Skip to main content
    • Aa
    • Aa

Impact of different pH thresholds for 24-hour dual probe pH monitoring in patients with suspected laryngopharyngeal reflux

  • O Reichel (a1) and W J Issing (a2)

The gold standard test for laryngopharyngeal reflux is 24-hour pH monitoring, which determines the reflux area index with a pH threshold of less than four (i.e. the reflux area index four). However, refluxed pepsin is able to cause laryngeal injury at pH levels above five.

Study design:

Prospective study.

Materials and methods:

In order to establish normative values for a reflux area index with a pH threshold of less than five (i.e. the reflux area index five), 29 healthy volunteers underwent pH monitoring. In 45 patients with suspected laryngopharyngeal reflux, reflux area index four and reflux area index five were determined by pH study.


In healthy volunteers, the reflux area index five was 72.6 (95th percentile). In 29 of 44 patients, laryngopharyngeal reflux was diagnosed due to a reflux area index four of greater than 6.3. However, the reflux area index five revealed laryngopharyngeal reflux in six more patients.


For exact analysis of pH monitoring results, two pH thresholds (less than four and less than five) must be considered. Further studies with a larger number of healthy volunteers are necessary in order to reveal normative values for the reflux area index five parameter.

Corresponding author
Address for correspondence: Dr Oliver Reichel, Department of Otorhinolaryngology, Head and Neck Surgery, Ludwig Maximilians University Munich, Klinikum Grosshadern, Marchionini-Strasse 15, 81377 Munich, Germany. Fax: +49 89 70 95 68 69 E-mail:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1 KW Altman , RM Stephens , CS Lyttle , KB Weiss . Changing impact of gastroesophageal reflux in medical and otolaryngology practice. Laryngoscope 2005;115:1145–53

2 JA Koufman , GJ Weiner , CW Wallace , DO Castell . Reflux laryngitis and its sequelae. J Voice 1988;2:78–9

3 O Reichel , H Hagedorn , A Berghaus . Diagnosis and treatment of laryngopharyngeal reflux. Laryngorhinootologie 2006;85:919–24

4 PD Karkos , JA Wilson . Empiric treatment of laryngopharyngeal reflux with proton pump inhibitors: a systematic review. Laryngoscope 2006;116:145–8

5 DA Vincent , JD Garrett , SL Radionoff , LA Reussner , CR Stasney . The proximal probe in esophageal pH monitoring: development of a normative database. J Voice 2000;14:247–54

6 DW Piper , BH Fenton . pH stability and activity curves of pepsin with special reference to their clinical properties. Gut 1965;6:506–8

8 N Johnston , J Knight , PW Dettmar , MO Lively , J Koufman . Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope 2004;114:2129–34

9 J Knight , MO Lively , N Johnston , PW Dettmar , JA Koufman . Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope 2005;115:1473–8

10 PC Belafsky , GN Postma , JA Koufman . Validity and reliability of the reflux symptom index (RSI). J Voice 2002;16:274–7

11 PC Belafsky , GN Postma , JA Koufman . The validity and reliability of the reflux finding score (RFS). Laryngoscope 2001;111:1313–17

12 CF Smit , J Tan , PP Devriese , LM Mathus-Vliegen , M Brandsen , PF Schouwenberg . Ambulatory pH measurements at the upper esophageal sphincter. Laryngoscope 1998;108:299302

14 DT Book , JS Rhee , RJ Toohill , TL Smith . Perspectives in laryngopharyngeal reflux: an international survey. Laryngoscope 2002;112:1399–406

15 CF Milstein , S Charbel , DM Hicks , TI Abelson , JE Richter , MF Vaezi . Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope). Laryngoscope 2005;115:2256–61

16 SG Tuttle , F Ruffin . The physiology of heartburn. Ann Intern Med 1961;55:292300

17 JM DelGaudio . Direct nasopharyngeal reflux of gastric acid is a contributing factor in refractory chronic rhinosinisitis. Laryngoscope 2005;115:946–57

19 A Tasker , PW Dettmar , M Panetti , JA Koufman , JP Birchall , JP Pearson . Is gastric reflux a cause of otitis media with effusion in children? Laryngoscope 2002;112:1930–4

20 T Adhami , JR Goldblum , JE Richter , MF Vaezi . The role of gastric and duodenal agents in laryngeal injury: an experimental canine model. Am J Gastroenterol 2004;99:2098–106

21 GA Gill , N Johnston , A Buda , M Pignatelli , J Pearson , PW Dettmar Laryngeal epithelial defences against laryngopharyngeal reflux: investigations of e-cadherin, carbonic anhydrase isoenzyme III, and pepsin. Ann Otol Rhinol Laryngol 2005;114:913–21

22 N Johnston , D Bulmer , GA Gill , M Panetti , PE Ross , JP Pearson Cell biology of laryngeal epithelial defences in health and disease: further studies. Ann Otol Rhinol Laryngol 2003;112:481–91

23 N Johnston , PW Dettmar , MO Lively , GN Postma , PC Belafsky , M Birchall Effect of pepsin on laryngeal stress protein (Sep 70, Sep 53, and Hsp 70) response: role in laryngopharyngeal reflux disease. Ann Otol Rhinol Laryngol 2006;115:4758

24 PC Belafsky , MF Vaezi , K DeVault . Treatment of chronic throat symptoms with PPIs should be preceded by pH monitoring. Debate. Am J Gastroenterol 2006;101:611

25 MF Vaezi , JE Richter , CR Stasney , JR Spiegel , RA Iannuzzi , JA Crawley Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope 2006;116:254–60

26 MR Amin , GN Postma , P Johnson , N Digges , JA Koufman . Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg 2001;125:374–8

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The Journal of Laryngology & Otology
  • ISSN: 0022-2151
  • EISSN: 1748-5460
  • URL: /core/journals/journal-of-laryngology-and-otology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 1
Total number of PDF views: 9 *
Loading metrics...

Abstract views

Total abstract views: 60 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 30th May 2017. This data will be updated every 24 hours.