Changes in the quality of life of patients with laryngopharyngeal reflux after treatment

Association Between Height and Laryngopharyngeal Reflux: Analysis Using the 24-Hour Hypopharyngeal-Esophageal Multichannel Intraluminal Impedance-pH Monitoring

OBJECTIVE

Height has the strongest correlation with esophageal length among the external anthropometric indices. Based on the association between laryngopharyngeal reflux (LPR) and the upper esophageal sphincter, this study aimed to investigate the relationship between height and LPR.

METHODS

Retrospective chart analysis of patients who visited an outpatient clinic with symptoms of LPR and underwent a 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-hr HEMII-pH) monitoring. The study analyzed the relationship between height and LPR by (1) in total of 219 patients, (2) in males and females, and (3) in patients under age 60 and over age 60.

RESULTS

The relationship between height and LPR was analyzed for a total of 219 patients. There was no statistical significance between the number of pharyngeal reflux episodes and the height of subjects. When same analysis was done according to gender, the number of pharyngeal reflux episodes decreased as height increased in males, which was statistically significant, but not in females. Further analysis was done according to age in male and female, respectively. In male under age 60, there was statistical significance between the number of pharyngeal reflux episodes and the height of subjects, but not in over age 60. Also, in female under age 60 and over age 60, there was no statistical significance between the number of pharyngeal reflux episodes and the height of subjects.

CONCLUSIONS

This study suggests a correlation between height and pharyngeal reflux events in males and individuals under 60 years old tested with the 24-hr HEMII-pH monitoring.

Translation and Validation of the Arabic Version of the Reflux Symptom Score, Short Version 12 (RSS-12)

BACKGROUND

The Reflux Symptom Score (RSS) is a patient-related outcomes measure (PROM) that was developed to diagnose Laryngopharyngeal reflux (LPR), by assessing the severity and frequency of specific symptoms and their respective impact on quality of life (QoL).

OBJECTIVE

To develop the Arabic version of RSS-12 (Ar-RSS-12), and to assess its validity and reliability.

METHOD

The RSS-12 was translated from French into Arabic using the forward-backward translation method, and the translated version underwent transcultural validation. A case-control study was conducted at the otolaryngology clinics of a referral hospital, during the period November to December 2022. It included 61 patients with LPR-related symptoms and a Reflux Symptom Index (RSI) score >13, and 61 control without LPR-related symptoms and negative RSI scores ≤13. The internal consistency, internal and external validity, and Test-Retest reliability of Ar-RSS-12 were analyzed.

RESULT

Patients had significantly higher scores than controls in all 12 items and total Ar-RSS and QoL impact scores, with high Z score values. Item scores showed variable correlation levels with total Ar-RSS score, with ear-nose-throat items showing the strongest correlation (Spearman's rho 0.592-0.866). The QoL scores were more strongly correlated to the symptoms' severity than frequency. The internal consistency was high, with Cronbach's alpha = 0.878. Regarding external validity, correlations with RSI score showed high Spearman's rho values for total Ar-RSS (0.905) and QoL total score (0.903). No statistically significant difference was observed between Test and Retest results in any of the 12 items' score or the total score and QoL, indicating the reproducibility of the test.

CONCLUSION

The Ar-RSS is a valid and reproducible tool for the screening, assessment, and monitoring of LPR in Arabic speaking patients. The inclusion of symptoms severity and frequency, as well as their individual effects on patient's QoL, support the superior clinical applications of RSS compared to other existing PROMs.

Diagnostic utility of salivary pepsin in laryngopharyngeal reflux: a systematic review and meta-analysis

OBJECTIVES

Salivary pepsin has emerged as a biomarker for Laryngopharyngeal Reflux (LPR), which, however, has been questioned for its efficacy due to a lack of supporting medical data. Therefore, this study analyzed the diagnostic value of salivary pepsin for LPR and assessed a better cutoff value.

METHODS

Studies were searched in PubMed, Embase, and Cochrane Library from their receptions to October 1, 2021. Then, RevMan 5.3 and Stata 14.0 were utilized to summarize the diagnostic indexes for further meta-analysis. Data were separately extracted by two reviewers according to the trial data extraction form of the Cochrane Handbook. The risk of bias in Randomized Control Trials (RCTs) was evaluated with the Cochrane Risk of Bias Tool.

RESULTS

A total of 16 studies matched the criteria and were subjected to meta-analysis. The results revealed a pooled sensitivity of 61% (95% CI 50%-71%), a pooled specificity of 67% (95% CI 48%-81%), a positive likelihood ratio of 2 (95% CI 1.2-2.8), a negative likelihood ratio of 0.58 (95% CI 0.47‒0.72), and the area under the receiver operating characteristic curve of 0.67 (95% CI 0.63‒0.71). Subgroup analyses indicated that the cutoff value of pepsin at 50 ng/mL had a higher degree of diagnostic accuracy than that of pepsin at 16 ng/mL in cohort studies.

CONCLUSION

The review demonstrated low diagnostic performance of salivary pepsin for LPR and that the cutoff value of 50 ng/mL pepsin had superior diagnostic accuracy. Nevertheless, the diagnostic value may vary dependent on the utilized diagnostic criteria. Therefore, additional research is needed on the improved way of identifying salivary pepsin in the diagnosis of LPR, and also longer-term and more rigorous RCTs are warranted to further assess the effectiveness of salivary pepsin.

Acute, Recurrent, and Chronic Laryngopharyngeal Reflux: The IFOS Classification

OBJECTIVE

To investigate the clinical patterns and disease evolution of laryngopharyngeal reflux (LPR) patients.

METHODS

Patients with LPR diagnosed by hypopharyngeal-esophageal impedance-pH monitoring were prospectively followed in three medical centers. Symptoms and findings were assessed with reflux symptom score (RSS) and reflux sign assessment (RSA). Patients were treated with 3-to 9-month diet and combination of proton pump inhibitors, alginate or magaldrate. Patients were followed for 3 years to determine the clinical evolution of symptoms over time. LPR that did not recur was defined as acute. Recurrent LPR consisted of reflux with one or several recurrences yearly despite successful treatment. Chronic LPR was reflux with a chronic course of symptoms. Predictive indicators of clinical evolution were investigated.

RESULTS

One hundred forty patients and 82 healthy individuals completed the evaluations. Among patients, 41 (29.3%), 57 (40.7%), and 42 (30.0%) had acute, recurrent, or chronic LPR respectively. Baseline quality of life-RSS (QoL-RSS) and RSS total scores were significantly higher in chronic LPR patients. The post-treatment decrease of QoL-RSS and RSS of acute LPR patients were significantly faster as compared to recurrent and chronic patients. QoL-RSS >5 reported adequate sensitivity (94.2) and specificity (75.3). QoL-RSS thresholds defined acute (QoL-RSS = 6-25), recurrent (QoL-RSS = 26-38), and chronic (QoL-RSS > 38) LPR.

CONCLUSION

Baseline QoL-RSS may predict the clinical course of LPR patients: acute, recurrent, or chronic. A novel classification system that groups patients according to the longevity, severity, and therapeutic response of symptoms was proposed: the International Federation of Otorhinolaryngological Societies Classification of LPR.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1073-1080, 2023.

[Value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux in children]

OBJECTIVE

To study the value of airway pH monitoring in determining the association between chronic cough and laryngopharyngeal reflux (LPR) in children.

METHODS

A total of 274 children with chronic cough who were treated from January 2016 to December 2019 were enrolled. The DX-pH detection system was used to conduct 24-hour airway pH monitoring. The association between chronic cough and LPR was analyzed.

RESULTS

Among the 274 children, there were 168 boys and 106 girls, with a median age of 62.8 months and a median airway pH value of 7.3. Of all the 274 children, 99 (36.1%) had LPR, and the incidence rate of LPR was 36.9% (62/168) in boys and 34.9% (37/106) in girls (P=0.737). The comparison of the incidence rate of LPR among children aged < 1 year, 1-6 years, and > 6 years showed that the younger children had a significantly higher incidence rate of LPR than the older ones (P=0.003). There was no significant difference in the incidence of LPR between the two groups with chronic cough of unknown etiology and definite etiology. The incidence of chronic cough was positively correlated with that of LPR (r_s=0.861, P < 0.01). Among the 99 children with positive RYAN index, 65 (66%) suffered from simple LPR.

CONCLUSIONS

LPR is highly associated with the development of chronic cough, and airway pH monitoring may be a safe and effective method for the diagnosis of LPR.

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.

Laryngopharyngeal reflux and dysphagia in patients with obstructive sleep apnea: is there an association?

INTRODUCTION

There is evidence that patients with obstructive sleep apnea (OSA) tend to have a high prevalence of laryngopharyngeal reflux (LPR) and dysphagia. These diseases are known to share the same risk factors and may be interrelated, but there is a lack of studies evaluating their co-occurrence.

OBJECTIVES

To evaluate whether the presence of signs and symptoms suggestive of LPR may be associated with the presence of dysphagia in patients with moderate and severe obstructive sleep apnea (OSA), as well as assess the additional impact of these diseases on quality of life in patients with OSA.

METHODS

Seventy adult patients with moderate or severe OSA were included in the study. The RSI (Reflux Symptom Index) and Swallowing Quality of Life (SWAL-QOL) in dysphagia questionnaires were administered, laryngoscopy was performed to calculate the Reflux Finding Score (RFS), and fiber-optic endoscopic evaluation of swallowing (FEES) was conducted.

RESULTS

The prevalence of LPR was 59.7%, and the prevalence of dysphagia was 27.3%. The association between LPR and dysphagia was present in 17.9% of patients, but with no statistically significant difference. Lower SWAL-QOL scores were observed in several domains in patients with LPR and in only one domain in patients with evidence of dysphagia on FEES.

CONCLUSIONS

Although 17.9% of patients presented with findings suggestive of concomitant LPR and dysphagia, there was no statistically significant association between these two conditions. Patients with LPR had worse scores in several domains of dysphagia-related quality of life, while FEES evidence of dysphagia was associated with worse quality of life in only one domain.

Perceptual, Aerodynamic, and Acoustic Characteristics of Voice Changes in Patients with Laryngopharyngeal Reflux Disease

Laryngopharyngeal reflux (LPR) is an inflammatory condition suspected to be associated with dysphonia. In this study, we investigated multidimensional perceptual, aerodynamic, and acoustic voice changes in patients with clinically diagnosed LPR compared to healthy participants. We prospectively included 80 outpatients with Reflux Finding Score (RFS) >7 and Reflux Symptom Index (RSI) >13 from September 2013 to April 2016 and we compared clinical and voice quality assessments of these patients with 80 healthy participants. Statistically significant differences were found between groups with regard to Voice Handicap Index, perceptual voice quality (grades of dysphonia, roughness, strain, breathiness, asthenia, and instability), phonatory quotient, percentage jitter, percentage shimmer, peak-to-peak amplitude variation, standard deviation of fundamental frequency, and noise to harmonic ratio. Granulation score of RFS was found to affect the highest number of acoustic parameters. We did not identify significant correlation between vocal fold edema and objective voice quality measurements. This study supports that patients with LPR have significant deterioration of both subjective and objective voice quality compared to healthy participants.

Evaluation and Management of Laryngopharyngeal Reflux Disease: State of the Art Review

OBJECTIVE

To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR).

DATA SOURCES

PubMed, Cochrane Library, and Scopus.

METHODS

A comprehensive review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature.

CONCLUSIONS

The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance-pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved.

IMPLICATIONS FOR PRACTICE

The development of multichannel intraluminal impedance-pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR.

Clinical outcomes of laryngopharyngeal reflux treatment: A systematic review and meta-analysis

OBJECTIVES

To investigate the therapeutic benefit of proton pump inhibitors (PPIs) over placebo in patients with laryngopharyngeal reflux (LPR) and to analyze the epidemiological factors of heterogeneity in the literature.

METHODS

An electronic literature search was conducted to identify articles published between 1990 and 2018 about clinical trials describing the efficiency of medical treatment(s) on LPR. First, a meta-analysis of placebo randomized controlled trials (RCTs) comparing PPIs versus placebo was conducted according to diet. The heterogeneity, response to PPIs, and evolution of clinical scores were analyzed for aggregate results. Second, a systematic review of diagnosis methods, clinical outcome of treatment, and therapeutic regimens was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

The search identified 1,140 relevant publications, of which 72 studies met the inclusion criteria for a total of 5,781 patients. Ten RCTs were included in the meta-analysis. The combined relative risk was 1.31 in favor of PPIs and increased to 1.42 when patients did not receive diet recommendations. Randomized controlled trials were characterized by a significant heterogeneity due to discrepancies in clinical therapeutic outcomes, diagnosis methods (lack of gold standard diagnostic tools), and therapeutic scheme. The epidemiological analysis of all articles supports the existence of these discrepancies in the entire literature. In particular, many symptoms and signs commonly encountered in LPR are not assessed in the treatment effectiveness. The lack of diagnosis precision and variability of inclusion criteria particularly create bias in all reported and included articles.

CONCLUSION

This meta-analysis supports a mild superiority of PPIs over placebo and the importance of diet as additional treatment but demonstrates the heterogeneity between studies, limiting the elaboration of clear conclusions. International recommendations are proposed for the development of future trials. Laryngoscope, 129:1174-1187, 2019.

Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications

OBJECTIVE

To determine if an anti-reflux induction program relieves laryngopharyngeal reflux (LPR) symptoms more effectively than medication and behavioral changes alone.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care academic center.

SUBJECTS AND METHODS

A database was populated with patients treated for LPR. Patients were included in the study group if they completed a two-week anti-reflux program (diet, alkaline water, medications, behavioral modifications). Patients were included in the control group if they completed anti-reflux medications and behavioral modifications only. Patients completed the voice handicap index (VHI), reflux symptom index (RSI), cough severity index (CSI), dyspnea index (DI) and eating assessment tool (EAT-10) surveys and underwent laryngoscopy for examination and reflux finding score (RFS) quantification.

RESULTS

Of 105 study group patients, 96 (91%) reported subjective improvement in their LPR symptoms after an average 32-day first follow-up and their RSI and CSI scores improved significantly. No significant differences were found in VHI, DI, or EAT-10 scores. Fifteen study patients who had previously failed adequate high-dose medication trials reported improvement and their CSI and EAT-10 scores improved significantly. Ninety-five percent of patients with a chief complaint of cough reported improvement and their CSI scores improved significantly from 12.3 to 8.2. Among 81 controls, only 39 (48%) patients reported improvement after an average 62-day first follow-up. Their RSI scores did not significantly change.

CONCLUSION

The anti-reflux program yielded rapid and substantial results for a large cohort of patients with LPR. It compared favorably with medication and behavioral modification alone. It was effective in improving cough and treating patients who had previously failed medications alone.

Photographic Objective Alterations for Laryngopharyngeal Reflux Diagnosis

OBJECTIVE

Diagnosis of laryngopharyngeal reflux (LPR) in clinical practice is generally made subjectively based on history, symptoms, and endoscopic assessment. This study presents the diagnostic role of the digital photographic assessment of the laryngopharyngeal region for LPR.

METHODS

Seventy-two patients with LPR symptoms and 35 healthy volunteers were evaluated using the Reflux Finding Scores (RFS) and the Reflux Symptom Index (RSI). The results of these scales were recorded in 72 patients representing group 1 with LPR diagnosis; they returned after 1 and 2 months of treatment as groups 2 and 3, respectively. Thirty-five volunteers represented group 4. Laryngopharyngeal regions of all subjects were examined and photographed endoscopically. Red, green, and blue (RGB) values of particular oropharyngeal and laryngeal points were measured.

RESULTS

RSI and RFS values of group 1 were significantly different from the other three groups, as were the scores of group 2; however, the comparison of the RSI and RFS values of groups 3 and 4 did not reveal a statistically significant difference. Laryngopharyngeal RGB values also duplicated statistical significance as above.

CONCLUSION

Measurement of RGB values can be a cheap and easy-to-use method to quickly provide objective and corroborative information to help in the diagnosis of LPR in conjunction with subjective methods.