Laryngopharyngeal reflux: state of the art diagnosis and treatment

Association Between Helicobacter pylori and Laryngopharyngeal Reflux Disease: A Systematic Review and Meta-Analysis

BACKGROUND

It is controversial that Helicobacter pylori (H pylori) is involved in the pathogenesis or development of laryngopharyngeal reflux disease (LPRD).

OBJECTIVE

To investigate the potential association between LPRD and H pylori infection.

MATERIAL AND METHODS

A systematic review was performed of studies assessing the diagnosis or treatment of LPRD among patients with H pylori infection. Data sources are PubMed/MEDLINE, EMBASE[Ovid], Cochrane Library, and Web of Science, and ClinicalTrials.gov.

RESULTS

Fifteen studies were analyzed in the review, with all eligible for the meta-analysis. A significant association between H pylori infection and LPRD was detected for higher rates of H pylori infection in patients with LPRD than in non-LPRD patients (relative risk (RR), 1.35; 95% CI, 1.12-1.63; P = 0.002), and H pylori-positive patients had a higher prevalence of LPRD than H pylori-negative patients (RR, 1.19; 95% CI, 1.07-1.31; P = 0.001). The prevalence of H pylori among patients with LPRD was 49% (95% CI, 36-61), the prevalence of H pylori among patients with non-LPRD was 35% (95% CI, 23-49).

CONCLUSION AND SIGNIFICANCE

The limited evidence indicated the association between LPRD risk and increased H pylori infection. Different population races, diagnostic approach to LPRD, variant H pylori testing methods, age and sex may contribute to the heterogeneity. Further well-designed studies regarding the efficacy of H pylori eradication in the treatment of LPRD are strongly recommended in the future.

Radiological Evaluation of the Effect of Laryngopharyngeal Reflux on the Thickness of Inferior Turbinate, Maxillary Sinus Mucosa and Nasal Septal Body

Background

We investigated the relationship between Laryngopharyngeal Reflux (LPR) and maxillary sinus mucosal thickness (MSMT), inferior turbinate mucosal thickness (ITMT), inferior turbinate width (ITW) and nasal septal body thickness (NSBT), which can be signs of chronic rhinosinusitis and allergic rhinitis.

Methods

The study, which included 87 patients, was designed as two groups. While 42 of the patients were included in the Laryngopharyngeal Reflux group, 45 were included in the control group. Age and gender information of the patients were noted. MSMT, ITMT, ITW and NSBT values were measured in patients who had Paranasal Sinus Computed Tomography. MSMT, ITMT and ITW were measured as right and left. Both groups were evaluated in terms of these values.

Results

Right ITMT, bilateral ITW and MSMT values were found to be significantly higher in the LPR group than in the control group (p < 0.05). MSMT values were higher in males (p < 0.05). The left-ITT and NSBT values were not significantly different between the LPR group and the control group, but both values were higher in the LPR group than in the control group (p > 0.05). In the LPR group, there were positive correlations between ITMT and ITW values of the right side; and left side separately (p < 0.05).

Conclusion

It has been shown that Laryngopharyngeal Reflux increases maxillary sinus mucosal thickness, inferior turbinate thickness and width, and nasal septal body thickness, which can be signs of chronic rhinosinusitis and allergic rhinitis. The negative effects of LPR on nasal and paranasal mucosa and structures were demonstrated in this study.

Observations of increased gastroesophageal reflux symptomology in an anhydrous ammonia exposed population

OBJECTIVE

This case series describes a cohort of patients exposed to anhydrous ammonia vapors with clinical findings of laryngopharyngeal reflux (LPR). The study characterizes the identification of LPR as a consequence of vapor inhalation and the utility of PPI therapy in LPR secondary to inhalational ammonia exposure.

METHODS

This is a case series of 15 patients exposed to anhydrous ammonia from a single chemical spill who experienced LPR several months after exposure. Symptoms of LPR were assessed at their initial consultation and by phone at least 30 days after treatment with low-dose PPI or diet modification. At this visit, patients underwent complete head and neck examination and flexible direct laryngoscopy.

RESULTS

15 patients were available for analysis before and after treatment. 93.3 % experienced at least three cardinal symptoms of LPR. 66 % of these patients had at least one LPR finding on flexible laryngoscopy. 73 % were treated with daily standard dose PPI, and 82 % of these patients experienced reduction of symptoms after 30 days of PPI treatment. Four of 15 patients were not taking the PPI as prescribed, and only one of these patients had resolution of LPR symptoms.

CONCLUSION

We conclude that there is an association between anhydrous ammonia exposure and the development of LPR symptoms. In this study, treatment with PPIs was successful in reducing symptoms for most patients, and patients who did not receive PPIs experienced symptoms for a longer time.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Pharyngeal pH Probe Findings in Patients with Postnasal Drainage

Background

Patients commonly present with complaints of postnasal drainage (PND). This study reports the pharyngeal pH probe findings in patients without rhinitis/rhinosinusitis who present with complaints of PND.

Methods

This is a prospective study of patients presenting with PND but no historical or endoscopic evidence of rhinitis/rhinosinusitis. Twenty-four-hour pharyngeal pH probe studies were done on 32 consecutive patients and compared with historical controls.

Results

There were a total of 32 patients with PND (mean age, 54 years) and 51 controls (mean age, 49 years). The proportion of patients with positive pH probe studies was higher in PND (28.1%) versus controls (17.6%) but did not reach statistical significance (p = 0.27). However, when comparing the mean number of pharyngeal acid exposure events, patients with PND had significantly more events (1.6) than controls (0.3; p < 0.002). In addition, the mean acid exposure time was significantly higher in PND (0.18%) versus controls (0.01%; p < 0.004).

Conclusion

The proportion of patients with PND displaying positive pharyngeal 24 pH probe studies is not significantly greater than controls. However, patients with PND do exhibit a statistically greater degree of pharyngeal acid exposure as compared with controls. Additional research is required to delineate the role of pharyngeal reflux in patients with PND.

Symptoms, Quality of Life, Videolaryngoscopy, and Twenty-Four-Hour Triple-Probe Ph Monitoring in Patients with Typical and Extraesophageal Reflux

A prospective study was designed to characterize patients with typical and extraesophageal reflux (EER) symptoms and seek predictive patterns for each group. Fifteen subjects without symptoms, 16 patients with symptomatic gastroesophageal reflux disease (GERD), and 37 patients with symptomatic EER were evaluated with outcomes tools, videolaryngoscopy, and 24-hour triple-probe pH monitoring. Higher symptom scores, Voice Handicap Index scores, and Gastrointestinal Symptom Rating Scale scores, as well as similarly decreased quality of life as measured by the Short Form 36, were noted among the two symptomatic groups. Patients with clinically diagnosed EER were more likely to have multiple abnormalities on laryngoscopy. There was a trend toward more pharyngeal reflux episodes in EER patients (6.9 ± 8.9) as compared to GERD patients (6.0 ± 9) and asymptomatic subjects (1.1 ± 1.9). On the basis of the pH monitoring of asymptomatic subjects, we define pathological pharyngeal reflux as more than 5 episodes in 24 hours. Pharyngeal acid exposure is more common in patients presumed to have EER, but some pharyngeal reflux does occur in asymptomatic subjects. Neither symptom scores nor videolaryngoscopic findings were predictive of pathological EER as indicated by pH monitoring.

Management of Benign Vocal Fold Lesions: A Survey of Current Opinion and Practice

Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of this report is to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology—Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling “never” and 5 equaling “always” and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

Pharyngeal pH monitoring in infants with laryngitis

Objective

To assess pharyngeal acid reflux (PAR) exposure with flexible laryngoscopy-guided pharyngeal pH monitoring in infants with laryngitis.

Study Design

Tertiary care children's hospital.

Subjects and Methods

Charts of 10 infants with laryngitis who underwent pharyngoesophageal pH monitoring were reviewed. Data included history, physical examination, and pharyngoesophageal pH monitoring findings.

Results

Six infants had PAR. Two patients were on acid suppressive therapy and exhibited PAR. The number of PAR observed in six infants ranged between 1 and 81. The percent acid exposure time (AET) in the pharynx was between 0.1% and 1.2%. Esophageal acid reflux documented in nine infants ranged between 5 and 173. The percent AET in the esophagus was between 0.1% and 4.8%.

Conclusions

The majority of the studied infants with laryngitis had PAR. Not all esophageal acid reflux reached the pharynx. Pharyngeal pH monitoring provides additional information that cannot be obtained with esophageal pH monitoring in infants with laryngitis.

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.

Mapping regional laryngopharyngeal mechanoreceptor response

Objectives

To map mechanoreceptor response in various regions of the laryngopharynx.

Methods

Five patients with suspected laryngopharyngeal reflux and six healthy control subjects underwent stimulation of mechanoreceptors in the hypopharynx, interarytenoid area, arytenoids, aryepiglottic folds, and pyriform sinuses. The threshold stimuli evoking sensation and eliciting laryngeal adductor reflex were recorded.

Results

In controls, an air pulse with 2 mmHg pressure evoked mechanoreceptor response in all regions, except bilateral aryepiglottic folds of one control. In patients, stimulus intensity to elicit mechanoreceptor response ranged between 2 mmHg and 10 mmHg and varied among the regions. Air pulse intensity differed between right and left sides of laryngopharyngeal regions in the majority of patients.

Conclusion

Laryngopharyngeal mechanoreceptor response was uniform among regions and subjects in the healthy group. Patients with suspected laryngopharyngeal reflux showed inter- and intra-regional variations in mechanoreceptor response. Laryngopharyngeal sensory deficit in patients with suspected laryngopharyngeal reflux is not limited to aryepiglottic folds.

Detection of chronic laryngitis due to laryngopharyngeal reflux using color and texture analysis of laryngoscopic images

OBJECTIVE

To determine if pattern recognition of hue and textural parameters can be used to identify laryngopharyngeal reflux (LPR).

METHODS

Laryngoscopic images from 20 subjects with LPR and 42 control subjects without LPR were obtained. LPR status was determined using the reflux finding score. Color and texture features were quantified using hue calculation and two-dimensional Gabor filtering. Five regions were analyzed: true vocal folds, false vocal folds, epiglottis, interarytenoid space, and arytenoid mucosae. A multilayer perceptron artificial neural network with varying numbers of hidden nodes was used to classify images according to pattern recognition. Receiver operating characteristic (ROC) analysis was used to evaluate diagnostic utility, and intraclass correlation coefficient analysis was performed to determine interrater reliability.

RESULTS

Classification accuracy when including all parameters was 80.5% ± 1.2% with an area under the ROC curve of 0.887. Classification accuracy decreased when including only hue (73.1% ± 3.5%; area under the curve = 0.834) or texture (74.9% ± 3.6%; area under the curve = 0.852) parameters. Interrater reliability was 0.97 ± 0.03 for hue parameters and 0.85 ± 0.11 for texture parameters.

CONCLUSIONS

This preliminary study suggests that a combination of hue and texture features can be used to detect chronic laryngitis due to LPR. A simple, minimally invasive assessment would be a valuable addition to the currently invasive and somewhat unreliable methods currently used for diagnosis. Including more data will likely improve classification accuracy. Additional investigations will be performed to determine if results are in accordance with those provided by pH probe monitoring.

Detection of helicobacter pylori in benign laryngeal lesions by polymerase chain reaction: a cross sectional study

BACKGROUND

Although Helicobacter Pylori (HP) was detected in some cases of chronic laryngitis, the results were not confirmed by polymerase chain reaction (PCR). By this time, it has not been found in laryngeal lesions by in house PCR, the most sensitive method for detecting the genome tracks. Regarding the previous results and also few numbers of studies about the presence of HP in benign laryngeal lesions, specifically by PCR, we aimed to investigate the presence of HP in benign laryngeal lesions by in-house PCR.

METHODS

The samples were taken from 55 patients with benign laryngeal lesions and frozen in -20°C. One milliliter (ml) of lysis buffer was added to 100 mg (mg) of each sample and the tube was placed in 56°C overnight. Then DNA extraction was carried out.

RESULTS

To find HP DNA, in-house PCR was performed that revealed 5 positive results among 55 patients with benign laryngeal lesions. Of them, 3 were polyp, 1 was nodule and 1 was papilloma.

CONCLUSION

Although the number of positive results was not a lot in this study, it was in contrast with previous studies which could not find any HP tracks in benign laryngeal lesions by other methods. More studies about the prevalence of HP in benign laryngeal lesions improve judging about the effect of this infection on benign laryngeal lesions.

The Association between Helicobacter Pylori and Laryngopharyngeal Reflux in Laryngeal Pathologies

We conducted a study to determine the presence or absence of Helicobacter pylori and laryngopharyngeal reflux (LPR) in 43 previously untreated patients who had presented with a laryngeal lesion. Our aim was to determine if there was any association among H pylori, LPR, and laryngeal lesions. H pylori status was determined by real-time polymerase chain reaction (PCR) assays of biopsy tissue obtained during direct laryngoscopy. The presence or absence of LPR was determined on the basis of patients’ reflux symptom index (RSI) and reflux finding score (RFS), which were based on their questionnaire responses and findings on endoscopic examination of the larynx, respectively. Patients with an RSI of 14 or more and/or an RFS of 8 or more were considered to have LPR. H pylori was present in 24 patients (55.8%) and absent in 19 (44.2%)—not a statistically significant difference. The prevalence of LPR was higher than the prevalence of H pylori; it was present in 30 patients (69.8%) and absent in 13 (30.2%). The difference was statistically significant (p = 0.01). We found no association between H pylori status and LPR status. Additionally, we analyzed two subgroups based on whether their lesions were benign or malignant/premalignant and found a significant relationship between LPR positivity and the presence of malignant/premalignant laryngeal lesions (p = 0.03). We found no association between H pylori status and either of the two subgroup categories.

Assessing Laryngopharyngeal Reflux Symptoms with the Reflux Symptom Index

Objective. To validate the Reflux Symptom Index (RSI) in Greek patients and estimate the prevalence of laryngopharyngeal reflux (LPR) symptoms in the Greek population.

Study Design. Prospective, controlled validation study.

Setting. Tertiary referral hospital and primary care.

Subjects and Methods. For validation purposes, the instrument was administered to 53 patients with confirmed LPR. Sex- and age-matched controls with no LPR or gastroesophageal reflux disease (GERD) symptoms presenting in a primary care setting composed the control group. Reliability and construct validity were statistically appraised. Using the RSI, the authors estimated the prevalence of LPR in a randomly selected sample of the Greek adult population.

Results. The mean (SD) RSI score of the 172 sex- and age-matched controls was 3.2 (3.5). The mean (SD) RSI score of the 53 confirmed LPR patients was 19.9 (6.8). Cronbach α was 0.865. Factor analysis verified that the RSI instrument consists of 2 principal factors. To estimate the prevalence of LPR, a representative sample of the Greek adult population (188 subjects) completed the RSI questionnaire: 36.3% were male, and 29.6% were smokers. Mean (SD) age was 53.4 (17.7) years. The instrument was able to discriminate 16 patients with LPR symptoms with a mean (SD) score of 18.91 (6.39).

Conclusion. The authors evaluated the internal consistency, reliability, and construct validity of the RSI for the Greek population. Factor analysis of the Greek translation of the RSI demonstrated that it can be a reliable tool in the diagnostic approach of LPR patients. Using the RSI, the authors recorded that the prevalence of LPR in a representative sample of the Greek population is 8.5%.

Does reflux have an effect on nasal mucociliary transport?

CONCLUSION

Gastroesophageal and laryngopharyngeal reflux were found to have no effect on nasal mucociliary transport.

OBJECTIVE

Gastroesophageal and laryngopharyngeal reflux have been recognized as causative factors for chronic rhinosinusitis but no definite mechanism has been described yet. We aimed to determine whether gastroesophageal and laryngopharyngeal reflux impair nasal mucociliary transport.

METHODS

This was a prospective cohort study in a tertiary referral center. Fifty patients with both laryngopharyngeal and gastroesophageal reflux comprised the study group. Reflux syndrome index and reflux finding score were calculated for each patient before and after treatment. Antireflux medication was given for 12 weeks. The control group consisted of 30 healthy volunteers. Nasal mucociliary transport was assessed by means of the saccharine test. It was performed before and after the treatment. Statistical analysis was performed using the saccharine test results of the study and control groups.

RESULTS

No statistical difference was found between the saccharine test results of the study group and control group before treatment. The differences between the pretreatment and post-treatment reflux symptom index and reflux finding scores were statistically significant. The difference between the post-treatment saccharine test results of the patients in whom reflux scores returned to normal and those with remaining high scores was not statistically significant.

Adjuvant use of liquid alginate suspension for post-tonsillectomy morbidity: Double-blind randomized clinical trial of efficacy

Objective: To evaluate the efficacy of liquid alginate suspension in alleviating post-tonsillectomy morbidity in adult patients.

Methods: A prospective, double-blind, randomized, placebo-controlled study comparing the effect of liquid alginate suspension with placebo was performed on 40 patients who underwent tonsillectomy at Derince State Hospital, Kocaeli, Turkey. The patients were randomly chosen, and each used liquid alginate suspension four times daily or a placebo solution at the same regimen. Tonsillectomy was performed under general anesthesia by cold dissection and suture ligation. Patients were examined at postoperative days 1, 3, 5, and 7 for healing, instructed to note the amount of analgesics used, and asked to mark the visual analog score of throat pain every day for a week.

Results: The study group had statistically significant lower pain scores at day 2 ( P = 0.03). Study group required less analgesic than the control group during the study period, but the difference was statistically different only on day 2 ( P = 0.003) day. Healing was statistically significant on day 5 ( P = 0.03) in the study group.

Conclusion: Use of the antireflux suspensions in patients undergoing tonsillectomy may be effective in reducing postoperative morbidity in adjunct with classic analgesics.

Association between Helicobacter pylori infection and laryngo-hypopharyngeal carcinoma: a case-control study and review of the literature

BACKGROUND

Gastroesophageal reflux, by exposing the pharynx to Helicobacter pylori (H. pylori), is a potential risk factor for laryngo-hypopharyngeal carcinoma. Its possible association has been inconsistent. In this case-control study, we investigated the relationship between H. pylori seropositivity and laryngo-hypopharyngeal carcinoma in Iran.

METHODS

We had 105 healthy controls (group A), 70 cases of laryngeal carcinoma (group B), and 28 cases of hypopharyngeal carcinoma group (group C). Age, sex, smoking habit, alcohol use, and H. pylori serology were determined for all subjects.

RESULTS

Groups were matched in age and alcohol use. Smoking and H. pylori seropositivity were more common in groups B and C, and male sex was more common in group B (compared with group A). In multivariate regression, the effect of smoking (p <.01, odds ratio [OR] = 2.92) and H. pylori seropositivity (p <.01, OR = 11.49) remained highly significant.

CONCLUSION

H. pylori is an independent risk factor for laryngo-hypopharyngeal carcinoma.

Correlation between nasal mucociliary clearance time and gastroesophageal reflux disease: our experience on 50 patients

OBJECTIVES

It is increasingly suggested that gastroesophageal reflux disease (GERD) could play an important role in chronic rhinosinusitis. The aim of our study was to evaluate the nasal mucociliary clearance time in GERD patients and if any correlations could be assumed.

METHODS

Fifty GERD patients endoscopically diagnosed underwent an ear, nose and throat evaluation. The saccharin test and the 20-Item Sino-nasal Outcome Test (SNOT-20) were administered to 50 participants who correspond to our inclusion criteria. The saccharin test is a validated proof to verify the nasal mucociliary clearance time and the SNOT-20 is a disease-specific, health-related quality of-life questionnaire widely used for the assessment of rhinosinusitis.

RESULTS

Thirty-seven (74%) patients showed a significant increment in their saccharin test values in comparison with the others subjects (23.79+/-5.58 vs 8.15+/-2.06min; P=0.0001). This group of patients reported only typical gastroesophageal symptoms (GES) without any other complaint. Gastroesophageal endoscopic findings revealed some interesting and unexpected results in this subgroup. The remainder of patients considered (13/50; 26%) showed normal values for nasal mucociliary clearance time and they referred only typical extraesophageal symptoms (EES). In any case and in both groups rhinosinusitis complaints were present. The SNOT-20 test results were normal in all patients even if a significant difference for GES group could be highlighted (19.3 vs 7.4; P<0.005).

CONCLUSION

This study supports the assumption of possible and important correlations between nasal mucociliary clearance time and GERD. GERD could be an altering factor for nasal function also in absence of laryngo-pharyngeal symptoms although to verify this interesting hypothesis more validated data are necessary.

Chronic cough: epidemiology

Chronic cough is perhaps the commonest symptom of medical importance with some 12% of the general population having the symptom on a daily or weekly basis. Chronic cough causes a large degree of morbidity, with both the physical e.g. incontinence, and the psychological e.g. social isolation, domains. The causes of chronic cough are numerous, but fall into two broad categories; that causing an asthma-like syndrome characterized by eosinophilic infiltration of the airways, and oesophageal disease, particularly weakly acid reflux. Failure to make, particularly this latter, diagnosis leads to enormous consequences in terms of loss of employment, healthcare utilisation and a psychosocial morbidity.

Laryngopharyngeal reflux: diagnosis and treatment of a controversial disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux is a well-recognized and widely used term in ear, nose and throat practice. However, the symptoms and signs attributed to laryngopharyngeal reflux are non-specific and treatment is usually empirical. This review discusses current knowledge on diagnosis and treatment of laryngopharyngeal reflux.

RECENT FINDINGS

Information is evolving regarding the implications of laryngopharyngeal reflux in the development of pathological conditions affecting the upper aerodigestive tract epithelium such as chronic laryngitis, otitis media with effusion and chronic sinusitis. However, there is still much to learn about the pathophysiologic mechanisms of laryngopharyngeal reflux and their role in its related disease conditions and there is still considerable controversy on diagnostic as well as therapeutic parameters for this condition. There is no consensus on the diagnosis and treatment of laryngopharyngeal reflux and the majority of clinicians depend mainly on clinical findings and empirical therapeutic tests rather than more specific investigations.

SUMMARY

The concept of laryngopharyngeal reflux is still controversial. The current practice of empirical treatment with proton-pump inhibitors is based on weak evidence. However, this practice seems to be widely accepted and will not change until further clinical and laboratory studies improve our understanding of this common and well-recognized condition.

Laryngopharyngeal reflux: Current concepts in pathophysiology, diagnosis, and treatment

Laryngopharyngeal reflux (LPR) is the backflow of gastric contents into the pharynx and larynx. The diagnosis of LPR is primarily based on symptoms, including dysphonia, dysphagia, globus, throat-clearing, and post-nasal drip. The gold standard for diagnosis is dual-probe 24-hour pH testing with the upper probe positioned above the upper oesophageal sphincter. Treatment may require 3 months or more of twice-daily proton pump inhibitors along with lifestyle modifications. This review details the pathophysiology, symptoms, findings, treatment, and current controversies in LPR.

Flexible laryngoscopy-guided pharyngeal pH monitoring in infants

OBJECTIVE

To evaluate flexible laryngoscopy-guided pharyngeal pH probe monitoring as an alternative accurate and practical pharyngeal pH probe placement technique to eliminate the need for radiographs and esophageal manometry for pharyngeal pH monitoring in infants with extraesophageal reflux disease (EERD).

MATERIALS AND METHODS

Infants with suspected laryngopharyngeal acid reflux (LPR) who underwent pharyngoesophageal pH monitoring were included. Data analysis included description of the flexible laryngoscopy-guided pharyngoesophageal pH monitoring technique and pharyngoesophageal pH monitoring findings, including the number of acid reflux episodes and percent acid exposure time.

RESULTS

Six infants (3 boys, 3 girls, age range, 2 wk-7.5 mo) with suspected LPR underwent pharyngoesophageal pH monitoring. Flexible laryngoscopy was used, under direct vision, to guide pH probe placement in the laryngopharyngeal region. The esophageal pH probe was located 5 cm distal to the pharyngeal pH probe. All infants tolerated the procedure. Of the six infants, four had pharyngeal acid reflux, and six had esophageal acid reflux. The number of acid reflux episodes ranged from 4 to 81 in the pharynx and from 5 to 173 in the esophagus. The percentage of acid exposure time was between 0% and 1.2% in the pharynx and between 0.1% and 1.5% in the esophagus.

CONCLUSION

With the aid of flexible laryngoscopy, a pH probe can be placed in the laryngopharyngeal region in infants undergoing pharyngeal pH monitoring. Findings documented that not all esophageal acid reflux reach the pharynx. Flexible laryngoscopy-guided pharyngeal pH probe placement can be used to detect LPR in infants with EERD.

Is laryngopharyngeal reflux related to functional dysphonia?

OBJECTIVES

Laryngopharyngeal reflux (LPR) may be a contributing factor in chronic hoarseness. The association of LPR with functional dysphonia (FD), the most common voice clinic diagnosis, is unknown. We attempted to determine whether patients with FD have a higher rate of laryngeal exposure to acidic stomach contents than do healthy volunteers.

METHODS

We recruited through the voice clinic 23 patients who had had persistent dysphonia for 3 months. Pregnancy, major structural laryngeal abnormality, and vocal fold paralysis were exclusion criteria. Eight healthy volunteers were recruited. The subjects gave informed consent to enter the study, which had the approval of our hospital ethics committee. The patients and control subjects underwent 24-hour dual-probe pH-metry.

RESULTS

Twenty-two patients and 6 control subjects completed the study. Overall, there seemed to be no statistical differences between patients and controls on all but 2 channel 1 pH-metry parameters. These were the longest reflux episode (seconds) in a supine position, and the fraction of time the pH was less than 4 in a supine position. Both of these time periods were longer in patients than in the controls (p < .05).

CONCLUSIONS

Our study demonstrated an association between LPR and FD for 2 pH parameters. Larger studies are required to assess the potential relationship between nonorganic dysphonias and reflux. Furthermore, the presence of a multifactorial causation of FD, including "medical" and psychological causes, should be addressed in future studies.

Acoustic Analysis Findings in Objective Laryngopharyngeal Reflux Patients

OBJECTIVE

The aim of this study was to identify the effects of objective laryngopharyngeal reflux (LPR) on the acoustic parameters of patients by comparing their voice samples with that of control subjects.

STUDY DESIGN

Prospective study in two tertiary reference hospitals.

METHODS

48 consecutive patients with symptoms related to LPR and 64 control subjects were included in the study. Suspected LPR patients underwent a 24-hour ambulatory pH monitoring, and 25 (52%) of them were shown to have objective LPR. Acoustical evaluation results of objective LPR patients were compared with that of symptomatic LPR patients and control subjects.

RESULTS

All frequency perturbation values obtained from objective and symptomatic LPR patients were higher than the control subjects (P<0.01). Mean fundamental frequency, amplitude perturbation measures, and noise-to-harmonics ratio were not significantly different between groups.

CONCLUSION

LPR patients have significantly different frequency perturbation values than control subjects.

Reliability of Speech-Language Pathologist and Otolaryngologist Ratings of Laryngeal Signs of Reflux in an Asymptomatic Population Using the Reflux Finding Score

OBJECTIVE

To determine inter- and intrajudge agreement in rating signs of laryngopharyngeal reflux (LPR) under "ideal" conditions: Experienced coworkers in a practice devoted to voice-disordered patients, raters trained in the items on a standardized scale, raters from both speech-language pathology (SLP) and otolaryngology, and raters of asymptomatic participants.

STUDY DESIGN

Prospective study using a scale to rate videolaryngoscopic examinations.

METHODS

Two SLPs and two otolaryngologists used the Reflux Finding Scale (RFS) to independently rate videotapes of endoscopic examinations for 30 participants asymptomatic of reflux.

RESULTS

Thirteen (43%) were assigned a total score >7, indicative of LPR, by at least one rater. Intraclass correlation coefficients showed a significant lack of agreement in total scores provided by the otolaryngologists and by all raters combined. One otolaryngologist and the two SLPs demonstrated good interrater agreement in total scores. McNamar's statistic and Poisson regression modeling showed differences in rater agreement for many individual items. Repeated ratings of four participants showed no significant differences, indicating good intrarater reliability.

CONCLUSIONS

Level of rater agreement regarding the presence and the severity of physical findings attributed to LPR within and between otolaryngologists and SLPs differed. Given the role each profession plays in the diagnosis and treatment of LPR and related voice disturbances, higher levels of interprofessional agreement are desired. Results support the need for greater consensus among professionals regarding the discreet features of physical findings associated with LPR, a fuller understanding of normal variants, and greater emphasis on interrater reliability when rating physical findings.

Laryngopharyngeal reflux: A literature review

Laryngopharyngeal reflux (LPR) is a common condition encountered in otolaryngological practice in the United Kingdom. It is one of the most important aetiological factors for many inflammatory disorders of the upper aerodigestive tract. The presentations are diverse and include chronic hoarseness, sensation of a foreign body in the throat, sore throat, dysphagia, postnasal drip, excessive throat mucous, chronic cough and throat clearing. LPR patients may not complain of heartburn. Although LPR is common, its diagnosis may not be easy, as its symptoms are non specific and the laryngeal findings are not always associated with symptom severity. This article discusses an overall view of LPR in terms of pathophysiology, clinical presentation, diagnosis and treatment

Subjective and objective evaluation of voice quality in patients with asthma

OBJECTIVES

To evaluate the voice quality in patients with mild-to-moderate asthma by subjective and objective methods.

STUDY DESIGN

Comparative, controlled, cross-sectional study.

METHODS

Patients with mild-to-moderate asthma (n=40) and age- and sex-matched healthy controls (n=40) were included. Acoustic analyses were performed by the Multi-Dimensional Voice Program (MDVP; Kay Elemetrics Corporation, Lincoln Park, NJ) and the movements of the vocal cords were examined by videolaryngostroboscopy (VLS). In addition, the duration of illness, maximum phonation time, "s/z" values, and vital capacity were evaluated. Voice Handicap Index (VHI) and GRB scales were used for subjective evaluations.

RESULTS

Maximum phonation time values were significantly shorter both in male and female asthma patients compared with controls (P<0.0001). Also, average shimmer values in MDVP were higher for both sexes in the patient group compared with controls (P=0.002 and P=0.04, respectively). There was a significant difference between female patients and sex-matched controls with regard to mean noise-to-harmonic ratio values (P=0.006). Female patients with asthma had higher average jitter values compared with sex-matched controls (P<0.0001). A significant difference was noted between asthma and control groups with regard to GRB scale (P<0.0001, P<0.001, and P<0.0001, respectively). The VHI score was above the normal limit in 16 (40%), and VLS findings were abnormal in 39 (97.5%) asthmatics.

CONCLUSION

In asthmatic patients, maximum phonation time, frequency, and amplitude perturbation parameters were impaired, but the vital capacity and the duration of illness did not correlate with these findings.

Histopathologic examination for Helicobacter pylori as a possible etiopathogenic factor in laryngeal carcinoma

OBJECTIVE

We investigated the presence of Helicobacter pylori in laryngeal cancer specimens to reveal whether or not this is a risk factor in the development of squamous cell carcinoma of the larynx.

METHODS

Sixty-nine total laryngectomy specimens with the pathologic diagnosis of squamous cell carcinoma and 30 laryngeal tissue samples that had been taken for the investigation of nonneoplastic (polyp, nodule) diseases were studied. Specimens of both tumor and control groups were stained with hematoxylin-eosin and modified Giemsa stains, and then they were examined under a light microscope.

RESULTS

In both groups, H. pylori could not be found in any of the cases.

CONCLUSION

The histologic examination of our series did not reveal any clue related to the possible etiologic association between H. pylori and squamous cell carcinoma of the larynx.

Nasal pain disrupting sleep as a presenting symptom of extraesophageal acid reflux in children

A constellation of otolaryngologic signs and symptoms has been suggested to identify the association between extraesophageal reflux disease (EERD) and pediatric otolaryngologic disorders. We describe chronic nasal pain as a manifestation of laryngopharyngeal acid reflux in a 4-year-old boy who presented with frequent night awakenings due to severe nasal pain. His presentation, relevant history physical examination, diagnostic studies, and response to therapy are described. This is the first report documenting nasal pain resolved with acid suppressive therapy in a child with EERD. The incidence and pathogenesis of EERD induced nasal symptoms in children merits further investigation.

Heterotopic gastric mucosa in the cervical esophagus: could this play a role in the pathogenesis of laryngopharyngeal reflux in a subgroup of patients with posterior laryngitis?

OBJECTIVE

Acid secretion produced by a heterotopic gastric mucosal patch (HGMP) in the proximal esophagus, instead of gastric acid, may be responsible for laryngopharyngeal reflux (LPR), passing the upper esophageal sphincter. The aim of this study was to investigate the prevalence of HGMP in the proximal esophagus in patients with posterior laryngitis indicating the presence of LPR in comparison with a control group and to elucidate the possible role of this lesion in the pathogenesis of LPR.

MATERIAL AND METHODS

A total of 36 consecutive patients with posterior laryngitis diagnosed on laryngoscopic examination were enrolled in the study. Esophagoscopy and ambulatory 24-h intra-esophageal dual-probe pH monitoring were performed in all patients. During endoscopy, special attention was paid to the proximal part of the esophagus, and the proximal electrode for pH monitoring was placed in this region under endoscopic view. The control group comprised 660 consecutive patients who had undergone upper gastrointestinal endoscopy for the usual indications. When HGMP was found, biopsies were taken for histological confirmation.

RESULTS

HGMP was detected in 5 out of 36 patients. One out of five patients with patches was excluded from the study because the histopathology of this patient's patch revealed antral-type mucosa, which is not capable of acid secretion. Thus a total of 35 patients were included in the study, yielding a HGMP prevalence of 11.4% (4/35). Compared with the prevalence of the control group (1.6%), a significant difference was observed (p<0.005). pH monitoring showed that 45.4% of the patients had abnormal proximal acid reflux. All of four HGMP (+) patients with posterior laryngitis revealed significantly higher abnormal proximal reflux compared to the patients without patches (p<0.05).

CONCLUSIONS

This first preliminary study may suggest that HGMP in the cervical esophagus could play a role in the pathogenesis of LPR, at least in a minor group of patients with posterior laryngitis, depending on its capability to produce acid in situ, although isolated proximal reflux could not be demonstrated. This finding may need to be supported by further studies with larger patient populations and using acid stimulation tests.

Direct Nasopharyngeal Reflux of Gastric Acid is a Contributing Factor in Refractory Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

To determine whether there is a difference in the prevalence of reflux in patients with refractory chronic rhinosinusitis (CRS) compared with control patients, including whether direct nasopharyngeal reflux (NPR) occurs in CRS patients. It is hypothesized that refractory CRS patients have a greater incidence of laryngopharyngeal reflux and NPR events and that NPR is a significant etiologic factor for CRS in these patients.

STUDY DESIGN

Prospective study.

METHODS

The study group consisted of 38 patients with a history of at least one endoscopic sinus surgery (ESS) with continued CRS symptoms and mucosal inflammation on endoscopy. The first control group consisted of 10 patients who had at least one ESS procedure and had no symptoms of CRS or mucosal inflammation a minimum of 1 year postoperatively. The second control group consisted of 20 subjects with no history of CRS or sinus surgery. All patients completed reflux symptom scales, a 20 item sinonasal outcome test, and a sinusitis symptom scale and underwent nasal endoscopy to grade the nasal mucosal findings. Patients underwent a 24 hour pH study with a specially designed probe with sensors located in the nasopharynx, 1 cm above the upper esophageal sphincter (UES), and the distal esophagus. The pH recordings were evaluated for NPR events less than pH 4 and 5. Reflux at the UES probe was considered pathologic if there were more than 6.9 episodes for the entire study or the reflux area index (RAI) exceeded 6.3. Esophageal reflux was defined as abnormal if greater than 4% of the study time was spent at pH less than 4. Statistical analysis was performed with Fisher's exact test to compare the reflux parameters and with analysis of variance and Tukey's post hoc analysis for the symptom and examination scores.

RESULTS

No statistical difference was found between the two control groups for any parameters at any sites. When a single outlier was dropped from the nonCRS control group, less NPR was found in the nonCRS group compared with the successful ESS control group (P = .03). Because these groups were statistically homogenous, they were collapsed into a single control group. Compared with the control group, the study group had significantly more patients with NPR events pH less than 4 (39% vs. 7%, P = .004) and an even greater difference in the number of patients with NPR events pH less than 5 (76% vs. 24%, P = .00003). At the UES, 74% of the study group had greater than 6.9 reflux episodes, compared with 38% of control patients (P = .006). The UES RAI was abnormal for 58% of the study group compared with 21% of the control group (P = .007). The study group also had more gastroesophageal reflux (66% vs. 31%, P = .007). For nasopharynx and UES reflux parameters, the differences between study and control groups increased when the patients with isolated frontal recess disease were removed from the dataset. The study group also had higher scores on all symptom and examination scores (P = .001 for each scale).

CONCLUSIONS

Patients with persistent CRS after ESS have more reflux at the nasopharynx, UES, and distal esophagus than controls. The greatest difference is in NPR, especially pH less than 5. This is the first study to document NPR in CRS patients, and it is likely to represent an important causative factor of refractory CRS in adults.

Cough. 1: Chronic cough in adults

The investigation and treatment of chronic cough in adults is generally rewarding, provided there is an understanding of its aetiology, particularly when it arises from sites outside the respiratory tract.

Empiric esomeprazole in the treatment of laryngopharyngeal reflux

OBJECTIVE

Objectives were to determine the efficacy of empiric treatment with esomeprazole for patients diagnosed with laryngopharyngeal reflux and to determine a treatment paradigm for this patient population.

STUDY DESIGN

Prospective study.

METHODS

Patients were treated with a once-daily dose of 40 mg esomeprazole for 8 weeks. All patients completed a subjective symptom scale (rating laryngeal symptoms and esophageal symptoms) and scoring of flexible fiberoptic examination before treatment and at 4 and 8 weeks of treatment. Nonresponders (<50% reduction in symptom score) were recommended to undergo 24-hour dual-probe pH study while on a regimen of 40 mg esomeprazole once a day, to evaluate for the adequacy of acid suppression.

RESULTS

Thirty patients completed the course of therapy. After 4 weeks of treatment, only 8 of 30 patients had significant improvement of their overall symptoms (8 of 30 improved on laryngeal score, and 11 of 18 improved on esophageal score). At 8 weeks of treatment, 19 of 30 patients had significant improvement on their overall symptoms (18 of 30 on laryngeal score, and 13 of 18 on their esophageal score). Five of seven nonresponders who agreed to be tested had positive findings on pH studies (on medication regimen) at 1 cm above the upper esophageal sphincter. Four of 10 nonresponders improved further after increasing their dosage to 40 mg twice a day. Laryngeal examination scores were statistically improved in responders after 8 weeks of treatment.

CONCLUSIONS

Laryngopharyngeal reflux symptoms require at least 8 weeks of treatment for significant improvement in the majority of patients. Esophageal symptoms improve sooner. Nonresponders at a daily dose of 40 mg should be treated with a dosage of 40 mg twice daily, and pH study on medication reserved for nonresponders at this higher dose. Laryngeal examination scores showed mild but statistically significant improvement at 8 weeks of therapy in responders.

Perspectives in laryngopharyngeal reflux: an international survey

OBJECTIVES

Although data exists to support the relationship between laryngopharyngeal reflux (LPR) and laryngitis, there is variability among otolaryngologists regarding the methods and criteria used to make the diagnosis. This study was undertaken to discern the current attitudes and practices of a select cohort of otolaryngologists in regards to LPR.

METHODS

Four hundred fifteen surveys were mailed to members of the American Broncho-Esophagological Association. Survey recipients were asked to rate patient symptomatology and physical examination findings in terms of their relationship to LPR and their preferred laryngeal visualization procedure in terms of clinical use and diagnostic accuracy. The role and validity of adjunctive diagnostic tests were also surveyed.

RESULTS

Survey response rate was 38%. Symptoms felt to be most related to reflux were: throat clearing (98.3%), persistent cough (96.6%), heartburn/dyspepsia (95.7%), globus sensation (94.9%), and voice quality change (94.9%). The physical examination findings felt to be most related to reflux included: arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%). Fiberoptic laryngoscopy was the most commonly performed diagnostic visualization procedure (75.7%) and was also considered to be most sensitive and specific (45.0%). The most commonly ordered adjunctive test was a double pH probe (37.2%), which was also felt to be the most sensitive and specific adjunctive test (75.9%).

CONCLUSION

A polling of a select group of otolaryngologists demonstrated agreement in the criteria used to diagnose reflux laryngitis, although some variability exists. The development of objective guidelines for the diagnosis of LPR is a critical initial step toward evaluating the manifestations and therapeutic interventions for this disease process.

Inflammatory and granulomatous lesions of the larynx and pharynx

A number of inflammatory and granulomatous lesions can involve the larynx and pharynx. These conditions are generally difficult to diagnose because of the range of symptoms. This article reviews the following conditions: supraesophageal complications of reflux disease, relapsing polychondritis, Wegener granulomatosis, sarcoidosis, tuberculous laryngitis, Teflon (polytetrafluoroethylene fluoropolymer resin; DuPont, Wilmington, DE) granuloma, amyloidosis, rheumatoid arthritis, and systemic lupus erythematosus. The purpose is to provide a brief review of each disease and its manifestations, symptoms, diagnosis, and treatment.