[Dysphagia] Pediatric aspiration problems

[eripley at yahoo.com (Irene Campbell-Taylor)]

It seems all to easy to assign recurrent respiratory problems in children to direct aspiration of oropharyngeal contents while the majority are actually due to aspirated reflux (pneumonitis). It seems that a great deal of emphasis os placed on "negative" Gi examinations, even pH monitoring. Little et al, found startling results on double probe pH monitorint in which while few children showed reflux on the lower probe, many showed reflux at the upper probe. This seems to be counter-intuitive but must be kept in mind as an explanation for recurrent respiratory problems that appear to be due to direct aspiration but may not be:
Diagnosis of Pediatic Laryngopharyngeal Reflux
by Double-Probe pH Monitoring:
Why The Pharyngeal Probe is Essential 
J.P. Little, MD *, B.L. Matthews, MD *, M.S. Glock, MD **,
Jamie Koufman, MD *, D. Berry, MD **, and W. Chwals, MD ***

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ABSTRACT 

Although laryngopharyngeal reflux (LPR) has been implicated in the etiology of many pediatric respiratory and airway diseases, the incidence and pathophysiology of LPR in these conditions remain unknown. Until the advent of pH monitoring, LPR was most commonly a clinical and radiographic diagnosis. Although tests such as radionuclide scanning and barium esophagography are specific, they lack sensitivity. 

Using 24-hour double-probe pH monitoring (pH-metry) we studied 130 children. The pharyngeal (upper) probe was placed 1 cm above the upper esophageal sphincter (behind the laryngeal inlet), and the esophageal (lower) probe was placed approximately 4 cm above the lower esophageal sphincter. 

Sixty-eight percent (89/130) of the entire study population had abnormal pH-metry. Of those with abnormal studies, 51% (45/89) had abnormal reflux documented by the lower probe, and 93% (83/89) had pharyngeal reflux documented by the upper probe. While only 7% (6/89) had esophageal reflux alone, 49% (44/89) had pharyngeal reflux alone.

 In other words, half of the patients with abnormal pH studies had documented pharyngeal reflux in the face of normal total acid exposure times in the esophageal probe. 

 

We conclude that LPR is underestimated, that pharyngeal pH monitoring is the most sensitive diagnostic test for LPR, and that control of LPR appears to be essential in the successful management of many pediatric patients with airway and respiratory diseases. 

Center For Voice Disorders of Wake Forest University



Dr I Campbell-Taylor
Clinical Neuroscientist
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