Diagnoss of Extra Oesophageal Reflux.docVIP

Diagnosis of Extra Oesophageal Reflux (EOR) There is a lack of specificity and sensitivity in the test methodologies available for diagnosing EOR. There is no consensus or standardisation of tests or diagnostic criteria, there is large inter-clinical variability, and often the same tests are used for EOR as for GORD. Differential diagnosis of EOR from GORD Currently, the diagnosis of EOR involves a combination of methods: Symptoms 24-hour dual-probe pH monitoring Laryngoscopy Reflux Symptom Index (RSI) Reflux Finding Score (RFS) Anatomic diagnostic protocol Other 1. Symptoms The most commonly reported symptoms specific to EOR are listed in Table 1 in approximate order of incidence. Table 1 – Common symptoms of EOR (in approximate order of incidence, according to Belafsky PC, et al, 2002) Chronic dysphonia Dysphagia Intermittent dysphonia Globus pharyngeus Vocal fatigue Heartburn Voice breaks Regurgitation Chronic throat clearing Airway obstruction Excessive throat mucus Paroxysmal laryngospasm Postnasal drip Wheezing Chronic cough ? The Reflux Symptom Index (RSI) can be given to patients to assess the presence and degree of symptoms. 2. 24-hour dual probe pH monitoring The most commonly used and most sensitive test for detection of acid reflux is ambulatory 24-hour pH monitoring. This measures the number of times (or overall percentage of time) period that the pH in the oesophagus is below 4 during a 24-hour. However, this may not be adequate or relevant for the diagnosis of EOR, as it is the gastric refluxate that comes into contact with the larynx, which causes the damage. The larynx may be more sensitive to the pepsin found in gastric contents than to the low pH. This is particularly relevant as pepsin is active at pH 5.0,[Dobhan R, 1993] and is not irreversibly inactivated until subjected to pH 6.5 [Panetti M, 2001] and can be as high as pH 8.0 [Piper DW, 1965]. A more relevant diagnostic test should include measurements at pH 5 in the phary