Oropharyngeal pH Testing Does Not Predict Response to Proton Pump Inhibitor Therapy in Patients with Laryngeal Symptoms

Abstract

Introduction Predicting response to proton-pump inhibitor (PPI) therapy in patients with laryngeal symptoms is challenging. The Restech Dx-pH probe is a transnasal catheter that measures oropharyngeal pH. In this study, we aimed to investigate the prognostic potential of oropharyngeal pH monitoring to predict responsiveness to PPI therapy in patients with laryngeal symptoms. Methods We conducted a physician blinded prospective cohort study at a single academic institution between 1/2013–10/2014. Adult patients with Reflux Symptom Index scores (RSI) ≥13 off PPI therapy were recruited. Patients underwent video laryngoscopy and 24-hour oropharyngeal pH monitoring, followed by an 8–12 week trial of omeprazole 40 mg daily. Prior to, and following PPI therapy, patients completed various symptom questionnaires. The primary outcome was the association between PPI response and oropharyngeal pH metrics. PPI response was separated into three subgroups based on post-treatment RSI score and % RSI response: Non-response = RSI ≥ 13; Partial response = post-treatment RSI < 13 and change in RSI < 50%; and Complete response = post-treatment RSI < 13 and change in RSI ≥ 50%. The primary analysis utilized a multinomial logistic regression controlling for pre-treatment RSI score. A secondary analysis assessed the relationship between change in RSI (post-pre) and oropharyngeal pH metrics via ordinary least square regression. Results Thirty-four patients completed the study and were included in final analysis. Symptom response to PPI therapy was as follows: 50% no response, 15% partial-response and 35% complete-response. Non-responders had a higher pre-treatment RSI (P < 0.01). There were no significant differences in oropharyngeal acid exposure (below pH of 4.0, 5.0, 5.5, 6.0 and RYAN scores) between responder types. The secondary analysis noted a trend between lower PPI response and greater total percent time below pH of 5.0 (P = 0.03), upright percent time below pH of 5.0 (p = .07) and RYAN supine (corrected) (P = 0.03), as well as an association between PPI response and greater decreases in the Anxiety Sensitivity Inventory (P < 0.01), Brief Symptom Inventory-18 (P < 0.01), and Negative Affect Scale (P < 0.01). Discussion Oropharyngeal pH testing did not predict laryngeal symptom response to PPI therapy. Contrary to hypothesis, our study signaled that the degree of oropharyngeal acid exposure is inversely related to PPI response. In addition, reduction in negative affect and psychological distress parallels PPI response.

The application of 24-hour pharyngeal pH-monitoring and Reflux Finding Score and Reflux Symptom Index questionnaires in the diagnostics of laryngopharyngeal reflux

“…Such use of these questionnaires was the main conclusion in the papers published so far, which was confirmed in many other studies, e.g. by Vailati et al [5], Reichel et al [6], and Yadlapati et al [7] and does not raise any doubts. However, regardless of the above, Belafsky reported also reference values that would indicate the occurrence of LPR on the basis of 95% confidence intervals of two control groups consisting of 40 (RFS scale) and 25 people (RSI scale), respectively.…”

Evaluating the yield of gastrointestinal testing in pediatric patients in aerodigestive clinic

“…35,36 PPI have not been shown to be consistently effective for anything other than GI tract inflammation. 12,29,30,37 With limited radiographic risk and a relative low cost, the data also supports continued use of the UGI to evaluate for suspected anatomic abnormalities in this specific high-risk aerodigestive population. We propose re-evaluating routine aerodigestive use of pH-MII due to its lower yield rate and additional cost ( Table 5).…”

Response to Song et al.

“…We thank you for the opportunity to respond to the comments of Song and colleagues 12 We agree that although the reflux symptom index (RSI) questionnaire is commonly used in clinical research to examine symptom severity, the RSI has several shortcomings as an outcome metric. The RSI is a cumulative score based on throat symptoms and heartburn.…”