A meta-analysis for the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux

Reflux Finding Score and Reflux Symptom Index Potential Indicators for Diagnosis and Management of Laryngopharyngeal Reflux Disease

Retrograde movement of gastric contents into the pharynx is termed Laryngopharyngeal Reflux (LPR). It represents an extraesophageal manifestation associated with gastroesophageal reflux disease (GERD). The objective of the study is to investigate the clinical profile of LPR and its response to treatment. Three hundred consecutive patients who presented to the ENT outpatient department with a clinical profile of LPR were selected. The patients' symptoms were assessed using the Reflux Symptom Index (RSI), followed by an endoscopic examination of the larynx and scoring using the Reflux Finding Score (RFS). Patients were started on LPR treatment if they had an RSI score of 13 and an RFS of more than 7. The patients were then started on medication and monitored for three months. The most common symptom in our research sample (52%) was a foreign body sensation in the throat. On endoscopic examination of the larynx, the most common sign was hyperemia/erythema of laryngeal tissue, especially bilateral arytenoids. Most of our patients responded favorably to a combination of pantoprazole (40 mg) and domperidone (30 mg) for 4 weeks. This was measured by the reduction in RSI and RFS scores. LPR is a frequently encountered clinical entity, and otorhinolaryngologists should consider it when treating patients with chronic symptoms such as throat pain and voice changes. Appropriate LPR diagnosis and care can help prevent unnecessary prescriptions for antibiotics and surgical interventions in these patients.

Laryngopharyngeal Reflux Pathophysiology, Clinical Presentation, and Management: A Narrative Review

Laryngopharyngeal reflux (LPR) is a common and often misinterpreted clinical entity responsible for various symptoms affecting the upper aerodigestive tract. This narrative literature review aims to review the pathophysiology, symptoms, and management of LPR, emphasizing the emerging understanding of gastric content reflux in aerodigestive tissue irritation. Understanding the pathophysiology of LPR will allow general practitioners and specialists to accurately recognize and treat a condition that causes substantial morbidity in the affected patients. Using evidence-based findings from randomized controlled trials, clinical studies, and meta-analyses, the present investigation aims to outline and unify previous research into LPR. A review of anatomical structures, pathogenic mechanisms, endoscopic findings in LPR, and clinical manifestations and treatment options are also discussed. Though controversy around the diagnosis and management of LPR persists, emerging research in cellular damage and diagnostic tools promises to provide increasingly accurate and reliable modalities for characterizing LPR. Hopefully, future research will unify the field and provide overarching guidelines for both primary care and specialists. The present investigation provides an integrated perspective on LPR, a clinically prevalent and complex disease.

Laryngopharyngeal Reflux and Benign Vocal Fold Lesions: A Systematic Review and Meta-analysis

OBJECTIVE

There is a link between laryngopharyngeal reflux (LPR) and the formation of benign vocal fold lesions (BVFLs). However, previous studies have mainly focused on LPR suggested by symptoms and signs, rather than objectively diagnosed LPR via pharyngeal pH monitoring. We, therefore, conducted a Meta-analysis to evaluate the association between pharyngeal pH monitoring diagnosed LPR and the odds of BVFLs.

DATA SOURCES

Relevant observational studies were identified by searching PubMed, Embase, Cochrane Library, and Web of Science.

REVIEW METHODS

We evaluated between-study heterogeneity using the Cochrane Q test and estimated the I2 statistic. Random-effects models were used when significant heterogeneity was observed; otherwise, fixed-effects models were used.

RESULTS

Thirteen datasets from 9 studies were included. Among them, 493 were diagnosed with LPR and 344 had BVFLs. LPR was related to a higher odds of BVFLs (odds ratio: 3.26, 95% confidence interval: 1.84-5.76, P < .001) with moderate heterogeneity (P for Cochrane Q test = .006, I2  = 57%). Subgroup analyses showed that the association was similar in studies with only pharyngeal pH monitoring (Restech), with double-probe or 3-site pH monitoring, and with 24-hour multichannel intraluminal impedance-pH monitoring (P for subgroup difference = .15). In addition, subgroup analysis showed consistent results in studies from Asia and Europe (P for subgroup analysis = .12), and the association seemed to be consistent for vocal Reinke's edema, nodules, and polyps (P for subgroup difference = .09).

CONCLUSION

Pharyngeal pH monitoring diagnosed LPR is associated with the formation of BVFLs.

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.

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.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

INTRODUCTION

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.

AREAS COVERED

A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.

EXPERT OPINION

Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

Laryngopharyngeal reflux induced sleep-related laryngospasm

BACKGROUND

Sleep-related laryngospasm (SRL) has been defined as the sustained closure of the vocal cords during sleep. Studies have suggested that it is a rare manifestation of laryngopharyngeal reflux (LPR). Difficulties in diagnosing SRL and LPR have led to the condition being under-recognised in the clinical setting.

AIMS

The aim of this study was to determine if LPR was the cause of the SRL symptoms seen in our patients.

METHODS

A retrospective chart assessment of patients with SRL. Patients with risk factors for LPR were identified. These included smoking status, alcohol intake, a history of dyspepsia or history of gastroesophageal reflux disease, a history of late-night eating and a history of eating spicy or fatty foods before bed. A clinical diagnosis based on the history and response to management was made for the diagnosis of LPR. All were advised to refrain from late meals and those with signs of nasopharyngitis were commenced on proton pump inhibitor therapy.

RESULTS

Nineteen patients (mean age ± SD: 57.21 ± 15.18) were included in the study. All had at least one risk factor for LPR. Ten (52.6%) had signs of nasopharyngitis on nasendoscopy. Following treatment, 17 (89.5%) reported no further SRL symptoms at 1-year follow-up.

CONCLUSION

SRL is a largely unknown and under-diagnosed condition. We believe this study provides supportive evidence for the causal relationship between LPR and SRL.

Meta-analysis of Proton Pump Inhibitors in the Treatment of Pharyngeal Reflux Disease

The present study aimed to examine the safety and healing effects of proton pump inhibitors (PPIs) in people with laryngopharyngeal reflux disease (LPRD). To find all relevant studies published before April 1, 2022, we searched the PubMed, Embase, Web of Science, Clinical Trials, Cochrane Library, CNKI, and Wanfang databases. For SLE, we looked for all randomized controlled clinical trials related to PPIs versus placebo-controlled treatment of LPRD. Overall efficiency, reflux symptom index (RSI), reflux finding score (RFS), improvement in cough and hoarseness, and adverse reactions were compared using the Review Manager 5.3. Using the reflux symptom index (RSI) as an outcome indicator for efficacy assessment, the PPI group showed significant improvement compared with the placebo group [MD = 3.35, 95% CI (1.34, 5.37, P < 0.05)]. In terms of overall efficacy, the PPI group showed effectiveness, but its efficacy was not statistically significantly dissimilar from that of the placebo group [OR = 1.62, 95% CI (0.89, 2.95), P > 0.05].

Magnesium alginate versus proton pump inhibitors for the treatment of laryngopharyngeal reflux: a non-inferiority randomized controlled trial

PURPOSE

Proton pump inhibitors (PPIs) are commonly prescribed for laryngopharyngeal reflux (LPR), but their efficacy remains debated. Alginates is an option for the treatment of LPR with few adverse effects. The study aimed to investigate the non-inferiority of an alginate suspension (Gastrotuss®) compared to PPIs (Omeprazole) in reducing LPR symptoms and signs.

METHODS

A non-inferiority randomized controlled trial was conducted. Fifty patients with laryngopharyngeal symptoms (Reflux Symptom Index -RSI- ≥ 13) and signs (Reflux Finding Score -RFS- ≥ 7) were randomized in two treatment groups: (A) Gastrotuss® (20 ml, three daily doses) and, (B) Omeprazole (20 mg, once daily). The RSI and the RFS were assessed at baseline and after 2 months of treatment.

RESULTS

Groups had similar RSI and RFS scores at baseline. From pre- to 2-month posttreatment, the mean RSI significantly decreased (p = 0.001) in alginate and PPI group (p = 0.003). The difference between groups in the RSI change was not significant (95%CI:  - 4.2-6.7, p = 0.639). The mean RFS significantly decreased in alginate (p = 0.006) and PPI groups (p = 0.006). The difference between groups in the mean change RFS was not significant (95%CI:  - 0.8; 1.4, p = 0.608).

CONCLUSION

After 2 months of treatment, LPR symptoms and signs are significantly reduced irrespective of the treatment. Alginate was non-inferior to PPIs and may represent an alternative treatment to PPIs for the treatment of LPR.

The Effect of Hyaluronic Acid and Chondroitin Sulphate-Based Medical Device Combined with Acid Suppression in the Treatment of Atypical Symptoms in Gastroesophageal Reflux Disease

Extraesophageal reflux symptoms are increasingly common in the Western population and their clinical management is still controversial. Although therapy with proton-pump inhibitors (PPIs) represents the gold standard, to date, many patients are refractory to this treatment. The aim of this study was to evaluate, in patients with a recent diagnosis of GERD experiencing extraesophageal symptoms, the efficacy and safety of a 6-week treatment with PPI acid suppression in combination with Gerdoff^® (a hyaluronic acid and chondroitin sulphate-based medical device) compared to PPI monotherapy. The trial verified the reduction in symptom frequency and severity by evaluating the proportion of Responders and Non-Responder patients after 6 weeks of treatment, compared to baseline. The effects of Gerdoff^® + PPI treatment on extraesophageal symptoms were also evaluated after a 12-week follow up only in Responder patients. The analysis of the change in total Reflux Symptoms Index (RSI) score from baseline to the other time points showed that the extent of the decrease from baseline was higher in the Gerdoff^® + PPI group than in the PPI group at any time point. However, the comparison between groups did not show statistically significant differences at any time point. A statistically significant difference, in favor of the Gerdoff^® + PPI group, was observed for individual RSI items. Even if the trial showed some limitations, this is the first published study on the efficacy of a medical device containing hyaluronic acid and chondroitin sulphate with antacid in the treatment of extraesophageal reflux symptoms.

Reflux-related Extraesophageal Symptoms Until Proven Otherwise: A Direct Measurement of Abnormal Proximal Exposure Based on Hypopharyngeal Multichannel Intraluminal Impedance as a Reliable Indicator for Successful Treatment Outcomes

Background/Aims

The Lyon Consensus defined parameters based on upper endoscopy and 24-hour combined multichannel intraluminal impedance-pH (MII-pH), that conclusively establish the presence of gastroesophageal reflux disease (GERD). However, the true role of upper endoscopy and MII-pH to evaluate patients with extraesophageal symptoms (EES) has not been well established. Hypopharyngeal MII (HMII), which directly measures laryngopharyngeal reflux (LPR) events, has been utilized to evaluate patients with EES suggestive of LPR.

Methods

This was a retrospective study involving patients with EES for > 12 weeks despite proton pump inhibitor therapy, and had no endoscopic confirmatory evidence for GERD and negative MII-pH. All patients were subsequently referred for further evaluation of EES with "unknown" etiology and underwent laryngoscopy and HMII. Based on HMII, abnormal proximal exposure (APE) was defined as LPR ≥ 1/day and/or full column reflux (reflux 2 cm distal to the upper esophageal sphincter) > 4/day. Patients with APE were offered antireflux surgery (ARS) and the outcome of ARS was objectively assessed using Reflux Symptom Index.

Results

Of 21 patients with EES which was thought to be GERD-unrelated based on endoscopy and MII-pH, 17 patients (81%) had APE. Eight patients with APE who had undergone ARS had significant symptomatic improvement in the Reflux Symptom Index score (19.6 ± 4.9 pre-ARS to 5.8 ± 1.4 post-ARS, P = 0.008).

Conclusions

A conventional diagnostic approach using endoscopy and MII-pH may not be sufficient to evaluate patients with EES suggestive of LPR. HMII is essential to evaluate patients with EES, and APE could be a reliable indicator for successful treatment outcomes.

[Treatment of laryngeal pathology associated with gastroesophageal reflux disease]

OBJECTIVE

To increase the effectiveness of the treatment of laryngeal pathology associated with gastroesophageal reflux disease (GERD), to determine the indications for the appointment of anti-inflammatory therapy to these patients.

MATERIAL AND METHODS

120 patients were examined and treated, 58 of them men and 62 women, aged 30 to 82 years with GERD-associated laryngeal pathology. Three groups of patients were formed, comparable in age and gender, in accordance with the type of pachydermia in interarytenoid region; type 1 (40 patients) - pachydermia did not go beyond the middle of the interarytenoid cartilage (according to G.F. Ivanchenko), less than 3 mm, without signs of perifocal inflammation; type 2 (40 patients) - pachydermia of large size, extending beyond the middle of the interarytenoid cartilage with a spread to the entire interarytenoid region (according to G.F. Ivanchenko), often in combination with hyperkeratosis or epithelial dysplasia; type 3 (30 patients) - pachydermia of large size in combination with severe perifocal inflammation. All patients received antireflux therapy. Each group is divided into two subgroups: patients who did not receive anti-inflammatory therapy, and patients who received anti-inflammatory therapy, the basis of which was inhalation with degassed alkaline mineral water, as well as according to indications acetylcysteine, benzyldimethylammonium chloride 0.01% or hydroxymethylquinoxalindioxide, with severe swelling of the mucous membrane - budesonide. All patients completed the questionnaire "Reflux Symptoms Scale" before and after treatment.

RESULTS

In group 2 patients (with type 2 pachydermia), the effectiveness of anti-inflammatory therapy was 75%. Of the 20 patients in this group, after inhaled therapy, 4 patients had pachydermia in interarytenoid region disappeared, 11 patients had type 1 pachydermia visualized, 5 (25%) patients had no pronounced dynamics. In group 3 patients (with type 3 pachydermia), the effectiveness of inhaled treatment was 100%, out of 15 patients after inhaled therapy, type 2 pachydermia was diagnosed in 8 patients, type 1 pachydermia - in 7 patients. In 4 patients, complex therapy led to the complete disappearance of reflux-associated laryngeal granulomas without surgical treatment. The effectiveness of inhaled therapy in relation to patient complaints after a month was 87%, while the effectiveness of treatment of patients without inhalation was 45%.

CONCLUSIONS

Indications for the appointment of inhaled anti-inflammatory therapy in patients with reflux-associated pathology of the larynx are the presence of complaints of hoarseness, dryness, tickling, lump in the throat and chronic cough, endolaryngoscopic signs of exacerbation of chronic inflammation of the mucous membrane of the posterior larynx.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

The acid test: Proton pump inhibitors in persistent throat symptoms: A systematic review of systematic reviews

INTRODUCTION

Proton pump inhibitors (PPIs) have evolved to become a frequent treatment option for patients with persistent throat symptoms. The evidence for their use in this context is, however, conflicting. This review assesses the quality of the published systematic reviews and meta-analyses evaluating PPIs in persistent throat symptoms.

METHODS

Following a literature search, systematic review were evaluated using the Reporting of Bias in Systematic Reviews (ROBIS) tool and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Outcome measures were analysed using the "checklist to operationalize measurement characteristics of patient-reported outcome measures."

RESULTS

10 systematic reviews were assessed. All but one were at high risk of bias. No review met the PRISMA checklist criteria. No identified PROM met the checklist requirements for validation. Significant methodological concerns include inappropriate selection of studies for inclusion, poor selection of outcome measures, a lack of appropriate bias assessments and inconsistent reporting of reviews.

CONCLUSION

The quality of evidence concerning the role of PPIs in persistent throat symptoms gives serious cause for concern. Collectively, nine studies at high risk of bias have been cited 714 times. Systematic reviews typically attract these high numbers of citations and, if their premises and conclusions do not withstand scrutiny, they are open to widespread misinterpretation, perpetuation of misunderstanding and negative clinical impact.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update

Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques

OBJECTIVES

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis.

RESULTS

A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity.

CONCLUSIONS

It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

Alternatives to Acid Suppression Treatment for Laryngopharyngeal Reflux

OBJECTIVE

Laryngopharyngeal reflux (LPR) and associated symptoms can be refractory to treatment with acid suppressing medication. We investigated the role and evidence for complementary and alternative medicine (CAM) for LPR in this systematic review.

REVIEW METHODS

Complementary and alternative treatment was defined in this systematic review as any non-acid suppressing medication, treatment, or therapy. A literature search was performed by two authors in consultation with a medical librarian using controlled vocabulary for "complementary and alternative medicine" and "laryngopharyngeal reflux" in the databases PubMed and EMBASE, with supplemental searches with Google Scholar.

RESULTS

Twenty articles were included in this review for the modalities: alginate, diet modification, prokinetics, respiratory retraining, voice therapy, rikkunshito (RKT), hypnotherapy, and sleep positioning. The studies were analyzed for bias based on the Cochrane criteria for RCTs and Methodological Index for non-RCT (MINORS) criteria for all other studies. For each modality a level of evidence was assigned to the current body of evidence using the GRADE approach.

CONCLUSION

There is mixed evidence with a high degree of bias and heterogeneity between studies for the modalities presented in the paper. Based on this review, an anti-reflux diet is recommended for all patients and there is some low-quality evidence to support alkaline water. For patients with predominant vocal symptoms there is evidence that supports voice therapy. There is insufficient evidence to recommend prokinetics at this time. For patients with predominant globus symptoms, alginate, RKT, and relaxation strategies may be used in conjunction with acid suppressing medications for symptom relief.

A Prospective Randomized Clinical Trial of Combination Therapy with Proton Pump Inhibitors and Mucolytics in Patients with Laryngopharyngeal Reflux

OBJECTIVES

To identify whether combination therapy with mucolytics and proton pump inhibitors (PPIs) leads to faster and more effective symptomatic relief in patients with laryngopharyngeal reflux (LPR).

METHODS

Patients diagnosed as LPR with a reflux symptom index (RSI) ≥ 13 and a reflux finding score (RFS) ≥ 7 were enrolled in this prospective study. Patients were randomly allocated to control (PPI only) or experimental (PPI + mucolytics) groups and changes in RSI and RFS values were assessed at 1- and 3-month follow-up.

RESULTS

One hundred sixteen patients were randomly allocated into either the control group (n = 59) or the experimental group (n = 57). The RSI and RFS scores significantly decreased in both groups (all P < .001) after 1 month of treatment; however, there was no significant difference in RSI change between groups (P = .223). After 3 months of treatment, there remained no significant difference in RSI change between groups (P = .592).

CONCLUSIONS

Combination therapy with mucolytics and PPI compared to PPI alone did not lead to faster or more effective symptomatic relief in LPR patients.

Reflux finding score and reflux symptom index as potential predictors for proton pump inhibitor response in globus pharyngeus patients: A prospective study

OBJECTIVE

To evaluate the patient-reported reflux symptom index (RSI) and the doctors-reported Reflux finding score (RFS) as potential predictors for proton pump inhibitor (PPI) response in patients with suspected lower pharyngeal reflux, presenting with globus pharyngeus as their primary complaint.

METHODS

The research project was performed at the ENT department of Isala hospital Zwolle, the Netherlands. A before and after design was used for this single institution prospective exploratory study. 101 participants with globus pharyngeus symptoms as a primary complaint were included. All participants were assessed by an otorhinolaryngologist at enrollment and after eight weeks of esomeprazole use. Fiberoptic laryngoscopy was performed to document the RFS, and RSI questionnaires were self-administered by the participants. Our main outcome measurement was the patient- reported therapeutic response evaluation, that differentiated three categories: responders, partial responders and non-responders. For evaluation of the assessment tools, RFS > 7 and RSI > 13 were considered deviant.

RESULTS

Among the 101 participants, 43 (42.6%) were responders, 28 (27.7%) partial responders and 30 (29.7%) non-responders. Both baseline RSI > 13 and RFS > 7 were statistically significant associated with treatment response. Also, combined into RSI/RFS baseline categories, a significant overall association between baseline scores and patient-reported treatment response was found. Patients reported success rates for deviant RSI and RFS baseline scores were 76.6% and 96%, respectively. 95.5% of patients with both deviant RSI and RFS baseline scores, reported (partial) treatment response.

CONCLUSION

Both together, as well individually, pre-treatment RSI and RFS ratings can help predict treatment response of empirical PPI treatment in patients experiencing globus pharyngeus symptoms.

Comprehensive analysis of acidic pharyngeal reflux before and after proton pump inhibitor treatment in patients with suspected laryngopharyngeal reflux

OBJECTIVES

The usefulness of pharyngeal pH monitoring in patients with symptoms attributed to laryngopharyngeal reflux (LPR) has been questioned. One problem is the uncertainty whether the pharyngeal pH monitoring captures the aspects of LPR which are responsible for symptoms. We aimed to gain more insight into this problem by performing a comprehensive analysis of acidic pharyngeal reflux before and after the treatment with proton pump inhibitors (PPIs) in patients with suspected LPR.

METHODS

We used simultaneous pharyngeal and distal esophageal 24-hour pH/impedance monitoring to establish the gastroesophageal origin of pharyngeal reflux, and an unbiased approach to analysis by evaluating a whole range of pharyngeal reflux acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0).

RESULTS

PPI treatment substantially (by ~50%) improved the symptoms attributed to LPR. In contrast, PPI did not reduce the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level. This was also true in a subgroup of patients considered to be good responders to PPI (symptoms improvement by ~75%). Furthermore, good responders did not have more acidic pharyngeal reflux than the patients who were less responsive to PPI.

CONCLUSIONS

PPI treatment did not reduce acidic pharyngeal reflux despite substantially improving the symptoms attributed to LPR. This may be because pharyngeal pH monitoring does not quantitatively capture the aspects of LPR responsible for symptoms or because acid causes the symptoms also by mechanisms other than LPR. Our results argue against the utility of pharyngeal pH monitoring in patients with suspected LPR.

Treatment of Laryngeal Contact Granuloma: Surgical Therapy or Conservative Treatment

OBJECTIVE

Despite the fact that there are many treatment alternatives, laryngeal contact granuloma has a high tendency of persistence, spontaneous disappearance without treatment, and recurrence. A comparison of the effects of conservative treatment and surgical therapy on laryngeal contact granuloma was made in a retrospective review.

METHODS

A total of 124 patients with laryngeal contact granuloma were divided into 2 groups according to treatment: simple surgical excision (n = 36) and conservative treatment (n = 84). Additionally, the reflux finding score (RFS) and the reflux symptom index (RSI) were utilized to assess the disease.

RESULTS

A total of 124 patients, with a median age of 48.5 years, ranging from 9 to 74 years, were recruited (107 male, 17 female). According to the diagnostic criteria for laryngeal reflux (RSI >13 or RFS >7), there were 67 cases, accounting for 54.03% of the total. Surgery was effective in 15 patients (15/36, 41.67%), and conservative treatment was effective in 62 patients (62/84, 73.81%). The 2 groups had statistically significant differences.

CONCLUSIONS

Conservative treatment, which is a comprehensive anti-reflux therapy, is better than surgical therapy and plays an important role in the treatment of laryngeal contact granuloma.

The Clinician's Guide to Proton-Pump Inhibitor Discontinuation

There is increasing concern among patients and health care providers about the associations between PPI use and a multitude of potential adverse outcomes. Therefore, clinicians need to have a rational approach both to identifying PPI users who may not have an ongoing indication for their use and on how to encourage discontinuation of unnecessary PPI use. In this paper, we will provide a detailed review of the specific indications where the benefits of ongoing PPI use is of questionable value and will review the evidence on how to maximize the likelihood of being able to successfully discontinue PPI use while minimizing symptom recurrence.

Updates in the field of non-esophageal gastroesophageal reflux disorder

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

Proton Pump Inhibitors for the Treatment of Laryngopharyngeal Reflux. A Systematic Review

BACKGROUND

To give, if possible, an answer in the long-standing debate of the efficacy of proton pump inhibitors (PPIs) in treating laryngopharyngeal reflux (LPR) through published systematic reviews and meta-analyses.

METHOD

PubMed, Cochrane Library, and EMBASE were searched from 1984, the year the term LPR first appeared in the literature, until October 2018. Systematic reviews and meta-analyses comparing the treatment response of PPI therapy in patients with LPR were included in our study.

RESULTS

Nine eligible studies, two systematic reviews and seven meta-analyses, were identified and analyzed in our study. Three of these were published in 2006, one in 2007, one in 2013, and four in 2016. Five studies published before 2016 and one in 2016 showed no benefit from PPI therapy for LPR patients while the three remaining meta-analyses of 2016 showed a significant improvement in LPR symptoms but no significant difference in response rate and reflux finding scores (RFS) between PPI therapy and placebo treatment.

CONCLUSIONS

Based on the existing data, the use of PPI therapy for the treatment of LPR remains questionable. Six out of the nine systematic reviews/meta-analyses concluded that PPI therapy is not superior to placebo and three concluded that PPI therapy significantly improved LPR symptoms although they did not identify any difference in the post-treatment laryngoscopic findings. There is still a long way to go until we can give a definite answer to this question but in the meantime, the use of PPI therapy for the treatment of LPR will continue even though existing evidence is poor and weak, coming mainly from individual uncontrolled studies.

Laryngopharyngeal reflux: clinical significance, modern approaches to diagnosis and treatment

Gastroesophageal reflux disease (GERD) is one of the most common pathologies in modern clinical practice. Laryngopharyngeal reflux (LPR) is considered to be an extraesophageal manifestation of GERD and is characterized by retrograde ingestion of gastric content into the larynx and pharynx, leading to recurrent otolaryngological symptoms. Classical manifestations of LPR are hoarseness, perspiration, dryness and feeling of lump in the throat, coughing. There is no «gold standard» for the diagnosis of LPR. At the same time, several instrumental methods are used in clinical practice to verify the diagnosis: laryngoscopy and EGDS are the most common, and in some cases - 24-hour pH-metry and impedancemetry. In the case of an established diagnosis of LPR, it is recommended to use a standard dosage of PPI twice a day for 3–6 months.

Gaviscon® Advance alone versus co-prescription of Gaviscon® Advance and proton pump inhibitors in the treatment of laryngopharyngeal reflux

OBJECTIVES

Management of laryngopharyngeal reflux (LPR) typically comprises alginates and proton pump inhibitors (PPIs) alone or in combination, yet evidence to support any particular treatment regimen is lacking. We sought to evaluate the efficacy of Gaviscon® Advance alone versus co-prescription with a PPI in treating LPR.

METHODS

One hundred consecutive LPR patients with a reflux symptom index (RSI) score > 10 attending our joint voice clinic (JVC) were studied prospectively. All were treated with Gaviscon® Advance four times daily. If patients had been started on a PPI prior to their JVC attendance, this was optimised to a twice-daily dosing regimen and continued. RSI scores were recorded at first attendance and 3 months post-treatment via postal questionnaire. Scores were analysed using t tests and Levene's test for equality of variances.

RESULTS

Follow-up RSI scores were returned by 72 patients, 39 of whom were treated with Gaviscon® Advance only (group A) and 33 with Gaviscon® Advance + PPI (group B). Mean pre-treatment RSI scores were similar between groups [group A: 19.2, 95% confidence interval (CI) ± 2.4; group B: 21.3, 95% CI ± 3.2 (p = 0.65)]. No significant differences were observed with respect to 3-month post-treatment RSI scores [group A: 9.9, 95% CI ± 2.8; group B: 12.6, 95% CI ± 4.2 (p = 0.82)] and change in RSI scores [group A: 9.3, 95% CI ± 3.0; group B: 8.7, 95% CI ± 2.9 [p = 0.75]).

CONCLUSIONS

Gaviscon® Advance alone is effective in treating symptoms of LPR, while co-prescription with a high-dose PPI offers no additional benefit.

Discontinuing Long-Term PPI Therapy: Why, With Whom, and How?

Proton pump inhibitors (PPIs) are among the most widely used class of drugs prescribed over the long term in all of clinical medicine with 8-10% of ambulatory adults have been prescribed a PPI in the past 30 days. However, numerous studies have raised doubts about the long term safety of PPI use. The purpose of this review is threefold: (i) To provide an overview of the current evidence demonstrating associations between PPI use and adverse health outcomes and the likelihood of the associations being causal (Why?); (ii) To be able to identify long-term PPI users in whom the intensity of PPI therapy could be reduced or in whom PPIs could be eliminated outright (Who?); and (iii) To provide strategies on how to reduce or stop chronic PPI therapy while maintaining symptom control and reducing the risk for symptom or upper GI disease recurrence (How?).

High-resolution manometry in patients with and without globus pharyngeus and/or symptoms of laryngopharyngeal reflux

Background

Globus pharyngeus is common and has a low cure rate. Its etiology is complex and reported to be associated with laryngopharyngeal reflux (LPR). However, some patients with globus do not exhibit any reflux symptoms or respond to proton pump inhibitors (PPIs) treatments. The purpose of this study was to clarify the related risk factors of these patients with a final objective of improving the curative effect.

Methods

Forty two patients afflicted with globus pharyngeus (G group) and 38 patients without globus pharyngeus (NG group) were included in this study. According to the laryngopharyngeal Reflux Symptom Index and the response to PPIs treatments, the patients were further divided into reflux groups (G-R, NG-R) and non-reflux groups (G-NR, NG-NR). High Resolution Manometry (HRM) was performed to assess esophageal motility. Questionnaires, including categories such as life exposure factors, were conducted.

Results

a) The average resting and residual pressures of the upper esophageal sphincter (UES) in the G-NR group was higher than in the NG-NR and NG-R groups (P < 0.05). b) The average resting and residual pressures of the lower esophageal sphincter showed no differences between the G-NR group and the NG-NR group (P > 0.05). c) The esophageal distal contractile integral score of the G-NR group was not different from the NG-NR group (P > 0.05). d) Compared to the NG-NR group, the G-NR group showed higher incidence of stress, smoking, drinking, high salt and anxiety (P < 0.05).

Conclusions

Globus pharyngeus without LPR may occur due to high UES pressure. Stress, smoking, alcoholic drinking, high salt and anxiety may be its risk factors.

Electronic supplementary material

The online version of this article (10.1186/s12876-017-0666-x) contains supplementary material, which is available to authorized users.

Comparison of the effects of esomeprazole plus mosapride citrate and botulinum toxin A on vocal process granuloma

OBJECTIVES

Vocal process granulomas have a high tendency for persistence despite many treatment alternatives. Anti-reflux medications or botulinum toxin A injections are the main current therapies. There are no studies that compare the effects on vocal process granuloma of proton pump inhibitors plus prokinetic agents with botulinum toxin A injections.

STUDY DESIGN

Prospective cohort study.

METHODS

Adult patients reporting to our outpatient department complaining of trachyphonia and/or abnormal pharyngeal sensations who were found to have contact granulomas. Patients were divided into two groups according to the treatment: esomeprazole with mosapride citrate (n=26) or botulinum toxin A injection (n=20). The reflux symptom index and reflux finding score determined by electronic fibrolaryngoscopy were utilized to assess efficacy.

RESULTS

Forty-six patients were recruited (43 male; 3 female). The mean age (range) was 48.3years (38-69) and the body mass index was 23.51kg/m² (19.13-27.89). Laryngopharyngeal reflux disease diagnosed by RSI or RFS was found in 18 and 27 patients, respectively, and 18 diagnosed without laryngopharyneal reflux disease. Twenty patients (95%) were cured in the esomeprazole with mosapride citrate group and nine (45%) in the botulinum toxin A group. Eleven (55%) patients had recurrence after botulinum toxin A injection, with an average interval of 3.1months (range 1-6). The recorded symptoms after therapy resolved within 6months with a statistically significant improvement in the esomeprazole with mosapride citrate group.

CONCLUSIONS

Combined proton pump inhibitor plus prokinetic drug therapy plays a significant role in the treatment of vocal process granulomas or after surgery.

Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression

BACKGROUND

The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications.

METHODS

The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence.

RESULTS

Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile.

CONCLUSIONS

Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .