms (globus and throat clearing). As suggested in another study,24 the saliva pepsin concentration in the morning would be more representative of the quantity of deposited pepsin in the upper aerodigestive tract mucosa over the previous 12 to 24 hours.
Future studies are needed to confirm our results and to specify the best times for saliva samples. In the same vein, a recent report found a high degree of variability and random errors of up to 36 ng/mL when analyzing a single specimen with a single device.25 The interpretation of the results related to the Peptest needs to be particularly cautious. Future studies need to corroborative the device with other validated methods such as pepsin enzyme-inked immunosorbent assay and Western blot.
Because pepsin is probably not the only gastroduodenal enzyme able to irritate the laryngopharyngeal mucosa, the future studies should consider the measurement of additional gastroduodenal enzymes such as elastase, lipase, amylase, trypsin, and bile salts; the latter being already identified in saliva of LPR patients.26
CONCLUSIONThe majority of HREs occur outside 60 minutes postmeal time, in the daytime, and while upright. Patients may be classified in two categories regarding the HEMII-pH profile and the occurrence of nighttime and recumbent HREs. Patients with nighttime and recumbent HREs had more severe HEMII-pH parameters and symptom scores. Because more than half of LPR patients had no nighttime HREs, a modification of the current therapeutic schemes would make sense for these patients through a reduction of PPI doses and a shift of administration of alginate or magaldrate from postmeal times to the times with the largest number of HREs.
From the Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the International Federation of Otorhinolaryngological Societies (J.R.L., F.B., G.D., P.E., F.M., D.D., A.R., V.M., S.S.), Paris, France; Department of Human Anatomy and Experimental Oncology, Faculty of Medicine (J.R.L., G.D., S.S.), University of Mons Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, School of Medicine (J.R.L.), Training and Research Unit, Simone Veil, University of Versailles Saint-Quentin-en-Yvelines (University of Paris–Saclay), Paris, France; Department of Otorhinolaryngology and Head and Neck Surgery (J.R.L., M.H., M.-P.T., D.D., A.R., S.S.), University Hospital Centers Brussels, University Hospital Centers Saint-Pierre, School of Medicine, Free University of Brussels, Brussels, Belgium; Department of Otolaryngology (F.B.), Polyclinic of Poitiers–Elsan, Poitiers, France; European Laparoscopic School, School of Medicine (G.D.), Free University of Brussels, Brus sels, Belgium; Department of Gastroenterology and Endoscopy (P.E., C.S., V.M.), University Hospital Centers Brussels, University Hospital Centers Saint-Pierre, School of Medicine, Free University of Brussels, Brussels, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery (F.M.), University Hospital Centers Lille, Hospital Claude Huriez, School of Medicine, University of Lille, Lille, France; and the International School Reduced Scar Laparoscopy (G.D.), Brussels, Belgium.
Editor’s Note: This Manuscript was accepted for publication on April 21, 2020.
† J.R.L. and F.B. have contributed equally to this work and should be regarded as joint first authors.
# V.M. and S.S. have contributed equally to this work and should be regarded as joint last authors.
This study was accepted by American Broncho-Esophagological Association as an oral presentation at the American Broncho-Esophageal Association Meeting at the Combine d Otolaryngology Spring Meetings, Atlanta, Georgia, U.S.A., April 22 –24, 2020. That was presented in the ONLINE ABEA Meeting 2 Mai, Saturday.
This study was funded by a Vesale grant and an Institute for Research and Socioeconomic Information grant (King Baudouin Foundation).
The authors have no other funding, financial relationships, or conflicts of interest to disclose.
Send correspondence to Jay R. Lechien, MD, PhD, MS, Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, Avenue du Champ de mars, 6, B7000 Mons, Belgium. E-mail: jerome.lechien@ umons.ac.be
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