Clinical and polysomnographic predictors of laryngopharyngeal reflux in obstructive sleep apnea syndrome

Integrative effects of transcutaneous auricular vagus nerve stimulation on esophageal motility and pharyngeal symptoms via vagal mechanisms in patients with laryngopharyngeal reflux disease

Background and aim

Laryngopharyngeal reflux disease (LPRD) is primarily characterized by discomfort in the pharynx and has limited treatment options. This research aimed to assess the efficacy of transcutaneous auricular vagus nerve stimulation (tVNS) in patients with LPRD and delve into the potential underlying mechanisms.

Methods

A total of 44 participants, diagnosed with LPRD were divided into two groups randomly. Twice-daily stimulation was delivered for 2 weeks for patients in experimental group, with stimulation ranging from 1.0 mA to 1.5 mA (n = 22), while the control group underwent sham tVNS (n = 22) with the same stimulation parameters and different anatomical location. The severity of symptoms and levels of anxiety and depression were monitored using questionnaires. High-resolution esophageal manometry data were collected, and the patients' autonomic function was assessed through heart rate variability analysis.

Results

There was a positive correlation between reflux symptom index (RSI) scores and low frequency/high frequency (LF/HF) ratio (r = 0.619; p < 0.001), Hamilton anxiety scale (HAMA) scores (r = 0.623; p < 0.001), and Hamilton depression scale (HAMD) scores (r = 0.593; p < 0.001). Compared to the pre-tVNS phase, RSI (p < 0.001), HAMA (p < 0.001), and HAMD (p < 0.001) scores were significantly reduced after 2 weeks of treatment. Additionally, the resting pressure of the upper esophageal sphincter (UESP; p < 0.05) and lower esophageal sphincter (LESP; p < 0.05) showed significant enhancement. Notably, tVNS led to an increase in root mean square of successive differences (RMSSD; p < 0.05) and high frequency (HF; p < 0.05) within heart rate variability compared to the pre-treatment baseline. Compared to the control group, RSI (p < 0.001), HAMA (p < 0.001), and HAMD (p < 0.001) scores in tVNS group were significantly lower at the end of treatment. Similarly, the resting pressure of UESP (p < 0.05) and LESP (p < 0.05) in tVNS group were significantly higher than that of control group. Notably, RMSSD (p < 0.05) and HF (p < 0.05) in tVNS group were significantly higher than that of control group.

Conclusion

This study demonstrated that tVNS as a therapeutic approach is effective in alleviating LPRD symptoms. Furthermore, it suggests that improvements in esophageal motility could be associated with vagus nerve-dependent mechanisms.

Correlation Between Rapid Eye Movement Sleep Duration and Laryngopharyngeal Reflux in Patients with Obstructive Sleep Apnea

Objectives: The aim of this study was to investigate the correlation between rapid eye movement (REM) sleep duration and laryngopharyngeal reflux (LPR) in patients with obstructive sleep apnea (OSA). Methods: In all, 99 patients with OSA were enrolled in this study, and the correlation between REM sleep duration and the severity of LPR was analyzed after the polysomnography (PSG) and reflux symptom index (RSI) scores were completed. Subsequently, a multiple linear regression analysis was performed to further clarify the factors affecting LPR. Results: Partial correlation analysis showed that the REM sleep duration was positively correlated with the RSI scores (r = 0.236, P = .022) after controlling for apnea-hypopnea index (AHI), body mass index (BMI), lowest oxygen saturation (LSO2), age, and sex. The multiple linear regression analysis indicated that only REM sleep duration was a factor influencing LPR (t = 2.330, P = .022). Conclusions: Our study found a correlation between REM sleep duration and LPR in OSA patients. The shorter the REM sleep duration, the less severe the LPR symptoms.

Self-reported symptoms of laryngopharyngeal reflux using the reflux symptom score in patients with obstructive sleep apnea syndrome

BACKGROUND

Obstructive sleep apnea (OSA) is associated with many chronic diseases among which is laryngopharyngeal reflux disease (LPRD).

OBJECTIVE

To investigate the prevalence of laryngopharyngeal reflux (LPR)-related symptoms in patients with OSA using the Reflux Symptoms Score (RSS) and Reflux Symptom Index (RSI).

METHODS

The medical records and video-recordings of patients with OSA who presented to a tertiary referral center were reviewed. The diagnosis of OSA was made using the STOP-BANG questionnaire and/or polysomnography. The prevalence of LPR-related symptoms was assessed using both the RSS and RSI questionnaires.

RESULTS

Thirty-nine patients were included in this study. Twenty-seven patients (69.2%) had a positive RSS in comparison to only 7 (17.9%) using the RSI (p = .052). Subgroup analysis of those who had polysomnography (n = 24) showed that 18 patients (75%) had a positive RSS in comparison to only 5 patients (20.8%) using the RSI. Patients in the high-risk category for OSA were also found to have a higher prevalence of LPR-related symptoms using both the RSS and RSI questionnaires in comparison to those in the lower risk categories.

CONCLUSION

The results of this investigation indicate that the prevalence of LPR-related symptoms is higher using the RSS in comparison to the RSI.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Laryngopharyngeal Reflux in Sleep-Disordered Breathing Patients

INTRODUCTION

Our study aims to evaluate the distribution of laryngopharyngeal reflux (LPR) in patients with sleep-disordered breathing (SDB) via the Reflux Symptom Index (RSI) and to describe the sleep architecture in SDB patients with and without LPR.

MATERIALS AND METHODS

A cross-sectional, descriptive study was conducted. Patients with SDB were identified via the Epworth Sleepiness Scale (ESS) and STOP-BANG questionnaire; they were then screened with the RSI and physical examination for LPR. PSG was performed to evaluate obstructive sleep apnea (OSA).

RESULTS

Of 45 patients, 15 were scored as having LPR via the RSI. Utilizing the Respiratory Disturbance Index (RDI), patients were further classified into four groups: 9 non-LPR with non-OSA SDB, 21 non-LPR with OSA, 4 LPR with non-OSA SDB, and 11 LPR with OSA. The prevalence of LPR was 30.8% in the non-OSA SDB group and 34.4% in the OSA group. All SDB parameters in both groups were similar. SDB patients with high body mass index tended to have LPR and/or OSA. Average ESS scores in the four groups suggested excessive daytime sleepiness, and patients with LPR had higher ESS scores. Regardless of LPR status, SDB patients had a lower percentage of REM sleep and a higher percentage of light sleep.

CONCLUSIONS

The incidence of LPR in OSA patients was similar in non-OSA SDB patients. REM sleep percentage decreased in the four groups, with the non-OSA SDB group having the lowest percentage of REM sleep; light sleep percentage increased in the four groups, with the OSA group having the highest percentage of light sleep.

The effect of laryngopharyngeal reflux on arousal in patients with obstructive sleep apnea

BACKGROUND

Laryngopharyngeal reflux (LPR) may be associated with the severity of obstructive sleep apnea (OSA). However, it is unknown whether LPR may be associated with arousal.

OBJECTIVE

To clarify the effect of LPR on arousal in OSA.

METHODS

This study included 120 OSA patients. The correlations between LPR scores and arousal index (ArI) were analyzed. Finally, to further clarify the effect of LPR on ArI, we analyzed the correlations between respiratory event-related arousal index (BERAI), leg-movement-related arousal index (LMRAI), snore-related arousal index (SRAI), spontaneous arousal index (SAI), and RSI score.

RESULTS

Partial correlation analysis showed that the RSI score was positively correlated with ArI (p = .000), mainly correlated with BERAI and SAI (r = 0.422, p = .000; r = 0.212, p = .020). While controlling for apnea-hypopnea index (AHI), the RSI score was still positively correlated with ArI (p = .002), mainly correlated with BERAI and SAI (r = 0.252, p = .006; r = 0.200, p = .029).

CONCLUSIONS AND SIGNIFICANCE

The effect of LPR symptoms on arousal in OSA exists. The more severe the LPR was, the more frequent the arousal in OSA patients was. Thereinto, respiratory event-related arousal and spontaneous arousal were the most obvious.

Association between laryngopharyngeal reflux and obstructive sleep apnea in adults

Background

Obstructive sleep apnea syndrome (OSAS) and laryngopharyngeal reflux (LPR) have been found to coexist in the population. OSAS and LPR also share obesity as an important risk factor. However, the relationship between LPR and OSAS remains unclear. This study aimed to correlate LPR as measured by the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS) with OSAS.

Methods

This cross-sectional study included sixty-four subjects who underwent anamnesis to complete the RSI and the Epworth Sleeping Scale (ESS). The subjects were then divided into the OSAS and non-OSAS groups based on the Apnea-Hypopnea Index (AHI) obtained through a polysomnography examination. Both groups underwent a flexible fiberoptic nasopharyngolaryngoscopy examination to determine the RFS. LPR was identified based on the RSI and RFS.

Results

The mean BMI of the OSAS group significantly was higher than the non-OSAS group (p < 0.05). Most of the subjects in the OSAS group exhibited mild-moderate OSAS (AHI 10-29), and severe OSAS occurred in only seven subjects. The mean RSI and RFS values in the OSAS group did not differ significantly from the non-OSAS group (p = 0.34 and p = 0.36, respectively). The proportion of LPR between the mild-moderate OSAS group, the severe OSAS group, and the non-OSAS group did not differ significantly (p = 1.00). RSI and RFS did not significantly correlate with AHI. Based on RSI, the proportion of LPR between the ESS (+) and ESS (-) groups did not significantly differ (adjusted p = 0.062). The proportion of LPR based on RFS was almost equal between the ESS (+) and ESS (-) groups (p = 0.817).

Conclusions

The BMI of the OSAS group was significantly higher than the non-OSAS group. There was no significant difference in RSI and RFS between the OSAS and non-OSAS groups. There was no significant correlation between RSI and AHI, or between RFS and AHI. There was no significant difference in the proportion of RSI between the ESS (+) and the ESS (-) groups.

Analysis of effects of laryngopharyngeal reflux disease and proton pump inhibitor treatment on Eustachian tube function in patients with obstructive sleep apnea hypopnea

OBJECTIVE

This study aims to explore the effects of laryngopharyngeal reflux disease (LPRD) and proton pump inhibitor (PPI) treatment on Eustachian tube function in patients with obstructive sleep apnea (OSA).

METHODS

The Eustachian tube score-7 (ETS-7) was observed before and after PPI treatment in the control group, OSA only group, and OSA + LPRD group.

RESULTS

Age, sex, smoking history, and drinking history showed no differences among 3 groups (P > .05). The body mass index (BMI) in the control group was lower than that in other groups (P < .017). Before PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group statistically differed from that in the control group and the OSA only group (P < .017). After PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group exhibited no significant differences compared with that in the control group and the OSA only group (P > .017), and it declined remarkably compared with that before PPI treatment (75% vs 35%, χ² = 13.334, P = .001). Moreover, the multivariate analysis revealed that only LPRD had an independent correlation with the abnormality of ETS-7 (OR = 1.245, 95% CI: 1.759-6.861, P = .000).

CONCLUSION

In view of its high incidence in OSA patients, LPRD may be a considerable factor for the high incidence of abnormality rate of ETS-7 in OSA patients, and PPI therapy is of significant value in improving Eustachian tube function in OSA patients with LPRD.

Correlation and Influencing Factors Between Laryngopharyngeal Reflux Disease and Sleep Status in Patients

Objective

To observe the correlation between laryngopharyngeal reflux disease (LPRD) and patients' sleep status, and to explore the related factors of LPRD.

Methods

Four hundred and sixteen patients who visited the otorhinolaryngology clinic in our hospital from June 2019 to June 2021 were selected as the research subjects. According to the scale of reflux symptom index, the subjects were divided into a patients group (120 patients) with an the reflux symptom index (RSI) &gt; 13 and a control group (296 patients) with an RSI ≤ 13 according to the RSI scale score. General patient information was collected. The sleep state and emotional state of patients in the two groups were evaluated, and the related influencing factors for LPRD were also evaluated. The correlation between sleep state and depression in LPRD patients was analyzed.

Results

Four hundred and sixteen patients were divided into patients group and control group according to RSI score, the ratio of the two groups was 1:2.47. In the patients group, the common symptoms of RSI score and the top three of the total score were as follows: Foreign body sensation in throat in 112 patients, 438 points; Keep voice clear in 108 patients, 381 points; Excessive phlegm or nasal discharge reflux in 101 patients, 348 points. The PSQI and HADS scores in the patients group were higher than those in the control group (t = 19.990, 13.007, 14.690, P all &lt;0.001). Logistic regression analysis showed that high-fat diet and high PSQI score were the risk factors for the development of LPRD (P = 0.012, P = 0.007). According to the PSQI score, the patients in the patients group were divided into 35 patients with abnormal PSQI score, 85 patients with normal PSQI score, and the HADS scores of those with abnormal PSQI score were all lower than those with normal PSQI score (P &gt; 0.05). The PSQI score of the patients in the patients group was positively correlated with the HADS score (r = 0.714, P = 0.013).

Conclusion

Sleep disorder may lead to the occurrence or aggravation of anxiety and depression in patients with LPRD, and it is an independent risk factor for the development of LPRD. Clinical attention to the treatment of sleep disorders in patients with LPRD may be conducive to improving the efficacy of LPRD.

Sorting out the Relationship between Gastroesophageal Reflux Disease and Sleep

PURPOSE OF REVIEW

Gastroesophageal reflux disease is one of the most common conditions encountered by primary care physicians, gastroenterologists, foregut surgeons and otolaryngologists. While approximately 50% of patients experience nocturnal reflux symptoms, the relationship between gastroesophageal reflux disease and sleep is often overlooked. The aim of this review is to provide an update on the current understanding of this relationship and its clinical implications. Recent studies pertaining to the association between GERD and sleep with focus on sleep disturbances, obstructive sleep apnea, extraesophageal manifestations of GERD and treatment are discussed.

RECENT FINDINGS

There is a close relationship between GERD and sleep disturbances, but the nature of this relationship remains to be elucidated. Similarly, new data supports the association between GERD and obstructive sleep apnea, but whether this association is independent of confounding risk factors remains unresolved. Extraesophageal manifestations due to nocturnal GERD are primarily respiratory and can be explained by microaspiration and vagally-induced bronchospasm. Treatment of nocturnal GERD, both pharmacologically and surgically, improves sleep quality. Conversely, pharmacologic treatment of sleep disorders can improve nocturnal GERD symptoms. There is a bi-directional relationship between GERD and sleep. GERD is associated with various sleep disturbances. Sleep deficiency can exacerbate GERD. There is an association between extraesophageal manifestations and nocturnal GERD. Treatment directed towards GERD can improve sleep experience, and treatment directed to improve sleep can improve GERD symptoms.

Proton pump inhibitors for the treatment of laryngopharyngeal reflux disease: A protocol for systematic review and meta-analysis

BACKGROUND

Laryngopharyngeal Reflux disease refers to abnormal reflux of gastric contents through the esophagus into the throat, which irritates and damages the pharyngeal mucosa, and causes corresponding symptoms. Proton Pump Inhibitors are an important class of gastric acid secretion inhibitors after H2 receptor blockers, which can be used clinically to treat peptic ulcer, abnormal gastric acid secretion and other related diseases. The common clinical drugs include omeprazole, lansoprazole, rabeprazole and so on. Clinical practice has shown that Proton Pump Inhibitors have a good therapeutic effect on Laryngopharyngeal Reflux disease, but evidence of evidence-based medicine is lacking. The purpose of this protocol is to systematically evaluate the efficacy and safety of Proton Pump Inhibitors in the treatment of Laryngopharyngeal Reflux disease and to improve the evidence-based basis for the clinical application of Proton Pump Inhibitors in the treatment of Laryngopharyngeal Reflux disease.

METHODS

English computer retrieval database (PubMed, Embase, Web of Science, the Cochrane Library) and Chinese computer retrieval database (Wanfang Database, VIP Information Chinese Journal Service Platform, Chinese Biomedical Database) . In addition, Baidu Scholar and Google Scholar were manually searched for randomized controlled clinical studies on the treatment of laryngeal reflux disease with Proton Pump Inhibitors from the establishment of the database to July 2020. Two researchers independently extracted and evaluated the data of the included studies, and meta-analysis was conducted on the included literatures with RevMan5.3 software without language restrictions.

RESULTS

In this study, the efficacy and safety of Proton Pump Inhibitors in the treatment of Laryngopharyngeal Reflux disease are evaluated by the overall response rate, clinical symptom remission rate and other indicators.

CONCLUSIONS

This study will provide reliable evidence-based evidence for the clinical application of Proton Pump Inhibitors in the treatment of Laryngopharyngeal Reflux disease.OSF Registration number: DOI 10.17605 / OSF.IO / NY6SC.

Nocturnal Gastroesophageal Reflux Disease (GERD) and Sleep: An Important Relationship That Is Commonly Overlooked

Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.

The effect of obstructive sleep apnea surgery on laryngopharyngeal reflux with obstructive sleep apnea

Background: Obstructive sleep apnea (OSA) may play a role in the occurrence of laryngopharyngeal reflux (LPR). OSA surgery also may have a significant curative effect on LPR with OSA.Objectives: To analyze the role of OSA in LPR and the effect of OSA surgery on LPR with OSA.Methods: Forty-five OSA patients with LPR symptoms were enrolled and were divided into the LPR positive group (RSI > 13) and the LPR suspicious group (1 ≤ RSI ≤ 13) based on reflux symptom index (RSI). All the patients underwent OSA surgery. The RSI scores at three different time points postoperatively were compared with that preoperatively.Results: In the LPR positive and LPR suspicious group, the result revealed that there were significant differences in RSI score between one month, three months, six months after surgery and before surgery (p < .001 for all). Moreover, in the LPR positive group, there was a significant difference in RSI score among one month, three months and six months after surgery (p = .01).Conclusions and significance: The effect of OSA on LPR exists and OSA surgery can improve the symptoms of LPR with OSA obviously. For some LPR patients with OSA, the combination therapy of OSA and LPR is needed.

Laryngopharyngeal Reflux Diagnosis in Obstructive Sleep Apnea Patients Using the Pepsin Salivary Test

Background: To investigate the presence of laryngopharyngeal reflux in patients with obstructive sleep apnea (OSA) employing the salivary pepsin concentration method. To compare the results of pepsin concentration with the severity of the pathology. Methods: Seventy-five OSA patients (44 males, 31 females) were enrolled in the study. For each patient, the AHI (apnea–hypopnea index) and the BMI (body mass index) were initially evaluated. All the patients enrolled were assessed using the reflux symptom index (RSI) and the reflux finding score (RFS) in order to perform a clinical diagnosis of laryngopharyngeal reflux. In all patients a salivary sample was taken to estimate the presence of pepsin and its concentration. Results: The incidence of LPR (laryngopharyngeal reflux) in OSA patients, evaluated using the salivary pepsin concentration test (PEP-test), was found to be 32% of cases. Linear regression testing did not show any correlation between AHI and pepsin concentration in salivary samples (p = 0.1). Conclusion: A high number of patients with OSA seem to show positivity for salivary pepsin, correlated to an LPR. There does not appear to be a correlation between the severity of apnea and the grade of salivary pepsin reflux. On the other hand, direct correlation between BMI and the value of pepsin in salivary specimens was observed.