How many cases of laryngopharyngeal reflux suspected by laryngoscopy are gastroesophageal reflux disease-related?

Pathophysiology, diagnosis, and pharmacological treatment of gastro-esophageal reflux disease

INTRODUCTION

Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions.

AREAS COVERED

This review provides an overview of our advancements in understanding the complex pathophysiology, improving the diagnosis and defining the modern pharmacological therapeutic approach to GERD.

EXPERT OPINION

The growing clinical application of impedance-pH testing has allowed us to know the diversity of patients with non-erosive reflux disease (NERD), who nowadays represent about 70% of the whole population with reflux symptoms. We have realized that NERD has to be considered as an umbrella term covering various subgroups with different pathophysiologies. The development of new impedance metrics, in particular mean nocturnal baseline impedance, seems to be promising in the improvement of the diagnostic process of this disease. There are no particularly innovative features in the pharmacological therapy of GERD, unless the interest toward drugs is able to increase the defense properties of esophageal mucosa and/or its protection. These compounds can be of help in combination with proton pump inhibitors in NERD patients with partial response to antisecretory drugs alone.

Personalized Approach in the Work-up and Management of Gastroesophageal Reflux Disease

Patients with gastroesophageal reflux disease (GERD) present with heterogeneous symptoms, response to treatment, and physiologic profiles, requiring distinct and personalized management. This article provides a stepwise framework to phenotype GERD beginning with (1) characterization of symptom profile and response to acid suppression; (2) endoscopic evaluation of mucosal and anatomic integrity; (3) ambulatory reflux monitoring to characterize reflux burden and sensitivity; and (4) esophageal physiologic testing to assess gastroesophageal reflux mechanism and effectors of reflux clearance, and evaluate for alternate causes.

Idiopathic pulmonary fibrosis and GERD: links and risks

Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.

Clinical and polysomnographic predictors of laryngopharyngeal reflux in obstructive sleep apnea syndrome

Introduction

Obstructive sleep apnea syndrome and laryngopharyngeal reflux are diseases with a high prevalence in the overall population; however, it remains unclear whether they are diseases with the same risk factors present in the same populations or if there is any association between them.

Objectives

To evaluate and determine the prevalence of laryngopharyngeal reflux in patients with moderate and severe obstructive apnea syndrome and also to determine its predictive factors.

Methods

Historical cohort, cross-sectional study of patients aged 18–70 years, referred to a tertiary service Otorhinolaryngology outpatient clinic with a polysomnographic diagnosis of moderate or severe obstructive sleep apnea syndrome. The reflux symptom index questionnaire and the reflux finding score at indirect videolaryngoscopy were applied to the assessed population, considering the inclusion and exclusion criteria.

Results

Fifty-six patients were evaluated, of which 64.3% had a positive laryngopharyngeal reflux (positive reflux symptom index and/or positive endolaryngeal reflux finding score). Body mass index was a predictor of reflux presence in this group of patients with moderate to severe obstructive sleep apnea syndrome. In patients with positive score for endoscopic findings and reflux symptom index (12.3%), there was a trend toward significance for a higher mean apnea–hypopnea index and a higher percentage of sleep time with oxyhemoglobin saturation below 90% (p = 0.05).

Conclusion

The prevalence of laryngopharyngeal reflux was higher in this group of patients with moderate to severe obstructive sleep apnea syndrome, and the body mass index was a predictor of laryngopharyngeal reflux in these patients. There was a trend toward greater oxyhemoglobin desaturation in patients with a positive score for reflux symptoms index (RSI) and reflux finding score (RFS).

Laryngopharyngeal reflux and dysphagia in patients with obstructive sleep apnea: is there an association?

INTRODUCTION

There is evidence that patients with obstructive sleep apnea (OSA) tend to have a high prevalence of laryngopharyngeal reflux (LPR) and dysphagia. These diseases are known to share the same risk factors and may be interrelated, but there is a lack of studies evaluating their co-occurrence.

OBJECTIVES

To evaluate whether the presence of signs and symptoms suggestive of LPR may be associated with the presence of dysphagia in patients with moderate and severe obstructive sleep apnea (OSA), as well as assess the additional impact of these diseases on quality of life in patients with OSA.

METHODS

Seventy adult patients with moderate or severe OSA were included in the study. The RSI (Reflux Symptom Index) and Swallowing Quality of Life (SWAL-QOL) in dysphagia questionnaires were administered, laryngoscopy was performed to calculate the Reflux Finding Score (RFS), and fiber-optic endoscopic evaluation of swallowing (FEES) was conducted.

RESULTS

The prevalence of LPR was 59.7%, and the prevalence of dysphagia was 27.3%. The association between LPR and dysphagia was present in 17.9% of patients, but with no statistically significant difference. Lower SWAL-QOL scores were observed in several domains in patients with LPR and in only one domain in patients with evidence of dysphagia on FEES.

CONCLUSIONS

Although 17.9% of patients presented with findings suggestive of concomitant LPR and dysphagia, there was no statistically significant association between these two conditions. Patients with LPR had worse scores in several domains of dysphagia-related quality of life, while FEES evidence of dysphagia was associated with worse quality of life in only one domain.

Association between laryngopharyngeal reflux and benign vocal folds lesions: A systematic review

OBJECTIVES

To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF).

METHODS

PubMed, Cochrane Library, and Scopus were searched by three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinke's edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

RESULTS

Of the 155 relevant publications, 42 studies were included. Thirty-five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (pH monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinke's edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell-to-cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma.

CONCLUSIONS

Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinke's edema. However, the heterogeneity and the low number of high-quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF. Laryngoscope, 129:E329-E341, 2019.

Evaluation and Management of Laryngopharyngeal Reflux Disease: State of the Art Review

OBJECTIVE

To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR).

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

METHODS

A comprehensive review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature.

CONCLUSIONS

The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance-pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved.

IMPLICATIONS FOR PRACTICE

The development of multichannel intraluminal impedance-pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR.

Proton Pump Inhibitor Ameliorates Taste Disturbance among Patients with Laryngopharyngeal Reflux: A Randomized Controlled Study

Patients with laryngopharyngeal reflux (LPR) were reported to suffer from hypogeusia that affects quality of life. Proton pump inhibitor (PPI) is a useful drug in the treatment of LPR, but its effect on hypogeusia is not known. We therefore assessed the effects of PPI or a histamine H2 receptor antagonist (H2 blocker) on hypogeusia among patients with LPR. Both PPI and H2 blocker could inhibit acid reflux. LPR was diagnosed with reflux finding score and reflux symptom index. The visual analogue scale (VAS) of taste disturbance symptoms and the gustatory tests were assessed before and 8 weeks after treatment with esomeprazole, a PPI (20 patients, aged 50.0 ± 1.7 years) or famotidine, a H2 blocker (20 patients, aged 47.1 ± 1.8 years). There were no significant differences in VAS scores and recognition thresholds for four basic tastes between the two groups before treatment. Only PPI therapy significantly decreased the VAS scores, suggesting the improvement of taste perception. Moreover, PPI therapy significantly decreased recognition thresholds for bitter taste in the anterior tongue (chorda tympani nerve area) and the thresholds in the posterior tongue (glossopharyngeal nerve area) for salty, sour, and bitter tastes. By contrast, H2-blocker therapy caused no significant changes of thresholds in the anterior tongue, but improved the threshold only for bitter in the posterior tongue, the value of which was however significantly higher than that in PPI group. In conclusion, PPI could ameliorate hypogeusia by improving bitter, salty, and sour tastes among patients with LPR.

Vocal Tract Discomfort and Dysphonia in Patients Undergoing Empiric Therapeutic Trial with Proton Pump Inhibitor for Suspected Laryngopharyngeal Reflux

INTRODUCTION

the aim of this study was to evaluate the correlation among dysphonic and vocal tract discomfort symptoms in patients who underwent empiric therapeutic trial with proton pump inhibitor (PPI) for a suspected laryngopharyngeal reflux (LPR).

MATERIALS AND METHODS

A total of 34 patients with suspected LPR were enrolled in this study. All of them were evaluated using the reflux finding score, the reflux symptom Index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) before and after the PPI treatment.

RESULTS

A significant difference was found between pretreatment and posttreatment reflux finding score, RSI, VTDS, and VoiSS scores. Significant correlations among RSI, VTDS, and VoiSS before the PPI treatment were found.

CONCLUSION

PPI treatment determined a significant improvement of symptoms related to dysphonia and vocal tract discomfort in patients with suspected LPR, in addition, significant correlations among the RSI, VTDS, and VoiSS scores were demonstrated thus suggesting that LPR might influence the response of questionnaires not specifically developed in order to assess the complains in LPR patient.

Globus: Current Concepts and Dilemmas

Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.

Throat Clearing, Frequently Reported, But is it GERD Related?

GOALS

To identify the association of throat clearing (TC) with gastroesophageal reflux disease (GERD) during objective reflux monitoring in a large number of patients studied in our esophageal testing laboratory.

BACKGROUND

TC is frequently reported and considered to be an atypical symptom of GERD. Atypical GERD symptoms have been widely investigated and empirically treated with proton pump inhibitors.

STUDY

We reviewed ambulatory impedance-pH studies of 186 patients referred for evaluation of possible GERD from January 2011 to December 2015 to evaluate the symptom association (SA) of TC with both an abnormal number of reflux episodes and also abnormal esophageal acid exposure (EAE). Patients were divided into 2 groups; group 1: TC is the only reported symptom, group 2: TC is one of the symptoms. All patients were studied off proton pump inhibitors therapy.

RESULTS

Group 1 where TC was the only symptom in 27/186 (14.5%) patients. There was no significant difference in positive SA between this group (6/27; 22%) and group 2 (43/159; 27%) (Z score P=0.59). There was also no significant association between SA and abnormal EAE whether TC was the only presenting symptom (χ, P=0.7) or one of the reported symptoms (χ, P=0.10). None of the 6/27 had abnormal EAE.

CONCLUSION

Although TC is often considered a possible GERD-related symptom, we found a low probability of objective association. TC is not likely to be the only presenting symptom, and if it happens, it is unlikely to be associated with GERD. Perhaps, TC should not be considered as a GERD symptom, even as an atypical one.

Proton pump inhibitors: use and misuse in the clinical setting

INTRODUCTION

The introduction of proton pump inhibitors (PPIs) into clinical practice has greatly improved our therapeutic approach to acid-related diseases for their efficacy and safety. Areas Covered: The following evidence-based indications for PPI use are acknowledged by many scientific societies: treatment of the various forms and complications of gastroesophageal reflux disease, eradication of H. pylori infection in combination with two or more antibiotics, short- and long-term therapy of H. pylori-negative peptic ulcers, healing, and prevention of NSAID/COXIB-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger Ellison syndrome. Expert Commentary: Despite the above well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and the endless expansion of the PPI market has created important problems for many regulatory authorities for two relevant features: the progressive increase of the costs of therapy and the greater potential harms for the patients. The major reasons for the misuse of PPIs are the prevention of gastro-duodenal ulcers in patients without risk factors and the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anti-platelet or anti-coagulant treatment in patients without risk of gastric injury and the overtreatment of functional dyspepsia.

Appropriateness in prescribing PPIs: A position paper of the Italian Society of Gastroenterology (SIGE) - Study section "Digestive Diseases in Primary Care"

The introduction of proton pump inhibitors (PPIs) into clinical practice about thirty years ago has greatly improved our therapeutic approach to acid-related diseases for their well-recognized efficacy and safety. Despite the well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and this phenomenon poses serious queries that include the onset of potential adverse effects and the increase in health care costs. The major reason explaining this worrying market expansion is the inappropriate use of PPIs. In order to re-establish a correct use of these effective drugs in daily clinical practice, the Italian Society of Gastroenterology (SIGE), nominated a panel of experts who reviewed the available clinical literature and produced a series of updated position statements on the use of PPIs in clinical practice.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Sleep and Nocturnal Gastroesophageal Reflux: An Update

Nocturnal gastroesophageal reflux has been associated with poor sleep quality. Normal physiological adaptations of the aerodigestive system to sleep prolong and intensify nocturnal reflux events. This occurrence leads to sleep disruption, as well as to esophageal, laryngeal, and laryngopharyngeal reflux. Controversy exists on whether OSA and nocturnal reflux are causally linked or merely associated because of shared risk factors. Advances in diagnostic technology have provided new insights into gastroesophageal reflux and the mechanisms of nocturnal reflux during sleep. This update reviews new data on causal links between sleep and gastroesophageal reflux disease.

Facts and Fantasies on Extraesophageal Reflux: A Gastroenterologist Perspective

Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.

Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study

OBJECTIVE

Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR.

DESIGN

Single center prospective cohort study.

SETTING

Tertiary medical center PARTICIPANTS: 27 adult patients with diagnosed laryngopharyngeal reflux.

INTERVENTION

An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6h per night for 28 consecutive nights.

MAIN OUTCOMES

Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28days of SPD use.

RESULTS

27 patients (19 female and 8 male; age 57.1±12.8, BMI 29.0±8.1) were recruited. At baseline mean N-GSSIQ was 50.1±22.4 and mean RSI of 29.6±7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p=0.0004) points by two weeks and 26.5 points by 4weeks (p<0.0001). RSI decreased an average of 5.3 points by 2weeks (p=0.0425) and an average of 14.0 points by 4weeks (p<0.0001).

CONCLUSIONS

In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.

A review of pharmacotherapy for treating gastroesophageal reflux disease (GERD)

INTRODUCTION

Medical therapy of gastroesophageal reflux disease (GERD) is based on the use of proton pump inhibitors (PPIs) as first choice treatment. Despite their effectiveness, about 20-30% of patients report an inadequate response and alternative drugs are required. Areas covered: This review provides an overview of current pharmacotherapy for treating GERD by showing the results of PPIs, reflux inhibitors, antidepressants and mucosa protective medications. Expert opinion: Medical therapy of GERD does not definitely cure the disease, because even PPIs are not able to change the key factors responsible for it. However, they remain the mainstay of medical treatment, allowing us to alleviate symptoms, heal esophagitis and prevent complications in the majority of cases. Nevertheless, many patients do not respond, because acid does not play any pathogenetic role. Prokinetics and reflux inhibitors have the potential to control motor abnormalities, but the results of clinical trials are inconsistent. Antidepressant drugs are effective in specific subgroups of NERD patients with visceral hypersensitivity, but larger, controlled clinical studies are necessary. Protective drugs or medical devices have been recently adopted to reinforce mucosal resistance and preliminary trials have confirmed their efficacy either combined with or as add-on medication to PPIs in refractory patients.

Association of Oral Antireflux Medication With Laryngopharyngeal Reflux and Nasal Resistance

Importance

Laryngopharyngeal reflux (LPR) is thought to be a potential exacerbating factor in upper airway diseases.

Objective

To describe the effect of pharmacologic therapy of laryngopharyngeal reflux on nasal resistance.

Design, Setting, and Participants

Prospective observational study performed between August 30, 2014, and October 1, 2015, at a tertiary care academic center including 50 patients with Reflux Symptom Index higher than 13 and Reflux Finding Score higher than 7 and 50 controls with no history of LPR and nasal disease.

Interventions

Oral antireflux medication was given to the LPR group for 12 weeks.

Main Outcomes and Measures

The measurements of total nasal resistance (TNR) were performed by means of active anterior rhinomanometry technique and Nasal Obstruction Symptom Evaluation (NOSE) was assessed.

Results

The LPR group had 29 (58%) women and a median age of 41.5 years (range, 18-64 years). The control group had 27 (54%) women and a median age of 38.5 years (range, 19-63 years). After treatment, a significant decrease was observed in all parameters. The median (range) TNR scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median TNR score of the control group was 0.20 (range, 0.11-0.32). Whereas the TNR scores of the LPR group were higher than those of the control group before treatment (difference, -0.77; 95% CI, -0.10 to 0.05), they were almost the same after treatment (difference, 0.01; 95% CI, -0.01 to 0.03). The median (range) NOSE scores of the LPR group before and after treatment were 0.29 (0.12-0.36) and 0.19 (0.10-0.31), respectively. The median NOSE score of the control group was 0.20 (range, 0.11-0.32).

Conclusions and Relevance

In this study, laryngopharyngeal reflux had a negative effect on nasal resistance and nasal congestion. Treatment was associated with improved subjective and objective nasal findings.

Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery

A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.

The Utility of the Reflux Symptom Index for Diagnosis of Laryngopharyngeal Reflux in an Allergy Patient Population

BACKGROUND

Laryngopharyngeal reflux (LPR) is associated with asthma, vocal cord dysfunction, cough, postnasal drainage, and throat irritation. The Reflux Symptom Index (RSI) is a clinical tool to predict the presence of LPR, but a threshold RSI score has never been validated for the diagnosis of LPR in an allergic patient population.

OBJECTIVE

To identify the optimal threshold RSI score predictive of LPR in an allergy clinic population.

METHODS

The 9-question RSI questionnaire was administered to 84 patients in the Kaiser Permanente San Diego Allergy Department. The patient's allergist (who was blinded to the patient's RSI responses) was asked to determine whether the patient had symptoms consistent with LPR. Each subject's RSI score was then compared with a corresponding physician-based diagnosis. After determining the correlation between the subject's RSI score and physician-diagnosed LPR/supraesophageal reflux, a cutoff level above which LPR/supraesophageal reflux would be highly suspected was calculated on the basis of most optimal balance of sensitivity and specificity determined via a receiver-operating curve analysis.

RESULTS

Thirty of the 84 patients (36%) were diagnosed with LPR. The mean RSI score for the group without LPR was 18.3 ± 9.8 (out of 45 possible), while the LPR group's mean was 25.0 ± 8.3 (P < .01). The optimal RSI score cutoff was determined to be 19. An abbreviated questionnaire was also generated using 6 of the RSI questions found to be significantly different between patients with and without LPR.

CONCLUSIONS

An RSI score of 19 appears to represent the best threshold for predicting LPR in an allergy clinic patient population.

The natural history of gastro-esophageal reflux disease: a comprehensive review

Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.

Role of PH Monitoring in Laryngopharyngeal Reflux Patients with Voice Disorders

INTRODUCTION

Laryngopharyngeal reflux (LPR) is considered an important cause of voice disorder. We aimed to determine the frequency of LPR in patients with voice disorder and the association between Koufman Reflux Symptom Index (RSI), Reflux Finding Score (RFS), gastroesophageal reflux disease (GERD), and proximal acid reflux in these patients.

MATERIALS AND METHODS

We performed a prospective study in patients aged more than 18 years presenting at the ear, nose, and throat (ENT) clinic with a change in voice lasting more than 3 weeks. All patients underwent nasopharyngolaryngoscopy and a dual-probe esophageal pH study. LPR was diagnosed by a Koufman RSI of >13 and/or RFS of >7. GERD was diagnosed according to a DeMeester Johnson score of >14.7. Proximal acid reflux was diagnosed if acid exposure time was >0.02% in a proximal pH probe.

RESULTS

The study included 30 patients with a voice disorder. The mean age of participants was 38.5 years and 40% of patients were female. Using either of the two criteria, LPR was present in 46.7% of patients, half of whom had GERD. Among the remaining 53.3% patients with a voice disorder and no evidence of LPR, GERD was present in 25%. There was no significant association between the presence of LPR based on RSI (P=1) and GERD or RFS and GERD (P=0.06). Proximal acid reflux was present in only 10% patients with a voice disorder, and there was no significant association of this test with RFS (P=1) or RSI (P=1).

CONCLUSIONS

Approximately half of the patients with a voice disorder have LPR, and only a subset of these patients have evidence of GERD. Fiberoptic laryngoscopic findings (RFS) complementing RSI appears to be important in diagnosing possible reflux etiology in voice disorders and can be an indicator for instituting anti-reflux therapy. However, there is no significant association between RSI, RFS, and GERD suggesting that these tests evaluate different features of the disease. Proximal acid reflux is uncommon in patients with voice disorder based on current measurement criteria. Acid exposure time as measured in the proximal probe of a 24-hour dual pH probe may need to be re-evaluated as one of the diagnostic criteria for LPR.

Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus

AIM

To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.

METHODS

In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared.

RESULTS

We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001).

CONCLUSION

In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.

Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study

BACKGROUND/AIMS

Patients with otorhinolaryngologic (ear, nose, and throat-ENT) symptoms attributed to gastroesophageal reflux disease (GERD) are usually treated with medication based on the findings of nasal endoscopy and laryngoscopy only. This study aims to determine sensitivity and specificity of symptoms, nasal endoscopy, and laryngoscopy for the diagnosis of GERD as compared to pH monitoring.

METHODS

We studied 79 patients (mean age 53 years, 38 % males) in whom ENT symptoms were assumed to be secondary to GERD. All patients underwent a transnasal laryngoscopy by the ENT team and upper endoscopy and esophageal function tests by the surgical team. GERD was defined by a pathological pH monitoring.

RESULTS

Pathologic reflux by pH monitoring was documented in 36 of the 79 patients (46 %), with a mean DeMeester score of 44. In 25 of the 36 patients (69 %), distal and proximal reflux was present. Among patients with negative pH monitoring, one patient was diagnosed with achalasia. ENT symptom sensitivity for globus, hoarseness and throat clearing was respectively 11, 58, and 33 %; specificity was respectively 77, 42, and 58 %. Positive predictive value for nasal endoscopy and laryngoscopy was 46 %. Among patients with positive pH monitoring, 13 (36 %) had a hypotensive lower esophageal sphincter (p < 0.01) and 27 (34 %) had abnormal peristalsis (p < 0.01).

CONCLUSIONS

In conclusion, the results of this study showed that (a) ENT symptoms were unreliable for the diagnosis of GERD and (b) laryngoscopy had a low positive predictive value for the diagnosis of GERD. These data confirm the importance of esophageal manometry and pH monitoring in any patient with suspected ENT manifestations of GERD before starting empiric therapy with acid-reducing medications since pathologic reflux by pH monitoring was confirmed in less than half of the patients with suspected GERD.

Diagnosis and Anti-Reflux Therapy for GERD with Respiratory Symptoms: A Study Using Multichannel Intraluminal Impedance-pH Monitoring

Background/Aims

Respiratory symptoms are often associated with gastroesophageal reflux disease (GERD). Although the role of multichannel intraluminal impedance–pH (MII-pH) monitoring in GERD is clear, little is known regarding the characteristics of patients with respiratory symptoms based on MII-pH monitoring and anti-reflux therapy. We evaluated a cohort of GERD patients to identify the MII-pH parameters of GERD-related respiratory symptoms and to assess the anti-reflux therapy outcomes.

Methods

We undertook a prospective study of patients who were referred for GERD evaluation from January 2011 to January 2012. One hundred ninety-five patients underwent MII-pH monitoring and esophageal manometry, and one hundred sixty-five patients underwent invasive anti-reflux therapy that included laparoscopic Toupet fundoplication (LTF) and the Stretta procedure. The patient characteristics and MII-pH parameters were analyzed, and the symptom scores were assessed at baseline and at 1- and 3-year follow-up evaluations.

Results

Of the 195 patients, 96 (49.2%) exhibited respiratory symptoms and significantly more reflux episodes (70.7±29.3) than patients without respiratory symptoms (64.7±24.4, p = 0.044) based on the MII-pH monitoring results. Moreover, the group of patients with respiratory symptoms exhibited more proximal reflux episodes (35.2±21.3) than the non-respiratory symptomatic group (28.3±17.9, p = 0.013). One hundred twenty-five patients following the Stretta procedure (n = 60, 31 with respiratory symptoms) or LTF (n = 65, 35 with respiratory symptoms) completed the designated 3-year follow-up period and were included in the final analysis. The symptom scores after anti-reflux therapy all decreased relative to the corresponding baseline values (p<0.05), and there were no significant differences in the control of respiration between the Stretta procedure and LTF (p>0.05). However, LTF significantly reduced the recurrence (re-operation) rate compared with the Stretta procedure (0 vs. 19.4%, p = 0.006).

Conclusions

MII-pH monitoring effectively detected respiratory-related predictive parameters, including total/proximal reflux episodes and symptom correlations. We found that GERD patients with respiratory symptoms exhibited more proximal and total reflux episodes but not more acid-related episodes, as determined by MII-pH monitoring. Thus, such monitoring could be useful for diagnosing atypical GERD patients with respiratory symptoms. Furthermore, LTF exhibited a more significant effect on controlling typical symptoms in all GERD patients and reducing the recurrence rate than the Stretta procedure in patients with respiratory symptoms.

Respiratory disease and the oesophagus: reflux, reflexes and microaspiration

Gastro-oesophageal reflux is associated with a wide range of respiratory disorders, including asthma, isolated chronic cough, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease and cystic fibrosis. Reflux can be substantial and reach the proximal margins of the oesophagus in some individuals with specific pulmonary diseases, suggesting that this association is more than a coincidence. Proximal oesophageal reflux in particular has led to concern that microaspiration might have an important, possibly even causal, role in respiratory disease. Interestingly, reflux is not always accompanied by typical reflux symptoms, such as heartburn and/or regurgitation, leading many clinicians to empirically treat for possible gastro-oesophageal reflux. Indeed, costs associated with use of acid suppressants in pulmonary disease far outweigh those in typical GERD, despite little evidence of therapeutic benefit in clinical trials. This Review comprehensively examines the possible mechanisms that might link pulmonary disease and oesophageal reflux, highlighting the gaps in current knowledge and limitations of previous research, and helping to shed light on the frequent failure of antireflux treatments in pulmonary disease.

Esophageal testing: What we have so far

Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.

High Prevalence of Laryngopharyngeal Reflux Disease in Patients With Lumbar Kyphosis

OBJECTIVE

To evaluate the relationship between laryngopharyngeal reflux disease and presence of lumbar kyphosis.

STUDY DESIGN

A cross-sectional study.

METHODS

We included 20 patients with lumbar kyphosis and 31 control subjects. A diagnosis of laryngopharyngeal reflux disease and gastroesophageal reflux disease was made if the Reflux Symptom Index score was ≥13 and if the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease was ≥8, respectively. We compared the prevalence of the two reflux diseases, frequent reflux symptoms, and demographic factors between the two groups.

RESULTS

There was no significant difference in demographic factors between the two groups. Five (25%) of 20 patients with lumbar kyphosis had a Reflux Symptom Index ≥13 compared with one (3.2%) of 31 controls. Seven (35.0%) of 20 patients had a Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease ≥8 compared with three (9.7%) of 31 controls. A comparison of the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease showed a significant difference between patients with kyphosis and controls (P value = 0.029 and 0.036, respectively). In Reflux Symptom Index, heartburn, hoarseness, and a swallowing problem were significantly frequent symptoms in the kyphosis group compared with the control group.

CONCLUSIONS

The prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls. Therefore, otolaryngologists and orthopedic surgeons should be aware that patients with lumbar kyphosis are likely to have gastroesophageal reflux disease and also laryngopharyngeal reflux disease.

An evaluation of olfactory function in adults with gastro-esophageal reflux disease

CONCLUSION

To the best of the authors' knowledge, this study is the first to evaluate the olfactory function of adult patients diagnosed with GERD. The results revealed that adults with GERD have diminished olfactory function.

OBJECTIVE

This study aimed to evaluate the olfactory abilities of subjects using the 'Sniffin' Sticks' olfactory test.

METHODS

A total of 35 men and women aged 18-60 years with a diagnosis of GERD and 45 healthy controls were included in the study. The Sniffin' Sticks olfactory test results of the two groups were compared, and the relationship between the study findings and the olfactory parameters was evaluated.

RESULTS

The odor threshold (10.1; 9.5, p = 0.016), odor identification (9.6; 8.1, p < 0.001), and odor discrimination (10.7; 8.9, p < 0.001) of the GERD group were significantly lower than those of the control group. A statistically significant positive correlation was detected between the accompanying chronic pharyngitis, chronic sinusitis, and odor parameters. A significant correlation was not detected between the laryngeal findings and the olfactory parameters.

In the Clinic. Gastroesophageal Reflux Disease

This issue provides a clinical overview of gastroesophageal reflux disease, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay

Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.

Influence of upper airway abnormalities on the control of severe asthma: a cross-sectional study

BACKGROUND

A better understanding of severe uncontrolled asthma (UA) in the upper airways is needed. The aims of this study were to assess the prevalence of upper airway abnormalities and their associations with UA.

METHODS

An observational study enrolled individuals with severe asthma. Sociodemographic and clinical questionnaires regarding asthma, rhinosinusitis, and laryngopharyngeal reflux (LPR) were administered. Skin-prick tests and fiber optic nasolaryngoscopies were also performed. Descriptive statistical analysis was performed, using a multiple Poisson regression model to obtain adjusted prevalence ratios (PRs) and to identify the clinical profiles associated with the highest and lowest percentages of the dependent variable, lack of asthma control.

RESULTS

The sample consisted of 64 participants who were divided into 2 groups according to asthma control. Thus, group I comprised 27 individuals with severe controlled asthma (CA), and group II consisted of 37 individuals with UA. Women represented 87.5% of the study population. The median age was 54 years, and 86% of the sample had rhinosinusitis. Relevant associations were detected between UA and hyposmia (PR = 2.04), hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) (PR = 1.45), arytenoids hyperemia (PR = 1.45), LPR (PR = 1.37), a positive family history of asthma (PR = 1.35), onset of asthma at age 10 years or older (PR = 0.59), and swelling of the vocal cords (PR = 0.54).

CONCLUSION

This study found a very high prevalence of rhinosinusitis in patients with severe asthma as well as associations between UA and hyposmia, hypersensitivity to NSAIDs, arytenoids hyperemia, and LPR. Clinical profiles prone to UA were identified.

Narrow-Band Imaging of Laryngeal Images and Endoscopically Proven Reflux Esophagitis

Objective

To compare the difference between white light (WL) and narrow-band imaging (NBI) endoscopy in evaluating patients who had reflux laryngitis and esophagitis.

Study Design

Retrospective review of medical records and endoscopic images.

Setting

Outpatient clinic.

Subjects and Methods

There were 102 consecutive patients with reflux esophagitis (mean age, 48 ± 11 years) who had office-based transnasal esophagoscopy (TNE) with WL and NBI views, including 60 men (59%) and 42 women (41%). We compared WL and NBI endoscopy in observing the laryngeal and esophageal epithelium. The nasopharynx, base of the tongue, epiglottis, hypopharynx, larynx, esophagus, gastroesophageal junction, and stomach were examined, and all procedures were digitally recorded. All patients were evaluated with WL and NBI views to determine the reflux finding score (RFS) in the larynx and Los Angeles (LA) classification grade in the esophagus.

Results

The NBI views were more sensitive than the WL views in the erythema/hyperemia, vocal cord edema, and global RFS scores. The NBI view facilitated the identification of the erythema/hyperemia change representing dilation or proliferation of microvessels caused by epithelial inflammation. The global RFS score was significantly associated with severity of LA grade only with the NBI view.

Conclusion

The endoscopic findings with the NBI view permit an easier identification of the RFS parameters of laryngeal erythema/vocal cord edema, which have a stronger correlation with the severity of reflux esophagitis, than the WL view. The importance of NBI in the evaluation of reflux laryngitis and gastroesophageal reflux disease deserves further study.

How uncomplicated total thyroidectomy could aggravate the laryngopharyngeal reflux disease?

Swallowing, voice disorders, throat discomfort and subjective neck discomfort are usually reported by patients with a known thyroid nodule and are correlated to nodular thyroid disease itself. Moreover, in endemic goitrous areas, total thyroidectomy (TT) is the most frequently performed surgical procedure. We are used to relate swallowing, voice and throat discomfort to the mechanical effects of nodular goiter or to thyroidectomy itself, but in both these cases the relationship between symptoms and the thyroid mass or its removal is not always clear or easily demonstrated. How can we explain the persistence of local neck symptoms after TT? And how can TT worsen the dysphagic or dysphonic disorders attributed to the goiter's effect over the surrounding structures? During these years, many articles have analyzed the relationship between the thyroid disease and the laryngopharyngeal reflux, finding more and more evidences of their consensuality, leading to important new management considerations and notable medico-legal implications; if the reason of local neck symptoms is not the thyroid disease, we have to study and specially cure the reflux disease, with specific test and drugs. Therefore, the aim of our study, relying on the published literature, was to investigate how, in demonstrated presence of reflux laryngopharyngitis in patients with nodular goiter and local neck symptoms before and after uncomplicated TT, the surgery could influence our anti-reflux mechanism analyzing the anatomical connection as well as the functional coordination; can we play a part in the post-operative persistence of swallowing and voice alterations and throat discomfort?

Voluntary and controlled weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with gastroesophageal reflux disease: a comparative study

A wide variety of pieces of evidence has suggested that obesity is associated with a significant increase in the risk for gastroesophageal reflux disease (GERD) symptoms and its complications. The aim of this study was to evaluate the effect of weight loss on reflux symptoms in overweight/obese patients with proven GERD. We enrolled overweight/obese patients with typical GERD symptoms and erosive esophagitis. At baseline, patients underwent detailed reflux symptoms evaluation and anthropometric assessment, and were divided into two treatment groups: group A received proton pump inhibitor (PPI) and a personalized hypocaloric diet and aerobic exercise; and group B received PPI and a 'standard of care diet'. The dietetic treatment was considered effective if at least 10% of weight loss was achieved within 6 months. All patients were evaluated in terms of anthropometric data, GERD symptoms, and PPI use. In group A, mean body mass index (BMI) decreased from 30.3 ± 4.1 to 25.7 ± 3.1 (P < 0.05), and mean weight decreased from 82.1 ± 16.9 kg to 69.9 ± 14.4 kg (P < 0.05). In group B, there was no change in BMI and weight. Symptom perception decreased (P < 0.05) in both groups during PPI therapy, but a higher improvement was recorded in group A. In group A, PPI therapy was completely discontinued in 27/50 of the patients, and halved in 16/50. Only 7/50 continued the same PPI dosage. In group B, 22/51 halved the therapy and 29/51 maintained full dosage of therapy, but none was able to discontinue PPI due to a symptom recurrence. Overall, weight loss of at least 10% is recommended in all patients with GERD in order to boost the effect of PPI on reflux symptom relief and to reduce chronic medication use.

Correlation between oropharyngeal pH-monitoring and esophageal pH-impedance monitoring in patients with suspected GERD-related extra-esophageal symptoms

BACKGROUND

24-hour esophageal pH-impedance (pH-MII) is not totally reliable for laryngopharyngeal reflux (LPR). Oropharyngeal (OP) pH-monitoring with the Dx-pH probe may detect LPR better. The correlation between these two techniques is not thoroughly established. Aim of this study is to examine the correlation between OP pH-metry and esophageal pH-MII monitoring.

METHODS

Thirty-six consecutive patients with suspected gastroesophageal reflux disease-related extra-esophageal symptoms were evaluated using 24-h OP-pH and concomitant esophageal pH-MII monitoring. OP events were defined as: drop in pH below thresholds of 5.5, 5.0, 4.5, 4.0 or drop in pH of at least 10% from a running baseline. Temporal relationship between OP and esophageal reflux events and outcomes of the two tests were evaluated.

KEY RESULTS

2394 refluxes were detected by pH-MII; of these only 120 were detected also by OP Dx-probe. On the other hand, the proportion of OP-pH events which were temporally related to an episode of distal reflux ranged from 0% to 17%, depending on the proximal pH criteria used. In 8/36 patients both tests were pathological, while in 10/36 they were both normal; 14/36 patients had pathological OP reflux, but a normal pH-MII test; 4/36 patients had pathological pH-MII, but a normal OP reflux.

CONCLUSIONS & INFERENCES

The correlation between OP pH-metry and pH-MII was weak. At present, the absence of a reliable gold standard for the diagnosis of LPR and the uncertain etiology of the pharyngeal pH alterations make it difficult to decide which is the most reliable technique for the diagnosis of true LPR.

Reflux pattern and role of impedance-pH variables in predicting PPI response in patients with suspected GERD-related chronic cough

BACKGROUND

Gastro-oesophageal reflux disease (GERD) may contribute to the onset of chronic cough (CC); however, the multichannel intraluminal impedance-pH (MII-pH) monitoring is often within the normal range and the response to proton pump inhibitors (PPIs) unsatisfactory. The measure of impedance baseline (IB) increases the sensitivity of MII-pH in patients with typical symptoms.

AIM

To evaluate the role of MII-pH variables, including IB, in predicting PPI response and to define the characteristics of the reflux pattern in CC patients.

METHODS

Prospectively selected CC patients suspected GERD-related underwent MII-pH monitoring and, therefore, received a double dose of PPIs for at least 6 weeks. Patients filled symptom scores before MII-pH and after PPI therapy. MII-pH data were compared with those obtained in 60 non-erosive reflux disease patients with typical symptoms.

RESULTS

A total of 156 CC patients entered the study: 68 (43.5%) responders and 88 (56.5%) nonresponders to PPIs. The number of reflux episodes was significantly higher in CC compared with that in typical symptoms patients. Nonresponder CC patients with a pathological acid exposure time (AET) and/or IB value were 43/88 (49%), while 15/88 (17%) presented only pathological AET (P < 0.001). CC patients with a pathological AET or IB, or with both a pathological AET and IB, showed a probability of PPI response twofold greater than patients with normal AET and IB.

CONCLUSIONS

The presence of a pathological AET or pathological IB in CC patients is associated with a greater probability of PPI response. IB is a promising variable in patients with CC, as it increases the diagnostic yield of MII-pH and allows confirmation of the GERD diagnosis in these patients.