Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms

Abstract

INTRODUCTION: Among patients with chronic laryngeal symptoms, ambulatory reflux monitoring off acid suppression is recommended to evaluate for laryngopharyngeal reflux (LPR). However, reflux monitoring systems are diverse in configuration and monitoring capabilities, which present a challenge in creating a diagnostic reference standard in these patients. This study aimed to compare diagnostic yield and performance between reflux monitoring systems in patients with chronic laryngeal symptoms. METHODS: This multicenter, international study of adult patients referred for evaluation of LPR over a 5-year period (March 2018–May 2023) assessed and compared diagnostic yield of pathologic gastroesophageal reflux (GER+) on ambulatory reflux monitoring off acid suppression. RESULTS: Of 813 patients, 296 (36%) underwent prolonged wireless pH, 532 (65%) underwent 24-hour pH-impedance monitoring, and 15 (2%) underwent both tests. Overall diagnostic yield for GER+ was 36% and greater for prolonged wireless pH compared with that for 24-hour pH-impedance monitoring (50% vs 27%; P < 0.01). Among 15 patients who underwent both prolonged wireless pH and 24-h pH-impedance monitoring, concordance between systems for GER+ was 40%. The most common source of discordance was strong evidence of GER+ across multiple days on prolonged wireless pH compared with no evidence of GER+ on pH-impedance. DISCUSSION: In this multicenter international study of patients with chronic laryngeal symptoms referred for LPR evaluation, diagnostic yield of ambulatory reflux monitoring off acid suppression was 36% and rose to 50% when using wireless pH monitoring. In patients referred for chronic laryngeal symptoms, 24-hour pH-impedance monitoring may risk a low negative predictive value in patients with unproven GER+ disease.

Diagnostic Value of Fasting and Bedtime Saliva Pepsin Measurements in Laryngopharyngeal Reflux

“…The clinical diagnosis of LPR is challenging regarding the non-specificity of symptoms and signs and the low therapeutic success rate of empirical treatment [15][16][17][18][19]. HEMII-pH is considered as the most reliable tool, but this approach remains expensive and poorly tolerated by patients [8].…”

Review article: Diagnosis and management of laryngopharyngeal reflux

“…In a recently published multicentre study of 813 patients with chronic laryngeal symptoms, investigators identified higher diagnostic yield of pathological GERD on prolonged wireless pH monitoring compared to 24 h impedance-pH, even when taking into account non-acidic and weakly acidic reflux events identified on impedance-pH monitoring. 50 Another complicating factor is that the presence of conclusive GERD on reflux monitoring does not necessarily attribute GERD as the aetiology of symptoms. 12 Overall, ambulatory reflux monitoring is a key diagnostic test in evaluating patients with LPR.…”

Update on extraesophageal manifestations of gastroesophageal reflux

“…The choice of reflux testing for LPR may, therefore, entail balancing between prolonged monitoring to increase sensitivity (wireless pH), shorter study with additional nonacidic information (catheter-based MII-pH), and pharyngeal-focused monitoring with less standardized distal data (HEMII-pH). In a recent multicenter international study, wireless pH monitoring outperformed MII-pH and HEMII-pH in identifying abnormal reflux in patients with chronic laryngeal symptoms [25 ▪ ]. However, the definition for abnormal reflux utilized in the study was based on criteria from the Lyon consensus [26], which was established for typical reflux symptoms with focus on acid reflux, rather than specifically for EER.…”