Surgical Treatment for Laryngopharyngeal Reflux Disease: A Systematic Review

In vitro model to evaluate effect of acidic pepsin on vocal fold barrier function

The pathophysiology of laryngopharyngeal reflux (LPR) and its impact on the vocal fold is not well understood, but may involve acid damage to vocal fold barrier functions. Two different components encompass vocal fold barrier function: the mucus barrier and tight junctions. Mucus retained on epithelial microprojections protects the inside of the vocal fold by neutralizing acidic damage. Tight junctions control permeability between cells. Here we developed an in vitro experimental system to evaluate acidic injury and repair of vocal fold barrier functions. We first established an in vitro model of rat vocal fold epithelium that could survive at least one week after barrier function maturation. The model enabled repeated evaluation of the course of vocal fold repair processes. Then, an injury experiment was conducted in which vocal fold cells were exposed to a 5-min treatment with acidic pepsin that injured tight junctions and cell surface microprojections. Both of them healed within one day of injury. Comparing vocal fold cells treated with acid alone with cells treated with acidic pepsin showed that acidic pepsin had a stronger effect on intercellular permeability than acid alone, whereas pepsin had little effect on microprojections. This result suggests that the proteolytic action of pepsin has a larger effect on protein-based tight junctions than on phospholipids in microprojections. This experimental system could contribute to a better understanding of vocal fold repair processes after chemical or physical injuries, as well as voice problems due to LPR pathogenesis.

Magnetic Sphincter Augmentation for Laryngopharyngeal Reflux: An Assessment of Efficacy and Predictors of Outcome

INTRODUCTION

Magnetic sphincter augmentation (MSA) is an effective treatment for typical reflux symptoms, but data on its impact on laryngopharyngeal reflux (LPR) is limited. This study aimed to determine the efficacy of MSA for LPR and to identify predictors of outcome.

METHODS

This was a retrospective review of 775 patients who underwent MSA between 2013 and 2021. LPR was defined as presence of atypical reflux symptoms and a reflux symptom index (RSI) score >13. Favorable outcome was defined as primary symptom resolution, freedom from proton pump inhibitors, and five-point improvement or RSI score normalization. Preoperative clinical, high-resolution manometry, and impedance-pH data were analyzed for impact on favorable outcome using univariate followed by multivariable analysis.

RESULTS

There were 128 patients who underwent MSA for LPR. At a mean (SD) follow-up of 13 (5.4) months, favorable outcome was achieved by 80.4% of patients, with median (IQR) RSI score improving from 29 (22-35) to 9 (4-17), (P < 0.001). Independent predictors of favorable outcome on multivariable analysis included LPR with typical reflux symptoms [OR (95% CI): 8.9 (2.3-31.1), P = 0.001], >80% intact swallow on high-resolution manometry [OR (95% CI): 3.8 (1.0-13.3), P = 0.035], upper esophageal sphincter (UES) resting pressure >34 mmHg [OR (95% CI): 4.1 (1.1-14.1), P = 0.027] and short total proximal acid clearance time [OR (95% CI): 1.1 (1.0-1.1), P = 0.031]. Impedance parameters including number of LPR events, full column reflux and proximal acid exposure events were similar between outcome groups (P > 0.05).

CONCLUSION

MSA is an effective surgery for patients with LPR. Patients with concomitant typical reflux symptoms, normal esophageal body motility, and competent UES benefit the most from surgery. Individual impedance-pH parameters were not associated with outcome.

Review article: Diagnosis and management of laryngopharyngeal reflux

BACKGROUND

Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux.

AIMS

To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux.

METHODS

We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches.

RESULTS

We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients.

CONCLUSIONS

Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.

Inhaled fosamprenavir for laryngopharyngeal reflux: Toxicology and fluid dynamics modeling

Objectives

Approximately 25% of Americans suffer from laryngopharyngeal reflux (LPR), a disease for which no effective medical therapy exists. Pepsin is a predominant source of damage during LPR and a key therapeutic target. Fosamprenavir (FOS) inhibits pepsin and prevents damage in an LPR mouse model. Inhaled FOS protects at a lower dose than oral; however, the safety of inhaled FOS is unknown and there are no inhalers for laryngopharyngeal delivery. A pre-Good Lab Practice (GLP) study of inhaled FOS was performed to assess safety and computational fluid dynamics (CFD) modeling used to predict the optimal particle size for a laryngopharyngeal dry powder inhaler (DPI).

Methods

Aerosolized FOS, amprenavir (APR), or air (control) were provided 5 days/week for 4 weeks (n = 6) in an LPR mouse model. Organs (nasal cavity, larynx, esophagus, trachea, lung, liver, heart, and kidney) were assessed by a pathologist and bronchoalveolar lavage cytokines and plasma cardiotoxicity markers were assessed by Luminex assay. CFD simulations were conducted in a model of a healthy 49-year-old female.

Results

No significant increase was observed in histologic lesions, cytokines, or cardiotoxicity markers in FOS or APR groups relative to the control. CFD predicted that laryngopharyngeal deposition was maximized with aerodynamic diameters of 8.1-11.5 μm for inhalation rates of 30-60 L/min.

Conclusions

A 4-week pre-GLP study supports the safety of inhaled FOS. A formal GLP assessment is underway to support a phase I clinical trial of an FOS DPI for LPR.

Level of Evidence

NA.

Medium-term clinical efficacy of endoscopic antireflux mucosectomy on laryngopharyngeal reflux: a retrospective multicenter cohort study

BACKGROUND AND AIMS

Studies on the effect of antireflux mucosectomy (ARMS) on laryngopharyngeal reflux disease (LPRD) are lacking. We conducted a multicenter retrospective study to explore the clinical efficacy of ARMS on LPRD.

METHODS

We retrospectively analyzed the data of patients diagnosed with LPRD by oropharyngeal 24-hour Dx-pH monitoring who underwent ARMS. The effects of ARMS on LPRD were evaluated by comparing the 36-Item Short-Form Survey (SF-36), reflux symptom index (RSI), and 24-hour Dx-pH monitoring scores before and 1 year after surgery. Patients were divided into groups according to gastroesophageal flap valve (GEFV) grade to explore the effect of GEFV on prognosis.

RESULTS

One hundred eighty-three patients were included in the study. The oropharyngeal pH monitoring results showed that the effective rate of ARMS was 72.1% (132/183). After surgery, the SF-36 score was higher (P = .000), RSI score was lower (P = .000), and the symptoms of constant throat clearing; difficulty swallowing food, liquids, and pills; coughing after eating or after lying down; troublesome or annoying cough; and breathing difficulties or choking episodes were significantly improved (P < .05). Upright reflux was dominant in GEFV grade I to III patients, and the SF-36, RSI, and upright Ryan index scores were significantly improved after surgery (P < .05). In GEFV grade IV patients, regurgitation was dominant in the supine position, and the above evaluation indexes were worse after surgery (P < .05).

CONCLUSIONS

ARMS is effective for LPRD. The GEFV grade can predict the prognosis of surgery. ARMS is effective in GEFV grade I to III patients, but the effect is not exact in GEFV grade IV patients and may even be aggravated.

Endoscopic therapy for gastroesophageal reflux disease: where are we, where are we going?

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is the most common chronic condition with increasing prevalence in the Western world. Despite medical therapy, a considerable proportion of patients continue to experience symptoms, thus fueling the demand for minimally invasive GERD treatment options. This review will assess the currently available endoscopic approaches by analyzing their outcomes data, indication for use and limitations.

RECENT FINDINGS

With increasing evidence of the safety and efficacy of endoscopic therapies, recent guidelines and consensus society documents have updated their recommendations for the endoscopic treatment of GERD. In this review, we have comprehensively assessed the current landscape of endoscopic approaches for the treatment of GERD and provided insight into future directions.

SUMMARY

Endoscopic therapies for GERD show promise as new treatments emerge and existing therapies evolve into safer and more reproducible options. They are well positioned to cater to a large subset of the population suffering from chronic condition of GERD.

Amprenavir inhibits pepsin-mediated laryngeal epithelial disruption and E-cadherin cleavage in vitro

Background

Laryngopharyngeal reflux (LPR) causes chronic cough, throat clearing, hoarseness, and dysphagia and can promote laryngeal carcinogenesis. More than 20% of the US population suffers from LPR and there is no effective medical therapy. Pepsin is a predominant source of damage during LPR which disrupts laryngeal barrier function potentially via E-cadherin cleavage proteolysis and downstream matrix metalloproteinase (MMP) dysregulation. Fosamprenavir (FDA-approved HIV therapeutic and prodrug of amprenavir) is a pepsin-inhibiting LPR therapeutic candidate shown to rescue damage in an LPR mouse model. This study aimed to examine amprenavir protection against laryngeal monolayer disruption and related E-cadherin proteolysis and MMP dysregulation in vitro.

Methods

Laryngeal (TVC HPV) cells were exposed to buffered saline, pH 7.4 or pH 4 ± 1 mg/mL pepsin ± amprenavir (10-60 min). Analysis was performed by microscopy, Western blot, and real time polymerase chain reaction (qPCR).

Results

Amprenavir (1 μM) rescued pepsin acid-mediated cell dissociation (p < .05). Pepsin acid caused E-cadherin cleavage indicative of regulated intramembrane proteolysis (RIP) and increased MMP-1,3,7,9,14 24-h postexposure (p < .05). Acid alone did not cause cell dissociation or E-cadherin cleavage. Amprenavir (10 μM) protected against E-cadherin cleavage and MMP-1,9,14 induction (p < .05).

Conclusions

Amprenavir, at serum concentrations achievable provided the manufacturer's recommended dose of fosamprenavir for HIV, protects against pepsin-mediated cell dissociation, E-cadherin cleavage, and MMP dysregulation thought to contribute to barrier dysfunction and related symptoms during LPR. Fosamprenavir to amprenavir conversion by laryngeal epithelia, serum and saliva, and relative drug efficacies in an LPR mouse model are under investigation to inform development of inhaled formulations for LPR.

Current Treatment of Laryngopharyngeal Reflux

Objectives: Laryngopharyngeal reflux (LPR) is a complex syndrome characterized by the reflux of gastroduodenal contents into the pharynx or larynx, resulting in a range of symptoms, including chronic cough, throat clearing, pain, dysphagia, hoarseness, and dysphonia. Despite the lack of a gold standard for diagnosis or treatment, various strategies have been proposed to manage LPR. However, the effectiveness of these treatments is compromised by the lack of a uniform treatment protocol, which places a burden on patients, physicians, and the healthcare system. This study aims to systematically review the treatments of LPR and provide updated and useful clinical information to clinical physicians. Methods: The literature with an emphasis on LPR and related keywords is searched and reviewed in PubMed. Results: Treatment of LPR includes health education, lifestyle modification, dietary changes, medications, and surgery, as well as the emergence of a novel treatment method involving external upper esophageal sphincter compression devices. Conclusions: Currently, medication is the main treatment, supplemented with lifestyle and dietary changes, but there is still a lack of effective means for patients with drug-resistant or intolerant LPR. More high-quality and rigorous trials must continue to be conducted to determine the best treatment options and find novel treatments. Taking into account the complexity of LPR, this study proposes a simple algorithm to help clinicians with the initial management of this disease.

AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert advice regarding the clinical management of patients with suspected extraesophageal gastroesophageal reflux disease.

METHODS

This article provides practical advice based on the available published evidence including that identified from recently published reviews from leading investigators in the field, prospective and population studies, clinical trials, and recent clinical guidelines and technical reviews. This best practice document is not based on a formal systematic review. The best practice advice as presented in this document applies to patients with symptoms or conditions suspected to be related to extraesophageal reflux (EER). This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of potential extraesophageal manifestations of gastroesophageal reflux disease (GERD) and should inquire about such disorders including laryngitis, chronic cough, asthma, and dental erosions in GERD patients to determine whether GERD may be a contributing factor to these conditions. BEST PRACTICE ADVICE 2: Development of a multidisciplinary approach to extraesophageal (EER) manifestations is an important consideration because the conditions are often multifactorial, requiring input from non-gastroenterology (GI) specialties. Results from diagnostic testing (ie, bronchoscopy, thoracic imaging, laryngoscopy, etc) from non-GI disciplines should be taken into consideration when gastroesophageal reflux (GER) is considered as a cause for extraesophageal symptoms. BEST PRACTICE ADVICE 3: Currently, there is no single diagnostic tool that can conclusively identify GER as the cause of EER symptoms. Determination of the contribution of GER to EER symptoms should be based on the global clinical impression derived from patients' symptoms, response to GER therapy, and results of endoscopy and reflux testing. BEST PRACTICE ADVICE 4: Consideration should be given toward diagnostic testing for reflux before initiation of proton pump inhibitor (PPI) therapy in patients with potential extraesophageal manifestations of GERD, but without typical GERD symptoms. Initial single-dose PPI trial, titrating up to twice daily in those with typical GERD symptoms, is reasonable. BEST PRACTICE ADVICE 5: Symptom improvement of EER manifestations while on PPI therapy may result from mechanisms of action other than acid suppression and should not be regarded as confirmation for GERD. BEST PRACTICE ADVICE 6: In patients with suspected extraesophageal manifestation of GERD who have failed one trial (up to 12 weeks) of PPI therapy, one should consider objective testing for pathologic GER, because additional trials of different PPIs are low yield. BEST PRACTICE ADVICE 7: Initial testing to evaluate for reflux should be tailored to patients' clinical presentation and can include upper endoscopy and ambulatory reflux monitoring studies of acid suppressive therapy. BEST PRACTICE ADVICE 8: Testing can be considered for those with an established objective diagnosis of GERD who do not respond to high doses of acid suppression. Testing can include pH-impedance monitoring while on acid suppression to evaluate the role of ongoing acid or non-acid reflux. BEST PRACTICE ADVICE 9: Alternative treatment methods to acid suppressive therapy (eg, lifestyle modifications, alginate-containing antacids, external upper esophageal sphincter compression device, cognitive-behavioral therapy, neuromodulators) may serve a role in management of EER symptoms. BEST PRACTICE ADVICE 10: Shared decision-making should be performed before referral for anti-reflux surgery for EER when the patient has clear, objectively defined evidence of GERD. However, a lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into the decision process.

[Current possibilities and challenges in the treatment of laryngopharyngeal reflux]

Laryngopharyngeal reflux (LPR) is characterized by backflow of gastric or gastroduodenal content and gases into the upper aerodigestive tract, which can damage the mucus membranes of the larynx and pharynx. It is associated with a variety of symptoms such as retrosternal burning and acid regurgitation, or other unspecific symptoms such as hoarseness, globus sensation, chronic cough, or mucus hypersecretion. Due to the lack of data and the heterogeneity of studies, diagnosis of LPR is problematic and challenging, as recently discussed. Moreover, the different therapeutic approaches are also discussed controversially in the face of the poor evidence base, and include pharmacologic and conservative dietary measures. Hence, in the following review, the available options for treatment of LPR are critically discussed and summarized for daily clinical use.

Oral and Inhaled Fosamprenavir Reverses Pepsin-Induced Damage in a Laryngopharyngeal Reflux Mouse Model

OBJECTIVE

More than 20% of the US population suffers from laryngopharyngeal reflux. Although dietary/lifestyle modifications and alginates provide benefit to some, there is no gold standard medical therapy. Increasing evidence suggests that pepsin is partly, if not wholly, responsible for damage and inflammation caused by laryngopharyngeal reflux. A treatment specifically targeting pepsin would be amenable to local, inhaled delivery, and could prove effective for endoscopic signs and symptoms associated with nonacid reflux. The aim herein was to identify small molecule inhibitors of pepsin and test their efficacy to prevent pepsin-mediated laryngeal damage in vivo.

METHODS

Drug and pepsin binding and inhibition were screened by high-throughput assays and crystallography. A mouse model of laryngopharyngeal reflux (mechanical laryngeal injury once weekly for 2 weeks and pH 7 solvent/pepsin instillation 3 days/week for 4 weeks) was provided inhibitor by gavage or aerosol (fosamprenavir or darunavir; 5 days/week for 4 weeks; n = 3). Larynges were collected for histopathologic analysis.

RESULTS

HIV protease inhibitors amprenavir, ritonavir, saquinavir, and darunavir bound and inhibited pepsin with IC50 in the low micromolar range. Gavage and aerosol fosamprenavir prevented pepsin-mediated laryngeal damage (i.e., reactive epithelia, increased intraepithelial inflammatory cells, and cell apoptosis). Darunavir gavage elicited mild reactivity and no discernable protection; aerosol protected against apoptosis.

CONCLUSIONS

Fosamprenavir and darunavir, FDA-approved therapies for HIV/AIDS, bind and inhibit pepsin, abrogating pepsin-mediated laryngeal damage in a laryngopharyngeal reflux mouse model. These drugs target a foreign virus, making them ideal to repurpose. Reformulation for local inhaled delivery could further improve outcomes and limit side effects.

LEVEL OF EVIDENCE

NA. Laryngoscope, 133:S1-S11, 2023.

Acute, Recurrent, and Chronic Laryngopharyngeal Reflux: The IFOS Classification

OBJECTIVE

To investigate the clinical patterns and disease evolution of laryngopharyngeal reflux (LPR) patients.

METHODS

Patients with LPR diagnosed by hypopharyngeal-esophageal impedance-pH monitoring were prospectively followed in three medical centers. Symptoms and findings were assessed with reflux symptom score (RSS) and reflux sign assessment (RSA). Patients were treated with 3-to 9-month diet and combination of proton pump inhibitors, alginate or magaldrate. Patients were followed for 3 years to determine the clinical evolution of symptoms over time. LPR that did not recur was defined as acute. Recurrent LPR consisted of reflux with one or several recurrences yearly despite successful treatment. Chronic LPR was reflux with a chronic course of symptoms. Predictive indicators of clinical evolution were investigated.

RESULTS

One hundred forty patients and 82 healthy individuals completed the evaluations. Among patients, 41 (29.3%), 57 (40.7%), and 42 (30.0%) had acute, recurrent, or chronic LPR respectively. Baseline quality of life-RSS (QoL-RSS) and RSS total scores were significantly higher in chronic LPR patients. The post-treatment decrease of QoL-RSS and RSS of acute LPR patients were significantly faster as compared to recurrent and chronic patients. QoL-RSS >5 reported adequate sensitivity (94.2) and specificity (75.3). QoL-RSS thresholds defined acute (QoL-RSS = 6-25), recurrent (QoL-RSS = 26-38), and chronic (QoL-RSS > 38) LPR.

CONCLUSION

Baseline QoL-RSS may predict the clinical course of LPR patients: acute, recurrent, or chronic. A novel classification system that groups patients according to the longevity, severity, and therapeutic response of symptoms was proposed: the International Federation of Otorhinolaryngological Societies Classification of LPR.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1073-1080, 2023.

Awareness about laryngopharyngeal reflux disease among Chinese otolaryngologists: a nationwide survey

OBJECTIVES

This study aimed to investigate the status of the current knowledge about laryngopharyngeal reflux disease (LPRD) among Chinese otolaryngologists.

DESIGN

Multi-centre cross-sectional survey.

SETTING

220 medical centres in different regions of China.

PARTICIPANTS

A total of 2254 otolaryngologists from 220 medical centres in China who were successfully on-site surveyed between November 2019 and December 2020.

MAIN OUTCOME MEASURES

Awareness about LPRD included knowledge about risk factors, symptoms, laryngoscope signs, related diseases, current diagnostic methods and treatments.

RESULTS

The percentage of participants who had heard of LPRD was 96.4%, with academic conferences as the most common source of information (73.3%). The most commonly known risk factor, symptom, laryngoscope sign, related disease, diagnostic method and treatment were alcohol consumption (44.0%), pharyngeal foreign body sensation (66.9%), hyperaemia (52.4%), pharyngolaryngitis (54.8%), pH monitoring (47.6%) and medication (82.1%), respectively. Only 28.3% of all participants knew that 24 h pH or multichannel intraluminal impedance pH monitoring was the most accurate diagnostic test. As many as 73.1% of all participants knew that proton pump inhibitors were the first-line treatment drugs. An analysis of the overall status of awareness using a scoring system suggested that otolaryngologists were better aware owing to more access, working at 3A hospitals, and postgraduate or above educational background (all p<0.05).

CONCLUSION

Although the majority of Chinese otolaryngologists had heard of LPRD, their overall awareness about the disease was not encouraging. More efforts are needed to increase the knowledge about LPRD among this group of physicians.

TRIAL REGISTRATION NUMBER

ChiCTR1900025581.

Distinct Clinical Physiologic Phenotypes of Patients With Laryngeal Symptoms Referred for Reflux Evaluation

BACKGROUND & AIMS

Heterogeneous presentations and disease mechanisms among patients with laryngeal symptoms account for misdiagnosis of laryngopharyngeal reflux (LPR), variations in testing, and suboptimal outcomes. We aimed to derive phenotypes of patients with laryngeal symptoms based on clinical and physiologic data and to compare characteristics across phenotypes.

METHODS

A total of 302 adult patients with chronic laryngeal symptoms were prospectively enrolled at 3 centers between January 2018 to October 2020 (age 57.2 ± 15.2 years; 30% male; body mass index 27.2 ± 6.0 kg/m²). Discriminant analysis of principal components (DAPC) was applied to 12 clinical and 11 physiologic variables collected in stable condition to derive phenotypic groups.

RESULTS

DAPC identified 5 groups, with significant differences across symptoms, hiatal hernia size, and number of reflux events (P < .01). Group A had the greatest hiatal hernia size (3.1 ± 1.0 cm; P < .001) and reflux events (37.5 ± 51; P < .001), with frequent cough, laryngeal symptoms, heartburn, and regurgitation. Group B had the highest body mass index (28.2 ± 4.6 kg/m²; P < .001) and salivary pepsin (150 ± 157 ng/mL; P = .03), with frequent cough, laryngeal symptoms, globus, heartburn, and regurgitation. Group C frequently reported laryngeal symptoms (93%; P < .001), and had fewest esophageal symptoms (9.6%; P < .001) and reflux events (10.7 ± 11.0; P < .001). Group D commonly reported cough (88%; P < .001) and heartburn. Group E (18%) was oldest (62.9 ± 14.3 years; P < .001) and distinguished by highest integrated relaxation pressure.

CONCLUSIONS

DAPC identified distinct clinicophysiologic phenotypes of patients with laryngeal symptoms referred for reflux evaluation: group A, LPR and gastroesophageal reflux disease (GERD) with hiatal hernia; group B, mild LPR/GERD; group C, no LPR/No GERD; group D, reflex cough; and group E, mixed/possible obstructive esophagogastric junction. Phenotypic differences may inform targeted clinical trials design and improve outcomes.

Laryngopharyngeal Reflux: Evolution and Predictive Value of Symptoms and pH-Impedance Features on Clinical Evolution

OBJECTIVES

To investigate the features of patients with laryngopharyngeal reflux (LPR) who did not respond to medical treatment.

STUDY DESIGN

Prospective uncontrolled study.

SETTING

Multicenter study.

METHODS

Patients with LPR at 24-hour HEMII-pH monitoring (hypopharyngeal-esophageal multichannel intraluminal impedance-pH) were prospectively recruited from 3 European university centers. Patients were treated with 3- to 6-month medication (proton pump inhibitor and alginate) and categorized as mild to moderate responders, high responders, or nonresponders according to Reflux Symptom Score (RSS) changes at 6 months posttreatment. The predictive value of the following outcomes was studied: epidemiologic data, HEMII-pH, gastrointestinal endoscopy findings, baseline RSS and Reflux Sign Assessment, and early therapeutic response (6-week RSS).

RESULTS

A total of 148 patients completed the evaluations, accounting for 40 mild to moderate responders (20%-60% RSS changes), 76 high responders (>60% RSS changes), and 32 nonresponders. Nonresponders presented more often with hiatal hernia and lower esophageal sphincter insufficiency when compared with mild to moderate and high responders (P = .032). Baseline otolaryngologic, digestive, and respiratory RSS and the number of pharyngeal reflux events at the HEMII-pH were predictive of the 6-month therapeutic response (P < .05). The early therapeutic response (6 weeks posttreatment) was predictive of the 6-month treatment response.

CONCLUSION

Hiatal hernia and baseline and 6-week RSS were the most predictive indicators of therapeutic effectiveness in patients with LPR.

Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux

BACKGROUND

The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR).

METHODS

This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI.

RESULTS

Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m² (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01).

CONCLUSION

This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).

Itopride in treatment of laryngopharyngeal symptoms of gastroesophageal reflux disease

In everyday otolaryngological and gastroenterological practice, the diagnosis and treatment of extraesophageal forms of gastroesophageal reflux disease are often challenging. It is sometimes the case that treatment ordered by other specialists proves ineffective or even worsens the symptoms. There is no golden standard of diagnosis for otolaryngological forms of GERD, and currently used tools (gastroscopy, laryngoscopy, impedance and pH testing) have low sensitivity and specificity. After finishing a course of successful treatment, the patients often come back to our offices with the very same symptoms. In order to improve the efficacy of treatment, a prokinetic agent can be added to the standard proton pump inhibitor therapy.

An update on current treatment strategies for laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux (LPR) is a syndrome caused by reflux of gastric contents into the pharynx or larynx, which leads to symptoms of throat clearing, hoarseness, pain, globus sensation, cough, excess mucus production in the throat, and dysphonia. LPR is a challenging condition, as there is currently no gold standard for diagnosis or treatment, and thus this presents a burden to the healthcare system. Strategies for treatment of LPR are numerous. Medical therapies include proton pump inhibitors, which are first line, H2 receptor antagonists, alginates, and baclofen. Other noninvasive treatment options include lifestyle therapy and the external upper esophageal sphincter compression device. Endoscopic and surgical options include antireflux surgery, magnetic sphincter augmentation, and transoral incisionless fundoplication. Functional laryngeal disorders and laryngeal hypersensitivity can present as LPR symptoms with or without gastroesophageal reflux disease. Though there are minimal studies in this area, neuromodulators and behavioral interventions are potential treatment options. Given the complexity of these patients and numerous available treatment options, we propose a treatment algorithm to help clinicians diagnose and triage patients into an appropriate therapy.

The efficacy of a personalised treatment depending on the characteristics of reflux at multichannel intraluminal impedance-pH monitoring in patients with acid, non-acid and mixed laryngopharyngeal reflux

OBJECTIVE

To assess the evolution of symptoms and findings of laryngopharyngeal reflux (LPR) patients according to the type of reflux (acid, non-acid, mixed and gastro-oesophageal (GERD)).

DESIGN

Prospective uncontrolled multicentre study.

METHODS

One hundred and six patients with LPR have been recruited from 3 European Hospitals. According to the reflux characteristics at the impedance-pH monitoring (acid, non-acid, mixed, GERD), patients received a personalised treatment based on the association of diet, pantoprazole, alginate or magaldrate for 3 months. Reflux Symptom Score (RSS) was assessed at baseline, 6 and 12 weeks post-treatment. Reflux Sign Assessment (RSA) has been used to rate laryngeal and extra-laryngeal findings at baseline and 12 weeks post-treatment. Overall success rate and the evolution of symptoms and findings were evaluated according to the LPR types.

RESULTS

One hundred and two LPR patients (42 acid, 33 non-acid, 27 mixed, including 49 with LPR and GERD) completed the study. RSS and RSA total scores significantly improved from baseline to post-treatment time in acid, mixed and non-acid groups. The presence of GERD in addition to LPR did not impact the clinical improvement. The 3-month success rates of treatment ranged from 62% to 64%, and there were no significant differences between groups. The success rate of patients with non-acid LPR was similar to those of patients with mixed and acid LPR.

CONCLUSION

MII-pH is useful to specify the type of LPR and the related most adequate therapeutic regimen. Non-acid or mixed LPR similarly respond to treatment than acid LPR but require a treatment based on alginate or magaldrate covering the non-acid proximal reflux events.

Proximal reflux: biochemical mediators, markers, therapeutic targets, and clinical correlations

Airway reflux is implicated in the pathophysiology of a wide range of adult and pediatric upper and lower airway diseases. However, the diagnosis of proximal reflux-associated disease remains challenging due to evolving clinical criteria and institutional and regional variances in diagnostic practices. Evidence suggests that nonacidic contents of reflux may serve as both pathologic mediators of and biomarkers for reflux in the upper airway. Furthermore, they offer potential pharmaceutical and surgical intervention targets and are the focus of novel clinical diagnostic tools currently under investigation.

Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease

Laryngopharyngeal reflux and atypical manifestations of gastroesophageal reflux disease have a high economic and social burden in the United States. There is increasing research supporting the reflex theory and hypersensitivity syndrome underlying this disease pathophysiology. Novel diagnostic biomarkers have gained more traction in the search for a more reliable diagnostic tool, but further research is needed. Current standard-of-care treatment relies on proton pump inhibitor therapy. Antireflux surgery is usually not recommended. Neuromodulators and treatments targeting specific neuronal receptors are discussed. A diagnostic algorithm is proposed for the evaluation of laryngeal symptoms suspected to be related to extraesophageal reflux disease.

Treatment of laryngopharyngeal reflux disease: A systematic review

BACKGROUNG

For a long time, laryngopharyngeal reflux disease (LPRD) has been treated by proton pump inhibitors (PPIs) with an uncertain success rate.

AIM

To shed light the current therapeutic strategies used for LPRD in order to analysis the rationale in the LPRD treatment.

METHODS

Three authors conducted a PubMed search to identify papers published between January 1990 and February 2019 about the treatment of LPRD. Clinical prospective or retrospective studies had to explore the impact of medical treatment(s) on the clinical presentation of suspected or confirmed LPRD. The criteria for considering studies for the review were based on the population, intervention, comparison, and outcome framework.

RESULTS

The search identified 1355 relevant papers, of which 76 studies met the inclusion criteria, accounting for 6457 patients. A total of 64 studies consisted of empirical therapeutic trials and 12 were studies where authors formally identified LPRD with pH-monitoring or multichannel intraluminal impedance-pH monitoring (MII-pH). The main therapeutic scheme consisted of once or twice daily PPIs for a duration ranged from 4 to 24 wk. The most used PPIs were omeprazole, esomeprazole, rabeprazole, lansoprazole and pantoprazole with a success rate ranging from 18% to 87%. Other composite treatments have been prescribed including PPIs, alginate, prokinetics, and H₂ Receptor antagonists.

CONCLUSION

Regarding the development of MII-pH and the identification of LPRD subtypes (acid, nonacid, mixed), future studies are needed to improve the LPRD treatment considering all subtypes of reflux.