Role of Measuring Proximal Reflux Events in the Evaluation of Patients with Upper Esophageal/Pharyngeal Symptoms: 69

Purpose: Upper esophageal/pharyngeal symptoms such as hoarseness and chronic cough are commonly attributed to gastroesophageal reflux. There is an increasing demand from ENT physicians to assess the presence of proximal reflux events. It is unknown if these symptoms are related to reflux. Whether identifying these events will confirm reflux as a cause of these symptoms is unknown. Objective: To determine 1) whether a higher rate of proximal reflux events is found in patients with upper esophageal/pharyngeal symptoms compared to patients with lower esophageal symptoms and 2) whether there is less evidence of reflux by number of reflux events or acid exposure on pH/impedance testing in patients with upper esophageal/pharyngeal symptoms than those with lower symptoms as might be expected if upper symptoms are unrelated to reflux. Methods: A retrospective review of pH/Impendence studies in a single center between May 2010 and November 2011 was performed. Subjects with mixed symptoms (upper and lower) were excluded. A positive reflux test was defined as greater than expected time of esophageal acid exposure and/or number of reflux events. Results are presented as mean ± standard deviation (SD). A student t-test was used to compare means of ordinal variables and linear regression was used to assess correlation between proximal symptoms and proximal events. Results: Eighty-nine patients met the study criteria. Demographics: mean age 46.4 ± 16.3; 40.4% of the subjects were male. 44.9% were on no proton pump inhibitor (PPI), 18% on daily dose PPI and 37.1% on double dose PPI. Of the 89 patients, 23 (26%) had upper symptoms and 65 (74%) had lower symptoms. There was no difference in demographics with respect to gender, age or medication in these two groups. Comparison of reflux events in the two groups is shown in Table 1. A logistic regression model showed no correlation between proximal symptoms and proximal reflux events. Even the subset of patients with a high upper symptom index (>0.5) failed to show a significantly greater number of proximal reflux events. Overall, abnormal pH/ Impedance testing was seen in 56.6% of patients with upper symptoms compared to 55.1% in patients with lower symptoms (P=0.53).Table 1: Comparison of reflux eventsConclusion: Since the rate of a positive reflux test was similar in patients with upper and lower symptoms, our data suggest that upper symptoms are part of a reflux complex but the lack of correlation of proximal reflux events and upper esophageal/pharyngeal symptoms indicates that these symptoms are not related directly to increased acid exposure in upper esophagus. Measurement of the frequency of proximal reflux events does not add any useful information to a standard pH/impedance study.