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Testing for Reflux Opening Doors to Improved Treatment

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Joel H. Blumin, MD, discusses the treatment algorithm for laryngopharyngeal reflux.

The management of reflux has long been a challenge because an empiric approach directed by an algorithm is most commonly used, but the development of objective testing is helping to collect data to change treatment.

Two speakers reviewed the evolution of diagnosis, the current state of testing, and the potential of future developments during a September 21 Instruction Course, “Reflux Testing in Otolaryngology: What You Need to Know.”

The algorithm for management and assessment of laryngopharyngeal reflux (LPR) often leads to the use of proton pump inhibitors (PPIs) following an empiric therapeutic trial of lifestyle, diet and PPI therapy. If symptoms do not resolve, a definitive assessment and monitoring can be ordered.

PPIs have been a staple of treatment because they compare favorably to the benefits, risks, inconvenience, and cost of testing, but that is changing, said Joel H. Blumin, MD, lead instructor of the course and a professor in the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin.

Assessment options include using a reflux symptom index, a disease evaluation, or a reflux finding score. Testing options can include imaging or the patient swallowing a pH probe, which is invasive and only provides a snapshot of the time when it is in the body, Dr. Blumin said.

That left PPI therapy as a safe option, but studies showed its use was “far from perfect” and often was used too long. Other alternatives to PPIs include a variety of products such as Gaviscon advance, apple cider vinegar, papaya pills, deglycyrrhinized licorice, GutsyGum, and lifestyle adjustments, such as weight loss.

The lack of success in management of reflux led to the development of new testing options such as dual pH multichannel intraluminal impedence (pH-MII) testing, barium swallows, a pH monitoring system using an esophageal capsule with a wireless transmitter, and a trans-nasal pharyngeal probe, Dr. Blumin said,

A promising option that is in the development stage is testing for pepsin, which is a digestive enzyme that is made only in the stomach and is an excellent marker for the presence of stomach contents, he said. The test uses western blotting to detect pepsin in tissue biopsies and oral, otic, or nasal secretions.

Among those test options, the new gold standard for reflux detection is dual pH-MII, said Jonathan M. Bock, MD, associate professor in the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin. Benefits of dual pH-MII testing include:

  • Adding impedance testing to detect liquid reflux, not just acid
  • Ability to detect GERD and LPR, both acidic and weakly acidic, and non-acid
  • Detecting liquid, vapor, and mixed phases
  • Distinguishing between anterograde (swallowing and eating) and retrograde (reflux) bolus movement
Jonathan M. Bock, MD, shows the position of a probe used in dual pH-MII.

Jonathan M. Bock, MD, shows the position of a probe used in dual pH-MII.

In addition, the development of new single probes with pharyngeal pH and impedence sensors increases patient comfort. The sensors have the ability to do complex symptom association assessments, Dr. Bock said.

The procedure requires a nurse or nurse practitioner to assist. In addition, the patient stops the use of PPIs for one week before the procedure and a reflux symptom index is performed.

Dr. Bock walked through the probe placement procedure, which follows nasal anesthesia and includes a large sip of water to aid swallowing. When the probe is properly placed, it is secured to the nose, cheek, and behind the ear with tape. The patient wears the probe for 24 hours and the data is recorded.

A DeMeester score is used for data interpretation, which includes reflux time, the number of episodes greater than five minutes, the longest episode, and the total episodes. Computer software is used generate a report, he said.

Studies of the pH-MII testing for impedence correlate well with salivary testing for pepsin as a marker for reflux, Dr. Bock said.

“We are getting more normative data, and we really think this is adding interesting data to a challenging clinical problem,” he said.

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