LPR testing.docx

LPR testing.docx

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LPRtesting

Laryngopharyngealrefluxtesting.

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Abstract

Refluxtestingisstillevolvingasnewtechnology.Newcriteriafordeterminationofclinicalandsubclinicalsubclinical /sub·clin·i·cal/（sub-klin´i-k'l）withoutclinicalmanifestations.

sub·clin·i·cal

adj.

Notmanifestingcharacteristicclinicalsymptoms.Usedofadiseaseorcondition. laryngopharyngealrefluxaresurfacing.ThetechniqueandinterpretationofpHmonitoring,thecurrentgoldstandard,arestillsomewhatcontroversial.Theauthors'experienceandopinionsarepresentedherein.

Introduction

Testingforlaryngopharyngealreflux（LPRSeeLPR/LPD.

lpr-Lineprinter.TheUnixprintcommand.Thisdoesnotactuallyprintfilesbutrathercopies（orlinks）themtoaspoolareafromwhereadaemoncopiesthemtotheprinter.

.....Clickthelinkformoreinformation.）caninvolvesixdifferentmodalities:

（1）thelaryngeallaryngeal /lar·yn·ge·al/（lah-rin´je-al）pertainingtothelarynx.

la·ryn·geal orla·ryn·gal

adj.

Of,relatingto,affecting,ornearthelarynx. examination,

（2）ambulatory24-hourdouble-probe（simultaneousesophagealandpharyngealpharyngeal /pha·ryn·ge·al/（fah-rin´je-al）pertainingtothepharynx.

pha·ryn·geal orpha·ryn·gal

adj.

Of,relatingto,locatedin,orcomingfromthepharynx.）pHmonitoring,（3）esophagealmanometryEsophagealmanometry

Atestinwhichathintubeispassedintotheesophagustomeasurethedegreeofpressureexertedbythemusclesoftheesophagealwall.

Mentionedin:

Achalasia,（4）esophagoscopyoresophagography,（5）laryngealsensorytesting,and（6）intraluminalimpedancemonitoring.Thesemodalitiesarenotequallyimportant.Impedancemonitoringisstillnewenoughthatitsvalueisasyetundetermined.

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WhenapatienthassymptomsthatsuggestLPR,theclinicianshouldperformacompleteotolaryngologicexaminationandfiberopticlaryngoscopy.TheclinicianshouldalsoconsiderpHmonitoringandascreeningexaminationoftheesophagus.

LPRisbestdiagnosedbyambulatory24-hourdouble-probepHmonitoring.（1,2）Bariumesophagography,radionucleotidescanning,theBernsteinacidperfusiontestacidperfusiontest

n.

SeeBernsteintest.,andesophagoscopywithbiopsyareoftennegativeinLPRpatients.ThisisprobablybecausemostLPRpatientsdonotdevelopesophagitisesophagitis /esoph·a·gi·tis/（e-sof?

ah-ji´tis）inflammationoftheesophagus.

chronicpepticesophagitis refluxe.

.....Clickthelinkformoreinformation.,whichistypicallyobservedingastroenterologypatientswithgastroesophagealrefluxdiseasegastroesophagealrefluxdisease（GERD）

Disordercharacterizedbyfrequentpassageofgastriccontentsfromthestomachbackintotheesophagus.SymptomsofGERDmayincludeheartburn,coughing,frequentclearingofthethroat,anddifficultyinswallowing. （GERDGERD gastroesophagealrefluxdisease.

GERD

abbr.

gastroesophagealrefluxdisease

GERD ）.TraditionaldiagnostictestsforGERDareoftenfalselynegativeinLPR.（1,2）

pHmonitoring

Ambulatory24-hourdouble-probepHmonitoring（pH-metry）isbothhighlysensitiveandspecificforLPR.（2-5）Infact,itissuperiortoanyotherdiagnosticmodality,includingbariumswallowbariumswallow

n.

SeeupperGIseries.

Bariumswallow

Bariumisusedtocoatthethroatinordertotakex-raypicturesofthetissuesliningthethroat.,endoscopyendoscopy

Examinationofthebody'sinteriorthroughaninstrumentinsertedintoanaturalopeningoranincision,usuallyasanoutpatientprocedure.Endoscopesincludetheuppergastrointestinalendoscope（fortheesophagus,stomach,andduodenum）,thecolonoscope（forthe,andsingle-probeesophagealpHtesting,inthediagnosisofLPR.Furthermore,pH-metryrevealsthepatternofreflux（figure1）50thatsubsequenttreatmentcanbecustom-tailoredtoeachpatient.

（2）Forexample,ifapatientdoesnothavesupinenocturnalreflux,elevationoftheheadofthebedneednotberecommended.Yet,despitethefactthatpH-metryisconsideredthegoldstandardforLPRtestinginotolaryngologicpractice,thereisnoconsensuswithrespecttothenumberofpHsensors,theirlocation,ortheinterpretationofresults.

（2）

Importanceofthepharyngealprobe.Theimportanceofthepharyngealsensorcannotbeoveremphasized.Whenthepharyngealprobeispositive,itisdiagnosticforLPR.（1,2）KatzshowedinasmallnumberofLPRpatientsthatrelianceononlyanesophagealprobecanresultinfalse-negativeresults.（6）

Areviewofaconsecutiveseriesof334pharyngeal-positivepHstudiesatourcenterdemonstratedthat126（38%）hadnormalesophagealacidexposuretimesintheesophagealprobe.（5）InotherwordsAdv.1.inotherwords-otherwisestated;"inotherwords,wearebroke"

putdifferently,theesophagealexposuretimeswereinthenormalrange,butsomeesophagealrefluxesophagealreflux

n.

Seegastroesophagealreflux. reachedthepharynxpharynx （fâr`ĭngks）,areaofthegastrointestinalandrespiratorytractswhichliesbetweenthemouthandtheesophagus.Inhumans,thepharynxisacone-shapedtubeabout41-2in.（11.43cm）long..Therefore,ifonlyasingle-probeesophagealstudyhadbeenperformedinthatgroup,38%wouldhavebeenfalselyassumednottohaveLPR.Similarlyinthepediatricpediatric /pe·di·at·ric/（pe?

de-at´rik）pertainingtothehealthofchildren.

pe·di·at·ric

adj.

Oforrelatingtopediatrics. population,Littleetalshowedthat78of168children（46%）withpH-documentedLPRhadnormalesophagealacidexposuretimes.（7）Itisclearthatmeasuringesophagealacidexposuredoesnotallowustomakeanyassumptionsconcerningthepresenceorabsenceofpharyngealreflux.

Onepointofclarificationforthereaderisneededhere.Inthestudiescitedabove,pharyngealrefluxoccurredinthefaceofnormalesophagealparameters.However,bydefinition,eachpharyngealrefluxeventwasprecededbyanesophagealrefluxevent.Afterall,therefluxatemusttraversetheesophagustoreachthepharynx.Butinthesituationdescribedabove,thepercentageoftimeofesophagealacidexposureand/orthetotalnumberofesophagealrefluxeventsfellwithinthenormalrange.If,forexample,a24-hourstudyshowedatotalofjust25esophagealrefluxevents,thatwouldbeconsiderednormal（inourlaboratory,upto51refluxeventsper24hoursisnormal）.Butifsomeofthoseesophagealrefluxeventsreachedthepharyngealprobe,thepatientwouldbediagnosedashavingLPR--thatis,refluxintothepharynx.AbnormalesophagealrefluxbypHmonitoringdoesnotimplyLPR;conversely,normalesophagealrefluxbypHmonitoringdoesnotruleitout.

Webelievethattheproximalprobeshouldbeplacedinthepharynxandnotintheupperesophagus（figure2）,ashasbeensuggestedbysome.ProximalesophagealrefluxdoesnotnecessarilycorrelatewithLPR.（8-10）TomeasurethegastricpHandextrapolateextrapolate-extrapolation thosedatatoimplyGERDisclearlyinvalid.Similarly,usingesophagealpHdata（evenataproximalesophageallocation）toprovethepresenceorabsenceofLPRisinvalid,becausetheupperesophagealsphincterTheupperesophagealsphincter（UES）referstothesuperiorportionoftheesophagus.

Unliketheloweresophagealsphincter,itiscomprisedofstriatedmuscleandisunderconsciouscontrol. （UESUESUNE（UniversityofNewEngland） EconomicsSociety

UESUpperEastSide（Manhattan,NY）

UESUpperEsophagealSphincter

UESUnifiedEnergySystemsofRussia

UESWaukesha,Wisconsin）functionsasthefinalbarrieragainstLPR.InnormalsandGERDpatients,experimentalacidinstillationintotheesophagusincreasestheUESrestingpressure,therebyenhancingitseffectivenessasabarriertoLPR.（11）

Esophagealmanometry.EsophagealmanometryisthepreferredmethodofguidingpHprobeplacement.Itisourcontentionthattheuseofmanometrymanometry /ma·nom·e·try/（-e-tre）themeasurementofpressurebymeansofamanometer.

analmanometry ratherthandirectvisualplacementisvitaltoensuringaccurateplacementofpHprobes.（1,2,12）Theavailablenormativedataforrefluxintheesophagusarederivedfromstandarddistalprobeplacement5cmabovetheloweresophagealsphincterloweresophagealsphincter

n.

Aringofsmoothmusclefibersatthejunctionoftheesophagusandstomach.Alsocalledcardiacsphincter. （LES）.EvensmalldegreesofvariancefromthispositioncanresultinsignificantchangesintheresultsobtainedfromtheesophagealpHprobe.Iftheprobeisnotintheproperposition,noreliableconclusionsregardingesophagealacidexposuredatacanbemade.

Usingvisualplacementtopositiontheproximalprobeinthehypopharynx（justabovetheUES）isanaccuratemethod（figure3）.（12,13）However,whenonedoesso,thefixeddistancebetweentheproximalanddistalsensorsoftheprobemeansthatthedistalprobeisplacedinanunknownpositioninreferencetotheLES.（12）Therefore,theesophagealacidexposuredatacannotbeinterpretedasnormalorabnormal.

ManometrynotonlyaccuratelylocatestheUESandLES,butitalsoallowsforevalua