Laryngopharyngeal reflux: the value of otolaryngology examination

Validation and Reliability of Polish Version of the Reflux Symptoms Index and Reflux Finding Score

(1) Background: To confirm the credibility, consistency, and replicability of the Polish versions of the Reflux Symptoms Index (PL-RSI) and the Reflux Finding Score (PL-RFS). (2) Methods: The translation followed the WHO recommendations. The study group included 100 volunteers (age 15−87) with hoarseness and pharyngolaryngeal complaints. The control group comprised 55 healthy volunteers (age 20−75). Study participants completed the PL-RSI; then, two independent otolaryngologists completed the PL-RFS based on pharyngeal videostroboscopy. Questionnaires were repeated after 7 days, with no treatment before the second round. Additionally, patients underwent 24 h pH-metry. The control group had a single round of questionnaires followed by pH-metry. (3) Results: The PL-RSI is consistent, reliable (Cronbach’s alpha 0.77−0.83; test−retest reliability 0.83), and significantly correlated with other patient-filled tools (p < 0.001). The PL-RFS intra-rater reliability is 0.84−0.91, and inter-rater is 0.88. Both questionnaires strongly correlate with pH-metry (PL-RSI upright Ryan Score 0.35, PL-RFS—0.60). Both clearly distinguish (i) healthy from persons with voice disorders, but without acid LPR (p < 0.0001), and (ii) within patient group between subjects with and without acid LPR (p = 0.0002). (4) Conclusions: The PL-RSI and PL-RFS are reliable and can be recommended to Polish-speaking otolaryngologists. Our findings confirm the role of country-specific factors in RSI results and that practitioners should always use a proper control group.

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 as a potential cause of persistent local neck symptoms after total thyroidectomy

Purpose

Local neck symptoms (LNS) may be related to goiter, but are also reported by patients suffering from laryngeal–pharyngeal reflux (LPR). The aim of this study was to investigate whether LPR could play a role in the persistence of some LNS after total thyroidectomy (TT).

Methods

A consecutive case series of 160 patients with multinodular goiter (MNG) candidate for TT were included in this study. Each patient was closely studied for both the thyroid pathology and reflux disease before and 6 months after surgery to assess the persistence of LNS after surgery.

Results

Only throat discomfort showed a significant improvement (p  = 0.031) after surgery. On the other hand, swallowing and voice disorders persisted after surgery in 82.3% and 77.3% of patients, respectively (p  = 0.250 and p  = 0.062), such as the correlated reflux laryngopharyngitis (p  = 0.5).

Conclusions

LPR can be considered a predisposing factor or an important concurrent causa to the persistence of LNS after TT, in particular for swallowing disorders and voice disorders. In patients with non-toxic MNG who complain of local neck symptoms, the investigation of a possible coexistence of a reflux disease is appropriate before surgery. Patients should be informed about the possibility that some symptoms can persist even after removal of the goiter.

Pepsin and Laryngeal and Hypopharyngeal Carcinomas

Laryngeal and hypopharyngeal carcinomas are common malignant tumors of the head and neck, and the incidence of both is increasing. Laryngopharyngeal reflux refers to the retrograde flow of gastric contents into the larynx, oropharynx, and/or nasopharynx. It remains controversial whether laryngopharyngeal reflux is a risk factor for laryngeal and hypopharyngeal cancers. The refluxing substances mainly include hydrochloric acid, pepsin, and occasionally bile acids and bile salts, as well as bacteria that colonize the gastrointestinal tract. Loss of epithelium in the mucous membrane of the larynx and hypopharynx is thought to be caused by pepsin. Here, we review the relationships between laryngopharyngeal reflux and both laryngeal and hypopharyngeal carcinomas, as well as the significance of pepsin, methods of clinical detection, and the mechanism of carcinogenesis.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

Purpose

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

Action Statements

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Disclaimer

This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia

Do laryngoscopic findings reflect the characteristics of reflux in patients with laryngopharyngeal reflux?

OBJECTIVE

To analyse the association between 24-hour multichannel intraluminal impedance-pH (24-h MII-pH) parameters and each item of the reflux finding score (RFS) to determine whether the laryngoscopic findings of the RFS could reflect the characteristics of reflux in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective cohort study.

SETTINGS

Tertiary care referral medical centre.

PARTICIPANTS

Patients complaining of LPR symptoms were evaluated via a 24-hour MII-pH. Among them, 99 patients whose LPR was confirmed via 24-hour MII-pH were enrolled in this study.

MAIN OUTCOME MEASURES

Correlations between RFS ratings and 24-hour MII-pH parameters were evaluated and compared between patients with or without each laryngoscopic finding used in the RFS.

RESULTS

Subglottic oedema had a statistically significant positive correlation with number of non-acid LPR and non-acid full column reflux events. Ventricular obliteration and posterior commissure hypertrophy showed a significant correlation with non-acid exposure time and total reflux exposure time. We also found a significant correlation between granuloma/granulation score and number of acid LPR events. The numbers of non-acid LPR and full column reflux events in patients with subglottic oedema were significantly higher than those without subglottic oedema.

CONCLUSION

Among the laryngoscopic findings used in the RFS, subglottic oedema is specific for non-acid reflux episodes, and granuloma/granulation is specific for acid reflux episodes.

The Role of Helicobacter pylori in Laryngopharyngeal Reflux

Objective The primary objective was to determine the prevalence of Helicobacter pylori among patients with laryngopharyngeal reflux. The secondary objective was determining if H pylori eradication leads to greater symptom improvement in patients with laryngopharyngeal reflux as compared with standard proton pump inhibitor therapy alone. Data Sources EMBASE, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov. Review Methods A systematic review was performed of studies assessing the diagnosis or treatment of H pylori among patients with laryngopharyngeal reflux. Randomized controlled trials, cohort studies, case-control studies, and case series were included. A meta-analysis of prevalence data and assessment of heterogeneity was performed on relevant studies. Results Fourteen studies were analyzed in the review, with 13 eligible for the meta-analysis. We determined that the prevalence of H pylori among patients with laryngopharyngeal reflux was 43.9% (95% confidence interval, 32.1-56.5). The heterogeneity of studies was high, with an overall I² value of 92.3%. We were unable to quantitatively assess findings for our secondary outcome, since H pylori identification and treatment were not the primary focus of the majority of studies. Conclusion There is a high rate of H pylori infection among patients with laryngopharyngeal reflux. The infection rate in North America and Western Europe has not been adequately studied. There is insufficient evidence to make a recommendation regarding the testing and treatment of H pylori infection among patients with laryngopharyngeal reflux.

Expression of CAIII and Hsp70 Is Increased the Mucous Membrane of the Posterior Commissure in Laryngopharyngeal Reflux Disease

PURPOSE

We tried to evaluate the difference in the expression of carbonic anhydrase (CA) III and heat shock protein (Hsp) 70 between laryngopharyngeal reflux disease (LPRD) and non-LPRD patients.

MATERIALS AND METHODS

The study involved 28 patients who underwent laryngeal microsurgery due to benign laryngeal disease from March to August 2008. Reflux symptom index (RSI) and reflux finding score (RFS) were measured for each person, and they were assigned either to the LPRD group (n=10) or non-LPRD group (n=18). Tissue samples were obtained from the mucosa of posterior commissure, and immunohistochemistry (IHC) staining of CAIII and Hsp70 was performed. The IHC scores were measured and compared with clinical features including RSI and RFS.

RESULTS

Total 10 patients were assigned as LPRD group, and 18 patients were as control group. The mean IHC score of CAIII and Hsp70 was 1.70 ± 1.06 and 1.90 ± 0.88, respectively, in LPRD patients, whereas the mean IHC score of CAIII and Hsp70 was 0.78 ± 0.73 and 0.94 ± 0.87, respectively, in non-LPRD patients. The difference between two groups was statistically significant (p<0.05).

CONCLUSION

CAIII and Hsp70 expressions were higher in LPRD patients that in non-LPRD patients, suggesting the possibility as one of biomomarker in LPRD diagnosis.

The role of the larynx in chronic cough

Cough lasting more than 8 weeks is considered chronic. If the classic causes of chronic cough have been discarded, vagus nerve sensory disturbances are currently considered the most important etiological cause. Patients with chronic cough of laryngeal origin have associated symptoms such as globus, dysphagia, dysphonia, dyspnoea and/or stridor. These patients are more likely to have paradoxical vocal fold movement. There is a higher cough reflex sensibility and neuropathic laryngeal response, mainly caused by viral infection or reflux. The cough associated with reflux has 2 mechanisms: Exposure to acid in the distal oesophagus (gastroesophageal reflux) and microaspiration of oesophageal contents into the larynx and tracheo-bronchial tree (pharyngo-laryngeal reflux). Laryngeal neuropathy hypersensitivity responds well to speech therapy as a treatment for refractory chronic cough. Because chronic cough is a sign of laryngeal sensory, neuropathy can improve with neuroleptic drugs such as amitriptyline and gabapentin.

Refractory chronic cough: new perspectives in diagnosis and treatment

In patients with chronic cough, nearly 40% of the population does not experience definitive improvement of their cough despite correctly applying the anatomic diagnosis. In many of these patients with refractory cough, laryngeal symptoms are frequent. The region of the larynx/pharynx is configured as a bridge between the esophagus and the upper and lower respiratory tract. The association of reflux in patients with chronic cough and symptoms such as globus pharyngis, itchiness or the need to clear one's throat have recently been given attention due to the possibility of joint therapeutic intervention of the gastroesophageal reflux and larynx, both with new medications as well as with laryngeal rehabilitation therapies, with observed benefits in the disappearance of chronic cough in cases that had been previously labeled as refractory.

Gastroesophageal reflux and laryngeal dysfunction in a dog

CASE DESCRIPTION

A 7-year-old neutered male Saint Bernard was evaluated because of a 6-month history of coughing, gagging, change in phonation, excessive panting, and chronic intermittent vomiting and diarrhea.

CLINICAL FINDINGS

Physical examination revealed no remarkable findings other than panting. Total thyroxine concentration and results of a CBC, serum biochemistry analysis, urinalysis, and thoracic radiography were within reference limits. A laryngeal examination revealed edema, erythema, and ulceration of the larynx and pharynx, with normal laryngeal movement. Results of bronchoscopy and cytologic examination of bronchoalveolar lavage fluid were diagnostic only for distal tracheitis. Esophagoscopy and an esophagography revealed esophagitis consistent with gastroesophageal reflux. Gastroduodenoscopy and histologic examination of biopsy specimens revealed Helicobacter colonization and lymphocytic or plasmacytic enteritis.

TREATMENT AND OUTCOME

Following treatment for gastroesophageal reflux and suspected Helicobacter infection with combination antacid and antimicrobial treatment, the dog's respiratory signs resolved but vomiting continued. Gastroduodenoscopy revealed complete resolution of the previous laryngitis, pharyngitis, and esophagitis. Treatment for the lymphocytic or plasmacytic enteritis was initiated with prednisone (1 mg/kg [0.45 mg/lb], p.o., q 12 h) and a novel protein diet. The previous treatment was also continued. Complete resolution of clinical signs was maintained 4 months after initiation of appropriate treatment.

CLINICAL RELEVANCE

Laryngeal dysfunction induced by gastroesophageal reflux as occurred in the patient described in this report is a previously undocumented association in the veterinary literature. This association could be a potential consideration in dogs with concurrent respiratory and gastrointestinal signs. The present report may provide a basis for further studies investigating this association.

The Value of Routine pH Monitoring in the Diagnosis and Treatment of Laryngopharyngeal Reflux

Objective. To assess the need for pH testing in diagnosing laryngopharyngeal reflux (LPR).

Study Design. Case series with planned data collection.

Setting. Tertiary care center.

Subjects and Methods. On the basis of symptoms and/or abnormal endoscopic findings, more than 500 patients underwent 24-hour pharyngeal pH testing at a single center (using the Dx-pH probe) between January 2009 and June 2011. A total of 163 patients not on proton-pump inhibitors at the time of study and with complete data available for analysis (pH results, body mass index, smoking status, pretest reflux symptom index) were divided into 2 groups by positive (n = 70) and negative (n = 93) Ryan Score. The Reflux Symptom Index (RSI) was compared between groups and assessed overall against Ryan Score parameters at different pH thresholds. The diagnostic utility of an RSI ≥ 13 for prediction of Ryan Score was assessed.

Results. No significant difference in RSI was seen between Ryan-positive (17.50 ± 11.47) and Ryan-negative (14.95 ± 11.43) patients ( P = .161). Overall, RSI correlated poorly with percentage time spent below pH thresholds 6.5, 6.0, 5.5, and 5.0 and upright and supine Ryan parameters at these thresholds (as determined by linear regression analysis). The sensitivity, specificity, positive predictive value, and negative predictive value of RSI ≥ 13 for Ryan positivity were 55.7%, 47.3%, 44.3%, and 58.7%, respectively.

Conclusion. Our findings show that in our population of otolaryngology patients, the diagnosis of LPR cannot be reliably made on the basis of symptoms alone. Diagnosis, and in particular treatment decisions, should ideally be made on the basis of a combination of symptoms, signs, and confirmatory testing.

Local neck symptoms before and after thyroidectomy: a possible correlation with reflux laryngopharyngitis

Local symptoms in the neck such as swallowing and voice disorders, and throat discomfort might be related to a goiter if present, but are also reported by patients suffering from reflux laryngopharyngitis. The aim of our study was to investigate the presence of reflux laryngopharyngitis in patients with nodular goiter before and after uncomplicated total thyroidectomy (TT) using a prospective study in University Hospital setting. We considered 25 patients, affected by non-toxic nodular goiter and candidates for TT, who complained of local symptoms in the neck. All the patients were carefully interviewed, with emphasis on swallowing and voice disorders, throat discomfort and reflux-related symptoms and underwent a videolaryngoscopy (VLS) and a videofluoroscopic swallowing study (VFSS) before and 3 months after TT. Before thyroidectomy, reflux laryngopharyngitis-related alterations were present in 68 and 50% at VLS and VFSS, respectively. After thyroidectomy, the swallowing and voice disorders persisted in 79 and 75%, respectively, while throat discomfort persisted in 91%. The results show that patients with a non-toxic nodular goiter who complain of local neck symptoms, before surgery it is appropriate to see if a reflux laryngopharyngitis is present; VLS and VFSS could be indicated for this and if necessary an antireflux treatment should be administered.

Clinical Practice Guideline: Hoarseness (Dysphonia)

Objective:

This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness.

Purpose:

The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

Results

The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.