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Background: Chronic cough can be caused by direct exposure of gastric refluxates to the aerodigestive tract. The treatment outcome has been conflicting due to the lack of objective testing to directly measure the proximal extent of gastric refluxates. The objective of this study was to evaluate the proximity of reflux events in patients with chronic cough and to assess the outcome of antireflux surgery (ARS) on patients, who were selected based on the presence of abnormal proximal exposure as measured by hypopharyngeal multichannel intraluminal impedance (HMII).

Methods: This is a retrospective review of symptomatic patients who were referred for the evaluation of gastroesophageal reflux disease (GERD) and subsequently underwent HMII with a specialized catheter to measure proximal reflux events such as laryngopharyngeal reflux (LPR) and full column reflux (reflux 2 cm distal to the upper esophageal sphincter) at our institution. Chronic cough was defined as persistent cough with unknown etiology, which lasted for more than 6 months. Patients with positive Tb test and a history of seasonal allergy or pulmonary diseases such as asthma and pulmonary fibrosis were excluded. Based on HMII, abnormal proximal exposure was defined as LPR ≥1/day and/or full column reflux ≥5/day. Patients with abnormal proximal exposure subsequently underwent ARS. The outcomes were reviewed.

Results: From October 2009 to June 2011, 314 symptomatic patients underwent HMII at our institution. Of 314, 55 patients were identified as having chronic cough with unknown etiology (male 16, female 39). Mean age and BMI were 57 years and 30.3, respectively. Six patients were excluded because of inadequate information available. Of the remaining 49 patients, 36 patients were found to have LPR ≥1/day (n=10, range 1-12/day) and/or full column reflux ≥5/day (n=35, range 5-32/day). Of these 36 patients with abnormal proximal exposure, 33 (92%) patients were found to have either endoscopic evidence of esophageal mucosal injury such as esophagitis or Barrett’s esophagus, radiographic evidence of hiatal hernia or PPI dependence. However, 67% (24/36) of patients had a negative DeMeester score. Of these 33 patients with abnormal proximal exposure and objective evidence of GERD, 14 patients subsequently underwent ARS including Nissen (n=8), Dor (n=2), Toupet (n=1) and esophagojejunostomy (n=3), and 12 patients (86%) had a complete resolution of cough and 2 (14%) had a significant improvement at a mean follow-up of 4 months (range, 0.5-12 months).

Conclusions: Abnormal proximal exposure as measured by HMII is likely to be associated with objective evidence of GERD in patients with chronic cough regardless of whether there is a positive DeMeester score. Presence of abnormal proximal exposure could be an indicator of successful ARS for patients with chronic cough.