Voice Problems, Negative Manometry, and Negative Esophageal pH Test

4/30/18 10:00 AM / by Dr Josef Schlömicher Thier

Dr. Josef Schlömicher-Thier
Chief of the International Voice Center Austria

Chief of the ENT Center in Neumarkt/Salzburg
Laryngology Specialist


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A 60 year old male presented with hoarseness, a heavy cough, and voice problems extending back at least four years. Symptoms had recently exacerbated leaving the individual out of work on sick leave. The patient reported multiple prior pneumonias, but presented with a normal pulmonary exam at the time of the initial assessment.

Prior to his office assessment, the patient was examined at a different hospital. This included the discovery of a minor hiatal hernia, which was accompanied by a negative esophageal manometry test and a negative duel channel pH test. Video Stroboscopy revealed hyperplasia/ leucoplakia. VRP showed a restricted mass.

Pre-Treatment Scores:

RSI=23  CSI=15  BSI=19  VHI=23

Pre-Treatment Images:

Riedler_Johannes pre-01 Riedler_Johannes pre-02 



A 48 hour Restech pH Study showed a positive upright RYAN Score of 161.34. In addition, the patient exceeded the 95th percentile at the <5.5 threshold and the 75th percentile at the <5.0 threshold when supine. An esophageal Function TNE showed a clear hiatal hernia and reflux according to the LA Classification of two. The positive Restech test, coupled with the negative esophageal pH test and manometry provided a diagnosis of LPR.

Restech pharyngeal pH test results: 


CS2 result chart    CS2 bar graph



A high dose PPI therapy of pantopracol (40mg BID) with Gaviscon and Antimycotica was initially prescribed. The hyperplasia reacted slowly however, so the treatment was changed to esemoptazol (40/20/40) with an evening H2 blocker for two weeks, reduced to 40mg BID step down and Lax Vox Therapy (8x4min per day) thereafter, which was very effective. 

After three months all symptoms (notably the hyperplasia, cough, and vocal distress) had resolved and the medication was tapered to a halt. Ongoing lifestyle and dietary modifications were ordered along with a continued program of voice exercises (Lax Vox).

Post-Treatment Scores


 Riedler_Johannes post 02 Riedler_Johannes post 02 



Restech was essential to the diagnosis of LPR in this patient as the negative esophageal pH test and manometry had initially led the patient’s doctors to rule out reflux as the cause of his symptoms. The positive upright RYAN Score and Moderate to Severe Supine Acid Exposure Graph provided a critical insight into an appropriate treatment plan. This was further verified by the initial lack of progress on pantopracol. Ultimately, the patient’s symptom resolution provides a testament to the importance of a precise and individualized treatment plan.


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Topics: voice, treatment, case study

Dr Josef Schlömicher Thier

Written by Dr Josef Schlömicher Thier

Born in Vorau in East Styria in 1954, brewing apprentice and brewer in Graz, studied medicine and singing in Graz. Vocal studies at the Conservatory of Graz and at the University of Music in Graz as baritone (solo singing with Prof. Suttheimer and Lied singing with Prof. Zeller). Opera dramatic lessons with Prof. Pöppelreiter. Piece contract at the Graz Opera in Don Carlos, master class students of Walter Berry. Regular appearances as a concert singer, most recently in 2013 in Philadelphia and Budapest. Former head of the cultural and educational platform "Die Kuppel" in the LKH Graz (from 1987 to 1991). Establishment and management of the student movement "Medicine and Ethics" at the Medical Faculty in Graz 1980 to 1984. Training as a general practitioner in Graz and Leoben. ENT specialist training in Salzburg with Prof. Albegger. Since 1996 ENT specialist practice in the city of Neumarkt am Wallersee and since 1992 as ENT doctor and occupational physician supervising physician of the Salzburg Festival. Establishment and management of the Austrian Voice Institute since 1996. Member of the American Voice Foundation, British Voice Association, German Voice and Language Society, Secretary General of the Collegium Medicorum Theatri (CoMeT). 2016 Founder of the Stimmzentrum Salzburg. Married to Dr. med. Luise Schlömicher, four adult children.

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