Reflux Finding Score (RFS) a Quantitative Guide for Diagnosis and Treatment of Laryngopharyngeal Reflux

The Impact of a Twice-daily Versus Once-daily Proton Pump Inhibitor Dosing Regimen on Laryngopharyngeal Reflux Symptoms: A Prospective Randomized Controlled Trial

Background/Aims

Proton pump inhibitors (PPIs) play a crucial role in managing laryngopharyngeal reflux (LPR), but the optimal dosing regimen remains unclear. We aim to compare the effectiveness of the same total PPI dose administered twice daily versus once daily in LPR patients.

Methods

We conducted a prospective randomized controlled trial at a tertiary referral hospital, enrolling a total of 132 patients aged 19 to 79 with LPR. These patients were randomly assigned to receive either a 10 mg twice daily (BID) or a 20 mg once daily (QD) dose of ilaprazole for 12 weeks. The Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) were assessed at 8 weeks and 16 weeks. The primary endpoint was the RSI response, defined as a reduction of 50% or more in the total RSI score from baseline. We also analyzed the efficacy of the dosing regimens and the impact of dosing and duration on treatment outcomes.

Results

The BID group did not display a higher response rate for RSI than the QD group. The changes in total RSI scores at the 8-week and 16- week visits showed no significant differences between the 2 groups. Total RFS alterations were also comparable between both groups. Each dosing regimen demonstrated significant decreases in RSI and RFS.

Conclusions

Both BID and QD PPI dosing regimens improved subjective symptom scores and objective laryngoscopic findings. There was no significant difference in RSI improvement between the 2 dosing regimens, indicating that either dosing regimen could be considered a viable treatment option.

Characterization of Laryngopharyngeal Reflux in the Elderly Population

INTRODUCTION

Laryngopharyngeal reflux (LPR) often is not diagnosed due to its presentation without heartburn. The aim of this study was to analyze the signs and symptoms of elderly patients undergoing treatment for LPR using subjective as well as objective measures including strobovideolaryngoscopies, 24-hour pH studies, and manometry to highlight appropriate considerations for diagnosis and treatment.

METHODS

This was a retrospective review of patients with laryngopharyngeal reflux who were seen from January 2010 to February 2021 in the practice of the senior author (Robert T. Sataloff) who had undergone 24-hour pH testing, and for whom all data were available. Patients aged 60 years and older were considered elderly and compared to patients younger than 40 and between the ages of 40 and 59. However, patients in their 60s, 70s, and 80s were evaluated and compared separately. Objective reflux findings, 24-hour pH studies, and manometry were compared between groups.

RESULTS

Two hundred and eighty-eight patients being treated for LPR were included, 100 of whom were over the age of 60. While 94.1% of patients younger than 40 had a chief complaint of hoarseness, 71% percent of those aged 60 and older complained of hoarseness. Patients aged 60 and older were more likely to present with no voice complaint as their age increased (P = 0.001). Lower esophageal sphincter residual pressure was 12.15 ± 6.28 in elderly patients compared to 4.90 ± 3.38 in patients younger than 40 (P < 0.001). Upper esophageal sphincter (UES) basal pressure was decreased in elderly patients at 83.84 ± 50.53 compared to 105.92 ± 51.49 in patients younger than 60 or younger (P = 0.029). Older patients in their 70s and 80s also had lower UES basal pressures at 75.79 ± 47.66 and 63.45 ± 14.50 (P = 0.003). Additionally, while 71.4% of patients younger than 40 had normal esophageal motility (Chicago classification v4), only 40% of elderly patients had normal esophageal motility (P < 0.001). More severe ventricular obliteration also was present in elderly patients compared to non-elderly patients (P = 0.032), and thick endolaryngeal mucus was less likely to be present in elderly patients (P = 0.007). Reflux finding score differed between age groups with patients aged less than 40 scoring 14.78 ± 2.5, 40-59 year olds scoring 15.83 ± 2.13 and patients 60 and older scoring 15.48 ± 2.43 (P = 0.018).

CONCLUSION

Elderly patients diagnosed with LPR have different presentations of the disease compared with younger patients.

Arytenoid granuloma: a single-institution experience of management of 62 cases

OBJECTIVE

This retrospective study was undertaken to assess the outcome of the medical and/or surgical management of patients presenting with clinical features of arytenoid granuloma.

METHODS

The records of 53 males and 9 females were reviewed for predisposing factors, types of treatment received and recurrence following the treatment.

RESULTS

Most of the patients (48 out of 62, 77.4 per cent) were treated conservatively with medical management and voice therapy, which resulted in complete resolution of arytenoid granuloma in over two-thirds of the patients treated (32 out of 48, 66.6 per cent). Overall, 28 patients (out of 62, 45.1 per cent) required surgery (14 failed medical treatment cases and 14 surgery as first-line treatment cases). Of these, five patients (out of 28, 17.9 per cent) had recurrence, and were managed with revision surgery and concurrent local injection of Botox.

CONCLUSION

Anti-reflux medication and voice therapy are effective first-line management options. Pre- and post-surgery adjuvant treatment improves the results of surgery. Local injection of Botox was successful in the treatment of failed surgical cases.

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.

Thyroidectomy-related Swallowing Difficulties: Review of the Literature

This study aims to provide insight into the etiology and frequency of swallowing complications that arise after thyroidectomy and to outline the available diagnostic procedures by revising the existing literature on this topic. We conducted a bibliographic search using the electronic database MEDLINE/PubMed to identify all relevant articles and 44 studies were included in the review out of a total of 218 published articles. Dysphagia after thyroid surgery is a common postoperative complication which, in the short- or long-term, significantly affects patient life quality. There is no standard diagnostic protocol for thyroidectomy-related swallowing impairment. Among the reviewed studies, 8 questionnaires and 12 instrumental diagnostic tools were used to identify swallowing difficulties related to thyroid surgery. The Swallowing Impairment Index (SIS-6) was the most-used questionnaire. Fiberoptic endoscopy is a standard diagnostic tool performed prior and after thyroid surgery, primarily to identify changes in vocal fold mobility. Although instrumental findings usually reveal non-specific alterations of swallowing; swallowing videofluoroscopy and esophageal manometry can be the most helpful tools in further management of thyroidectomy dysphagia. In patients with thyroidectomy-related swallowing difficulties and suspected laryngopharyngeal reflux, 24-hour MII-pH metry should be performed.

Treatment of laryngopharyngeal reflux disease: A systematic review

BACKGROUNG

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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