Table 2 Inclusion criteria of 10 Pubmed, 70 CINAHL, 60 Cochrane, Prevention of complications and nursing care in post-surgical management. What is the role of primary neurorrhaphy in the management of recurrent laryngeal nerve injury due to thyroid surgery? Copyright Merative 2023 Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. Patients with age < 16 and > 80 years, associated metabolic (diabetes), infective and hematologic pathologies and presence of other source of infection like ulcer, URTI, UTI. In this way the patient will gain security and Independence in their care.19. This rate is probably underestimated, because the diagnosis is frequently missed. Three months postoperatively, acoustic voice analysis showed that patients who were treated with conventional thyroidectomy had significantly lower fundamental frequencies, maximum phonation time, and number of semitones. 11.1%, respectively) and temporary vocal cord dysfunction (2.9% vs. 3.9%), but a higher readmission rate (4.5% vs. 1.2%).10 There are studies8 that use a more selective approach based on the measurement of calcium levels after the operation and parathyroid hormone (PTH) using a standard protocol to address the problem. Definite vocal changes may not manifest for days to weeks. The most frequent is Graves' disease, which represents 50-80% of cases of hyperthyroidism.1 There are different treatment options available depending on your more or less invasive individualization: anti-thyroid drugs, radioactive iodine, ethanol injection or surgery. Subscribe for free and receive an in-depth guide to coping Approximately 1% of the superior glands were behind the junction of the hypopharynx and upper esophagus. Complications included postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). 2023 May;47(5):1201-1208. doi: 10.1007/s00268-023-06932-7. Be extremely careful in this area during surgery. Hypothyroidism secondary to thyroid surgery should never be left untreated long enough to elicit signs and symptoms of myxedema (eg, hair loss, large tongue, cardiomegaly). Please enable it to take advantage of the complete set of features! Some studies suggest that the use of EBVSS results in shorter operating time, decreased postoperative drain volume, decreased transient postoperative hypoparathyroidism and hypocalcemia, and decreased postoperative stay compared with suture ligature technique. Pramod K Sharma, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, The Triological Society, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Utah Medical AssociationDisclosure: Nothing to disclose. The best way to preserve parathyroid gland function is to identify the glands and to maintain their blood supply. Among the surgical complications encountered were temporary recurrent laryngeal nerve (RLN) injury (four patients), permanent RLN injury (one patient), temporary bilateral RLN injury (one patient), delayed hematoma (two patients), and transient hypocalcemia (eight patients). In the setting of unilateral vocal-fold paralysis, management of the contralateral thyroid is controversial. Cancer of the endocrine system. It consists of two lobes, one on each side of your windpipe. Mechanisms of injury to the RLN include complete or partial transection, traction, contusion, crush, burn, misplaced ligature, and compromised blood supply. Allscripts EPSi. Updates Surg. Sex bias in differentiated thyroid cancer. Please confirm that you would like to log out of Medscape. Stretching exercises consist of 8 steps that should be performed 3 times a day (morning, afternoon and night), Before a patient leaves, it is important that nurses identify the learning needs and knowledge deficits of patients. In addition, they have no direct negative effect on wound healing. Wang YH, Bhandari A, Yang F, et al. Your type is determined when a sample of tissue from your cancer is examined under a microscope. The tumor can grow to invade nearby tissue and can spread (metastasize) to the lymph nodes in the neck. In the authors' experience, given the low rate of RLN injury, the best approach is not changing appropriate oncologic management and proceeding with total thyroidectomy. 70% for positive and 95% negative predictive values. As thyroid hormone levels decrease and as symptoms resolve, medications should be gradually weaned over the weeks after surgery. In the field (title, summary and / or abstract). Temiz Z, Ozturk D, Ugras GA, et al. Newly diagnosed with thyroid cancer and have 2 main concerns, Life after total thyroidectomy after papillary cancer, What is thyroid cancer? time. 2015 May 29. 2017 Oct. 96 (43):e8245. A medication that blocks the effects of radiation on the thyroid is sometimes provided to people living near nuclear power plants in the United States. Your skin is itchy, swollen, or has a rash. Otolaryngol Head Neck Surg. Intravenous steroids may be beneficial in this situation. The above information is an educational aid only. Medialization is most commonly performed. Hypoparathyroidism is another feared complication of thyroid surgery. Treat cellulitis with antibiotics that provide good coverage against gram-positive organisms (eg, against staphylococci and streptococci). In addition, the implant may be removed, though this requires another surgical procedure. - Symptomatology and complications to which you must be alert to notify the surgeon. Mayo Clinic; 2021. These are normal sensations. Risk factors for hypocalcemia and hypoparathyroidism following thyroidectomy: a retrospective Chinese population study. Your incision comes apart, or blood soaks through your bandage. Not everyone will experience all or even any of these issues, however. You have new voice weakness or hoarseness, or it is getting worse. World J Surg. However, in some cases, the superior parathyroids receive their vascular supply from the superior thyroid artery, the anastomotic loop between the inferior and superior thyroid arteries, or direct branches off the thyroid gland. By developing a thorough understanding of the anatomy and of the ways to prevent each complication, the surgeon can minimize each patient's risk. In addition, this technique is not ideal for removing carcinomas in which an intact capsule is desired for oncologic reasons and for accurate histologic assessment. In order to evaluate the studies and determine the nursing care of patients who underwent a partial or total sea thyroidectomy and reduce the associated complications, a literature review of the literature published from 2008 to the present in English and Spanish was made. The right RLN branches from the vagus more superiorly than does the left, at the level of the subclavian artery. You have sudden tingling or muscle cramps in your face, arm, or leg. At these appointments, your provider may ask if you've experienced any signs and symptoms of thyroid cancer recurrence, such as: Thyroid cancer sometimes spreads to nearby lymph nodes or to other parts of the body. the unsubscribe link in the e-mail. [QxMD MEDLINE Link]. Robotic technology was then introduced to this approach in 2007. Your thyroid gland plays an important role in regulating your bodys metabolism and calcium balance. Presence of malignancy was identified as a predictor of increased postoperative complications, Outpatient thyroidectomy; Same day thyroidectomy; Short stay thyroidectomy; Safety; Hematoma. Qurat C, Germain N, Dumollard J, et al. Thyroid Surgery: Guidelines for Improving Voice Outcomes. Carefully monitor oxygenation, because oxygen demands increase dramatically during a thyroid storm. WebThyroidectomy is the removal of the thyroid gland, which is shaped like a butterfly and lies across the windpipe (trachea). -Thyroid malignant pathology is associated with increased vascularization, immunosuppression and poor wound healing. 9:627-35. [QxMD MEDLINE Link]. The percentage of patients with recurrent laryngeal nerve (RLN) injury was 4.5%, of which 92.9% consisted of transient cases and 7.1% was made up of permanent cases. Repeated aspirations may be necessary. A complication that may appear, although less frequent is the swallowing disability that may exist after a thyroidectomy, which is known as a dysfunction of the nerves that maintain laryngeal motility. A dressing that covers the wound may mask hematoma formation, delaying its recognition. Minimally invasive video-assisted thyroidectomy: five years of experience. The external SLN branch travels inferiorly along the lateral surface of the inferior constrictor until it terminates at the cricothyroid muscle. 2016 May 3. If a drain is placed, its use should not substitute for intraoperative hemostasis. What are relevant anatomic landmarks in thyroid surgery? The type of thyroid cancer is considered in determining your treatment and prognosis. The effectiveness of the neck exercises following total thyroidectomy on reducing neck pain and disability: Randomized controlled trial. Hyperthyroidism affects 1-3% of the general population and is usually more common in women. Transoral thyroid surgery vestibular approach: is there an increased risk of surgical site infections? What are the signs and symptoms of thyrotoxic storm due to thyroid surgery? Consider assistance from an endocrinologist during this period to ensure appropriate monitoring (eg, of renal insufficiency due to hypothyroidism). In addition, there are some favors that can be evaluated in the early postoperative period that are the black race, a subsequent perceived atypical voice, a score of the voice disability index >18 points or an abnormality in the laryngeal examination can predict persistent dysphonia and therefore we can perform an early intervention to these patients.13 The vocal disability index (VHI) or Voice Handicap Index is a questionnaire in order to quantify the impact perceived by the affected subject of his voice alteration on his quality of life.13,20 Some of the limitations that should be considered in this review have to do with the search strategy, since no MeSH or DeSC terms were used, so it could have an impact on the number of documents found. Click here for an email preview. 2019;3(5):227-234. [QxMD MEDLINE Link]. The study, which involved data from 14,220 inpatient and 7215 outpatient thyroidectomies, found that persons from highhealth-risk communities undergoing thyroidectomy were more likely to be women and African Americans and that they had a higher likelihood of being operated on by low-volume surgeons. Electrophysiologic monitoring of the SLN is described, but it is not recommended for routine use. Good news: Serious thyroidectomy complications are relatively rare. How do the outcomes of inpatient and outpatient thyroid surgery compare? What is the role of EMG in the prevention of recurrent laryngeal nerve injury during thyroid surgery? However, most cancers are very treatable and the prognosis for most patients with thyroid cancer is excellent. Thyroid cancer is a growth of cells that starts in the thyroid. U.S. Nuclear Regulatory Commission. You have a health information, we will treat all of that information as protected health The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [Full Text]. Tucker ME. 1998; doi:10.1097/00000658-199809000-00005. 0.77% developed symptoms of dyspnea secondary to hematoma compression (0.38%) or laryngeal edema or laryngeal nerve injury (0.26%). What is the postoperative management for thyrotoxic storm following thyroid surgery? Surgery is generally recommended only when patients have Graves disease and other treatment strategies fail or when underlying thyroid cancer is suspected. The most obvious sign of infection is oozing of cloudy fluid or pus from the incision itself. Connect with other survivors. The gelatin sponge resorbs over time and is, therefore, a temporary treatment. The appearance of cervical hematoma does not have to be early can develop within days or hours after surgery and the inaccuracy of identifying patients at high risk generates anxiety for them.5 Bergenfelz et al.6 observed 2.1% of 3,660 patients who had to undergo surgery again due to re-bleeding due to compression hematoma. Patients with postoperative bleeding present with neck swelling, neck pain, and/or signs and symptoms of airway obstruction (eg, dyspnea, stridor, hypoxia). Minuto MN, Reina S, Monti E, Ansaldo GL, Varaldo E. Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients. Neither of these differences was statistically significant. In 1.9% of patients, the revision of hemostasis was necessary for postoperative hemorrhage. Controversy still surrounds the use of drains after thyroid surgery. On the left, the nerve courses posteriorly to the artery in 50% of patients; in approximately 35%, the nerve runs between branches. It is usually secondary to the lesion of the laryngeal or inferior superior nerve. Annals of Surgery. - 20% of patients had hypokalemia due to D2, definitive only 3%. The study involved 278 thyroid surgery patients. What are the signs and symptoms of postoperative bleeding, following thyroid surgery? L Caulley, S Johnson- Obsaseki, L Luo, et al. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). for: Medscape. Otolaryngology and Facial Plastic Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, Royal College of Physicians and Surgeons of Canada, American Academy of Facial Plastic and Reconstructive Surgery, British Association of Oral and Maxillofacial Surgeons. The thyroid gland is located at the base of the neck, just below the Adam's apple. Most of the surgical indications were multinodular goiter. Frequency of hormone replacement after lobectomy for differentiated thyroid cancer. 5 Treatment Changes to Know About, New Consensus on Thyroid Eye Disease Prompts Some Debate, Mutation Testing in Advanced Thyroid Cancer. What are the physical signs of recurrent laryngeal nerve (RLN) injury due to thyroid surgery? What is the anatomy of the superior laryngeal nerve relevant to thyroid surgery? -Complications at 30 days, of the total number of patients undergoing a total thyroidectomy was 7.74%. Most often, diagnosing thyroid cancer starts with the physical exam. 17 that dealt with the stated objective and that were added to a 2002 article because of its relevance. There is a problem with Medscape Medical News. Schoretsanitis et al (1998) also reported that the postoperative hospitalization time was longer in the patients with drains (3.4 vs 1.6 d), as was the duration of postoperative pain. The most damaging consequence is loss of the upper register. Some may develop pain in their neck or throat. Classic long-omicron signs on exam: swollen right small intestine & right upper liver. Which factors increase the risk of hypocalcemia after thyroidectomy? The symptoms. You have chest pain when you take a deep breath or cough, or you cough up blood. The technique was described using a central access with a 1.5-cm incision and external retraction. This is a butterfly shaped gland that sits at the base of your neck. Surgery. It's often treatable, and most people will have successful treatment. The prevention of postoperative bleeding depends on good intraoperative hemostasis. [Full Text]. It may be accomplished with injection laryngoplasty or laryngeal framework surgery. Send purulence expressed from the wound or drained from an abscess for Gram staining and culturing to direct the choice of antibiotics. This has evolved to a shorter incision placed in a skin crease higher in the neck. This content does not have an Arabic version. Del Rio P, Rossini M, Montana CM, et al. Thyroid surgery. Most patients who are hypocalcemic after thyroidectomy are initially asymptomatic. As thyroid cancer grows, it may cause: If you experience any signs or symptoms that worry you, make an appointment with your health care provider. Although the complication rate of thyroid surgery has certainly decreased, surgeons must nevertheless maintain a healthy respect for the possibility of complications. If you'd like to learn even more about thyroid cancer, watch our other related videos or visit mayoclinic.org. There are different ways to diagnose this complication, by laryngoscope or endoscopy, directly observing the mobility of the vocal cords or the associated alteration of the mucosa such as Barret's esophagitis by endoscope. Learn more about thyroid cancer from endocrinologist Mabel Ryder, M.D. All observations must be documented, drainage, volume, consistency, color and functionality of the state of the drainage equipment. CT imaging is useful when a deep neck abscess is thought possible. Laryngeal nerve injury is a serious complication of thyroid gland surgery. 2013 Jun 4. How is recurrent laryngeal nerve (RLN) injury due to thyroid surgery managed? According to the Ministry of Health and Consumption and Social Welfare, the procedures on thyroid, parathyroid and thyroglossal tract have a low percentage of mortality of 0.03% compared to other surgical procedures.2 Surgery offers an early remission of endocrine disorder and more stable than more conservative strategies and also an earlier detection of thyroid cancer.1 Goiter recurrence remains a problem that sometimes cannot be resolved with thyroxine suppressive therapy and primary surgery is a more aggressive but more effective way to prevent relapse. [QxMD MEDLINE Link]. Rare complications, such as damage to the sympathetic trunk, are occasionally reported. Symptoms of Surgical Site Infections. Patients having undergone a procedure where all parathyroid glands have been placed at risk for injury (total thyroidectomy, subtotal thyroidectomy, or completion thyroidectomy) should undergo evaluation for iatrogenic hypoparathyroidism. Observe the presence of neck thickening, subcutaneous congestion, hemorrhagic exudation in wound dressings, sudden increase in drainage fluid in bright red negative pressure and other symptoms of tracheal compression such as dyspnea.16 It is important to observe the coloration of the skin of the neck that may be black and blue due to swelling. What causes thyrotoxic storm during thyroid surgery? [QxMD MEDLINE Link]. 1999 Jan. 113(1):49-51. But as it grows, it can cause signs and symptoms, such as swelling in your neck, voice changes and difficulty swallowing. I am 8 month Post Thyroidectomy (Large Substernal with deviated Trachea. What are the benefits of using minimally invasive video-assisted thyroidectomy (MIVAT)? Your skin is itchy, swollen, or has a rash. Forty-two percent were on the anterior or lateral surfaces of the lower lobe of the thyroid, often hidden by vessels or creases in the thyroid. Both the upper and lower nerves give sensitivity to the posterior branches that innervate the esophagus and the cricopharyngeal muscle, which could help to understand the swallowing disability that may exist after thyroidectomy. Postoperative morbidity rates in patients seem to be equivalent to those of patients who have undergone conventional surgery. Pironi D, Pontone S, Vendettuoli M, et al. How is hypothyroidism prevented following thyroid surgery? Utility of the Voice Handicap Index as an Indicator of Postthyroidectomy Voice Dysfunction. Khavanin N, Mlodinow A, Kim JY, et al. The guidelines include a strong recommendation that surgeons performing thyroid surgery identify the recurrent laryngeal nerve or nerves. Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, Royal College of Physicians and Surgeons of CanadaDisclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merck. Data from a recent cadaveric study suggested that the nerve may cross the superior thyroid artery more than 1 cm above the upper pole of the thyroid gland (42%), less than 1 cm above the upper pole (30%), or under the upper pole (14%). This site needs JavaScript to work properly. Surgical site infections (SSI) affected 2% of patients. For this reason, the objective of this review is to identify those main cares in patients undergoing a thyroidectomy to reduce the complications associated with this surgical intervention. You feel very tired and cold, gain weight for no reason, and your skin is very dry. Prospective non-randomized analytical study. The condition may be due to direct trauma to the parathyroid glands, devascularization of the glands, or removal of the glands during surgery. Disclaimer. WebSigns that you may have low calcium are numbness and a tingling feeling in your lips, hands, and the bottom of your feet, a crawly feeling in your skin, muscle cramps and A large cadaveric study to identify the most common positions of the parathyroid glands demonstrated that 77% of superior parathyroid glands were at the cricothyroid junction and intimately associated with the RLN. Fiberoptic laryngoscopy may be warranted in patients with airway issues without apparent wound hematoma to assess vocal fold function. Health Education & Content Services (Patient Education). The main goal of surgery is to prevent recurrent hyperthyroidism because recurrent hyperthyroidism after surgery is more difficult than permanent hypothyroidism to manage. Control the patient's voice quality, swallowing reflex and postoperative respiratory status.16 According to Xiaojuan Jian B et al.11 the appearance of hoarseness in speech and coughing when drinking is often induced by injury to the laryngeal nerve, after surgery patients were encouraged to speak and observed if there were any symptoms that included hoarseness, aphonia, dyspnea, decreased cough, cough with liquids. The patient needs concomitant replacement of vitamin D with calcitriol (Rocaltrol) 0.25-1 mcg/d. Performance & security by Cloudflare. A total thyroidectomy is surgery to remove all of your thyroid gland. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. This approach has introduced new complications not associated with thyroidectomy in the past. It is still the same today 7 months later. Take steps to keep your body healthy during and after treatment. Patients who have asymptomatic hypocalcemia in the early postoperative period should not be treated with supplemental calcium. - The rest of the baseline characteristics and histopathological data (age, BMI, sex, smoking, professional voice status, inflammatory pathology and malignant pathology were not significantly associated with negative vox changes of an early or late nature. MIVAT provides endoscopic magnification of nerves and vessels, potentially decreasing the risk of injury to these structures. - Know what are the main educational interventions to the patient who is discharged after a thyroidectomy: Medication, activities of daily living, community and follow-up, feelings in relation to the condition, treatment and complications, quality of life, skin care. 5 (2):120-3. [4], Nonetheless,a retrospective study by Ayala and Yencha indicated that hospitals with a low surgical volume can safely perform outpatient thyroid surgery. The goal is to restore a state as close to euthyroid as possible before surgery. Transient RLN palsy occurred in 5 (8.5%) patients who underwent conventional surgery versus 3 (5.8%) patients in the video-assisted group; the difference was not significant. Advertising revenue supports our not-for-profit mission. - After a total thyroidectomy, hypocalcaemia occurred in 9.9% that had to be treated with vitamin D and fell to 4.4% in the 6-month follow-up. Furthermore, EMG may yield information concerning the prognosis of the patient with RLN injury. Minimally invasive video-assisted thyroidectomy (MIVAT) was described in 1998. However, a resultant neck scar remains. The risk of hematoma due to re-bleeding increased with the male sex, as did the increase in age. How is recurrent laryngeal nerve (RLN) injury prevented during thyroid surgery? Finally, avoid the use of neck dressings. Diagnosing an SLN injury with indirect or fiberoptic laryngoscopy is difficult. An implant is then placed to push the vocal fold medially. doi: 10.1016/j.ijsu.2008.12.024. Which factors increase the risk of hypoparathyroidism after thyroid surgery? You have sudden swelling in your neck or difficulty swallowing. The overall experience of alternate approaches to thyroidectomy is in the early stages. Poor scar formation is frequently preventable with proper incision location and surgical technique. If uncertainty remains 6 months after surgery, PTH levels may be checked evaluate recovery of parathyroid gland function. The methodological quality of the included studies was independently assessed. Society of Nuclear Medicine and Molecular Imaging. - Recurrent laryngeal nerve paralysis, 4 patients already presented it previously, 13 patients presented it after the operation, 5 recovered normal laryngeal movement within the year. Otolaryngol Head Neck Surg. The most useful laboratory test for detecting or monitoring of hypothyroidism in the patient who has undergone thyroidectomy is the measurement of thyrotropin (thyroid-stimulating hormone [TSH]) levels. Laryngoscope. All must be well aware of the surgical risks they are undertaking. McMullen C, Rocke D, Freeman J. How are injuries to the recurrent laryngeal nerve in thyroid surgery managed? Very high blood pressure systolic blood pressure over 180 millimeters of mercury (mm Hg) or diastolic blood pressure over 120 mm Hg High blood pressure that no longer responds to medication that previously controlled the blood pressure Sudden-onset high blood pressure before age 30 or after age 55 No family history of high blood pressure Meltzer et al developed a model to predict the risk of 30-day complications from thyroid surgery, with the presence of thyroid cancer being the most significant variable. [QxMD MEDLINE Link]. Worldwide thyroid-cancer epidemic? Thirty-nine percent were located within the superior tongue of the thymus. Niederhuber JE, et al., eds. Frequently asked questions about potassium iodide. Pino A, Mazzeo C, Frattini F, Zhang D, Wu CW, Zangh G, Dionigi G. Sisli Etfal Hastan Tip Bul. PTH also increases renal excretion of phosphorus. WebSigns and symptoms of mild and moderate thyrotoxicosis include: Experiencing unexplained weight loss. Results: Out of a total of 140 articles found, 30 met the inclusion criteria of the finally selected topics. Lack of education at discharge, ignorance of appropriate information causes patients to experience more anxiety and feel more dependent on ignorance. And hospital of 3.1 days. 2014 May 20. How are injuries to the superior laryngeal nerve (SLN) due to thyroid surgery treated? A window in the thyroid cartilage is created at the level of the true vocal fold. of chronic ear infection presents after psychiatric hospitalization for sudden surge in dramatic physical aggression. 2524 N. Broadway Edmond Oklahoma 73034. When the nerve is identified and dissected, the reported RLN injury rate during thyroidectomy is 0-2.1%. What is the pathophysiology of hypercalcemia due to thyroid surgery? What is the prevalence of complications of thyroid surgery? In approximately 5 of 1000 patients, a nonrecurrent laryngeal nerve is found on the right side. Other hypotheses have been put forth to account for transient hypocalcemia not caused by hypoparathyroidism. Hypothyroidism is an expected sequela of total thyroidectomy. The thyroid is a butterfly-shaped gland located at the base of the neck, just below the Adam's apple. Conclusion: This review has been made with the aim of knowing more about the most frequent complications after a thyroidectomy and establishing the basic learning needs that patients should know at discharge to take responsibility for their health. The search was conducted using free language, using these keywords: thyroidectomy surgery, complications, postoperative and intervention. At follow-up, such patients may present with dyspnea or stridor with exertion. HIV had a diagnostic accuracy of 86% sensitivity and 88% specificity to classify the results in the voice. - Articles that will analyze the hormonal level after the postoperative period. A literature review by Akritidou et al looking at procedure-related complications in transoral endoscopic thyroidectomy via a vestibular approach found the rates of transient and permanent hypoparathyroidism to be 6.11% and 0.21%, respectively. other information we have about you. The mean operative time was 41 minutes (range, 15-120 min) for lobectomy and 51.6 minutes (range, 30-140 min) for total thyroidectomy. - Tools for diagnosis: endoscopic, esophageal impedance, pH, esophageal manometry, etc.