Synopsis of key/new findings
Gastroesophageal reflux disease (GERD) and LPR are caused by the reflux
of gastric contents and mainly treated with PPI therapy despite some
differences in the clinical presentation and treatment
modalities.13 Most otolaryngologists prefer empirical
PPI therapy during 1~3 months,14,15and patients with LPR are expected to respond to acid suppression
therapy of sufficient dose and duration. However, PPIs would not be
effective when nonacid components of refluxate lead to
LPR.16 Alternative treatments, such as alginate and
magaldrate, are recommended but are not as commonly used as PPI.
Therefore, in this study, we analyzed reflux characteristics in patients
with suspected LPR treated with high-dose PPIs twice for at least 2
months prospectively.
MII-pH monitoring is a more objective diagnostic tool compared to
symptomatic or laryngeal tools for diagnosing LPR.17However, many otolaryngologists do not frequently use MII-pH because of
patient inconvenience and lack of tolerance, unclear indications, and a
perceived lack of benefit for LPR management.15Empirical PPI treatment without an objective diagnosis using 24-h MII-pH
monitoring in patients with suspected LPR can lead to prolonged
treatment, high cost, and refractory progression despite long-term
treatment. The responder rates after treatment during 2 months and total
medication periods were significantly higher in patients with LPR than
in those with no reflux according to the all proximal reflux episodes in
the 24-h MII-pH monitoring. The use of 24-h MII-pH monitoring in
patients with suspected LPR could be an important tool, probably because
of its cost effectiveness and provision of symptomatic relief compared
to empirical PPI therapy.
In addition, MII-pH monitoring includes parameters to systematically
identify reflux in patients with LPR. All reflux time, longest reflux
time, and reflux type at the hypopharynx and lower esophageal sphincter
can provide detailed information about the reflux, but there is no
standard for interpreting these parameters. Thus, we aimed to identify
parameters showing differences between patients with LPR responding well
and those refractory to PPI therapy. In this study, patients with LPR
responding well to PPI therapy showed higher values in proximal MII
parameters compared to those with LPR refractory to PPI therapy although
there were no significant differences in proximal reflux episodes
between two groups.
Additionally, we hypothesized that the ROC curve might help find
appropriate cut-off values of proximal all reflux time and proximal
longest reflux time to predict responders with LPR. We compared
sensitivity and specificity according to each cut-off value in the two
ROC curves. The sensitivity plus specificity was higher for the cut-off
value of proximal all reflux time than for that of proximal longest
reflux time (1.317 vs. 1.291). Thus, the cut-off value
(>0.000517%) of proximal all reflux time was an
appropriate value to predict responders with LPR despite the low
sensitivity (47.5%) in this study. We know that 0.000517% of 24 h is
equivalent to 44.67 s. In other words, patients with LPR showing
proximal all reflux time of more than 45 s can be expected to respond
well to PPI therapy.