Case 1
A 65-year-old patient was referred to the Reflux consultation of the Elsan Polyclinic (Poitiers) for a chronic history of belching, postnasal drip, dysphonia, globus and heartburn. The nasofiberoptic examination found posterior commissure hypertrophy and arytenoid erythema. The history of the patient included refractory gastroesophageal reflux disease (GERD), while the gastrointestinal (GI) endoscopy reported Hill 2 hiatal hernia and esophagitis (grade A). Regarding the laryngopharyngeal complaints and the previous resistance to proton pump inhibitors (PPIs), a HEMII-pH testing (Versaflex-Z®, Medtronic, Europe) was realized to confirm the diagnosis. The HEMII-pH was composed of 8 impedance segments and 2 pH electrodes. The catheter model used was introduced transnasally and considered the esophageal length of patient (GI endoscopy/manometry). Six impedance segments were placed along the esophagus zones (Z1 to Z6) and they were centered at 19, 17, 11, 9, 7 and 5cm above the lower esophagus sphincter (LES). Two additional impedance segments were placed 1 and 2 cm above the upper esophagus sphincter (UES) in the hypopharyngeal cavity. The two pH electrodes were placed 2 cm above LES and 1-2 cm below UES. The probe was fixed to an external electronic data recorder that monitors the esophageal pH. The association between symptoms and reflux episodes was studied: patient recorded the time of meals and the occurrence of key symptoms (belching, globus and heartburn) through the HEMII-pH device. The patient came back 24-hour after the placement of HEMII-pH catheter to remove it. He reported the occurrence of dysphagia 2 hours after the probe placement. The removal of the probe was associated with nose pain and the otolaryngologist discovered a distal probe node (Figure 1). The HEMII-pH tracing analysis showed a correct functioning of the system during the first hour of the testing period before the occurrence of several belching episodes, which were reported by the patient through the device. At this time, some parasites appeared in the tracing, reflecting the node formation (Figure 2). The rest of the recording confirmed the nonacid LPR diagnosis through the recording of the proximal probes, which were not impacted by the node. The patient consent was obtained for the publication.