Name: simultaneous laryngopharyngeal and conventional esophageal ph monitoring
Uploaded: 2020-12-14T12:30:00
Description: Watch this Scientific Journal Video about Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring at JoVE.com

The authors would like to thank Restech for providing an educational grant.

The following study protocol was reviewed and approved by the Ethics Committee of the Medical Faculty of the University of Cologne.
NOTE: Ensure that the patient arrives NPO for the following gastrointestinal function testing. Perform a high-resolution manometry to determine the exact location of the lower esophageal sphincter (LES) and to rule out esophageal dysmotility disorders such as achalasia. The patient should be off antisecretory medication for at least 7 days prior to ensure a valid ...

<ol>
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V., Kahrilas, P., Dent, J., Jones, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Montreal+definition+and+classification+of+gastroesophageal+reflux+disease:+a+global+evidence-based+consensus.">The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.</a> American Journal of Gastroenterology. 101 (8), 1900-1920 (2006).</li><li>Issing, W. J., Karkos, P. D., Perreas, K., Folwaczny, C., Reichel, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dual-probe+24-hour+ambulatory+pH+monitoring+for+diagnosis+of+laryngopharyngeal+reflux.">Dual-probe 24-hour ambulatory pH monitoring for diagnosis of laryngopharyngeal reflux.</a> Journal of Laryngology &amp; Otology. 118 (11), 845-848 (2004).</li><li>Smit, C. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ambulatory+pH+measurements+at+the+upper+esophageal+sphincter.">Ambulatory pH measurements at the upper esophageal sphincter.</a> Laryngoscope. 108 (2), 299-302 (1998).</li><li>Worrell, S. G., DeMeester, S. R., Greene, C. L., Oh, D. S., Hagen, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pharyngeal+pH+monitoring+better+predicts+a+successful+outcome+for+extraesophageal+reflux+symptoms+after+antireflux+surgery.">Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery.</a> Surgical Endoscopy. 27 (11), 4113-4118 (2013).</li><li>Ayazi, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+technique+for+measurement+of+pharyngeal+pH:+normal+values+and+discriminating+pH+threshold.">A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold.</a> Journal of Gastrointestinal Surgery. 13 (8), 1422-1429 (2009).</li><li>Becker, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+agreement+analysis+and+day-to-day+comparison+of+pharyngeal+pH+monitoring+with+pH/impedance+monitoring+in+patients+with+suspected+laryngopharyngeal+reflux.">First agreement analysis and day-to-day comparison of pharyngeal pH monitoring with pH/impedance monitoring in patients with suspected laryngopharyngeal reflux.</a> Journal of Gastrointestinal Surgery. 16 (6), 1096-1101 (2012).</li><li>Wilhelm, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pharyngeal+pH+monitoring+in+gastrectomy+patients+-+what+do+we+really+measure.">Pharyngeal pH monitoring in gastrectomy patients - what do we really measure.</a> United European Gastroenterology Journal. 4 (4), 541-545 (2016).</li><li>Mazzoleni, G., Vailati, C., Lisma, D. G., Testoni, P. A., Passaretti, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Correlation+between+oropharyngeal+pH-monitoring+and+esophageal+pH-impedance+monitoring+in+patients+with+suspected+GERD-related+extra-esophageal+symptoms.">Correlation between oropharyngeal pH-monitoring and esophageal pH-impedance monitoring in patients with suspected GERD-related extra-esophageal symptoms.</a> Neurogastroenterology &amp; Motility. 26 (11), 1557-1564 (2014).</li><li>Fuchs, H. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simultaneous+laryngopharyngeal+pH+monitoring+(Restech)+and+conventional+esophageal+pH+monitoring-correlation+using+a+large+patient+cohort+of+more+than+100+patients+with+suspected+gastroesophageal+reflux+disease.">Simultaneous laryngopharyngeal pH monitoring (Restech) and conventional esophageal pH monitoring-correlation using a large patient cohort of more than 100 patients with suspected gastroesophageal reflux disease.</a> Dis Esophagus. 31 (10), (2018).</li><li>Fuchs, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Refluxassoziierte+Ver&#228;nderungen+des+Rest&#246;sophagus+nach+&#214;sophagektomie+und+Magenhochzug+-+Funktionsdiagnostik+im+Langzeitverlauf+bei+Patienten+mit+&#214;sophaguskarzinom+mit+einem+neuen+Instrument.">Refluxassoziierte Ver&#228;nderungen des Rest&#246;sophagus nach &#214;sophagektomie und Magenhochzug - Funktionsdiagnostik im Langzeitverlauf bei Patienten mit &#214;sophaguskarzinom mit einem neuen Instrument.</a> Zeitschrift f&#252;r Gastroenterologie. 54 (08), 436 (2016).</li><li>Jamieson, J. 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Esophageal pH monitoring is commonly used to confirm the diagnosis of GERD in patients with typical reflux symptoms. However, many patients present, in addition to typical reflux symptoms, with atypical reflux symptoms such as cough or hoarseness most likely related to LPR. Current guidelines suggest an empiric trial with PPIs to proof a reflux related origin of those symptoms and a standardized objective measurement is lacking2. Laryngopharyngeal pH testing, due to its location above the upper es...

Gastroesophageal reflux disease (GERD) is one of the most common benign diseases affecting up to 20% of people in western countries1. In addition to typical symptoms such as heartburn or regurgitation, some patients may suffer from atypical symptoms such as cough, hoarseness, or asthma2,3. Despite the agreement that chronic cough, chronic laryngitis, and asthma can have a reflux related origin and are significantly associated with laryngopharyngeal reflux (LPR), the exact pathomechanism still remains unclear. As these symptoms are usually part of a multifactorial process, they depict a great diagnostic and therapeutic challenge4.
Distal esophageal pH monitoring 5 cm above the lower esophageal sphincter is commonly used to determine abnormal esophageal acid exposure in patients with suspected GERD2. In an attempt to use the same technique, proximal conventional pH monitoring was introduced in the late 1990s as a diagnostic device to measure abnormal acid exposure at the upper esophageal sphincter (UES) as the probe is placed at or slightly above the UES. However, this method does not always provide valid and accurate results as the probe is not designed for an oropharyngeal environment leading to the measurement of invalid artifacts such as pseudoreflux events caused by drying out of the probe5,6.
Lately, laryngopharyngeal pH monitoring was introduced as a new diagnostic device specifically designed to measure acid exposure in the oropharynx, as the probe is placed above the UES slightly lateral to the uvula (Figure 1). Since previous research has shown it to have a positive predictive value of 80% for a successful outcome after antireflux surgery in patients with primarily atypical symptoms, this new tool has been a valuable addition to the diagnostic pathway in selected patients. Its tear drop sensor is equipped with an antimony technology that detects liquid and aerosolized acid and does not need direct mucosal contact to measure valid results. In addition, the sensor can, in contrast to proximal pH monitoring, resist drying out which may lead to more reliable results7,8.
Current literature on the correlation of concomitant conventional esophageal and laryngopharyngeal pH measurement is sparse. Previous studies either included only a small number of patients or did not perform both measurements simultaneously9,10,11. We recently published data on the correlation between both pH measurements in a large cohort of 101 patients with suspected GERD. We concluded that laryngopharyngeal and esophageal pH measurement do not necessarily need to correspond due to the existence of a variety of different reflux scenarios12. We furthermore developed a human reflux model with patients following esophagectomy and reconstruction with a gastric interposition showing 100% correlation between both pH monitoring methods in volume-refluxers13.
Here, we aim to provide instructions for simultaneous pH measurement using distal esophageal and laryngopharyngeal pH monitoring. In addition, guidance on analysis of composite acid exposure scores and correlation between results obtained by both methods is given. We furthermore present the newest data of a large patient cohort evaluated using simultaneous esophageal and laryngopharyngeal pH monitoring.

<table>
	<tbody>
		<tr>
			<td>AA Battery</td>
			<td>-</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td>Calibration Solutions pH 4 and 7</td>
			<td>Medtronic</td>
			<td></td>
			<td>part of the Digitrapper Reflux Testing system</td>
		</tr>
		<tr>
			<td>CR 1632 Lithium coin cell battery</td>
			<td>-</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td>Digitrapper pH &#38; Impedance catheter</td>
			<td>Medtronic</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Digitrapper Recorder</td>
			<td>Medtronic</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Gelicain</td>
			<td>PUREN</td>
			<td></td>
			<td>topical gel</td>
		</tr>
		<tr>
			<td>Hydration vials with clear water</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>Leukoplast</td>
			<td>BSN medical GmbH</td>
			<td></td>
			<td>surgical tape</td>
		</tr>
		<tr>
			<td>Restech Dx pH probe</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>Restech Recorder</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>Restech Transmitter</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>Screwdriver</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>SD Card plus Adapter</td>
			<td>Respiratory Technology Corporation</td>
			<td></td>
			<td>part of the Restech Dx pH system</td>
		</tr>
		<tr>
			<td>tongue depressor</td>
			<td>NOBAMED</td>
			<td></td>
			<td>wooden</td>
		</tr>
	</tbody>
</table>

simultaneous laryngopharyngeal and conventional esophageal ph monitoring

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, hoarseness or asthma, which can be caused by laryngopharyngeal reflux (LPR). Due to their multifactorial origin, those symptoms can be a great diagnostic and therapeutic challenge. Esophageal pH-monitoring is commonly used to determine abnormal esophageal acid exposure and confirm the diagnosis of GERD. However, for better evaluation of acid exposure above the upper esophageal sphincter, a new laryngopharyngeal pH measurement system is now available and may lead to more reliable results in patients with predominantly extraesophageal symptoms. This article aims to present a standardized protocol for simultaneous pH measurement using esophageal and laryngopharyngeal pH probes in order to obtain acid exposure scores from both measurements.

A total of 181 patients were evaluated using the previously described standardized protocol. Results of the first 101 patients have been previously published12. The following data depicts an extension of the previously published cohort, however, evaluated using the new software for analyzation of results obtained by laryngopharyngeal pH testing15. Demographic data is depicted in Table 1. All patients presented with atypical symptoms including chronic cough,...

Watch this Scientific Journal Video about Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring at JoVE.com

Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring

Laryngopharyngeal pH monitoring has been specifically designed to measure acid exposure above the upper esophageal sphincter and complements diagnostic evaluation in patients that present with mainly extraesophageal reflux symptoms. Patients with suspected laryngopharyngeal reflux (LPR) were evaluated using distal esophageal and laryngopharyngeal pH testing simultaneously.

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, ...

Our protocol facilitates a comprehensive evaluation of acid exposure in a very challenging patient cohort with atypical GERD symptoms. In addition, it provides guidance on complementary laryngopharyngeal and esophageal pH monitoring. Different thresholds and probe locations make comparing both methods challenging.Our protocol facilitates simultaneous performance of esophageal and laryngopharyngeal pH monitoring and provides guidance on results analysis. Before beginning the analysis, calibrate the esophageal catheter in a solution with pH of 4 and a solution with pH of 7, rinsing the probe in water between solutions. To calibrate the laryngopharyngeal probe, select study and Hydrate in the laryngopharyngeal pH monitoring software and briefly agitate the laryngopharyngeal probe tip in clear water, then press any round key to start the laryngopharyngeal probe hydration process.When the probes have been calibrated, with the patient in the upright position, and looking forward, provide the patient with a small glass of water with a straw to assist swallowing and insert the esophageal probe straight into the patient's nose. Use the measuring scale on the probe shaft to position the probe 5 centimeters above the lower esophageal sphincter as previously determined by high resolution manometry. When the probe is in place, loop over the ear and use surgical tape to secure the probe to the cheek as close to the nares as possible, using tape to affix the probe behind and below the ear lobe.To place the laryngopharyngeal catheter, insert the probe straight into the other nostril posteriorly. When the probe is in place, the red light will be clearly visible, lateral to, or slightly below the uvula. Use surgical tape to secure the probe as close as possible to the nare and use a clip to secure the transmitter to the patient's clothing.When both probes are in place, simultaneously start the esophageal and laryngopharyngeal pH studies, selecting a 24-hour study for the laryngopharyngeal pH measuring device, then give the patient a diary and ask them to detail their meal times, exact times of supine periods, and any symptoms that they experienced during the study. At the end of the analysis, simultaneously press the two buttons located in the middle of the esophageal device until upload later appears on the display. To end the laryngopharyngeal pH study, simultaneously press the cough, escape, and heartburn buttons until complete appears on the display, then remove the tape and gently remove both catheters.To analyze the esophageal pH study data, connect the esophageal catheter device to a computer and upload the data into the appropriate analysis software program. Manually enter the patient data and information from the patient diary and delete any button presses that might have accidentally been performed by the patient during the study period, then use important parameters and thresholds from the report such as the composite score the total upright and supine percent pHs below baseline and the number of events to determine an abnormal esophageal acid exposure. To analyze the laryngopharyngeal pH study data, insert the SD card from the laryngopharyngeal catheter device into the computer and open analysis software.Click Retrieve to upload the study. Left-click and drag on the graph to highlight the area of interest to select the respective event. Delete any button presses that might have accidentally been performed by the patient during the study period, then use important parameters and thresholds to determine an abnormal oropharyngeal acid exposure.In this representative analysis, a total of 181 patients were evaluated as demonstrated. All of the patients presented with atypical symptoms, including chronic cough, hoarseness, sore throat, or pharyngeal burning. In addition, most patients suffered from typical GERD symptoms, such as regurgitation, heartburn and dysphagia.A normal oropharyngeal acid exposure obtained by laryngopharyngeal pH testing was defined as a RYAN score of less than 9.4 upright and/or less than 6.8 supine. A normal esophageal pH test result was defined as a DeMeester score of less than 14.72. Abnormal oropharyngeal acid exposure was observed in 76 patients more frequently in the upright position, with 72 patients demonstrating an abnormal RYAN score upright compared to nine patients in supine position.A normal oropharyngeal test result was reported for 105 patients. Most important for this protocol is the correct probe placement, with the esophageal probe being placed 5 centimeters above the LES and the oropharyngeal probe being placed lateral to the uvula.

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