Observational Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 28, 2024; 30(48): 5162-5173
Published online Dec 28, 2024. doi: 10.3748/wjg.v30.i48.5162
Link between pharyngeal acid reflux episodes and the effectiveness of proton pump inhibitor therapy
Yen-Yang Chen, Chen-Chi Wang, Chun-Yi Chuang, Yung-An Tsou, Yen-Chun Peng, Chi-Sen Chang, Han-Chung Lien
Yen-Yang Chen, Yen-Chun Peng, Division of Gastroenterology, Taichung Veterans General Hospital, Taichung 402, Taiwan
Chen-Chi Wang, Department of Otolaryngology, Taichung Veterans General Hospital, Taichung 402, Taiwan
Chen-Chi Wang, Yen-Chun Peng, Han-Chung Lien, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
Chen-Chi Wang, School of Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung 402, Taiwan
Chun-Yi Chuang, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
Chun-Yi Chuang, Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung 402, Taiwan
Yung-An Tsou, Department of Otorhinolaryngology-Head and Neck Surgery, China Medical University Hospital, Taichung 400, Taiwan
Chi-Sen Chang, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tungs’ Taichung Metro Harbor Hospital, Taichung 435, Taiwan
Han-Chung Lien, Division of Gastroenterology, Center for Functional Esophageal Disorders, Taichung Veterans General Hospital, Taichung 402, Taiwan
Han-Chung Lien, Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
Author contributions: Lien HC had full access to all of the data in the study and takes responsibility for the integrity and accuracy of the data and analysis; Chen YY and Lien HC performed the literature search and wrote the manuscript; Lien HC and Wang CC contributed to the study design; Chen YY, Wang CC, Chuang CY, Tsou YA, Peng YC, Lien HC, and Chang CS provided administrative, technical, or material support; Chen YY, Lien HC, and Wang CC were involved in data acquisition, data interpretation, and statistical analysis; Lien HC and Chang CS were involved with the critical revision of the manuscript for important intellectual content and study supervision; All authors have reviewed and approved the final manuscript.
Supported by the Taiwan’s National Science and Technology Council, No. MOST 111-2314-B-005-004-MY2.
Institutional review board statement: The study was approved by the Taichung Veterans General Hospital’s Institutional Review Board.
Informed consent statement: Informed consent was obtained from all subjects.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Data sharing statement: The technical appendix, statistical code, and dataset are available from the corresponding author at: lhc@vghtc.gov.tw.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Han-Chung Lien, MD, PhD, Associate Professor, Director, Division of Gastroenterology, Center for Functional Esophageal Disorders, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard, Section 4, Taichung 435, Taiwan. lhc@vghtc.gov.tw
Received: July 27, 2024
Revised: September 17, 2024
Accepted: October 22, 2024
Published online: December 28, 2024
Processing time: 125 Days and 6.1 Hours
Abstract
BACKGROUND

Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.

AIM

To investigate whether PAR episodes alone predict a positive response to PPI therapy.

METHODS

Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.

RESULTS

A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, n = 11), followed by EAR alone (59%, n = 68), both pH (+) (56%, n = 18), and both pH (-) (33%, n = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold (P = 0.008), 4.2-fold (P = 0.0002), and 3.4-fold (P = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.

CONCLUSION

In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.

Keywords: Pharyngeal acid reflux episodes; Laryngopharyngeal reflux; Hypopharyngeal multichannel intraluminal impedance-pH; 3-pH-sensor; Proton pump inhibitors

Core Tip: This study examines the link between pharyngeal acid reflux (PAR) episodes and the effectiveness of proton pump inhibitor (PPI) therapy in laryngopharyngeal reflux (LPR) patients. Using specific potential of hydrogen (pH) criteria for PAR episodes detected by hypopharyngeal multichannel intraluminal impedance-pH, researchers found that patients with ≥ 2 baseline PAR episodes had a significantly higher response rate (73%) to PPI therapy compared to those without acidic reflux (33%). These findings underscore the importance of hypopharyngeal reflux monitoring, as PAR episodes appear to be crucial in predicting PPI efficacy. Hence, the authors recommend a personalized approach to LPR diagnosis and treatment in order to enhance patient outcomes.