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.