Gastro-oesophageal reflux disease in chronic laryngitis: prevalence and response to acid-suppressive therapy

BACKGROUND

Gastro-oesophageal reflux is thought to cause chronic laryngitis through laryngopharyngeal reflux. Response of laryngitis to treatment with acid-suppressive therapy supports this causal link.

AIM

To determine the prevalence of gastro-oesophageal reflux disease in patients with chronic laryngitis and response to proton-pump inhibitor therapy.

METHODS

Patients with chronic laryngitis were recruited. The frequency and severity of reflux and laryngeal symptoms were scored and laryngitis graded by laryngoscopy. All patients underwent esophagogastroduodenoscopy and 24-h ambulatory pH monitoring before receiving lansoprazole 30 mg b.d. for 8 weeks.

RESULTS

The prevalence of gastro-oesophageal reflux disease was 65.6% (21 of 32). Based on positive pH test, the prevalence was 25% (eight of 32). The change in laryngeal symptom score and laryngitis grade was significantly higher in GERD compared with non-GERD patients (P = 0.010 for both). The proportion of patients with marked/moderate improvement in laryngeal symptoms were significantly higher in patients with reflux (14 of 21, 67%) compared to those without reflux (two of 11, 18%; P = 0.026).

CONCLUSIONS

The prevalence of gastro-oesophageal reflux disease amongst our patients with chronic laryngitis was high. The response to treatment with proton-pump inhibitors in patients with reflux disease compared to those without underlined the critical role of acid reflux in a subset of patients with chronic laryngitis.

Effect of antisecretory therapy on atypical symptoms in gastroesophageal reflux disease

The effect of proton pump inhibitor (PPI) therapy on extraesophageal or atypical manifestations of gastroesophageal reflux disease (GERD) remains unclear. This study aimed to evaluate the prevalence of atypical manifestations in patients with acid reflux disease and the effect of PPI treatment. Patients with symptoms and signs suggestive of reflux were enrolled. Erosive esophagitis was stratified using the Los Angeles classification. Demographic data and symptoms were assessed using a questionnaire and included typical symptoms (heartburn, regurgitation, dysphagia, odynophagia), and atypical symptoms (e.g., chest pain, sialorrhea, hoarseness, globus sensation, chronic coughing, episodic bronchospasm, hiccup, eructations, laryngitis, and pharyngitis). Symptoms were reassessed after a 3-month course of b.i.d. PPI therapy. A total of 266 patients with a first diagnosis of GERD (erosive, 166; non-erosive, 100) were entered in the study. Presentation with atypical symptoms was approximately equal in those with erosive GERD and with non-erosive GERD, 72% vs 79% (P = 0.18). None of the study variables showed a significant association with the body mass index. PPI therapy resulted in complete symptom resolution in 69% (162/237) of the participants, 12% (28) had improved symptoms, and 20% (47) had minimal or no improvement. We conclude that atypical symptoms are frequent in patients with GERD. A trial of PPI therapy should be considered prior to referring these patients to specialists.

[Modern attitude towards management of laryngopharyngeal form of gastroesophageal reflux disease. Lithuanian clinical practice guidelines for adults]

The aim of this article is to introduce Lithuanian clinical practice guidelines for the management of laryngopharyngeal form of gastroesophageal reflux disease for standardization of the diagnosis and treatment of the disease and prevention of its complications. Composed guidelines provide recommendations for primary care physicians as well as otorhinolaryngologists and gastroenterologists for the management of adults with uncomplicated laryngopharyngeal form of gastroesophageal reflux disease. Committee composed of experts from Lithuanian Otorhinolaryngological and Gastroenterological Societies developed guidelines based on a comprehensive review of the evidence-based literature related to laryngopharyngeal form of gastroesophageal reflux disease and guidelines of other countries. The guidelines provide description of each medicine groups with emphasis on proton pump inhibitors as the most effective drugs for the treatment of laryngopharyngeal form of gastroesophageal reflux disease. Indications for empirical treatment with proton pump inhibitors are described, as well as duration of treatment, doses, optimal regimen of use, and assessment of treatment efficacy. The therapy should begin with the application of proton pump inhibitors twice daily, before meal for three months. Combined therapy for nonresponders is described. Algorithm for stopping the medication is recommended. These recommendations may provide an efficient and economical approach to the management of this problem.

[Glottis morphology and perceptive-acoustic characteristics of voice and speech in patients with rheumatoid arthritis]

INTRODUCTION

The aim of this study was estimation of glottis morphology and perceptive-acoustic characteristics of voice and speech in patients suffering from rheumatoid arthritis (RA).

MATERIAL AND METHODS

77 patients (51 women and 15 men), 19-77 years of age (average 56,7) with recognized RA. The disease duration was from 1 month to 29 (average 9,4) years. Laryngeal, phoniatric examination and phonetic-acoustic analysis of voice and speech (program IRIS). One patient with bilateral vocal folds immobilization had computer tomography of the larynx and electromiography of internal laryngeal muscles.

RESULTS

The most frequent complains were: foreign body sensation in the throat 51% (n = 39/76), hoarseness - 47% (n = 36/76), weakness of voice - 29% (n = 22/76). Redness of the mucosal tissue in the area of arytenoids was stated in 41% (32/77) patients and edema in 28% (21/77). Complains and morphological features of inflammation in the larynx were considerably more frequent in patients with active RA. 3 patients had impairment of vocal folds mobility, in 2 of them it was bilateral immobilization requiring emergency tracheotomy. Subjective voice analysis was made according to GRBAS scale. In 35% (26/75) patients there was G2 or G3 stated. The average time of phonation [a] was 7 seconds. Average basic voice frequency was for women 216 Hz and for men 118 Hz. There was statistically important correlation between increasing of some acoustic voice parameters and RA activity and intensity.

CONCLUSIONS

Patient's complains for foreign body sensation in the throat and hoarseness, especially when RA is active, can indicate on inflammatory process in the larynx. For these reason it seems to be reliable to stay in close contact for rheumatologist, laryngologist and phoniatrist in every day practice.

Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials

OBJECTIVE

The role of proton pump inhibitors (PPIs) in suspected GERD-related chronic laryngitis (CL) is controversial. Hence, we performed a meta-analysis of the existing randomized controlled trials (RCTs) to evaluate the efficacy of PPIs in this disorder.

METHODS

Data extracted from MEDLINE (1966 to August 2005), Cochrane Controlled Trials Register (1997 to August 2005), EMBASE (1980 to August 2005), ClinicalTrials.gov website, and meetings presentations (1999-2005). Published and unpublished randomized placebo-controlled trials of PPIs in suspected GERD-related CL were selected by consensus. Random effects model was utilized with standard approaches to quality assessment, sensitivity analysis, and an exploration of heterogeneity and publication bias. The primary outcome measure was defined as the proportion of patients with >or=50% reduction in self-reported laryngeal symptoms.

RESULTS

Pooled data from 8 studies (N = 344, PPI 195, placebo 149; mean age 51 yr; males 55%; study duration 8-16 wk) were analyzed. No significant quantitative heterogeneity was found among the studies (chi2= 11.22, P= 0.13). Overall, PPI therapy resulted in a nonsignificant symptom reduction compared to placebo (relative risk 1.28, 95% confidence interval 0.94-1.74). No clinical predictors of PPI response were identified on meta-regression analysis done at study level.

CONCLUSIONS

PPI therapy may offer a modest, but nonsignificant, clinical benefit over placebo in suspected GERD-related CL. Validated diagnostic guidelines may facilitate the recognition of those patients most likely to respond favorably to PPI treatment.

The frontiers of reflux disease

Gastroesophageal reflux disease has frequently been implicated in a wide variety of complications beyond the esophagus. These so-called "extraesophageal" disorders range from diseases of the respiratory tract, such as asthma and bronchitis, to more remote sites and conditions such as otitis and dental erosion. Many articles proposing a link between reflux disease and a multitude of extraesophageal complications have been published, but indisputable evidence that these conditions are caused by reflux disease is rare. Much of the support for a link between reflux disease and a number of extraesophageal complications is based on the observation that reflux disease frequently coexists with other disorders. A causal link is difficult to prove, however, and this review aims to critically evaluate the available evidence, looking, where possible, at longitudinal studies, expert diagnoses, and response to acid-suppressive therapy as a means of determining the true relationship between GERD and its putative extraesophageal complications.

Otolaryngologic manifestations of gastro-oesophageal reflux disease in Lagos

BACKGROUND/AIM

Gastro-oesophageal reflux disease(GERD) is not an uncommon disease in Nigeria. The otolaryngologic (ORL) symptoms associated with GERD are varied. In the management of patients with ORL symptoms and disease, GERD is often not considered as a differential diagnosis The aim of this study is to identify patients with ORL complications of GERD from patients with ORL disease who have symptoms that mimic GERD using defined criteria in the light of limited diagnostic facilities.

MATERIALS/METHODS

A prospective study was conducted over a two year period at Lagos University Teaching Hospital Lagos and two private Otolaryngology clinics,within Lagos, among patients who presented primarily with laryngeal and pharyngeal symptoms . They were evaluated using structured questionnaire for duration of regurgitation, heartburn ,symptoms of peptic ulcer disease, clinical examination, esophagogastro - duodenoscopy findings and outcome of laryngopharyngeal symptoms following anti-reflux therapy.

RESULTS

A total of 92 patients were evaluated over a two year period .ORL diseases and symptoms at presentation were chronic laryngitis, chronic pharyngitis, globus pharyngeus, globus and chronic laryngitis, laryngeal carcinoma, cricopharyngeal spasm and throat hawking. History of symptoms of peptic ulcer disease and regurgitation was obtained in 47.8% and 65.2% respectively. Endoscopic findings revealed oesophageal reflux with gastroduodenits in 4.3%, Non specific gastritis in 17.4%, duodenal ulcer in 56.4%, and normal findings in 21.7%. Patients were treated medically with antacids, H2 antagonists, proton pump inhibitors and were followed up for 9-12 months. GERD was diagnosed in 4 (4.34%), 68 (73.9%) were diagnosed as non erosive reflux disease (NERD) and 20 (21.74%) with probable acid related problem that will need further evaluation . Following anti-reflux therapy 68 (73.9%) had disappearance of their laryngopharygeal symptoms for up to a year. ORL complications of GERD/NERD was seen in 72 (78.3%).

CONCLUSION

GERD should be a differential diagnosis in patient with pharyngeal and laryngeal symptoms not associated with sinus disease in the presence or absence of positive peptic ulcer disease or regurgitation and the management should be multidisciplinary.

Unusual presentation of intradural endodermal cysts in young children under 2 years of age. Report of two cases

INTRODUCTION

Spinal endodermal cysts are congenital maldevelopmental lesions usually presenting in early adulthood. Whereas the diagnosis is rare in newborns and it is usually led by cardiopulmonary distress or other associated malformations, no characteristic clinical findings associated with these entities have been described in older patients where spinal endodermal cysts usually behave as intraspinal space occupying lesions.

DISCUSSION

The authors report on two children under 2 years of age affected by cervical endodermal cysts that presented with a history of acute motor deficit following a laryngitis. The hypothesis about the pathogenesis is that the upper respiratory tract infection might have stimulated the secretion of the cyst lining, inducing growth of the cyst and the sudden appearance of the motor deficit. Because of the apparent lack of relation between the benign laryngitis and the motor deficit, the occurrence of such an association might have been underestimated in some of the previously reported cases.

Non-erosive reflux disease and atypical gastro-oesophageal reflux disease manifestations: treatment results

Gastro-oesophageal reflux disease (GERD) is a widespread complex disorder that may be responsible for a variety of different symptoms and clinical features. Despite the presence of symptoms, the majority of patients do not have endoscopic lesions of oesophagitis. Non-erosive reflux disease (NERD) is a chronic, relapsing condition that can adversely affect the quality of life despite the absence of mucosal breaks at endoscopy. In many patients GERD is associated with extra-oesophageal or atypical manifestations, including cough, asthma, laryngitis or non-cardiac chest pain. Acid suppression with proton pump inhibitors (PPI) remains the mainstay of GERD therapy. However, patients with NERD and extra-oesophageal manifestations are often poorly responsive to PPI therapy. Accurate diagnosis followed by adequate PPI dosage and compliance with therapy are essential for the successful control of NERD and extra-oesophageal manifestations. The better detection and characterization of acid and non-acid reflux episodes using developing technologies, such as combined pH-impedance monitoring, is extending our understanding of the pathophysiology of NERD and the extra-oesophageal manifestations of GERD, and will lead to the improved management of these often poorly responsive conditions. This article reviews the treatment results and outlines approaches to the evaluation, diagnosis and therapy of NERD and atypical GERD manifestations.

Effect of acid, pepsin, and bile acid on the stenotic progression of traumatized subglottis

BACKGROUND AND AIMS

Gastroesophageal reflux disease is related to various laryngeal sequelae. However, there is a lack of established reflux animal models covering longer observation periods. We evaluated the effects of acid, pepsin, and bile acid on healing of the traumatized subglottis in a simulated reflux model.

METHODS

In the first experiment, 48 rabbits were inflicted with a posterior subglottic injury using a diode laser, and there were 10 unwounded controls. After catheter insertion under transoral endoscopic guidance, animals were randomly assigned to one of the four groups: acid reflux (pepsin 0.3 mg/mL+taurodeoxycholic acid 0.155 mg/mL+acid pH 2); nonacid reflux (pepsin+taurodeoxycholic acid+pH 6); saline reflux; and unwounded control. Animals received catheter irrigation with 3 mL of a mixed solution or saline, twice daily for 6 wk. In the second experiment, 36 animals were inflicted with a subglottic injury followed by acid or saline reflux treatment and were sacrificed after 1, 2, and 4 wk for time-serial observations. Gross and histological findings were compared among the different groups.

RESULTS

Catheter-related problems were minor. Most animals received laryngopharyngeal irrigation with the solutions well, and 19 were excluded. Inflammation scores, fibrosis, thickening, and luminal stenosis were greatest in the acid reflux group (p<0.005). Values were not different between the nonacid reflux and saline reflux groups (p>0.1).

CONCLUSIONS

Our data suggest that subglottic wound healing is significantly affected by pepsin and bile acid only under acidic conditions. This implies that acid-suppressive therapy can prevent further subglottic inflammation and stenosis by laryngeal reflux.

Immediate hypersensitivity type of occupational laryngitis in a welder exposed to welding fumes of stainless steel

BACKGROUND

Although upper respiratory symptoms have been reported to occur in welders, occupational laryngitis of immediate hypersensitivity type due to welding fumes of stainless steel has not been previously reported.

METHODS

Occupational laryngitis was diagnosed based on the specific challenge test combined with the patient's history of occupational exposure and laryngeal symptoms.

RESULTS

During the past few years, a 50-year-old man had started to experience laryngeal symptoms while welding stainless steel. The welding challenge test with stainless steel caused significant changes in the laryngeal status 30 min after challenge: increased erythema, edema, and hoarseness of the voice. The referent inhalation challenge test by welding mild steel was negative.

CONCLUSION

The welding of stainless steel should be included in the etiological factors of occupational laryngitis of immediate hypersensitivity type.

Treatment of chronic posterior laryngitis with esomeprazole

OBJECTIVE

To evaluate the efficacy of acid-suppressive therapy with the proton pump inhibitor esomeprazole on the signs and symptoms of chronic posterior laryngitis (CPL) in patients with suspected reflux laryngitis.

STUDY DESIGN

Prospective, multicenter, randomized, parallel-group trial that compared twice-daily esomeprazole 40 mg with placebo for 16 weeks.

METHODS

Eligible patients had a history of one or more CPL symptoms (throat clearing, cough, globus, sore throat, or hoarseness) and laryngoscopic signs indicating reflux laryngitis based on CPL index (CPLI) scores measured during a screening laryngoscopy. Patients were randomized to treatment if their 7-day screening diary-card recordings showed a cumulative primary symptom score of 9 or higher and they had 3 or more days with moderately severe symptoms based on a 7-point scale. Efficacy was assessed by changes in symptoms as recorded by patients and investigators and by changes in CPLI scores based on laryngoscopic examinations.

RESULTS

The patients' primary CPL symptom at final visit (primary efficacy end point) was resolved in 14.7% (14/95) and 16.0% (8/50) of patients in the esomeprazole and placebo groups, respectively (P=.799). Esomeprazole and placebo were not significantly different for change from baseline to the final visit in mean total CPLI (-1.66+/-2.13 vs. -2.0+/-2.55, respectively; P=.446) or any other secondary efficacy end points based on patient diary card or investigator assessments.

CONCLUSION

This study provides no evidence of a therapeutic benefit of treatment with esomeprazole 40 mg twice daily for 16 weeks compared with placebo for signs and symptoms associated with CPL.

Acid reflux management: ENT perspective

Otolaryngological manifestations of acid reflux include a wide range of pharyngeal and laryngeal symptoms; and the constellation of symptoms has been called laryngopharyngeal reflux.

This is a prospective study in a cohort of patients with various throat symptoms suggestive of laryngopharyngeal reflux (LPR) who underwent flexible oesophago-gastroscopy, as a principal investigation. The aims were to look at the most reliable symptom(s) and sign(s), the diagnostic role of flexible oesophago-gastroscopy and the treatment response in these patients.

The endoscopy score of 0 to 3 was based on endoscopic findings and the treatment response was measured from 0 to 100 per cent improvement of symptoms, as described by the patients.

There were a total of 303 patients, 174 females and 129 males with ages ranging from 19 to 88 years. Seventy-five per cent had had symptoms for more than a year. Fifteen per cent were smokers. Globus, voice change, sore throat, dysphagia and cough were the predominant symptoms. Most patients, however, presented with a complex of various other secondary symptoms.

The endoscopic findings were abnormal in 98 per cent of patients. Apart from the finding of non-specific hyperaemia, usually of the posterior larynx (13 per cent), lesions of the larynx and vocal folds were surprisingly uncommon.

Proton pump inhibitors (PPI) were prescribed in 90 per cent of patients. A total of 233 (76.8 per cent) responded to treatment. The improvement of symptoms ranged from 25 per cent in 36 (23 per cent), 50 per cent in 60 (20 per cent), 75 per cent in 59 (19 per cent) and 100 per centin 78 (26 per cent) patients.

Accumulative analysis of variance showed a significant difference between treatment responders and non-responders (p <0.04). In a logistic regression model patients with globus, voice change and gastric prolapse were more likely to respond to treatment (p <0.04).

It can be concluded that voice change, sore throat, globus and cough choking are the most reliable symptoms of laryngopharyngeal reflux. Voice change and globus symptoms can be of predictive value in terms of successful treatment response. Flexible oesophago-gastroscopy (FOG) isa simple, safe and reliable way of assessment in these cases and treatment with PPI can be effective in the majority of patients.

Review article: the role of pH monitoring in extraoesophageal gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease is associated with several extraoesophageal disease states including laryngitis, asthma, chronic cough and non-cardiac chest pain. Currently, the exact role reflux of gastric contents play in the pathogenesis of extraoesophageal symptoms remain controversial. Twenty-four hours pH monitoring is often considered the 'gold standard' in the diagnosis of gastro-oesophageal reflux disease and is increasingly utilized in patients with extraoesophageal symptoms. The use of this test is aimed at improving the association between patients' extraoesophageal symptoms and oesophageal or hypopharyngeal acid reflux events. However, the clinical utility of pH monitoring in this patient population remains controversial. Important clinical questions in this area include: does the presence of abnormal oesophageal acid reflux suggest a causal association between patients' extraoesophageal symptoms and gastro-oesophageal reflux disease? Conversely, does the absence of abnormal acid exposure in the oesophagus suggest lack of such an association? Should the test be performed on or off therapy and does it matter? In this study, the role of pH monitoring in laryngitis, asthma, chronic cough and non-cardiac chest pain is examined and answers to the above questions are addressed based on current data.

Perceptual and Acoustic Characteristics of Voice Changes in Reflux Laryngitis Patients

The aim of the study was to outline the multidimensional perceptual, subjective, and instrumental acoustic voice changes in the group of reflux laryngitis (RL) patients. Data of multidimensional voice assessment of 108 RL patients and 90 healthy persons of the control group were subjected to comparative analysis. A slight hoarseness according to the GRB (G-grade, R- rough, B-breathy) scale was prevailing in the RL patients group. Statistically significant difference (P < 0.001) between RL patients group and the control group was found of all voice parameters measured, with the patients having worse results--increased mean jitter, shimmer, normalized noise energy, voice handicap index (VHI), and decreased parameters of phonetogram. The results of the study demonstrated that multidimensional voice assessment documented deteriorated voice quality and restricted phonation capabilities in the tested group of RL patients.

Chronic laryngitis associated with gastroesophageal reflux: prospective assessment of differences in practice patterns between gastroenterologists and ENT physicians

OBJECTIVES

Ear, nose, and throat (ENT) physicians often diagnose gastroesophageal reflux disease (GERD)-related laryngitis on the basis of symptoms and laryngeal signs; and may refer patients to gastroenterologists who contend that many such patients do not have reflux. Because of this dichotomy we designed this study to assess the practice pattern differences among ENT physicians and gastroenterologists in relation to the diagnosis and treatment of patients with GERD-related laryngitis.

METHODS

Separate surveys were specifically designed for ENT physicians and gastroenterologists to assess the following: the percentage of patients diagnosed with GERD-related laryngitis, dose and duration of therapy, treatment response, and other diagnostic options in nonresponders. A total of 2000 surveys were mailed randomly to members of both the American Academy of Otolaryngology Head and Neck Surgery and the American Gastroenterological Association.

RESULTS

Of the total 4,000 surveys sent, 782 (39%) ENT physicians and 565 (28%) gastroenterologists responded. Most respondents (both specialties) were private practitioners (82% and 74%, respectively). From the ENT survey, the diagnosis was most commonly suspected based on the following symptoms: globus = throat clearing > cough > hoarseness. The most useful signs were laryngeal erythema and edema reported by 70% of respondents. Seventy-four percent of ENT physicians reported they made the diagnosis more on symptoms than on laryngeal signs, and initiated therapy most often with proton pump inhibitor (PPI) once daily for 2 months. Gastroenterologists were divided on pre-therapy testing, 50% reporting testing with esophagogastro-duodenoscopy followed by pH monitoring (distal > proximal) prior to therapy, while the remaining 50% reported treating empirically with PPI twice daily for 3 months. Seventy percent of gastroenterologists reported treatment response of less than 60%, while 62% of ENT physicians reported response rate of greater than 60% (p < 0.05).

CONCLUSIONS

(1) Globus and throat clearing were considered the most useful symptoms in diagnosing GERD-related laryngitis, while laryngeal erythema and edema were considered the most useful signs for diagnosis and treatment of this condition by ENT physicians. However, these symptoms and signs may represent the least specific markers for reflux. (2) Many gastroenterologists perform pre-therapy testing which has low sensitivity in GERD-related laryngitis. (3) There is a dichotomy in treatment dose, duration, and perceived patient response to therapy between the two specialists. (4) Our study highlights a need for cross communication and education between these two disciplines in understanding and treating GERD-related laryngitis better.

Laryngeal examination is superior to endoscopy in the diagnosis of the laryngopharyngeal form of gastroesophageal reflux disease

OBJECTIVE

The laryngopharyngeal form of gastroesophageal reflux disease (LF GERD) is a frequent manifestation of supraesophageal GERD. Diagnosis of LF GERD is difficult: most of the common diagnostic methods of GERD have insufficient accuracy in establishing LF GERD. The purpose of this study was to evaluate the role of endoscopic and laryngologic examination in the diagnosis of LF GERD and to create a laryngoscopic reflux index (LRI).

MATERIAL AND METHODS

A total of 108 LF GERD patients and 90 controls were investigated. The criteria for LF GERD were: complaints, reflux-laryngitis, and esophagitis (endoscopically or histologically proven). Lesions in four laryngeal regions were evaluated: arytenoids (A), intraarytenoid notch (IAN), vestibular folds (VF), and vocal cords (VC). Three types of mucosal lesions were evaluated on a points basis: alterations of the epithelium, erythema, and edema. Total LRI was calculated by summing-up the indices in the separate laryngeal areas.

RESULTS

The LRI mean value (11.48+/-3.78 points) of LF GERD patients was statistically significantly greater than that (1.64+/-1.93 points) of the controls. The most significant laryngoscopic changes of LF GERD were: mucosal lesions of IAN, mucosal lesions of VC, and edema of VC. A combination of these three findings reliably distinguishes the LF GERD patients from controls in 95.9% of cases. The mucosal lesions of IAN have the greatest importance in diagnosing LF GERD: the odds ratio to LF GERD - 21.32, p<0.001. Endoscopic esophagitis was established in 36 (33.3%) cases. The severity of esophagitis did not correlate with the severity of the laryngeal findings.

CONCLUSIONS

Laryngoscopy is superior to endoscopy in diagnosing LF GERD. Endoscopy has limited value in the diagnosis of LF GERD. Establishing the LRI could be helpful in the differential diagnosis of the disease in the everyday clinical practice.

Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope)

OBJECTIVES

The objectives of this study were to 1) determine the prevalence of ENT findings in the normal asymptomatic population and 2) to compare findings between flexible and rigid laryngoscopes in an attempt to increase specificity of diagnosis of reflux in endoscopic laryngeal examinations.

STUDY DESIGN

Prospective study.

METHODS

Fifty-two nonsmoker volunteers (24 male, 28 female), mean age of 42.7 years, with no history of ENT abnormalities or gastroesophageal reflux disease, underwent both rigid and flexible videolaryngologic examinations with a digital endoscopic unit. A group of three expert judges reviewed the oral and transnasal examinations blindly and independently for physical signs of irritation/inflammation commonly associated with reflux.

RESULTS

Atleast one sign of tissue irritation was detected in 93% and 83% of the population when using a flexible and a rigid laryngoscope, respectively. Results showed a high incidence of posterior commissure bar (53.2% and 51.9%), arytenoid complex edema/erythema (76.3% and 53.2%), and pseudosulcus (37.2% and 7.7%). Most signs were more frequently detected on flexible transasal examinations than with rigid transoral examinations: posterior pharyngeal wall (<0.01), interarytenoid irritation (<0.01), arytenoids complex irritation (<0.01), ventricular obliteration (<0.01), and pseudosulcus (<0.01).

CONCLUSIONS

Several signs of posterior laryngeal irritation (e.g., interarytenoid bar, erythema of the medial wall of the arytenoids), which are generally considered to be signs of laryngopharyngeal reflux, are present in a high percentage of nonsymptomatic individuals, raising question about their diagnostic specificity. In addition, these signs were more often detected with flexible than with rigid laryngoscopes, suggesting that flexible laryngoscopy is more sensitive but less specific in identifying laryngeal tissue irritation.

[The laryngological complications of the Gastroesophageal Reflux Diseases]

The aim of the study was the quantitative and qualitative assessment of the pathological reflux episodes present in laryngological diseases in relation to GERD. These findings allowed for outlining the relationship between the reported subjective ailments and the disturbances of function and acidic refluxes diagnosed in pH-metric measurements. The study included 40 patients (23 women, 17 men) with clinical laryngological symptoms of GERD (aged 19-63 years, median 42.2): chronic persistent cough, laryngitis, pharyngitis, ulceration of vocal cords, hacking. The patients underwent laryngological check-up (direct laryngoscopy), gastroscopy, 24-hour pH-metry and manometry of the oesophagus. The analysis of the subjective symptoms reported by the patients was done according to the DeMeester's and Likert's scale. The 24-hour abdominal pH-metry was carried out with the use of microDigitrappr MARK III (Synecpol) pH-meter and antymon probe with the reference epidermal electrode. The manometric analysis of the pressure in lower oesophagal sphincter (LES) and the antral function was done with the use of Köenisberg probe integrated with microDigitrapper.

RESULTS

In 80% of the patients we observed the presence of pathological acid refluxes and so called high pharyngeal refluxes (the total number of reflux episodes--91 +/- 8.2, the number of reflux episodes lasting longer than 5 minutes--19.6 +/- 4.6, "fraction time" the percentage of pH < 4.0-7.1 +/- 2.9). In this group of patients chronic laryngitis was observed in 50% of cases, chronic hacking--in 31%, persistent pain in the pharynx--in 28.1%, strong cough--in 59.4%. In 18.7% of the patients with the pathological recurrent reflux of gastro-intestinal content to the oesophagus we observed inflammatory changes of various extent in gastroscopy. We found a strong causal relationship between cough and hacking and the pathological GERD (time interval 5 min, Wiener's indicator SI > or = 75%).

CONCLUSIONS

1. The achieved results confirm the significant role of pathological GERDS in the pathogenesis of many laryngological symptoms. 2. On the basis of the achieved data it seems purposeful that the diagnosis should be much more detailed with the use of 24-hour gastroesophageal pH-metry in the patients with persistent laryngological (mainly cough and hacking) symptoms, especially in case of the patients in whom the reported symptoms are not relieved after routine laryngological treatment. 3. Our findings create the possibility for the modification of the so far diagnostic and therapeutical procedures in this group of patients and the relief of the reported subjective ailments.

[Chronic hyperplastic laryngitis: problems of diagnosis]

Current methods of diagnosis of chronic hyperplastic laryngitis (CHL) are analysed. Etiology, clinical picture, classification of CHL, laryngeal cancer morbidity in Russia, malignant transformation of CHL, methods of additional device and laboratory examination are reviewed. Morphospectrophotometry is proposed for differential diagnosis between CHL and laryngeal cancer.

Beyond heartburn: a systematic review of the extra-oesophageal spectrum of reflux-induced disease

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a chronic condition affecting up to one-quarter of the Western population. GORD is characterized by heartburn and acid regurgitation, but is reported to be associated with a spectrum of extra-oesophageal symptoms.

OBJECTIVE

The aim of this systematic review was to critically evaluate postulated extra-oesophageal symptoms of GORD.

METHODS

Extra-oesophageal symptoms were identified from population-based studies evaluating their association with GORD (either defined as heartburn and/or acid regurgitation, or diagnosed in general practice). The response of these symptoms to acid-suppressive therapy was investigated using randomized, double-blind, placebo-controlled studies. Pathogenic mechanisms were evaluated using clinical and preclinical studies.

RESULTS

An association between GORD and symptoms or a diagnosis of chest pain/angina, cough, sinusitis and gall-bladder disease was evident from three eligible population-based studies of GORD. Randomized placebo-controlled studies (n=20) showed that acid-suppressive therapy provides symptomatic relief of chest pain, asthma and, potentially, chronic cough and laryngitis. Mechanistic models, based on direct physical damage by refluxate or vagally mediated reflexes, support a causal role for GORD in chest pain and respiratory symptoms, but not in gall-bladder disease.

CONCLUSION

GORD is likely to play a causal role in chest pain and possibly asthma, chronic cough and laryngitis. Further investigation is desirable, particularly for other potential extra-oesophageal manifestations of GORD such as chronic obstructive pulmonary disease, sinusitis, bronchitis and otitis. Acid-suppressive therapy is likely to benefit patients with non-cardiac chest pain, but further placebo-controlled studies are needed for other symptoms comprising the extra-oesophageal spectrum of GORD.

Evaluation and management of laryngopharyngeal reflux

CONTEXT

Laryngopharyngeal reflux (LPR) is a major cause of laryngeal inflammation and presents with a constellation of symptoms different from classic gastroesophageal reflux disease.

OBJECTIVE

To provide a practical approach to evaluating and managing cases of LPR.

EVIDENCE ACQUISITION

The PubMed database and the Ovid Database of Systematic Reviews were systematically searched for laryngopharyngeal reflux, laryngopharyngeal reflux fundoplication, laryngopharyngeal reflux PPI treatment, and gastroesophageal reflux AND laryngitis. Pertinent subject matter journals and reference lists of key research articles were also hand-searched for articles relevant to the analysis.

EVIDENCE SYNTHESIS

Reflux of gastric contents is a major cause of laryngeal pathology. The pathophysiology and symptom complex of LPR differs from gastroesophageal reflux disease. Laryngeal pathology results from small amounts of refluxate--typically occurring while upright during the daytime--causing damage to laryngeal tissues and producing localized symptoms. Unlike classic gastroesophageal reflux, LPR is not usually associated with esophagitis, heartburn, or complaints of regurgitation. There is no pathognomonic symptom or finding, but characteristic symptoms and laryngoscopic findings provide the basis for validated assessment instruments (the Reflux Symptom Index and Reflux Finding Score) useful in initial diagnosis. There are 3 approaches to confirming the diagnosis of LPR: (1) response of symptoms to behavioral and empirical medical treatment, (2) endoscopic observation of mucosal injury, and (3) demonstration of reflux events by impedance and pH-monitoring studies and barium swallow esophagram. While pH monitoring remains the standard for confirming the diagnosis of gastroesophageal reflux, the addition of multichannel intraluminal impedance technology improves diagnostic accuracy for describing LPR events. Ambulatory multichannel intraluminal impedance assessment allows for identification of gaseous as well as liquid refluxate and detection of nonacid reflux events that are likely significant in confirming LPR. Although some patients respond to conservative behavioral and medical management, as is the case with gastroesophageal reflux, most require more aggressive and prolonged treatment to achieve regression of symptoms and laryngeal tissue changes. Surgical intervention such as laparoscopic fundoplication is useful in selected recalcitrant cases with laxity of the gastroesophageal sphincter.

CONCLUSIONS

Laryngopharyngeal reflux should be suspected when the history and laryngoscopy findings are suggestive of the diagnosis. Failure to respond to a 3-month trial of behavioral change and gastric acid suppression by adequate doses of proton pump inhibitor medication dictates need for confirmatory studies. Multichannel intraluminal impedance and pH-monitoring studies are most useful in confirming LPR and assessing the magnitude of the problem.