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Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 60-63

Clinical utility of 24 hour pharyngeal pH monitoring for hoarseness

1 Texas Center for Voice and Swallowing, 7900 Fannin Suite 1800, Houston TX 77054, USA
2 Department of Speech and Language Pathology, College of Saint Rose, Albany, NY, USA

Date of Web Publication5-Feb-2013

Correspondence Address:
Mary E Beaver
Texas Center for Voice and Swallowing, Houston TX 7900 Fannin Suite 1800, Houston TX 77054
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-9748.106979

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Objective: To evaluate the contribution of 24 hour pharyngeal pH monitoring of patient presenting with symptoms of hoarseness, globus, throat clearing, and sore throat. Study Design: Retrospective case study. Setting: Tertiary laryngology practice. Materials and Methods: Results of 167 pharyngeal pH studies performed for complaints of hoarseness, globus, and throat clearing in an outpatient private practice setting from 5/09-12/09 were analyzed for pharyngeal reflux pattern and severity. Patient records were reviewed for chief complaint, symptom duration, ten item Voice Handicap Index (VHI-10) and Reflux Symptom Index (RSI) scores. Nonparametric testing was used to compare symptom duration, VHI-10 scores, and RSI scores between those patients with and without abnormal pharyngeal pH studies. Results: 71 studies (43%) were normal with zero events below pH 5.5. 32 studies (19%), or 33% of all positive studies showed supine pharyngeal reflux only. 46 studies or 48% of all positive studies showed combination upright daytime reflux events and supine reflux. 18 studies or 19% of all positive studies had only upright events. There was no significant difference in presenting symptoms, symptom duration, or severity scores in the patients that had negative vs. positive pharyngeal pH studies. Conclusion: 24 hour pharyngeal pH study eliminates the diagnosis of reflux in a significant percentage of patients with hoarseness. Severity or duration of symptoms of hoarseness, globus, or throat clearing does not reliably predict presence of reflux.

Keywords: Chronic laryngitis, cough, extraesophageal reflux, globus, hoarseness, laryngopharyngeal reflux, reflux, throat clearing

How to cite this article:
Beaver ME, Karow CM. Clinical utility of 24 hour pharyngeal pH monitoring for hoarseness. J Laryngol Voice 2012;2:60-3

How to cite this URL:
Beaver ME, Karow CM. Clinical utility of 24 hour pharyngeal pH monitoring for hoarseness. J Laryngol Voice [serial online] 2012 [cited 2023 Mar 20];2:60-3. Available from: https://www.laryngologyandvoice.org/text.asp?2012/2/2/60/106979

   Introduction Top

Hoarseness, throat clearing, globus, sore throat, and chronic cough are common complaints of patients that present to the otolaryngologist for evaluation. When these patients are found to have erythema or edema of the arytenoids, vocal folds, or subglottis, the diagnosis of gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux disease (LRPD) is often considered. Frequently, a therapeutic trial of proton pump inhibitors (PPI's) is considered. There is mixed evidence in the literature to support this approach. A prospective, multicenter, randomized, parallel-group trial that compared twice-daily esomeprazole 40 mg with placebo for 16 weeks for chronic laryngitis found no benefit of the patients treated with esomeprazole compared to placebo. [1] A meta-analysis of placebo controlled trials evaluating PPI use in chronic posterior laryngitis found no significant symptom reduction over placebo. [2] Other etiologies of chronic laryngeal inflammation, such as allergies, inhaled irritants, and upper respiratory infections can cause signs and symptoms of laryngeal inflammation. [3]

The prevalence of GERD in the United States is 10-20% as defined by weekly heartburn or acid regurgitation. [4] Self-reported symptoms of GERD do not correlate well with presence of pathologic reflux on objective testing. [5] In patients with symptoms of hoarseness and throat clearing, studies also suggest lack of correlation of symptoms with improvement on medical or surgical acid suppression. [6] Evaluation of the patient with symptoms or signs of laryngeal inflammation can be aided by 24 hour pharyngeal pH monitoring to determine presence and pattern of abnormal pharyngeal pH. The Restech Dx-pH device reliably detects pharyngeal acid events when compared to dual pH probe, is well tolerated, and has a design that minimizes drying artifact. [7] Previous studies performed with this device report normative data of zero reflux events at the pharynx. [8] A different standard for defining positive pharyngeal acid events exists as the percentage of time and acidity of events are much lower in the oropharynx compared to the esophagus. A pH of 3.1 in the esophagus corresponds to a pH of 5.6 in the oropharynx. [9] This study was designed to determine the incidence of pharyngeal acid reflux in a larger population presenting with symptoms of chronic laryngotracheitis (hoarseness, throat clearing, sore throat, globus, cough) as well as to determine diurnal pattern of pharyngeal reflux in the event-positive patients.

   Materials and Methods Top

The medical records of 170 patients presenting to the clinic from 5/2009 to 12/2009 with symptoms of hoarseness, sore throat, cough, throat clearing, or globus for greater than 4 weeks that received a pharyngeal pH study were prospectively reviewed. Institutional review board approval was obtained prior to study. Patients were excluded if they had a history of smoking, if they had taken acid suppression during the study, if they had an incomplete pH study, or if they had an incomplete medical record. 167 patient records were included for final analysis. Data about the patient's symptom type, symptom duration, and symptom severity [using the Reflux Symptom Index (RSI) and Voice Handicap-10 Index (VHI-10)] was recorded by a blinded technician. Duration of symptom data was capped at 60 months in patients with long term symptoms for data analysis purposes. The Restech Dx-pH device was used in all cases for the 24 hour pharyngeal pH monitoring. pH studies were analyzed by the Restech Dx Lite software and variables that were recorded included number of upright reflux events (as defined by drop in pharyngeal pH below 5.5), number of supine reflux events (defined by drop in pharyngeal pH below 5.5), total time below baseline supine, total time below baseline upright, percentage of time below baseline supine, and percentage of time below baseline upright. Pharyngeal pH drop below 5.5 was used to define as a reflux event as this had previously been shown to correlate with a lower esophageal pH of 3.1. [9] Data during mealtime, snacks, or ingestion of acidic beverages was excluded. Data for first 5 minutes after insertion was excluded as there was often an artifactual drop in pH during insertion. Data for first 5 minutes after supine period was excluded to allow for patient variation in marking the end of the supine period and to avoid marking acidic pH that persisted from supine period as an upright event. The final report for the pH study was then calculated and entered into an Excel spreadsheet. Statistical analysis was performed using SPSS version 17. Several of the data sets did not meet the normality of population assumptions for parametric testing; therefore, nonparametric testing was used for statistical comparisons. The Mann-Whitney rank sum test was applied as indicated.

   Results Top

There were no significant differences in duration of symptoms (z = -.59; P = .553) or symptom severity as measured by RSI (z = -1.15; P = .251) and VHI-10 (z = -1.14; P = .253) when comparing pH event-positive patients to pH-event negative patients [Table 1]. There were no significant differences between the two groups when comparing the distribution of duration of symptoms for hoarseness (z =-.452, P = .651), sore throat (z = .465, P = .642), globus (z = -.530, P = .957) or cough (z = -.131, P = .850) [Figure 1].
Figure 1: Duration (months) of chief complaint for the positive and negative pH studies

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Table 1: Mean reflux severity index, voice handicap index and duration of symptoms (in months) for patients with negative and positive pH studies

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The most common chief complaint in the pH event positive patients (57%) was hoarseness and pH event-negative patients (43%) was hoarseness and the percentages of other chief complaints were not significantly different between the two groups [Figure 2]. The pH event-positive patients comprised 57% of all subjects tested. The mean time spent below baseline for the event-positive patients was 81.56 minutes (SD = 109.25). Of the pH event positive patients, 33% had exclusively supine reflux, 48% had mixed supine and upright reflux, and 19% had exclusively upright reflux events [Figure 3]. The mean amount of time spent below baseline for supine events was 119.91 minutes (SD = 119.94) and for upright events was 30.98 minutes (SD 58.83). There was a significant difference between the time spent below baseline for supine compared to upright events (z = -5.51; P = .000) [Figure 4].
Figure 2: Chief complaint distribution between pH event positive and pH event negative patients

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Figure 3: pH-event positive event subjects (N = 96) showing distribution of upright refluxers, mixed supine and upright refluxers and supine refluxers

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Figure 4: Time in minutes below baseline for supine vs upright events

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   Discussion Top

In both the gastroenterology literature concerning GERD and the otolaryngology literature concerning LPRD, self-reported symptom scores do not reliably predict presence or severity of acid reflux disease. [6] This study contributes to that concept by illustrating no significant difference in presenting symptom type, severity, or duration in the patient with chronic laryngitis that has pharyngeal reflux events compared to the patient with chronic laryngitis that has no pharyngeal reflux on objective testing. Additionally, previous studies have shown that patients with laryngeal complaints that have LPRD tend to have a majority of upright reflux events. [10] This study showed a higher percentage of patients that had supine or mixed upright and supine events. The distribution of upright, supine, and mixed cases was very similar to GERD cases in a previous study on Nissen fundoplication. [11] Overall, in this study more than half of the subjects did have pharyngeal reflux events, which underscores the importance of reflux testing in patients with chronic hoarseness, cough, globus, and throat clearing. These patients may be "silent refluxers" as far as esophageal symptoms are concerned and should be screened with esophagoscopy for esophagitis and Barrett's metaplasia. The fact that nearly half of the subjects did not have pharyngeal reflux also helps to explain the poor utility of empiric acid suppression trials.

Strengths of this study include the larger number of subjects that were measured with a sensitive pharyngeal pH device. The weakness of this study is that it was a record review and therefore no conclusions regarding treatment of this condition were evaluated. However, it does advance understanding of the frequency of pharyngeal reflux as a factor in chronic laryngitis as well as implications for testing recommendations.

   Conclusion Top

Pharyngeal pH monitoring contributes significantly to the evaluation of the patient with signs and symptoms of chronic laryngitis. Upper pH probe testing eliminates the diagnosis of pharyngeal reflux in 43% of patients and may decrease time to diagnosis of etiology of chronic laryngitis.

   References Top

1.Vaezi MF, Richter JE, Stasney CR, Spiegel JR, Iannuzzi RA, Crawley JA, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006;116:254-60.  Back to cited text no. 1
2.Qadeer MA, Phillips CO, Lopez AR, Steward DL, Noordzij JP, Wo JM, et al. Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: A meta-analysis of randomized controlled trials. Am J Gastroenterol 2006;101:2646-54.  Back to cited text no. 2
3.Beaver ME, Karow CM. Incidence of seropositivity to bordetella pertussis and mycoplasma pneumoniae infection in patients with chronic laryngotracheitis. Laryngoscope 2009;119:1839-43.  Back to cited text no. 3
4.Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut 2005;54:710-7.  Back to cited text no. 4
5.Chan K, Liu G, Miller L, Ma C, Xu W, Schlachta CM, et al. Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring. J Gastrointest Surg 2010;14:427-36.  Back to cited text no. 5
6.Qadeer MA, Swoger J, Milstein C, Hicks DM, Ponsky J, Richter JE, et al. Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux. Laryngoscope 2005;115:1947-52.  Back to cited text no. 6
7.Golub JS, Johns MM 3rd, Lim JH, DelGaudio JM, Klein AM. Comparison of an oropharyngeal pH probe and a standard dual pH probe for diagnosis of laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 2009;118:1-5.  Back to cited text no. 7
8.Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: Normal values and discriminating pH threshold. J Gastrointest Surg 2009;13:1422-9.  Back to cited text no. 8
9.Wiener GJ, Tsukashima R, Kelly C, Wolf E, Schmeltzer M, Bankert C, et al. Oropharyngeal pH monitoring for the detection of liquid and aerosolized supraesophageal gastric reflux. J Voice 2009;23:498-504.  Back to cited text no. 9
10.Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA 2005;294:1534-40.  Back to cited text no. 10
11.Cowgill SM, Al-Saadi S, Villadolid D, Arnaoutakis D, Molloy D, Rosemurgy AS. Upright, supine, or bipositional reflux: Patterns of reflux do not affect outcome after laparoscopic Nissen fundoplication. Surg Endosc 2007;21:2193-8.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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