Multitime point pepsin testing can double the rate of the diagnosis of laryngopharyngeal reflux

Investigation of Reflux Characteristics in Outpatients of Otorhinolaryngology-Head and Neck Surgery by Age and Gender in the Chinese Population

OBJECTIVE

To investigate the characteristics of patients with reflux diseases in the otorhinolaryngology-head and neck surgery clinics through the Reflux Symptom Scale-12 (RSS-12) and the Gastroesophageal Reflux Disease Questionnaire (GERD-Q).

METHODS

All included patients completed the RSS-12 and GERD-Q scales and were considered to have LPR with an RSS-12 score >11 and GERD with a GERD-Q score >7. Data were analyzed according to genders (male and female) and age (18-40, 41-60, and >60 years).

RESULTS

A total of 977 patients were included. the mean RSS-12 and GERD-Q score were 11.32±21.34 and 6.31±1.21, and the positive rate of LPR and GERD were 28.76% and 8.90%, respectively. Males had a higher positive rate of LPR and GERD than females, and there were more males with LPR who also had GERD. Among those with both LPR and GERD, males had significantly higher ear-nose-throat (ENT) symptom scores such as hoarseness and excess throat mucus than females. However, females had significantly higher scores of gastrointestinal (GI) symptoms, mainly indigestion and abdominal pain, and elder patients (>60 years) had higher scores of ENT, GI, respiratory symptoms, as well as the impact of symptoms on quality of life than the young patients (18-40, and 41-60 years).

CONCLUSION

Patients in the otorhinolaryngology-head and neck surgery clinics have different reflux characteristics by gender and age in the Chinese population. Males had more severe ENT-related symptoms of distress, while females had more complaints of GI symptoms. Older patients had higher scores for ENT, GI and respiratory symptoms.

The Profiles of Laryngopharyngeal Reflux in Patients With Different Vocal Fold Lesions

OBJECTIVES

To investigate the profiles of laryngopharyngeal reflux (LPR) and the relationship between hypopharyngeal-proximal reflux episodes (HREs) and the positive rate of salivary pepsin testing in patients with vocal fold lesions (VFLs).

METHODS

The enrolled patients were divided into vocal fold cancer group (VFCG), vocal fold leukoplakia group (VFLG), benign vocal fold lesion group (BVFLG) and control group (CG). Patients benefited from multichannel intraluminal impedance-pH monitoring (MII-pH) and multi-time point salivary pepsin testing (MTPSPT). The LPR profiles of patients with VFLs were studied by analyzing the MII-pH findings. The relationship between HREs and positive rate of MTPSPT was investigated through the nonparametric test.

RESULTS

177 patients were included. According to 24 h MII-pH, the occurrence of HREs tended to increase after meals. 55.75%, 63.98%, 66.82% and 55.77% of the HREs in the VFCG, VFLG, BVFLG and CG occurred within 3 h after meals, respectively. The overall positive rate of MTPSPT was higher in the VFCG than the remaining groups. In the VFCG, there was a significant correlation between overall positive results of MTPSPT and HREs occurring within 3 h after meals.

CONCLUSION

In the Chinese population, the occurrence of HREs tend to more frequently after meals in patients with VFLs, and most HREs occur within 3 h after meals. By analyzing the 24h MII-pH findings, we can develop a more individualized anti-reflux therapeutic strategy for LPR patients.

Characteristics of Laryngopharyngeal Reflux in the Chinese Nurse Population

OBJECTIVES

To investigate the prevalence of laryngopharyngeal reflux (LPR) and knowledge of LPR in the Chinese nurse population.

METHOD

From October 2021 through December 2021, participants were recruited from the PLA General Hospital's Sixth Medical Center. All included participants completed the Reflux Symptom Index (RSI), and LPR was defined as RSI > 13. In addition, each participant was asked to record whether they had any habits such as preferring to consume high-fat food and carbonated beverages, over-eating at dinner, sedentary after meals and lying down within 2 hour after meals, as well as whether they were aware of LPR. For the participants with RSI >13 points, they were treated using diet and lifestyle behavioral recommendations and were prescribed a twice daily pantoprazole (20 mg, 3 months).

RESULTS

A total of 828 participants were included. The positivity and awareness rates of LPR were 3.38% and 55.96%, respectively. RSI scores were significantly higher in LPR-positive subjects than in LPR-negative (16.79 ± 4.43 vs. 1.33 ± 2.33). Among the participants with LPR, there were significant positive association between RSI scores and preferring to consume high-fat food and carbonated beverages, over-eating at dinner, lying down within 2 hour after a meal, and sedentary after meals. RSI scores in 63% of participants with LPR significantly decreased from baseline to 1 month posttreatment. From 1 to 3 months posttreatment, 90% of participants had significantly lower RSI scores than pretreatment.

CONCLUSIONS

There are a certain number of LPR patients in the Chinese nurse population, however, knowledge of LPR among nurses is unsatisfactory. Over-eating at dinner, lying down within 2 hour after a meal and sedentary after meals are risk factors for LPR. With combined regular dietary and lifestyle behavioral change and acid-suppressing treatment, most patients with LPR achieve effective remission.

Salivary pepsin testing for laryngopharyngeal reflux: will it change our management?

PURPOSE OF REVIEW

This review focus on the clinical value of salivary and laryngopharyngeal tissue pepsin measurement in the diagnosis and treatment of laryngopharyngeal reflux (LPR).

RECENT FINDINGS

A growing body of research suggests that salivary pepsin detection provides a noninvasive method for the identifying LPR occurrence. Pepsin detection testing is still variable, and an optimal method that balances utility with accuracy has not been agreed. Timing and number of test samples recommended also remains controversial, however literature indicates that increasing the number of tests over a day increases pepsin detection rate. It remains unclear whether detection of pepsin alone can be used to confirm LPR diagnosis. Pepsin positivity is correlated with improved response to proton pump inhibitor (PPI) therapy, and therefore may play a role in guiding therapeutic choices. Detection of pepsin in laryngeal tissue has the same clinical value as detection in saliva and requires further investigation to determine utility.

SUMMARY

As a noninvasive method for the diagnosis of LPR, the detection of salivary pepsin in the oropharynx shows potential clinical value, however the exact method of detection and diagnostic values are unclear. Salivary or tissue-based pepsin detection may be helpful in predicting therapeutic effects of PPI and providing personalized treatment options. The detection threshold of salivary pepsin may be different in different countries and regions. Timing and number of samples needed for detection is still controversial.

The reflux symptom score has good screening value for laryngopharyngeal reflux

OBJECTIVE

To investigate the consistency between the reflux symptom score (RSS) and the multitemporal salivary pepsin test in screening for laryngopharyngeal reflux (LPR) and the screening value of the RSS for LPR by simultaneously administering daytime multitemporal salivary pepsin test and RSS to patients.

METHODS

This was a single-center prospective observational study. All included patients underwent simultaneous daytime multitemporal salivary pepsin testing and RSS. A participant was considered to have LPR when one or more positive salivary pepsin test results or RSS score > 13 were obtained. The consistency between the multitemporal salivary pepsin test and the RSS was compared by the weighted Cohen's kappa statistic. The screening value of the RSS for LPR was investigated by receiver operating characteristic (ROC) analysis.

RESULTS

A total of 67 patients were included. The positivity rate of LPR was 71.64% according to the results of the multitemporal salivary pepsin test. According to RSS, the positive rate of LPR was 70.15%. The weighted Kappa value between the multitemporal salivary pepsin test and the RSS was 0.675 (p < 0.001). The area under curve of RSS screening for LPR was 0.843 (p < 0.01), and the sensitivity, specificity, positive predictive value, and negative predictive value of RSS screening for LPR were 89.58%, 78.95%, 91.49%, and 75%, respectively.

CONCLUSION

There is a good consistency between the RSS and the multitemporal salivary pepsin test, and the RSS has a good screening value for LPR, which can be applied to screen for LPR in otolaryngologic patients.

The Consistency Between Symptom Scales and Multi-time Point Salivary Pepsin Test for Diagnosing Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the screening diagnostic value of reflux symptom index (RSI) and reflux symptom score (RSS) for laryngopharyngeal reflux disease (LPRD).

METHODS

Fifty-two patients hospitalized in the Department of Otolaryngology-Head and Neck Surgery at The Sixth Medical Center of PLA General Hospital between October 2022 and April 2023 were enrolled in the study. These patients completed the RSS, RSI scales, as well as underwent the multi-time point salivary pepsin test (MTPSPT). Cohen's kappa test and receiver operating characteristic analysis were utilized to assess and compare the diagnostic values of the RSI and RSS.

RESULTS

A total of 52 patients, comprising 37 males and 15 females, with a mean age of 44 ± 12 years, were enrolled in the study. The Kappa values between RSS, RSI, and MTPSPT were found to be 0.403 (P < 0.05) and 0.192 (P < 0.05), respectively. When considering MTPSPT as the diagnostic criterion, the sensitivity and specificity of RSS were determined to be 76.70% and 76.90%, respectively, while those of RSI were 41.10% and 42.30%. Additionally, the negative predictive values for RSS and RSI stood at 77.70% and 64.70%, respectively, and their positive predictive values were 94.20% and 57.10%. Furthermore, the area under the curves (AUC) for RSS and RSI were calculated to be 0.677 (95% confidence interval [CI]: 0.464-0.742) and 0.609 (95% CI: 0.533-0.800), respectively.

CONCLUSIONS

RSS had a better concordance with multi-time point salivary pepsin test results and AUC values when screening for LPRD.

[Characteristics performance of laryngopharyngeal reflux in narrow band imaging]

Objective:To study the application value of narrow-band imaging in the diagnosis of laryngopharyngeal reflux. Methods:A total of 275 patients admitted to the inpatient department or laryngoscopy room of the Otolaryngology Head and Neck Surgery Department of the First Affiliated Hospital of Harbin Medical University from September 2022 to April 2023 due to throat discomfort were selected as the research subjects. All of them completed RSI, RFS scoring scales and electronic laryngoscopy（including ordinary white light and NBI）. According to the expert consensus of LPRD in 2022, RSI and RFS scoring scale were used as diagnostic criteria to divide them into LPR group and non-LPR group. Chi-square test was used to analyze the differences of positive rates of characteristic manifestations under NBI among different groups. The consistency of NBI and scale diagnostic methods was analyzed by Kappa, and RSI and RFS scoring were used as diagnostic criteria, The diagnostic efficiency of NBI method was analyzed. Results:There were 190 people in the LPR group, 157 of whom showed characteristic performance under the NBI mode, with a positive rate of 82.6%（157/190）; there were 85 people in the non-LPR group, with a positive rate of 18.8%（16/85）. There was a statistically significant difference in the positive rate between the two groups（χ²=102.47, P<0.05）. The consistency rate between RSI, RFS and NBI was 82.2%（226/275）. Kappa consistency analysis was used, and Kappa=0.605（P<0.05）, indicating good consistency between the two diagnostic methods. Using RSI and RFS as diagnostic criteria for LPR, the sensitivity of NBI diagnostic method was 82.6%（157/190）, specificity 81.2%（69/85）, positive predictive value 90.8%（157/173） and negative predictive value 67.6%（69/102）. Conclusion:Narrow-band imaging, as a new endoscopic imaging technique, can show small changes in mucosal surface micro vessels and play an important role in the diagnosis of laryngopharyngeal reflux.

Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review

Purpose: Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. Methods: A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. Findings: The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Conclusions: Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.

[Consistency analysis of pepsin immunohistochemistry and pepsin test box in the diagnosis of laryngopharyngeal reflux]

Objective:To analyze the consistency of pepsin assay kit, pepsin IHC, reflux symptom index（RSI） and reflux finding score（RFS） in the diagnosis of laryngopharyngeal reflux disease（LPRD）. Methods:The clinical data of 61 inpatients with laryngeal diseases who were admitted to the Department of Otolaryngology, the First Affiliated Hospital of Kunming Medical University from May 2020 to December 2021 were retrospectively analyzed. The RSI and RFS scores, the Formwitz score of pepsin immunohistochemistry, and the results of pepsin detection kit were recorded. ICC group correlation coefficient and Kappa consistency analysis was used for three detection methods. Results:Among 61 patients, 30 cases were positive and 31 cases were negative for the pepsin test kit, with a positive rate of 49.18%. The positive rate of pepsin immunohistochemistry was 45.90%（28/61）, and the diagnostic agreement rate between the two was 70.49%. The consistency between them was high（κ=0.409）. The positive rate of RSI and RFS in diagnosing LPRD was 62.30%（38/61）, and the consistency rate was 73.77% with pepsin detection kit. The consistency between them was high（κ=0.486）. Taking pepsin IHC as the reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of pepsin detection kit were 71.43%（20/28）, 69.70%（23/33）, 66.67%（20/30） and 74.19%（23/31）, respectively. Using RSI and RFS scales as reference criteria, the sensitivity, specificity, positive predictive value and negative predictive value of pepsin detection kit were 89.29%（25/28）, 60.61%（20/33）, 65.79%（25/38） and 86.96%（20/23）, respectively. Analysis of correlation coefficient within ICC group: ICC value was 0.628, 95% confidence interval（0.497-0.741）, the three methods have good consistency. Conclusion:The RSI and RFS scale scores were in good agreement with the pepsin test kit, and the pepsin test kit was also in good agreement with pepsin immunohistochemistry. As a non-invasive diagnostic technique, the pepsin test kit can be widely used in the diagnosis of pharyngeal reflux in combination with pepsin immunohistochemistry and RSI and RFS scale.

Characteristics of Laryngopharyngeal Reflux in Patients of Different Genders and Ages

OBJECTIVES

To investigate the differences in laryngopharyngeal reflux (LPR) characteristics between gender and age groups based on the Reflux Symptom Index (RSI), Reflux Finding Score (RFS) scale and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring.

METHODS

The enrolled were patients with LPR symptoms completed the 24h-HEMII-pH monitoring and divided into two gender groups (male and female) and elderly group (>60 years), middle-aged group (41-60 years) and young group (18-40 years). The total RSI and RFS scores of individuals were counted. Various potential differences as well as incidence of each type of LPR events between gender and age groups were analyzed.

RESULTS

A total of 420 patients were included, with 333 (79.3%) diagnosed with LPR confirmed by 24h-HEMII-pH monitoring. Females (n=49) had a statistically higher LPR positivity (91.0% vs. 76.6%, P < 0.01) than males (n=342). Female patients with LPR had significantly higher RSI scores (14.08 ± 6.72 vs. 11.08 ± 4.82, P < 0.001) than male patients. The positive rate of LPR were 82.6%, 80.7% and 63.3% in the elderly, middle-aged and young groups. The Elderly group had significantly lower RSI scores (10.20 ± 4.06 vs. 12.80 ± 6.58, 12.24 ± 5.57, P < 0.001) but higher RFS scores (9.37 ± 3.25 vs. 8.16 ± 3.34, 8.57 ± 2.58, P < 0.05) than the other two groups. The number of acid hypopharyngeal-proximal reflux episodes (HREs) and distal esophageal acid reflux were significantly higher in elderly than in young patients. Except for non-acid gas HREs, the positive rates of other types of HREs were increasing from young to middle-aged to the elderly group (P < 0.05).

CONCLUSIONS

Female patients with suspected LPR symptoms had a higher positive rate of LPR and RSI score than males. The prevalence of LPR and the number of acid reflux were progressively increasing with age, but the perception of reflux symptoms may diminish.

There is a Good Consistency Between Reflux Symptom Score-12 and Reflux Symptom Index in Chinese Population

OBJECTIVE

To investigate the consistency between the Reflux Symptom Score-12 (RSS-12) and Reflux Symptom Index (RSI) in Chinese people.

METHODS

Patients with symptoms of LPR from the outpatient otorhinolaryngology-head and neck surgery clinic were included. All included patients completed the RSS-12 and RSI. The patient with RSS-12>11 or RSI>13 suggested possible LPR. For the patients with RSI >13 or RSS-12>11, they were treated using diet recommendations and were prescribed a twice-daily pantoprazole for 12 weeks. The consistency between the RSS-12 and RSI was compared with the weighted Cohen's kappa statistic.

RESULTS

A total of 258 patients were included. The mean scores for RSS-12 and RSI were 13.21±17.31 and 12.86±6.15, respectively. The positive rate of LPR was 17.44% based on the RSI, and 24.42% based on the RSS-12. The kappa value between the RSS-12 and RSI was 0.736 (P < 0.001). Following 12 weeks of treatment, there was a significant reduction in both RSI and RSS-12. Based on the RSI, 73% of patients had a good treatment response, whereas according to the RSS-12, 85% of patients had a good treatment response.

CONCLUSION

There is a good consistency between RSS-12 and RSI, meaning that the RSS-12 is a feasible LPR initial screening tool. The RSS-12 provides a more comprehensive evaluation of reflux symptoms and treatment effect than RSI in patients with LPR.

Optimal Timing of the Salivary Pepsin Test for the Diagnosis of Laryngopharyngeal Reflux

OBJECTIVE

To investigate the optimal time point for diagnosing laryngopharyngeal reflux (LPR) through combining 24-h hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-h HEMII-pH) monitoring and the multi-time point salivary pepsin test (MTPSPT).

STUDY DESIGN

Prospective uncontrolled trial.

METHOD

Patients with and without LPR symptoms were included as the test group and the control group, respectively. The patients in the test group underwent 24-h HEMII-pH and MTPSPT. The results of 24-h HEMII-pH were used as a diagnostic criterion for LPR, and the diagnostic value of salivary pepsin tests performed at different time points was compared by receiver operating characteristic (ROC) analysis.

RESULTS

A total of 153 patients were included. Based on 24-h HEMII-pH, the positive rate of LPR in the test group of patients was 84.00%. In the control group, only one person (3.57%) had a positive salivary pepsin test result. The area under the curve (AUC) of the MTPSPT was 0.827. In addition, we separately calculated the AUC of the combined salivary pepsin test at different time points, and found good diagnostic value (AUC = 0.799) when the test was combined with the waking, 1 and 2 h after breakfast and lunch, and 1 h after dinner tests. However, when the number of tests were further increased, the diagnostic value did not improve significantly.

CONCLUSION

Salivary pepsin testing combined with waking, 1 h and 2 h after breakfast and lunch, and 1 h after dinner has almost the same diagnostic value as MTPSPT, and testing at these time points can be an effective method for diagnosing LPR.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Does hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring for the diagnosis of laryngopharyngeal reflux have to be 24 h?

PURPOSE

To investigate the diagnostic value of combined multi-timepoint salivary pepsin testing (MTPSPT) and hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) for laryngopharyngeal reflux (LPR) and whether an appropriate reduction in the duration of HEMII-pH would affect the accuracy of diagnosis of LPR.

METHODS

Recruited patients were studied with both MTPSPT and HEMII-pH. The diagnosis of LPR was based on the occurrence of > 1 reflux event and/or positive results on any of the MTPSPT. The diagnostic value of combined diagnosis was studied through combining a breakdown of the 24-h HEMII-pH finding and the results of the MTPSPT. The diagnostic value was expressed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Based on 24-h HEMII-pH and MTPSPT, the positive rate of LPR was 83.33% and 74.69%, respectively. According to the combined diagnosis, the positive rate of LPR was 90.74%. The sensitivity and specificity of the combined diagnosis both were 89.51% and 100%, when the HEMII-pH intervals were 7 a.m.-6 p.m. and 7 a.m.-7 p.m., respectively. However, when the monitoring time was extended to 8 p.m. and bedtime, the sensitivity, specificity, PPV and NPV of the combined diagnosis both were 100%.

CONCLUSIONS

The combination of MTPSPT and HEMII-pH increased the sensitivity and accuracy of diagnosis of LPR. For patients with positive MTPSPT results, the duration of HEMII-pH can be appropriately shortened to reduce patient sufferings.