Instruments evaluating the clinical findings of laryngopharyngeal reflux: A systematic review

Inter-rater Reliability of the Reflux Sign Assessment-10 (RSA-10)

OBJECTIVE

To evaluate the inter-rater reliability and internal consistency of the Reflux Sign Assessment-10 (RSA-10) among otolaryngologists and speech therapists with various experiences.

METHODS

Six experts (2 otolaryngologists, 2 speech-therapists, and 2 speech-therapist students) rated 300 clinical images of oral, laryngeal, and pharyngeal signs from patients with laryngopharyngeal reflux disease diagnosis at the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring. Inter-rater reliability and internal consistency were evaluated with Intraclass Correlation (ICC) and Cronbach-α. The severity of scores was compared between judges. The intra-rater (test-retest) reliability was evaluated with the Spearman correlation coefficient.

RESULTS

The pictures of 40 patients were included. There were 18 females and 22 males. The mean age was 52.6 ± 13.9 years. The Cronbach-α was 0.854, which indicates a high internal consistency between judges. The overall ICC was 0.787 (95% CI: 0.715-0.845; P = 0.001). The ICC varied among judges with the highest value for students (ICC = 0.960) and SLP seniors versus students (ICC = 0.805). The severity of RSA-10 rating scores was influenced by the number of reflux patients seen (rs =-0.941; P = 0.001) and the number of fiberscope examinations performed (rs =-0.812; P = 0.049). The RSA-10 was more severely scored by speech therapists with the least experience compared to otolaryngologists with the most experience in fiberscope/reflux patient assessment.

CONCLUSION

The RSA-10 demonstrated adequate global ICC and internal consistency among otolaryngologists and speech therapists with various degrees of experience. The assessment of RSA was influenced by the fibroscopy experience, and the number of reflux patients seen.

Validity and Reliability of the Reflux Sign Assessment-10 (RSA-10)

OBJECTIVE

To develop and validate the Reflux Sign Assessment-10 (RSA-10) for documenting the physical findings of laryngopharyngeal reflux disease (LPRD).

METHODS

Patients with LPRD at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring and asymptomatic individuals were consecutively recruited from two European hospitals. Three experienced otolaryngologists rated RSA-10 in patients and controls for assessing internal validity. RSA-10 was rated within a 7-day period to assess test-retest reliability. Internal consistency was measured using Cronbach's α in patients and controls. Convergent validity was evaluated through a correlation analysis between RSA-10 and Reflux Finding Score (RFS). Interrater reliability was evaluated by comparing the RSA-10 evaluations of the three otolaryngologists through Fleiss kappa. Pre- to posttreatment change of RSA-10 was evaluated to assess responsiveness to change. The RSA-10 thresholds were examined by receiver operating characteristic analysis.

RESULTS

Fifty-five patients completed the pre- to posttreatment evaluations from January 2020 to December 2023. A total of 115 asymptomatic individuals completed the study. RSA-10 reported high internal consistency reliability (α = 0.822) and test-retest reliability (rs = 0.725). The RSA-10 scores of patients were significantly higher than those of controls (p = 0.001), suggesting high internal validity. RSA-10 was significantly correlated with the RFS (rs = 0.771). The interrater reliability was adequate for sub- and total RSA-10 scores (k = 0.708). RSA-10 significantly improved from baseline to 3-month posttreatment (p = 0.001). An RSA-10 > 13 may be suggestive of LPRD. Both RSA-10 > 13 and Reflux Symptom Score-12 > 11 were associated with a sensitivity of 92.7% and a specificity of 97.3%.

CONCLUSION

The RSA-10 is a reliable and valid clinical instrument for documenting the most prevalent laryngeal and extra-laryngeal findings associated with LPRD.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3981-3988, 2024.

Image analysis in laryngopharyngeal reflux disease: A road less traveled

Background

Laryngopharyngeal reflux disease (LPRD) is a common condition affecting patients reporting to an otolaryngologist. However, the diagnosis of this condition is usually hinged on the combination of largely non-specific symptoms, and clinical findings on laryngoscopy. This study aimed at evaluating the utility of digital image analysis to quantitatively evaluate the severity of signs as recorded with laryngoscopy in patients of LPRD.

Methods

The study group included individuals who were aged between 18 and 65 years and reported to the ENT OPD. These were then divided into two groups depending on symptoms and laryngoscopic findings. The LPRD group had symptomatic patients with an Reflux finding score (RFS) score >7. Those with an RFS of <6 were designated as the 'Normal group'. The Laryngoscopic images were recorded and analyzed using Image J software as per the set protocol. The Red Green Blue (RGB) values of the laryngoscopic images of each group were obtained and subjected to statistical analysis.

Results

200 participants were enrolled in the study with 100 participants in the LPRD group (mean age = 46.2, 40 males, 60 females) and 100 in the control group (mean age = 43.6, 55 males, 45 females). The measured RGB values were more in the LPRD group as compared to the control group and the results were statistically significant (P < 0.001).

Conclusion

By providing an objective value to the degree of inflammation, RGB value measurement provides a quick, economical, adaptable tool for auxiliary and corroborative information for the diagnosis of LPRD.

The Effects of Hard Voice Onset on Objective Voice Function in Patients With Laryngopharyngeal Reflux

OBJECTIVE

Laryngopharyngeal reflux (LPR) causes laryngopharyngeal hypersensitivity and laryngeal muscle hyperfunction, which may result in hard voice onset in patients with LPR. The purpose of this study is to examine the incidence of hard voice onset in patients with LPR and the effects of hard voice onset on objective voice function in patients with LPR.

METHODS

Forty patients with confirmed LPR were enrolled in the LPR group, and 40 healthy subjects were enrolled in the non-LPR group. Subjects underwent laryngeal high-speed videoendoscopy, and the presence or absence of hard voice onset in each subject was determined by two experienced laryngologists based on whether glottal closure was complete or incomplete before vocal fold vibration. Based on the results, the subjects with LPR were divided into a hard voice onset group and a non-hard voice onset group. The voice onset time (VOT) was measured and compared between the hard and non-hard voice onset groups within the LPR group. Laryngeal aerodynamic assessment was also carried out on the LPR group, and subglottal pressure, phonation threshold pressure (PTP), glottal resistance, and mean flow rate were measured. The voice acoustic signals of subjects were additionally analyzed in the LPR group, and the fundamental frequency, jitter, shimmer, and noise-harmony ratio were determined. The kappa statistic, chi-square test and independent-samples t test in SPSS were used for statistical analysis.

RESULTS

The two laryngologists had substantial inter-rater consistency on the evaluation of hard voice onset and non-hard voice onset, with a kappa statistic of 0.71. In the LPR group, 42.5% of patients had hard voice onset (17/40), significantly more than in the non-LPR group (8/40, 20%) (P < 0.05). The VOT in the LPR group was significantly longer than in the non-LPR group (P < 0.05). Within the LPR group, the VOT, PTP and shimmer were significantly greater in the hard voice onset group than in the non-hard voice onset group (all P < 0.05). The other laryngeal aerodynamic parameters and acoustic parameters were not significantly different between the hard voice onset group and the non-hard voice onset group (P > 0.05).

CONCLUSION

Changes in vocal production may occur in LPR patients, causing them to be more susceptible to hard voice onset. The patients with hard voice onset require longer VOT and greater PTP to initiate phonation.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

OBJECTIVE

The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.

METHODS

Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.

RESULTS

After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.

CONCLUSION

A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1614-1624, 2024.

Validity and reliability of the Group for Learning Useful and Performant Swallowing (GLUPS) tool

INTRODUCTION

To validate the Group for Learning Useful and Performant Swallowing (GLUPS), a clinical tool dedicated to videofluoroscopy swallowing study (VFSS).

METHODS

Forty-five individuals were recruited from January 2022 to March 2023 from the Department of Otolaryngology Head and Neck Surgery of University Hospital Saint-Pierre (Brussels, Belgium). Subjects underwent VFSS, which was rated with GLUPS tool by two blinded otolaryngologists and one speech-therapist. VFSS were rated twice with GLUPS within a 7-day period to assess test-retest reliability.

RESULTS

Twenty-four patients and twenty-one controls completed the evaluations. The internal consistency (α = 0.745) and the test-retest reliability (rs = 0.941; p = 0.001) were adequate. GLUPS reported a high external validity regarding the significant correlation with the Penetration-Aspiration Scale (rs = 0.551; p = 0.001). Internal validity was adequate, because GLUPS score was significant higher in patients compared to controls (6.21 ± 4.42 versus 2.09 ± 2.00; p = 0.001). Interrater reliability did not report significant differences in the GLUPS sub- and total score among the independent judges. The mean GLUPS score of individuals without any evidence of VFSS abnormalities was 2.09/23 (95% CI  1.23-2.95), which supported that a GLUPS score ≥ 3.0 is suggestive of pathological VFSS.

CONCLUSIONS

GLUPS is a clinical instrument documenting the abnormal findings of oral and pharyngeal phases at the VFSS. GLUPS demonstrated high reliability and excellent criterion-based validity. GLUPS may be used in clinical practice for the swallowing evaluation at the VFSS.

The Relation Between Endoscopic and Subjective Laryngopharyngeal Reflux Signs, Vocal Tract Discomfort, Voice Handicap, and Voice Disorder Type: Same Yet Different?

OBJECTIVES

This study aimed to investigate the relation between subjective voice-related symptoms and endoscopic findings in patients with different etiology of voice disorder and vocally healthy subjects with and without laryngopharyngeal reflux (LPR).

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

The study involved 149 participants (106 female, 43 male) including 125 with various voice disorders (functional, structural, and neurogenic) and 24 vocally healthy individuals. For self-rating the German versions of the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) Scale, and Reflux Symptom Index (RSI) were applied, while endoscopic evaluations utilized the Reflux Finding Score (RFS) and Reflux Sign Assessment (RSA). Statistical analyses incorporated ANOVA with Bonferroni posthoc tests to identify group variations. Correlations between VTD Scale, VHI, RSI, RFS, and RSA were evaluated using Pearson's correlation coefficient. To examine test sensitivity and specificity for the VTD Scale and RSA, we performed a receiver operating characteristics analysis. Youden's-Index was applied to determine the cut-off-value with best discriminatory abilities. The diagnosis of LPR was assumed when the criteria of RFS > 7 AND RSI > 13 was met.

RESULTS

Significant differences for all voice diagnosis groups and vocally healthy individuals for RFS and all three self-rating questionnaires were found. Moreover, there was significant correlation between VTD Scale and VHI and RSI as well as RSI and RFS, which was moderate, negative in the group of persons with LPR. However, there was no significant difference for RSA results between the vocally healthy or any diagnosis group.

CONCLUSION

Thus, the RFS may be more suitable to predict reflux and voice-related symptoms. The VTD Scale is a useful instrument in screening voice disorders but also LPR and can therefore be used as a tool for decision-making when transferring to a specialist.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians

INTRODUCTION

To update the European guidelines for the assessment of voice quality (VQ) in clinical practice.

METHODS

Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.

RESULTS

Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases.

CONCLUSION

The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Association between secretory otitis media and laryngopharygeal reflux in adults

BACKGROUND

The relationship between Secretory Otitis Media (SOM) and Laryngopharygeal Reflux (LPR) hasn't been well investigated in adult.

PURPOSE

To study the involvement of LPR- in adult SOM.

METHODS

We analyzed 60 adult SOM patients who were admitted to Department of Otolaryngology and Head and Neck Surgery, the First Affiliated Hospital of Anhui Medical University, China from January 2022 to October 2022. First, we instructed the patients to fill Reflux Symptom Index (RSI) form and Reflux Finding Score (RFS). Second, Dx-ph monitor was used to monitor patients' oropharyngeal PH for 24 h. Finally, we obtained Ryan index based on the characteristics of reflux events in different body postures. In addition, all patients were evaluated by the Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7).

RESULTS

The positive rate of RSI and/or RFS scale was 73.33% (44/60) in 60 SOM patients. The positive rate of Ryan index was 76.67% (46/60), and the index was the highest in upright position in 60 SOM patients. The positive rate of ETDQ-7 was 100% (46/46) in 46 SOM patients with LPR.

CONCLUSION

LPR may be involved in SOM in adults by impairing the function of the eustachian tube.

Vocal Fold Pathologies Among Undergraduate Singing Students In Three Different Genres

OBJECTIVE

This study aimed to compare the prevalence and incidence of vocal fold pathologies among undergraduate classical, musical theatre, and contemporary commercial music (CCM) students over two-time points.

METHODS

This study is part of a longitudinal investigation. Videostroboscopic examinations were rated, with consensus among three of four expert blinded raters confirming the presence of pathology. Association between genre of singer and the presence of pathology, interrater reliability, and intra-rater reliability were calculated. Prevalence and incidence of pathologies were compared across genres.

RESULTS

During first-year evaluations, 32% of musical theatre, 18% of CCM, and 0% of classical students had vocal pathologies. The prevalence at third-year evaluations showed 22% of classical, 39% of musical theatre, and 27% of CCM participants having vocal fold pathologies. The incidence of pathologies was 67% of musical theatre students compared to 22% of classical students and 27% of CCM students. The four raters demonstrated fair to moderate interrater agreement. Singing Voice Handicap Index-10 scores were normal for CCM singers at both time points but elevated for musical theatre and classical singers.

CONCLUSION

No classical singers were found to have pathology during first-year evaluations, although CCM and musical theatre singers showed evidence of vocal fold pathologies. At third-year evaluations, all three genres had an apparent increase in prevalence of pathologies. Implications of this study suggest that more time in the field and intense voice usage may lead to a greater risk of pathology for all singers, regardless of genre.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:2317-2324, 2023.

A Comparison Between W Score and RYAN Score in Diagnosing Laryngopharyngeal Reflux Disease

OBJECTIVE

To assess the diagnostic value of the W score in differentiating laryngopharyngeal reflux disease (LPRD) patients from the normal population by pharyngeal pH (Dx-pH) monitoring, compared with the RYAN score.

METHODS

One hundred and eight patients with suspected LPRD and complete follow-up results after more than 8 weeks of anti-reflux therapy were enrolled from the Department of Otolaryngology-Head and Neck Surgery, Gastroenterology and Respiratory Medicine of seven hospitals. Their Dx-pH monitoring data before treatment were reanalyzed to obtain the W score in addition to the RYAN score and then the diagnostic sensitivity and specificity were compared and evaluated with reference to the result of anti-reflux therapy.

RESULTS

In eighty-seven (80.6%) cases, anti-reflux therapy was effective, and in 21 patients (19.4%), therapy was ineffective. Twenty-seven patients (25.0%) had a positive RYAN score. The W score was positive in 79 (73.1%) patients. There were 52 patients who had a negative RYAN score, but a positive W score. The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of the RYAN score were 28.7%, 90.5%, 92.6%, and 23.5%, respectively (kappa = 0.092, P = 0.068), whereas those of the W score for LPRD was 83.9%, 71.4%, 92.4%, and 51.7%, respectively (kappa = 0.484, P < 0.001).

CONCLUSIONS

W score is much more sensitive for the diagnosis of LPRD. Prospective studies with larger patient populations are necessary to validate and improve diagnostic efficacy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800014931.

Noninvasive, MultiOmic, and Multicompartmental Biomarkers of Reflux Disease: A Systematic Review

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal disorder that may complicate conditions such as obstructive airway disease. Our group has identified predictive biomarkers of GERD in particulate exposed first responders with obstructive airway disease. In addition, GERD diagnosis and treatment is costly and invasive. In light of these clinical concerns, we aimed to systematically review studies identifying noninvasive, multiOmic, and multicompartmental biomarkers of GERD.

METHODS

A systematic review of PubMed and Embase was performed using keywords focusing on reflux disease and biomarkers and registered with PROSPERO. We included original human studies in English, articles focusing on noninvasive biomarkers of GERD published after December 31, 2009. GERD subtypes (non-erosive reflux disease and erosive esophagitis) and related conditions (Barrett's Esophagus [BE] and Esophageal Adenocarcinoma). Predictive measures were synthesized and risk of bias assessed (Newcastle-Ottawa Scale).

RESULTS

Initial search identified n = 238 studies andn 13 articles remained after applying inclusion/exclusion criteria. Salivary pepsin was the most studied biomarker with significant sensitivity and specificity for GERD. Serum assessment showed elevated levels of Tumor Necrosis Factor-alpha in both GERD and Barrett's. Exhaled breath volatile sulfur compounds and acetic acid were associated with GERD. Oral Microbiome: Models with Lautropia, Streptococcus, and Bacteroidetes showed the greatest discrimination between BE and controls vs Lautropia; ROCAUC 0.94 (95% confidence interval; 0.85-1.00).

CONCLUSION

Prior studies identified significant multiOmic, multicompartmental noninvasive biomarker risks for GERD and BE. However, studies have a high risk of bias and the reliability and accuracy of the biomarkers identified are greatly limited, which further highlights the need to discover and validate clinically relevant noninvasive biomarkers of GERD.

Usefulness, acceptation and feasibility of electronic medical history tool in reflux disease

OBJECTIVES

To investigate usefulness, feasibility, and patient satisfaction of an electronic pre-consultation medical history tool (EPMH) in laryngopharyngeal reflux (LPR) work-up.

METHODS

Seventy-five patients with LPR were invited to complete electronic medical history assessment prior to laryngology consultation. EPMH collected the following parameters: demographic and epidemiological data, medication, medical and surgical histories, diet habits, stress and symptom findings. Stress and symptoms were assessed with perceived stress scale and reflux symptom score. Duration of consultation, acceptance, and satisfaction of patients (feasibility, usefulness, effectiveness, understanding of questions) were evaluated through a 9-item patient-reported outcome questionnaire.

RESULTS

Seventy patients completed the evaluation (93% participation rate). The mean age of cohort was 51.2 ± 15.6 years old. There were 35 females and 35 males. Patients who refused to participate (N = 5) were > 65 years old. The consultation duration was significantly lower in patients who used the EPMH (11.3 ± 2.7 min) compared with a control group (18.1 ± 5.1 min; p = 0.001). Ninety percent of patients were satisfied about EPMH easiness and usefulness, while 97.1% thought that EPMH may improve the disease management. Patients would recommend similar approach for otolaryngological or other specialty consultations in 98.6% and 92.8% of cases, respectively.

CONCLUSION

The use of EPMH is associated with adequate usefulness, feasibility, and satisfaction outcomes in patients with LPR. This software is a preliminary step in the development of an AI-based diagnostic decision support tool to help laryngologists in their daily practice. Future randomized controlled studies are needed to investigate the gain of similar approaches on the traditional consultation format.

Validity and reliability of a french version of the olfactory disorders questionnaire

Objective

To validate a French version of the Olfactory Disorders Questionnaire (Fr-ODQ).

Methods

Patients with olfactory disorder (OD) and controls were enrolled from two medical centers. Individuals completed the Fr-ODQ and the French version of the sinonasal outcome tool-22 (SNOT-22). The extended Sniffin'Sticks procedure was used to test odor Threshold, Discrimination, and Identification (TDI). Cronbach’s alpha was used to measure the internal consistency of Fr-ODQ. The reliability and the external validity were evaluated through a test–retest approach and by correlating Fr-ODQ and SNOT-22 scores.

Results

Eighty-nine patients with OD and 65 healthy individuals completed the evaluations. The Cronbach’s alpha was 0.827, reporting adequate internal consistency. The test–retest reliability was high (r_s = 0.944, p = 0.001). The external validity was adequate regarding the significant correlation between Fr-ODQ and SNOT-22 (r_s = 0.498; p = 0.001). Patients with OD reported a significant higher score of Fr-ODQ than healthy individuals (p < 0.001), indicating a high internal validity. The baseline Fr-ODQ significantly improved after 3-month olfactory training, which corroborated the improvement of TDI scores.

Conclusion

The Fr-ODQ is the first patient-reported outcome questionnaire validated for French speaking patients. Fr-ODQ is reliable and valid for the evaluation of the olfactory dysfunction and the related impact on quality of life of French-speaking patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-022-00598-2.

Differences in Diagnostic Rates After Hypopharyngeal-esophageal Impedance-pH Monitoring of Laryngopharyngeal Reflux Patients by Age and Sex

PURPOSE

To evaluate the differences in diagnostic rates according to the age and sex of patients with suspected laryngopharyngeal reflux (LPR) symptoms and completed the 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24h-HEMII-pH) monitoring.

METHODS

Patients with LPR symptoms underwent the 24h-HEMII-pH monitoring. We compared the diagnostic rates of LPR in patients with LPR symptoms according to age and sex. The number of reflux episodes and type of reflux were compared among patients who were confirmed to have LPR according to age and sex.

RESULTS

A total of 249 patients with suspected LPR symptoms who completed 24h-HEMII-pH monitoring were analyzed. A total of 170 patients (68.3%) were diagnosed with LPR after 24h-HEMII-pH monitoring. There were 57 (67.1%) men and 113 (68.9%) women. The old age group (older than 55 years) showed a statistically significant higher diagnostic rate than the young age group (73.5%, 60.8%, p=0.034). Women's diagnostic rate was statistically higher in the old age group than that in the young age group (75% vs. 58.3%, p=0.026). There were no specific differences in the number of refluxes in the diagnosed patients between the age groups, and there were no differences in the initial reflux symptom index.

CONCLUSIONS

Among those who visited the clinic with suspected LPR symptoms and performed 24h-HEMII-pH monitoring, the diagnostic rate of LPR was higher in the older age group than that in the younger age group.

Do Otolaryngologists Over- or Underestimate Laryngopharyngeal Reflux Symptoms and Findings in Clinical Practice? A Comparison Study between the True Prevalence and the Otolaryngologist-Estimated Prevalence of Symptoms and Findings

Purpose: To investigate the prevalence of symptoms and signs of laryngopharyngeal reflux (LPR) and to compare them with the otolaryngologist-estimated prevalence of the most common LPR-related symptoms and signs. Methods: The prevalence of LPR symptoms and signs was determined through the clinical data of 403 patients with a positive LPR diagnosis on hypopharyngeal−esophageal multichannel intraluminal impedance pH monitoring. The otolaryngologist-estimated prevalence was assessed through an international survey investigating the thoughts of 824 otolaryngologists toward LPR symptom and sign prevalence. The determination of potential over- or underestimation of LPR symptoms and findings was investigated through a data comparison between the ‘true’ prevalence and the ‘estimated prevalence’ of symptoms and findings by otolaryngologists. Results: The prevalence of breathing difficulties, coated tongue, and ventricular band inflammation was adequately evaluated by otolaryngologists. The prevalence of hoarseness, throat pain, odynophagia, dysphagia, throat clearing, globus sensation, excess throat mucus, tongue burning, heartburn, regurgitations, halitosis, cough after eating or lying down, and troublesome cough was overestimated by otolaryngologists (p < 0.01), while the prevalence of chest pain was underestimated as an LPR symptom. Most laryngeal signs, e.g., arytenoid/laryngeal erythema, inter-arytenoid granulation, posterior commissure hypertrophy, retrocricoid edema/erythema, and endolaryngeal sticky mucus, were overestimated (p < 0.01). The occurrence of anterior pillar erythema and tongue tonsil hypertrophy was underestimated by participants. Conclusion: Most laryngopharyngeal reflux symptoms and laryngeal signs were overestimated by otolaryngologists, while some non-laryngeal findings were underestimated. Future studies are needed to better understand the reasons for this phenomenon and to improve the awareness of otolaryngologists toward the most and least prevalent reflux symptoms and signs.

Validity and Reliability of the Persian Version of Reflux Symptom Score-12 in Patients with Laryngopharyngeal Reflux Disease

OBJECTIVE

Cross cultural adaptation of the reflux symptom score-12 (RSS-12) into Persian language and to evaluate its validity and reliability in the assessment of patients with laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

A cross-sectional and prospective cohort design.

METHODS

A standard forward and backward translation was followed to cross-culturally adapt the RSS-12 into Persian language. To study discriminative validity, the RSS-12p was administrated to 63 patients with LPRD (40 men and 23 women; mean age: 39.26 ± 9.79 years) and 50 healthy volunteers (31 men and 19 women; mean age: 37.24 ± 10.28 years). The patients completed the reflux symptom index (RSI) to assess construct validity. The test-retest reliability was investigated in 31 patients (time interval = 7 days).

RESULTS

There were no missing responses and floor or ceiling effects. The assessing of discriminative validity showed that the questionnaire was able to discriminate between patients with LPRD and healthy participants (P<0.001). Construct validity was confirmed by the Pearson correlation between the RSS-12p and the RSI (rp= 0.87; P<0.00). The internal consistency was confirmed with Cronbach α 0.85 and 0.72 for the RSS-12p and quality of life (QoL), respectively. Test-retest reliability was excellent (ICCagreement = 0.98 for the RSS-12p and 0.94 for QoL).

CONCLUSIONS

The Persian version of RSS-12 is a valid and reliable self-administered questionnaire for assessing LPRD in Persian-speaking patients.

Fasting salivary pepsin level as a reliable non-invasive method of screening for laryngopharyngeal reflux in Egyptian patients

Background

Laryngopharyngeal reflux (LPR) is caused by the regurgitation of gastric contents above the upper esophageal sphincter. Diagnostic gold standard tests like multichannel intraluminal impedance (MII) and 24-h dual-probe pH-metry are invasive and expensive which limits their accessibility especially in resource-limited settings. Since pepsin is only produced in the stomach, detecting pepsin in the laryngopharynx would make it a specific marker for reflux.

Therefore, in this study, we measured fasting salivary pepsin in patients with symptoms suggestive of LPR. We aimed to confirm the role of fasting salivary pepsin as a non-invasive diagnostic tool of LPR, to detect a cut-off value for it in Egyptian patients and to study predictors of changes in its level.

Methods

We conducted a prospective case control study at the gastroenterology clinic in Ain Shams University Hospitals. After testing with esophageal pH-metry, 25 symptomatic patients with confirmed LPR and 25 healthy controls were enrolled in the study. Patients diagnosed with organic upper gastrointestinal disorders, autoimmune diseases, diabetes, malignancy or organ failure were excluded. Patients on PPI were advised to stop 2 weeks before testing. All patients were tested for fasting salivary pepsin levels, esophageal pH-metry, and indirect laryngoscopy in addition to routine laboratory parameters.

Results

Out of the 25 LPR patients, 16% of patients had laryngoscope abnormality in the form of mucosal hyperemia and inflammation, and the average percentage of time pH < 4 in esophageal pH-metry testing was 29.14 ± 39.5%.

Comparative study between the 2 groups revealed a significant increase in salivary pepsin in LPR group compared to control group (p < 0.001). By using ROC-curve analysis, salivary pepsin at a cut-off point > 5 ng/ml diagnosed patients with LPR, with fair (77.9%) accuracy, sensitivity = 100% and specificity = 56% (p = 0.0001) while pH-metry (% Time pH < 4) at a cut-off point > 14% diagnosed patients with LPR, with good (87%) accuracy, sensitivity = 80%, and specificity = 100% (p < 0.0001)

Conclusion

Fasting salivary pepsin level at a cut-off value of > 5 ng/ml is a reliable, non-invasive method for detection of LPR especially in resource-limited settings.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis

BACKGROUND

A rapid lateral flow test (Peptest) to detect pepsin in saliva/sputum has been considered as a valuable method for diagnosing laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD). The aim of this meta-analysis is to analyze the utility of Peptest for diagnosis of LPR and GERD.

METHODS

PubMed, EMBASE, and the Cochran Library (from January 1980 to 26 January 2020) were searched for pepsin in saliva for LPR/GERD diagnosis. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve data were summarized to examine the accuracy.

RESULTS

A total of 16 articles that included 2401 patients and 897 controls were analyzed. The pooled sensitivity and specificity for the diagnosis of GERD/LPR with Peptest were 62% (95% confidence interval [CI] 49%-73%) and 74% (95% CI 50%-90%), respectively. The summarized diagnostic odds ratio and area under the curve were 5.0 (95% CI 2-19) and 0.70 (95% CI 0.66-0.74), respectively.

CONCLUSION

Peptest shows moderate diagnostic value for LPR and GERD. More studies with standard protocols should be done to verify its usefulness.

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.

Evaluation of the Reflux Symptom Index and the Endolaryngeal Findings Scale after Treatment in Individuals with Laryngopharyngeal Reflux

Introduction  Laryngopharyngeal reflux (LPR) is a prevalent condition in outpatients visiting the otorhinolaryngological clinic, with many controversies regarding its diagnosis and follow-up. Therefore, there is a need for clinical instruments that can diagnose individuals and monitor the results of their treatment. Objective  To evaluate the applicability of the scores translated and adapted to Brazilian Portuguese: Reflux Symptom Index (RSI) and Endolaryngeal Reflux Findings Scale (ERFS), as instruments for post-treatment follow-up of LPR. Method  A total of 35 individuals with atypical symptoms of gastroesophageal reflux disease and with an objective diagnosis of LPR, confirmed by high digestive endoscopy and 24-hour esophageal pH-metry dual probe test were submitted to the RSI and ERFS questionnaires, used in the pre- and post-treatment of 90 days with a Proton Pump Inhibitor. Result  The evaluation of RSI and ERFS in the pre- and post-treatment showed a reduction in the results of the two scores, with a higher drop in the RSI ( p  < 0.001) than in the ERFS ( p  = 0.014). Although there was an improvement in the values in 23.9% of the individuals in the ERFS, there was no change in the category ( p  = 0.057), different from the RSI ( p  < 0.001), where there was a 67.4% improvement in values, as well as change in category (score went from positive to negative). There was a correlation between RSI and ERFS, moderate in the pretreatment and strong in the post-treatment. Conclusion  The RSI and ERFS scores, when translated and adapted for Brazilian Portuguese and applied simultaneously, can be considered a good tool for post-treatment LPR follow-up.

Laryngopharyngeal Reflux Disease: Outcome of Patients After Treatment in Otolaryngology Clinics

Introduction Laryngopharyngeal reflux (LPR) is a different entity from gastroesophageal reflux disease (GERD). Patients with LPR usually present with a variety of symptoms such as hoarseness, voice fatigue, burning sensation in the throat, persistent cough, sore throat, dysphagia, a sensation of a lump in the throat, and chronic throat clearing. The management of LPR is based on medications (proton pump inhibitors) along with lifestyle and dietary modifications. It has been suggested that the Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) are useful parameters to assess patients with LPR. The aim of this study is to assess the subjective and objective benefits of RFS and RSI for diagnosing and management of LPR in the tertiary care center and to find the difference in RSI and RSI scoring with respect to gender. Methods A prospective study was performed and 102 patients were included according to inclusion criteria. RFS and RSI questionnaires were filled on the first visit of patients and then treatment with proton pump inhibitors was started along with lifestyle modification instructions. Questionnaires were filled after four weeks and then 12weeks post-treatment. Repeated measure analysis of variance (ANOVA) was performed to compare the mean RFS and RSI from baseline to the end of treatment. The post hoc analysis was done using the Bonferroni test of multiple comparisons. An independent sample t-test was also used to compare the mean RFS and RSI between genders. P-values less than 0.05 were considered statistically significant Results RFS and RSI were found to be significantly decreased post-treatment after four weeks and 12 weeks post-treatment (p-value- <0.01). Eight point eight percent (8.8%) side effects were observed in the study, the change in quality of life after a three-month treatment was significantly improved among 62.7% patients, and 75.5% did lifestyle modifications. In the mean comparison of RFS and RSI with respect to gender, it was observed that the mean RFS of females samples after one month and three months of treatment were significantly less as compared to male samples, p<0.01. There was no significant mean difference observed for RSI after one month and three months of treatment with respect to gender (p>0.05). Conclusion RFS and RSI are convenient and helpful for diagnosing LPR, and they can be easily implemented in ear, nose, throat (ENT) clinics for the subjective and objective assessment of LPR. Females showed greater improvement on laryngoscopy findings (RFS scores) post-treatment as compared to males.

Signs and symptoms of laryngopharyngeal reflux and its relation to complaints and vocal quality

PURPOSE

To verify the association between laryngopharyngeal reflux (LPR) with age, gender, vocal deviation and voice complaints.

METHODS

The study included patients between 18 and 70 years old, referred to the Otorhinolaryngology service for complaints of voice or reflux, of both sexes. Endolaryngeal findings were classified using the Reflux Finding Score (RFS) scale. The presence or absence of vocal and reflux complaints was verified and correlated with the RFS classification. On the same date, they were submitted to sustained vowel voice recording and chained speech. The auditory-perceptual assessment was performed by a speech therapist, classifying the general degree of vocal deviation based on the GRBASI scale.

RESULTS

Ninety-seven patients were evaluated, with a mean age of 42. 6 years, 62. 3% female, and mean RFS scores of 6. 26 points. Among the patients, 48 subjects had vocal complaints, 34 women with a mean age of 44. 9 years and an average RFS score of 6. 94 points. The other 49 individuals had no vocal complaints, and of these 27 were women, with a mean age of 41. 2 years and a mean RFS score of 5. 5 points. The variables "reflux complaint", "vocal complaint" and age were the ones that most correlated with the RFS scale scores.

CONCLUSION

There is a relationship among reflux complaints, laryngeal findings and vocal complaint.

Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians

Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.

Laryngeal signs and pH-multichannel intraluminal impedance in infants and children: The missing ring: LPR and MII-pH in children

OBJECTIVE

to investigate the reliability of laryngeal reflux finding score (RFS) and symptom index (RSI) in assessing gastroesophageal reflux (GER) in children and infants.

METHODS

patients with laryngeal or respiratory symptoms, who underwent laryngoscopy and esophageal pH-impedance (MII-pH) were recruited. RSI and RFS were correlated to MII-pH results. A RSI>13, RFS>7, acid exposure index>7%, total reflux episodes>100/24 h in infants or>70/24 h in children, or a positive symptom index or association probability, were considered pathological. Analysis considering age (</>12 months) was performed. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the laryngeal scores were calculated.

RESULTS

197 children (median 53 months, 61 infants) were enrolled. MII-pH was pathological in 5/10 patients with RFS>7, and in 17/31 with RSI>13. RFS>7 had 3.9% sensitivity, 93% specificity, a PPV of 50 and a NPV of 34 in predicting GER disease. RFS was inversely associated to weakly acidic and proximal GER. RSI>13 had 13% sensitivity, 83% specificity, and a PPV and NPV similar to RFS. RSI was significantly associated with the number of acid reflux episodes, and, in infants, with bolus exposure index.

CONCLUSIONS

RSI and RFS aren't accurate in predicting GER in infants and children. Acid reflux relates to laryngeal symptoms, but neither acid, nor proximal and weakly acidic GER relate to laryngeal alterations.

Changes of Laryngeal and Extralaryngeal Symptoms and Findings in Laryngopharyngeal Reflux Patients

OBJECTIVES/HYPOTHESIS

To assess the evolution of laryngeal and extralaryngeal symptoms and findings of laryngopharyngeal reflux (LPR) throughout a 3-month to 9-month treatment.

STUDY DESIGN

Prospective Controlled Study.

METHODS

One hundred twenty-seven LPR patients and 123 healthy individuals were enrolled from four European hospitals. Patients were managed with a 3-month personalized treatment considering the LPR characteristics at the impedance-pH monitoring. Regarding the clinical therapeutic response, treatment was adapted for 3 to 6 additional months. Symptoms and findings were assessed throughout the therapeutic course with the Reflux Symptom Score (RSS) and the short version of the Reflux Sign Assessment (sRSA). The relationship between patient and reflux characteristics, symptoms, and findings was assessed.

RESULTS

One hundred twenty-one LPR patients completed the study. LPR patients exhibited more laryngeal and extralaryngeal symptoms and findings than healthy individuals. RSS significantly improved from baseline to 6 weeks posttreatment and continued to improve from 3 months to 6 months posttreatment. sRSA significantly improved from baseline to 3 months posttreatment. No further improvement was noted at 6 months posttreatment for pharyngeal and oral findings. Laryngeal findings continued to improve from 3 months to 6 months posttreatment. There was a significant association between patient stress level and RSS (P = .045). At 3 months posttreatment, 28.1% of patients had high or complete response, whereas 47.1% required 6 months or 9 months of treatment. Overall, 24.8% of patients had an LPR chronic course.

CONCLUSIONS

Laryngeal and extralaryngeal symptoms and findings significantly improved throughout treatment in LPR patients. The improvement of laryngeal findings was slower. Regarding the low prevalence of some digestive or otolaryngological symptoms, a short version of the RSS could be developed.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1332-1342, 2021.

Is empirical treatment a reasonable strategy for laryngopharyngeal reflux? A contemporary review

BACKGROUND

Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.

OBJECTIVES

To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.

METHODS

PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.

RESULTS

The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-oesophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR.

CONCLUSIONS

Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with non-acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.

Validation of the Brazilian Portuguese Version of the Reflux Finding Score

INTRODUCTION

Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language.

OBJECTIVE

To validate the Brazilian Portuguese version of the RFS.

MATERIAL AND METHOD

For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested.

RESULTS

A statistically significant difference was observed in the mean RFS between patients with LPR (10.26 ± 3.58) and controls (5.52 ± 1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1 = 0.956; R2 =  0.948).

CONCLUSION

The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.

A Multicentre Study in UK Voice Clinics Evaluating the Non-invasive Reflux Diagnostic Peptest in LPR Patients

Questionnaires and invasive diagnostic tests are established for diagnosing gastro-esophageal reflux disease (GERD) but shown not to be sensitive or specific for diagnosing laryngopharyngeal reflux (LPR) where vast majority of reflux events are weakly acidic or non-acidic. The research question addressed in the current multicentre study was to determine if the measurement of salivary pepsin is a sensitive, specific and reliable diagnostic test for LPR. Five UK voice clinics recruited a total of 1011 patients presenting with symptoms of LPR and a small group of subjects (n = 22) recruited as asymptomatic control group. Twenty-six patients failed to provide demographic information; the total patient group was 985 providing 2927 salivary pepsin samples for analysis. Study participants provided 3 saliva samples, the first on rising with two samples provided post-prandial (60 min) or post-symptom (15 min). The control group provided one sample on rising and two post-prandial providing a total of 66 samples. Pepsin analysis was carried out using Peptest as previously described. High prevalence of pepsin in patient groups (75%) represents a mean pepsin concentration of 131 ng/ml. The greatest prevalence for pepsin was in the post-prandial sample (155 ng/ml) and the lowest in the morning sample (103 ng/ml). The mean pepsin concentration in the control group was 0 ng/ml. Patients across all 5 clinics showed high prevalence of salivary pepsin (ranging from 69 to 86%), and the overall sensitivity was 76.4% and specificity 100%. Pepsin was shown to be an ideal biomarker for detecting airway reflux and LPR.

Validity and Reliability of the Reflux Sign Assessment

OBJECTIVE

To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR).

METHODS

A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall's W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis.

RESULTS

A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy (P < .001). RSA exhibited good intra- (r = 0.813) and interrater (Kendall's W = 0.663) reliabilities (N = 56). There was no significant association between the RSA, gastrointestinal endoscopy findings, and the types of reflux (acid, nonacid, or mixed) according to impedance-pH monitoring. An RSA >14 may be suggestive of LPR.

CONCLUSION

The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review

OBJECTIVE

To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients-those who do not respond to anti-reflux medical treatment.

METHODS

A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated.

RESULTS

Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non-acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy.

CONCLUSION

To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients.

LEVEL OF EVIDENCE

2a.

Perceptual, Aerodynamic, and Acoustic Characteristics of Voice Changes in Patients with Laryngopharyngeal Reflux Disease

Laryngopharyngeal reflux (LPR) is an inflammatory condition suspected to be associated with dysphonia. In this study, we investigated multidimensional perceptual, aerodynamic, and acoustic voice changes in patients with clinically diagnosed LPR compared to healthy participants. We prospectively included 80 outpatients with Reflux Finding Score (RFS) >7 and Reflux Symptom Index (RSI) >13 from September 2013 to April 2016 and we compared clinical and voice quality assessments of these patients with 80 healthy participants. Statistically significant differences were found between groups with regard to Voice Handicap Index, perceptual voice quality (grades of dysphonia, roughness, strain, breathiness, asthenia, and instability), phonatory quotient, percentage jitter, percentage shimmer, peak-to-peak amplitude variation, standard deviation of fundamental frequency, and noise to harmonic ratio. Granulation score of RFS was found to affect the highest number of acoustic parameters. We did not identify significant correlation between vocal fold edema and objective voice quality measurements. This study supports that patients with LPR have significant deterioration of both subjective and objective voice quality compared to healthy participants.

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.