Marys Medicine

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SMU Medical Journal, Volume – 1, No. 1, January 2014
cartilages to diffuse laryngeal edema and hyperemia with granuloma formation and airway obstruction. Pseudosulcusvocalis is a pattern of subglottic edema that extends from the anterior commissure to the posterior part of the larynx. Ventricular obliteration is a common finding seen in approximately 80% of the cases. True vocal cord edema may be of mild to severe grading. Hypertrophy of the posterior commissure is another frequent finding . Posterior commissure hypertrophy ( PCH ) is graded as mild when there is moustache like appearance of the posterior commissure mucosa, moderate when the posterior commissure mucosa is swollen enough to create a straight line across the posterior aspect of the larynx. PCH is graded as severe when there is bulging of the posterior part of the larynx into the airway. Lymphoid hyperplasia ( cobble stoning ) of pharyngeal mucosa with palatal and uvular edema may occasionally be seen. SMU Medical Journal, Volume – 1, No. 1, January 2014

Dual probe pH monitoring:
Though there are telltale signs of LPR which is visible on laryngeal examination, yet these findings are nonspecific. The gold standard modality for the diagnosis of LPR is 24 hours pH monitoring with dual probe.3 The distal probe is placed 5 cm above the lower esophageal sphincter and the proximal probe is placed in the hypopharynx 1cm above the upper esophageal sphincter. The recording is done in an upright position and in supine position.The most important parameter for diagnosis of GERD is the percentage of time the pH at the distal probe is less than 4. For upright position the upper limit of normal is 8.5% and in supine position it is approximately 2.5%.Reflux recorded at the proximal probe is diagnostic of LPR.
Bravo pH monitoring:
It is a wireless pH recording system where a small implantable capsule adheres to the esophageal mucosa and transmits the intraluminal data to a small receiver that the patient carries.
The major disadvantage with the pH recording systems is their inability to detect non acidic reflux that occurs in the absence of pH changes.
Newer methods to detect non acidic duodenogastro-esophageal reflux:
Bilitec 2000
It is an useful method to measure bile contents in the esophagus using the Bilitec SMU Medical Journal, Volume – 1, No. 1, January 2014
sensor.(Bilitec 2000; Synectics Medical, Stockholm, Sweden )4 Intraluminal impedance measurement:
This new technique is based on the demonstration of fluid or gas in the esophagus by changes in electrical conductance across electrodes placed in the esophageal lumen. Addition of a pH probe to the system allows detection of both acidic and non acidic reflux.5 Life style modification with changes in dietary habits is required. Foods like fatty meal, citrus fruits, tomato based products, coffee, chocolate and alcohol needs to be avoided. Weight reduction is required in overweight patients.
ACID SUPPRESSIVE THERAPY:
Use of proton pump inhibitors ( PPI ) is recommended at a higher twice daily dosing as it has been shown that they are more efficacious in early healing of lesions and preventing relapses when compared with histamine 2 antagonists.PPI should be continued for about 8 – 12 weeks. Omeprazole, lansaprazole, pantoprazole and esomeprazole have been found to be equally effective. It should be borne in mind that children of 1 -5 years age group have a higher metabolic rate of the PPIs and as such higher doses per kg body weight is often required in children more than 1 year age. 1. Dent J, DoddsWJ,Friedman RH et al, Mechanism of gastroesophageal refluxing recumbent asymptomatic human subjects, J Clin Invest 1980; 65; 256 -67. 2. Sutphen JL, Dillard VL. Effects of maturation and gastric acidity on gastroesophageal reflux in patients. Am J Dis Child 1986; 140: 1062 - 1064 3. Jecker P, Orloff LA, Mann WJ. Extra esophageal reflux and upper aerodigestive tract diseases. ORL J OtorhinolaryngolRelat Spec 2005;67; 185 - 91 4. Orel R, Vidmer G. Do acid and bile reflux into the esophagus simultaneously? Temporal relation between duodenogastro- esophageal reflux and esophageal pH.PaedtrInt 2007; 49: 226 – 231.
5. Welz TG, Moroder C, Trachterna M et al. Esophageal pH monitoring and impedance measurement: a comparison of diagnostic tests for gastroesophageal reflux. J PediatrGastroenterolNutr 2002; 34: 519 - 523 6. Ballenger's Otorhinolaryngology Head and Neck Surgery, 1185-93, 16thed, BC Decker SMU Medical Journal, Volume – 1, No. 1, January 2014
KEY NOTES:
· LPR is a common disorder and its manifestations are varied.
· Esophageal pH monitoring with dual probe is the gold standard investigation.
· Life style and dietary modifications with acid suppression therapy is the primary modality of treatment.
SMU Medical Journal, Volume – 1, No. – 1, January, 2014, PP. 54 – 59
2014, SMU Medical Journal

Source: http://medjournal.smu.edu.in/articles/6.pdf