Reflux (Acid, Non-Acid, Mixed Types) in Neonates & How It May Also Apply to Adults

A study was published this month in the journal Pediatric Research which described reflux characteristics in neonates, but the findings can certainly be applied to adults as well.

What I found gratifying about this study was not so much that reflux was evaluated, but what measurements obtained by 24 hour pH-impedance were taken which apply just as much to adults as neonates. Just exactly what was measured and what did the study find (at least in neonates suspected of having reflux)?

• Only 54% of reflux events was associated with symptoms

• Defined by physical characteristics of reflux events:

• 51.3% were liquid
• 29.1% were gas
• 19.6% were mixed

• Defined by chemical characteristics of the reflux events:

• 48.5% were acidic
• 51.5% were non-acidic

• Defined by how high the reflux traveled away from the stomach:

• 79.2% reached the throat/mouth level
• 20.8% stayed in the chest level

Although these findings are specific for neonates, adults experience similar problems, though precise numbers are probably different and need more study.

Laryngopharyngeal reflux is when reflux reaches the throat level. Depending on the chemical characteristics of the reflux (acid vs non-acid as well as how high it goes), the symptoms may be quite variable. NON-acid reflux is considered "silent" and patients may not experience any symptoms of heartburn. Rather, common symptoms include:

• Phlegmy throat
• Chronic cough
• Swollen sensation in the throat (globus)
• Chronic throat-clearing

These results point out another issue... Common medications used to treat reflux (zantac, pepcid, nexium, prilosec, prevacid, etc) only treats ACID reflux. Not NON-acid reflux.

As such, other modalities must be pursued to address symptomatic non-acid reflux beyond medications involving lifestyle changes including diet as well as surgery.

Whether it be babies or adults, characterization of the spatial-temporal-physical-chemical nature of reflux events as defined by pH-impedance methods offers the best chance of evaluating and treating symptoms due to reflux.

Or in more simplistic terms...

NOT ALL REFLUX IS ACID!!!

NOT ALL REFLUX CAUSES HEARTBURN!!!

Reference:
Significance of gastroesophageal refluxate in relation to physical, chemical, and spatiotemporal characteristics in symptomatic intensive care unit neonates. Pediatr Res. 2011 Aug;70(2):192-8.

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New Webpage on Peritonsillar Abscess Added to Website

Our office has created a new webpage on the evaluation and treatment of peritonsillar abscess.

Peritonsillar abscess is when a pus collection develops behind the tonsil causing a severe sore throat and trouble swallowing.

Read more on how this condition is treated here.

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R&B Singer R. Kelly Undergoes Peritonsillar Abscess Drainage

Reuters on July 20, 2011 reported that R&B singer R. Kelly suffered from a peritonsillar abscess that required emergency drainage.

Peritonsillar abscess is when a pus collection develops within the tonsil causing it to swell. This may occur over a period of 24 hours resulting in a severe sore throat and trouble swallowing. This condition is in contrast to tonsillitis which is when the tonsil itself is infected, but no pus collection is present.

On exam, the affected tonsil may be huge crossing the midline (see picture). The uvula often is pushed to the opposite side and the soft palate may be asymmetrically huge as well.

Treatment is immediate incision and drainage. In an adult, this can be easily performed in the clinic after adequate local anesthesia. The pus is allowed to drain out and the patient often feels much improved within 12 hours. Antibiotics and a short burst of steroids is often prescribed afterwards.

Read the story here.

Read more about peritonsillar abscess management here.

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New Video on Esophageal Manometry and 24 Hour Multi-Channel pH and Impedance Testing

Our office has created a new video describing what a patient goes through when they undergo esophageal manometry as well as 24 hour multi-channel pH and impedance testing.

This test is often ordered when a patient is suspected to be suffering from reflux, whether acid or non-acid, or is possibly suffering from abnormal muscle activity of the esophagus.

Symptoms that a patient may experience that may lead to such testing include:

- phlegmy throat
- lump sensation in the throat
- chronic throat clearing
- chronic cough
- difficulty swallowing

Watch the video here!

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What is Considered a Normal Number of Reflux Episodes?

Depending on whether one is talking about GERD (gastroesophageal reflux disease) or LPR (layrngopharyngeal reflux), I believe the answer is completely different.

As it pertains to GERD and what literature, doctor, or testing equipment is used, 73 plus or minus some change is what is considered a normal number of reflux episodes a typical adult may experience in a 24 hour period of time.

What exactly does this number mean? This number describes how many times stuff in the stomach regurgitates up into the esophagus which is the tube that carries food down to the stomach after food is swallowed.

The reason why heartburn is not initially experienced is because the lining of the esophagus has a protective layer preventing acid damage. However, once the number of reflux episodes goes higher than 80, the protective layer breaks down and acid damage starts to occur leading to typical symptoms of heartburn and/or chest pain.

Now what about laryngopharyngeal reflux (LPR)?

I would argue that even ONE episode is not normal if symptomatic. (Also see references below.)

LPR is when stomach contents regurgitate up to the level of the voicebox. At its most basic limited definition, LPR is a near-vomit (vomit being stomach contents that reach the mouth level and beyond). The only difference between LPR and vomit is the volume of regurgitation and location it reaches.

When such regurgitation reaches the voicebox level, a number of symptoms occur, even if it happens one single time.

First, when LPR occurs, the throat feels phlegmy leading the patient to throat-clear the mucus up and out or to re-swallow.

Second, when enough LPR episodes occur, the mucosal lining of the voicebox region starts to get irritated that may lead to a chronic cough. At its worst, it may lead to vocal cord dysfunction and even laryngospasm. Some episodes may even be aspirated into the lungs leading to bronchitis and reactive airway disease.

Third, the sphincter (upper esophageal sphincter) that separates the esophagus from the voicebox may start to tighten which is the body's way of attempting to prevent further reflux from reaching the voicebox. Such muscle tightening may lead to symptoms of difficulty swallowing with food getting stuck at the voicebox level as well as lump in throat sensation (globus).

Heartburn is not very common with LPR (though it may occur) as one needs to remember that there is a protective barrier preventing acid damage to the mucosal lining.

Also, non-acid reflux may be present rather than acid reflux. With non-acid reflux, heartburn symptoms are not as common due to lack of acid presence that would lead to damage (though other factors are present including bile, enzymes, etc).

Given even a single episode of LPR can be considered abnormal if symptomatic, many studies will come back NORMAL due to timing. A barium swallow typically does not take more than a few minutes to perform done during business hours. Same goes for upper endoscopy. BUT... what if the few episodes of LPR occur in the evening or early morning NOT when the studies are performed?

As such, what I consider the BEST study to evaluate for LPR is a 24 hour multi-channel pH and impedance testing. This test looks for reflux during a continuous 24 hour period of time. If it sees reflux, it records what time, how long it lasts for, how high does the reflux go up, what the pH level is, etc. BRAVO or single or dual-probe pH studies are inadequate as they measure ONLY whether acid GERD is occurring or not. These alternative tests can not evaluate for LPR or non-acid reflux.

BOTTOM LINE

With GERD, up to around 73 episodes of reflux is considered normal.

With LPR, even a single episode can be considered abnormal if symptomatic. Check out references below.

Watch a video I made below showing a patient who is experiencing a non-acid LPR episode during an examination. This patient had a normal upper endoscopy, normal pH study, and normal barium swallow. Look at all the frothy mucus that is bubbling up to and around his voicebox leading to his complaint of phelgmy throat and chronic cough/throat-clearing. Treatment was surgery (nissen fundoplication).

References:

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg. 2012 Jan;16(1):16-24; discussion 24-5. Epub 2011 Oct 28.

Gastroesophageal and laryngopharyngeal reflux detected by 24-hour combined impedance and pH monitoring in healthy Chinese volunteers. J Dig Dis. 2011 Jun;12(3):173-80. doi: 10.1111/j.1751-2980.2011.00502.x.

The importance of the number of reflux episodes in the diagnosis of laryngopharyngeal reflux disease. Otolaryngol Head Neck Surg. 2013 Feb;148(2):261-6. doi: 10.1177/0194599812466534. Epub 2012 Nov 2.

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ICD-10 Coding Primer for Otolaryngologists

If you are a physician... you probably already know what I am talking about...

ICD is the "International Statistical Classification of Diseases and Related Health Problems" used by physicians to code a given medical problem whenever a patient sees a doctor. This "code" is what is submitted to insurance companies along with medical charges.

Periodically, ICD undergoes an update and in the United States, it is about to undergo a MAJOR update come October 1, 2013 to version ICD-10-CM. The current ICD being used in the Unites States is ICD-9-CM.

What are these changes as it relates to otolaryngolgists?

First the basics:

Differences in organization & structure, code composition, and level of detail.
ICD-9-CM	ICD-10-CM
Consists of three to five characters First digit is numeric or alpha (E or V) Second, third, fourth, and fifth digits are numeric Always at least three digits Decimal placed after the first three characters	Consists of three to seven characters First digit is alpha All letters used except U Second and third digits are numeric Fourth, fifth, sixth, and seventh digits can be alpha or numeric Decimal placed after the first three characters

ICD-10-CM codes may consist of up to seven digits, with the seventh digit extensions representing visit encounter or sequelae for injuries and external causes.

ICD-9-CM Code Format	ICD-10-CM Code Format

SO... here are some examples of how the code changes from ICD-9-CM to ICD-10-CM:

Diagnosis	ICD-9-CM	ICD-10-CM
Right Earwax	380.4	H61.21
Left Earwax	380.4	H61.22
Bilateral Earwax	380.4	H61.23
Unspec Earwax	380.4	H61.20
Right Acute Otitis Externa	380.1	H60.311
Left Acute Otitis Externa	380.1	H60.312
Bilateral Acute Otitis Externa	380.1	H60.313
Unspec Acute Otitis Externa	380.1	H60.319

As you can see, what used to be a single code like 380.4 for earwax is now split into as many as 4 different codes based on side. Such increased specificity goes across the board for pretty much every diagnosis.

ICD-10-CM has numerous other new features allowing for a greater level of specificity and clinical detail.

• Combination codes for conditions and common symptoms or manifestations
• Combination codes for poisonings and external causes
• Added laterality
• Added extensions for episode of care
• Expanded codes (injury, postoperative complications)
• Expanded detail relevant to ambulatory and managed care encounters
• Changes in timeframes specified in certain codes
• External cause codes no longer a supplementary classification

ICD-10-CM also includes added standard definitions for two types of excludes notes. Excludes1 indicates not coded here. The code being excluded is never used with the code. The two conditions cannot occur together. For example, B06 Rubella [German measles] has an Excludes1 of congenital rubella (P35.0).

Excludes2 indicates not included here. The excluded condition is not part of the condition represented by the code. It is acceptable to use both codes together if the patient has both conditions. For example, J04.0, Acute laryngitis has an Excludes2 of chronic laryngitis (J37.0).

An additional feature is the expansion of codes for certain conditions like postoperative complication codes. Here's one if you accidentally leave behind a neuro paddy in the nose after sinus surgery causing nasal obstruction:

• T81.524 codes for "obstruction due to foreign body accidently left in body following endoscopic examination"

Code extensions (seventh character) have been added for injuries and external causes to identify the encounter: initial, subsequent, or sequela. The extensions are:

• A Initial encounter
• D Subsequent encounter
• S Sequelae

So that's a primer on how ICD-10-CM coding WILL affect otolaryngologists. A lot more time will be spent on coding than now.

The American Academy of Family Physicians has produced a superbill comparing ICD-9 and ICD-10. What took only 2 pages with ICD-9 will take up 9 pages once ICD-10 goes into effect. Sigh!

Click for ICD-9 and ICD-10 Superbill

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Zenker's Diverticulum Endoscopic Treatment Confusion

Having treated many patients with Zenker's Diverticulum using the endoscopic approach, I've had many confused patients ask me how the diverticulum is treated if it is not removed.

For those unfamiliar with this disorder, click here for more information.

The basic concept of treating this rare disorder is that there is a common wall that divides the esophagus from the diverticulum pouch. This common wall is endoscopically divided such that the pouch now becomes the new back wall of the esophagus. So when the patient swallows, food/liquids can no longer get "trapped" causing symptoms.

Still confused? Here are some picture illustrations...

When endoscopically exposed, the pouch is denoted by the arrow.

When looking through the scope placed into the mouth down into the throat, there is a common wall that is between the pouch (blue arrow) and esophagus (green arrow).

Endoscopically, whether using a stapler or laser, this wall is divided down the middle. This picture shown below is when a stapler is used.

Here is the side view before and after common wall division:

After the procedure, any food/liquid substances that are swallowed can't be trapped in the pouch. Therefore, even though nothing is surgically removed, the patient's swallowing symptoms completely disappear.

Hopefully, this explanation helps clear up any confusion of what exactly happens!

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New Video Produced on How/What a Normal Swallow Looks Like

Our office has produced a new video on what/how a normal swallow looks like from BOTH an x-ray as well as endoscopic view. In order to best illustrate the swallowing mechanism, a modified barium swallow test is shown. The video has been uploaded to our YouTube channel and can be watched here.

Watch the video below as well as the slow motion action of what the epiglottis does from the inside during a swallow!

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Pediatric ENT Care of Warrenton, Virginia (Fauquier County)

Recently, there has been some confusion regarding whether our office deals with adults only or do we see kids as well... Strangely enough, we also get asked by parents whether our office sees adults when seeing a pediatric patient.

To clear up any confusion, our office does see kids AND adults... starting from birth to the elderly.

Dr. Chang who joined the office in October 2005, was named one of America's Top Physicians by the Consumer's Research Council of America in 2008 as well as a Northern Virginia Top Doctor for 2011 (to be published in February 2011).

Some common problems and procedures for which Dr. Chang sees kids specifically include:

- Tongue Tie Release (starting from ONE DAY OLD!)
- Tonsillectomy
- Adenoidectomy
- Sinus Surgery starting with adolescents
- Ear Tube placement
- Hearing Loss
- Nasal Obstruction
- Nasal Congestion
- Snotty Nose
- Speech Delay
AND many other issues...

Our office has even created videos on a few common pediatric procedures including tonsillectomy, adenoidectomy, earwax removal, ear tubes placement. Watch the video below on tonsillectomy.

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Bone Drugs May Increase Risk of Throat Cancer

Well, at least that is what USA Today reported on September 3, 2010 with the title "Bone drugs may raise throat cancer risk". In actuality, bone drugs like boniva, fosamax, actonel, etc may possibly increase the risk of esophageal cancer which is actually not "throat cancer" and is in fact treated by a totally different specialty than ENT who is historically considered the throat expert.

Really, the specialty to see regarding esophageal cancer are the gastroenterology doctors or a general surgeon.

In any case, the study published in JAMA found that when taking bone drugs, the risk of developing esophageal cancer (not throat) was 2 in 1,000. Normally, the risk of developing cancer of the esophagus in people aged 60 to 79 is 1 in 1,000.

The increase is not that staggering. Not even close. I call it a "blip" of an increase.

Read the USA Today story here.

Read the JAMA research abstract here.

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Should Boys Also Get Vaccinated for HPV?

NPR on Aug 20, 2010 aired a story whether boys should also get vaccinated for HPV. It is well established that vaccines like Gardasil (FDA approved for boys last year) and Cervarix protect against two of the HPV types (HPV-16 and HPV-18) that can cause cervical cancer and some other genital cancers including anal, vulvar, vaginal, and penile cancers.

However, it may potentially prevent other types of HPV related disorders (NOT mentioned in the NPR story) involving the head & neck in both men and women, including:

Respiratory Papillomas (benign)
Throat Cancer
Oral Cancer (tongue, tonsil, salivary gland)
Oral ulcers/lesions/warts (benign)

According to epidemiological studies, there has been a dramatic increase in cancer involving the salivary glands and tongue attributed to HPV and were of squamous, acinar, and mucoepidermoid morphologic types. This increase in oral cavity cancer has occurred mainly in the 10-40 years age group and suspected to be secondary to increased acceptance of oral-genital sexual practices.

What is my personal feeling on whether boys should get vaccinated? I believe the answer is yes.

In order to receive the beneficial effect of the vaccine, the vaccine needs to be given in 3 doses (at $130 per dose) ideally between ages 9-26.

Read the NPR article here.

References:
Cancer of the oral cavity and pharynx in young females: increasing incidence, role of human papilloma virus, and lack of survival improvement. Semin Oncol. 36 (5), 451-9.

Prevention of human papillomavirus infections and associated diseases by vaccination: a new hope for global public health. Public Health Genomics. 12 (5-6), 319-30.

The epidemiology behind the HPV vaccine discovery. Ann Epidemiol. 19 (4), 239-44.

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Coffee Decreases Risk of Head & Neck Cancer

Researchers at University of Utah found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Read a CNN report on this here.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev, June 22, 2010; 1055-9965.

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New Video on Botox Injection for Spasmodic Dysphonia

A new video has been created and uploaded to our practice YouTube Channel describing botox injection for spasmodic dysphonia.

Two views are shown in the video... the first is what a patient sees as well as another view of what it looks like from inside the throat. Check it out!



Dr. Chang performs botox injections for spasmodic dysphonia every Friday afternoon. He also performs botox injections for facial wrinkles, torticollis, migraine headaches, TMJ, etc. Click here to see the full list.

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Machine Gun Sneezing

ABC News on November 11, 2009 aired a story about a 12 year old girl with an unfortunate condition called "machine gun sneezing". Apparently, she sneezes up to 16 times a minute all day except while sleeping and started after recovering from a mild cold.

To be frank, it's a condition I've never seen before.

Per an allergist interviewed for this story, the condition is extremely rare and "can be triggered by hundreds of causes, including allergies, sinus problems, or growths in the nasal passage."

Read more here. A video of the report can also be found at the link.

This girl was eventually found to have a diagnosis called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)! Read more here.

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WSJ: FDA Approves Gardasil for Boys (and Girls)!

This was reported by the Wall Street Journal on Oct 16, 2009. Why is this significant from an ENT perspective?

Well, gardasil is supposed to vaccinate people from getting HPV related diseases like genital warts which would help both genders when individuals become sexually active. Of more note, it has been specifically shown to help prevent cervical cancer in females which is a big killer of women.

However, it may potentially prevent other types of HPV related disorders involving the head & neck in both men and women (which has not been studied, but likely to still help), including:

Respiratory Papillomas (benign)
Throat Cancer
Oral ulcers/lesions/warts (benign)

In order to receive the beneficial effect of the vaccine, the vaccine needs to be given in 3 doses (at $130 per dose) between ages 9-26.

Read the WSJ article here.

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