Laryngopharyngeal reflux disease, prevalence and clinical characteristics in ENT department of a tertiary hospital Tanzania

The 2-week wait pathway for suspected head and neck cancers in patients with throat and voice symptoms: referral patterns, common clinical practice and diagnostic efficacy of NICE guidelines

INTRODUCTION

The 2-week wait (2ww) referral pathway has been introduced into UK clinical practice to increase the early detection of cancer and improve survivals. The efficiency of this system for head and neck (H&N) cancers has been questioned over the years because of evidence of low pick-up rates. H&N cancers present with a wide variety of non-specific symptoms, particularly throat and voice symptoms. These symptoms need to be accurately interpreted together with risk factors if they are to be addressed adequately and overload of cancer facilities avoided. One of the most common outcomes of H&N 2ww referrals is laryngopharyngeal reflux (LPR), a common condition that could be diagnosed and managed in the primary care setting with a prescription of proton pump inhibitors (PPI) trials.

METHODS

We retrospectively analysed a cohort of consecutive patients referred on the 2ww pathway for throat and voice symptoms at University College London Hospital H&N cancer clinic during two months in 2019.

RESULTS

A total of 101 patients (43.6% men, mean age 53.3 years) were included. Throat and voice symptoms were described as intermittent in 52.5% and non-lateralised in 88.1%. Diagnosis of LPR was made in 59.4% of the referrals. A PPI trial was prescribed by general practitioners (GPs) in only 7.9% of cases. The cancer pick-up rate in our cohort is 2.9%.

CONCLUSIONS

An improved awareness of the symptoms of LPR could guide GPs to prescribe trials of PPIs in low-risk patients before rushing into a referral on a cancer pathway. This would improve the 2ww process on many levels, reduce the burden on the National Health Service and avoid patients' psychological distress.

In vitro model to evaluate effect of acidic pepsin on vocal fold barrier function

The pathophysiology of laryngopharyngeal reflux (LPR) and its impact on the vocal fold is not well understood, but may involve acid damage to vocal fold barrier functions. Two different components encompass vocal fold barrier function: the mucus barrier and tight junctions. Mucus retained on epithelial microprojections protects the inside of the vocal fold by neutralizing acidic damage. Tight junctions control permeability between cells. Here we developed an in vitro experimental system to evaluate acidic injury and repair of vocal fold barrier functions. We first established an in vitro model of rat vocal fold epithelium that could survive at least one week after barrier function maturation. The model enabled repeated evaluation of the course of vocal fold repair processes. Then, an injury experiment was conducted in which vocal fold cells were exposed to a 5-min treatment with acidic pepsin that injured tight junctions and cell surface microprojections. Both of them healed within one day of injury. Comparing vocal fold cells treated with acid alone with cells treated with acidic pepsin showed that acidic pepsin had a stronger effect on intercellular permeability than acid alone, whereas pepsin had little effect on microprojections. This result suggests that the proteolytic action of pepsin has a larger effect on protein-based tight junctions than on phospholipids in microprojections. This experimental system could contribute to a better understanding of vocal fold repair processes after chemical or physical injuries, as well as voice problems due to LPR pathogenesis.

Impact of Laryngopharyngeal Reflux in Patients with Voice Disorders

Objective

The aim of this study is to evaluate the presence of laryngopharyngeal reflux in patients with voice disorders thereby aiding in the early management and improving the quality of life.

Study Design

Cross Sectional study.

Methods

This cross sectional study was carried out in a tertiary care hospital, patients with history of voice change for more than 3 weeks were included, and divided into 4 groups depending upon the level of voice use. Patients were asked to fill Koufmann Reflux Symptom Index questionnaire followed by video laryngoscopy and findings were plotted according to Reflux Finding Score. Based on the scoring, impact of LPRD in patient with voice disorders was analysed.

Results

Among the 90 study participants, 74 (82.2%) were found to have LPRD. The mean age was 42.76 ± 10.33 years. Majority (43.2%) belong to the age group of 41-50 years, with female predominance (70.3%). Majority (41.9%) of them were level IV voice users. 59.5% were positive Koufman reflex symptom index, 67.6% were positive Reflex finding score. Hoarseness (58.1%) the most common symptom.

Conclusion

Laryngopharyngeal reflux disease has to be considered in patients presenting with hoarseness of voice for more than three weeks. Simple and highly reproducible scores like Reflux Symptom Index and Reflux Finding Score proven useful and valuable tools in diagnosing LPRD thereby aiding in early diagnosis and prompt management and improves the patient's quality of life.

Level of Evidence

Level 1.

Effect of Laryngopharyngeal Reflux Disease on Middle Ear Function: A Case-Control Study

Aims

To identify the effect of acid reflux on the middle ear function in patients with laryngopharyngeal reflux disease (LPRD) with no pre-existing otologic complaints.

Materials and Methods

Patients presenting with complaints suggestive of LPRD were identified and Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) were calculated. 73 individuals with RSI ≥ 13 and RFS ≥ 7 was diagnosed with LPRD and chosen as cases. An equal number of healthy controls who had no symptoms of LPRD, matched for age and sex were chosen. Pure tone audiometry (PTA) and Impedance Audiometry were done in both the groups to assess middle ear function and the findings were compared.

Results

PTA values indicated hearing impairment among 61.64% of cases as compared to 17.81% controls (p value < 0.001). Result of Impedance Audiometry also revealed that 54.8% cases of LPRD had deranged middle ear function compared to 6.85% of controls (p value < 0.001).

Conclusion

Laryngopharyngeal reflux disease can have silent manifestations in the ear in the form of altered middle ear function. This can lead to a wide spectrum of dysfunctions in the form of serous otitis media, retraction pockets and squamosal variant of chronic otitis media, which has its own set of complications. Hence, early management of LPRD can reduce possibility of middle ear disease.

A Study on the Prevalence of Laryngopharyngeal Reflux in Saudi Arabia

Introduction Laryngopharyngeal reflux (LPR) is a condition characterized by the backflow of gastric contents rising through the esophagus, affecting the aerodigestive tract and leading to throat symptoms such as hoarseness, chronic cough, and throat clearing. LPR is recognized as a separate condition from gastroesophageal reflux disease, despite the fact that they both involve the backflow of the stomach contents as their primary pathology. Our study aimed to evaluate the prevalence of LPR within the population of Saudi Arabia. Methods A cross-sectional study was conducted using an electronic questionnaire from August to November 2023, involving participants from all five regions of Saudi Arabia. A total of 1140 participants completed the questionnaire, which included the Reflux Symptom Index (RSI) to assess the prevalence of LPR. Results LPR was found to be prevalent in 31.2% of the study population, with the most common associated demographics being female gender (p = 0.032) and adults aged 36-45 years (p = 0.006). However, no significant relationship was observed based on region of residence or other demographic factors such as education level or occupation. Conclusion LPR has a high prevalence in the population of Saudi Arabia. Therefore, further research and awareness about this condition are warranted to better understand its impact, improve diagnosis, and develop appropriate management strategies.

Predictors of Early and Late Response to Esomezol and Lifestyle Modification in Adults With Laryngopharyngeal Reflux Disease: A Prospective, Multicenter, Open-Label Cohort Study

OBJECTIVES

This study aimed to assess predictors of the response to varying durations of proton pump inhibitor (PPI) use and lifestyle modification treatment for laryngopharyngeal reflux disease (LPRD).

METHODS

Between October 2014 and June 2016, a prospective, multicenter, open-label, single-cohort, intention-to-treat, observational study was conducted at eight referral hospitals across the Republic of Korea to examine predictors of early and late response to treatment in adult patients (age ≥19 years) with LPRD. Participants underwent standard treatment (PPI [Esomezol] and lifestyle modification) for 3 months. Response to treatment was defined as greater than 50% improvement in reflux symptom index score. The primary outcome was potential predictors of treatment response at 1 and 3 months. The secondary outcome was potential predictors distinguishing early from late responders.

RESULTS

In total, 394 patients were enrolled. Improved sleep habits was a positive predictor (odds ratio [OR], 1.785; 95% confidence interval [CI], 1.06-3.007; P=0.029), while initial alcohol consumption (OR, 0.587; 95% CI, 0.355-0.969; P=0.037) and past medication history (OR, 0.438; 95% CI, 0.215-0.891; P=0.005) were negative predictors of response after 1 month of treatment. High pre-reflux finding score was a positive predictor (OR, 1.187; 95% CI, 1.049- 1.344; P=0.007), while male sex (OR, 0.516; 95% CI, 0.269-0.987; P=0.046), higher depression score (OR, 0.867; 95% CI, 0.784-0.958; P=0.005), and past thyroid hormone medication history (OR, 0.161; 95% CI, 0.033-0.788; P=0.024) were negative predictors of response after 3 months of treatment. Past medication history (OR, 0.438; 95% CI, 0.215-0.891; P=0.023) was the only negative predictor for early responders compared to late responders.

CONCLUSION

Adult patients with LPRD and a history of prior medication use may require longer treatment durations to achieve a therapeutic response. Future research should explore the incorporation of diverse treatment approaches to improve treatment outcomes for patients exhibiting negative prognostic indicators.

D, Rajan S. Clinical Evaluation of Laryngopharyngeal Reflux and its Response to Proton Pump Inhibitors

Aim

To clinically evaluate the patients of laryngopharyngeal reflux(LPR) and their response to Proton Pump Inhibitors(PPIs) using laryngeal Reflux Symptom Index (RSI) and Reflux Finding Score (RFS).

Method

This prospective observational study was conducted on 128 patients attending the ENT-OPD of VSSIMSAR,Burla,India, who had persistent laryngeal symptoms for more than 2 months.Data was collected using standardized RSI and RFS after taking detailed history and laryngoscopic examination.Patients who were diagnosed of LPR on the basis of their RSI & RFS were subjected to treatment with PPI-Pantoprazole & were called back for follow up at 2nd, 4th and 6th months.Pre and post treatment RSI & RFS were compared using appropriate statistical tests and results with p-value< 0.01 were considered statistically significant.

Results

The overall effect of PPIs on all symptoms & signs of LPR,included in RSI and RFS respectively,is statistically significant except on swallowing (not statistically significant at p <0.01) showing a careful usage of RSI & RFS while diagnosing LPR clinically.Study also elucidated that PPI are effective in relieving symptoms of LPR patients.Evaluating Pearson correlation coefficient,the value of R=0.3717;R2 =0.1382 shows low positive correlation between the RSI & RFS.RSI & RFS are related to each other and any change in the RSI will affect the value of RFI and vice versa.

Conclusion

From this study we conclude that LPR is prevalent in age of 28-37 years & has female preponderance.PPIs are effective in treating LPR.Though RSI and RFS are effective and valid parameters for managing LPR cases but have to be used cautiously while interpreting the results.

Assessment of the Current Knowledge and Practice of General Practitioners Towards Laryngopharyngeal Reflux in Saudi Arabia

Background General practitioners (GPs) have a significant role in the diagnosis of patients with laryngopharyngeal reflux (LPR). Some published data revealed a lack of knowledge among GPs about the disease, consequently, this lack of knowledge impacted their performance. This survey aims to assess the current knowledge and practice of general practitioners regarding laryngopharyngeal reflux in Saudi Arabia. Methodology This survey study was conducted to assess the current knowledge and practice of general practitioners regarding laryngopharyngeal reflux in Saudi Arabia using an online questionnaire. The questionnaire was distributed and collected from the five regions in Saudi Arabia, which are The Central Region (Riyadh, Qassim), Eastern Region (Dammam, Al-Kharj, Al-Ahasa), Western Region (Makkah, Madinah, Jeddah), Southern Region (Asir, Najran, Jizan), and Northern Region (Tabuk, Jouf, Hail). Results In the current study, we collected data from 387 general practitioners, 61.8% of whom were aged between 21-30 years old, and 57.4% of the participants were males. Moreover, 40.6% of the participants thought that both LPR and gastroesophageal reflux disease (GERD) share pathophysiology, however, they are two different diseases considering their clinical presentation. Moreover, it was found that heartburn was the most known symptom of LPR among the participants (Mean score 2.14 (SD=1.31), where a lower score indicated more relation). Considering the treatment of LPR, 40.6% and 40.3% of the participants reported using proton pump inhibitors once or twice daily respectively. In contrast, antihistamine/H2 blockers, alginate, and magaldrate were used to a lesser extent as reported by 27.1%, 21.7%, and 12.1%. Conclusion The current study showed limited knowledge among general practitioners considering LPR with a higher rate of referring patients to other departments depending on symptoms which may increase the pressure on other departments of mild cases.

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.

Characteristics of Laryngopharyngeal Reflux in Patients of Different Genders and Ages

OBJECTIVES

To investigate the differences in laryngopharyngeal reflux (LPR) characteristics between gender and age groups based on the Reflux Symptom Index (RSI), Reflux Finding Score (RFS) scale and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (HEMII-pH) monitoring.

METHODS

The enrolled were patients with LPR symptoms completed the 24h-HEMII-pH monitoring and divided into two gender groups (male and female) and elderly group (>60 years), middle-aged group (41-60 years) and young group (18-40 years). The total RSI and RFS scores of individuals were counted. Various potential differences as well as incidence of each type of LPR events between gender and age groups were analyzed.

RESULTS

A total of 420 patients were included, with 333 (79.3%) diagnosed with LPR confirmed by 24h-HEMII-pH monitoring. Females (n=49) had a statistically higher LPR positivity (91.0% vs. 76.6%, P < 0.01) than males (n=342). Female patients with LPR had significantly higher RSI scores (14.08 ± 6.72 vs. 11.08 ± 4.82, P < 0.001) than male patients. The positive rate of LPR were 82.6%, 80.7% and 63.3% in the elderly, middle-aged and young groups. The Elderly group had significantly lower RSI scores (10.20 ± 4.06 vs. 12.80 ± 6.58, 12.24 ± 5.57, P < 0.001) but higher RFS scores (9.37 ± 3.25 vs. 8.16 ± 3.34, 8.57 ± 2.58, P < 0.05) than the other two groups. The number of acid hypopharyngeal-proximal reflux episodes (HREs) and distal esophageal acid reflux were significantly higher in elderly than in young patients. Except for non-acid gas HREs, the positive rates of other types of HREs were increasing from young to middle-aged to the elderly group (P < 0.05).

CONCLUSIONS

Female patients with suspected LPR symptoms had a higher positive rate of LPR and RSI score than males. The prevalence of LPR and the number of acid reflux were progressively increasing with age, but the perception of reflux symptoms may diminish.

Clinical characteristics of protracted bacterial bronchitis in adults

There are few data regarding adult protracted bacterial bronchitis (PBB). This study aimed to delineate the clinical features of PBB and evaluate their potential diagnostic value in adults. We recruited 55 adult patients with PBB and selected randomly 220 patients with non-PBB as control. A diagnosis of PBB was considered if patients had a cough lasting ≥3 weeks, no abnormalities of chest computed tomography, positive bacterial culture in sputum and/or response well to oral moxifloxacin for 1-4 weeks. The clinical manifestations and laboratory investigations were compared between PBB patients and non-PBB patients. Of the 55 patients with PBB, approximately three-fifths (34, 61.8%) were females with a median age of 46.0 years, which were similar to that of patients with non-PBB. We observed a shorter cough duration in PBB than non-PBB (median 3.0 versus 24.0 months, p < 0.001). Compared to non-PBB patients, PBB patients had higher incidences of productive cough, yellow phlegm and a sensation of mucus in the throat (SMIT) (all p < 0.001). Sputum neutrophils and lymphocytes were markedly elevated in PBB patients than non-PBB patients (both p = 0.004). Bacterial pathogens were detected in eight (28.6%) of 28 cases with PBB. The multivariate analyses showed yellow phlegm, productive cough, SMIT, increased sputum lymphocytes (≥2.3%) and cough duration ≤8.5 months with moderate sensitivity (50.9-81.8%) and moderate-high specificity (60.5-94.4%) for determining PBB. In summary, adults with PBB are characterized by productive cough, yellow phlegm, SMIT and neutrophilic airway inflammation. These cough features and increased sputum lymphocytes may be useful to indicate PBB.

Characteristics of Laryngopharyngeal Reflux in the Chinese Nurse Population

OBJECTIVES

To investigate the prevalence of laryngopharyngeal reflux (LPR) and knowledge of LPR in the Chinese nurse population.

METHOD

From October 2021 through December 2021, participants were recruited from the PLA General Hospital's Sixth Medical Center. All included participants completed the Reflux Symptom Index (RSI), and LPR was defined as RSI > 13. In addition, each participant was asked to record whether they had any habits such as preferring to consume high-fat food and carbonated beverages, over-eating at dinner, sedentary after meals and lying down within 2 hour after meals, as well as whether they were aware of LPR. For the participants with RSI >13 points, they were treated using diet and lifestyle behavioral recommendations and were prescribed a twice daily pantoprazole (20 mg, 3 months).

RESULTS

A total of 828 participants were included. The positivity and awareness rates of LPR were 3.38% and 55.96%, respectively. RSI scores were significantly higher in LPR-positive subjects than in LPR-negative (16.79 ± 4.43 vs. 1.33 ± 2.33). Among the participants with LPR, there were significant positive association between RSI scores and preferring to consume high-fat food and carbonated beverages, over-eating at dinner, lying down within 2 hour after a meal, and sedentary after meals. RSI scores in 63% of participants with LPR significantly decreased from baseline to 1 month posttreatment. From 1 to 3 months posttreatment, 90% of participants had significantly lower RSI scores than pretreatment.

CONCLUSIONS

There are a certain number of LPR patients in the Chinese nurse population, however, knowledge of LPR among nurses is unsatisfactory. Over-eating at dinner, lying down within 2 hour after a meal and sedentary after meals are risk factors for LPR. With combined regular dietary and lifestyle behavioral change and acid-suppressing treatment, most patients with LPR achieve effective remission.

Ear, nose and throat (ENT) manifestations and complications of reflux

Laryngopharyngeal reflux disease describes the backflow of acidic stomach content towards the larynx and is associated with symptoms such as cough, throat clearing and globus. It is a common presentation in primary care and the sequelae of symptoms that arise from the disease often present in ear, nose and throat clinics. Assessment and examination of patients presenting with reflux symptoms includes questionnaires, as well as direct visualisation of the pharynx and larynx, and takes a multidisciplinary team approach. Treatment options include lifestyle modification, medical therapy and in some specialist centres, surgical management to address the multitude of symptoms associated with the disease.

Laryngopharyngeal reflux in chronic rhinosinusitis patients and the role of endoscopic sinus surgery

OBJECTIVES

Latest literature proposes laryngopharyngeal reflux (LPR) as the underlying contributory factor for chronic inflammation in both upper and lower airways. In this study, we investigated LPR symptoms and signs of CRS patients and the various factors on their LPR symptoms and signs. We also evaluated the effect of the LPR symptoms and signs of CRS patients after endoscopic sinus surgery (ESS).

METHODS

We performed a retrospective analysis from 91 patients who underwent primary ESS. They were assessed for LPR symptoms with Reflux Symptom Index (RSI) and Reflux Finding Scores (RFS) before ESS. Sino-Nasal Outcome Test (SNOT)-22, Lund-Mackay (LM) scoring system, and Lund-Kennedy (LK) scoring system were evaluated for CRS severity. They had to fulfill SNOT-22, RSI, and RFS at 6 months after surgery.

RESULTS

Nasal polyps, smoking, asthma, allergy, LM scores and LK scores didn't have significant correlations with preoperative RSI and RFS (P > .05 for all). RSI had significant correlations with SNOT-22 preoperatively and postoperatively (P < .05 for all). RFS had a significant correlation with postoperative SNOT-22 (P = 0.034). RSI and RFS decreased significantly more after ESS (P < 0.001 for both). Smoking had a significant effect on the postoperative RFS (P = 0.003). Non-smoker showed significantly lower scores of postoperative RFS (P = .0.003).

CONCLUSION

Our study suggests that subjective CRS symptoms were related with subjective LPR symptoms and ESS was effective in reducing signs and symptoms of LPR in CRS patients. Especially, smoking was associated with less improvement of laryngoscopic findings after ESS.

Extraesophageal signs of gastroesophageal reflux disease: otorhinolaryngologist’s view

The data on association between various pathologies of the ENT organs and gastroesophageal reflux disease (GERD) is analysed in the article. The variety of extraesophageal signs of GERD in children and adults is given, what is advisable to inform physicians of different specialties about the possibilities of antireflux therapy. These options are expanded with the emergence of a unique new drug, Alfasoxx. Its bioadhesive formula is based on hyaluronic acid and chondroitin sulphate thereby protecting the esophageal mucosa. Alfasoxx acts on the surface of the esophageal mucosa without penetrating into the systemic bloodstream and it also has a low allergenic potential, which has been confirmed by numerous studies. With its healing and repairing effect on erosive lesions of the esophageal epithelium, Alfasoxx in combination with proton pump inhibitors is more effective in achieving regression of clinical manifestations of the disease and improving patients quality of life (according to SF-36 questionnaire) compared to proton pump inhibitors monotherapy.