Symptoms, laryngeal findings, and 24-hour pH monitoring in patients with suspected gastroesophago-pharyngeal reflux

Characterization of Laryngopharyngeal Reflux in the Elderly Population

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validity and Reliability of the Persian Version of Reflux Symptom Score-12 in Patients with Laryngopharyngeal Reflux Disease

OBJECTIVE

Cross cultural adaptation of the reflux symptom score-12 (RSS-12) into Persian language and to evaluate its validity and reliability in the assessment of patients with laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

A cross-sectional and prospective cohort design.

METHODS

A standard forward and backward translation was followed to cross-culturally adapt the RSS-12 into Persian language. To study discriminative validity, the RSS-12p was administrated to 63 patients with LPRD (40 men and 23 women; mean age: 39.26 ± 9.79 years) and 50 healthy volunteers (31 men and 19 women; mean age: 37.24 ± 10.28 years). The patients completed the reflux symptom index (RSI) to assess construct validity. The test-retest reliability was investigated in 31 patients (time interval = 7 days).

RESULTS

There were no missing responses and floor or ceiling effects. The assessing of discriminative validity showed that the questionnaire was able to discriminate between patients with LPRD and healthy participants (P<0.001). Construct validity was confirmed by the Pearson correlation between the RSS-12p and the RSI (rp= 0.87; P<0.00). The internal consistency was confirmed with Cronbach α 0.85 and 0.72 for the RSS-12p and quality of life (QoL), respectively. Test-retest reliability was excellent (ICCagreement = 0.98 for the RSS-12p and 0.94 for QoL).

CONCLUSIONS

The Persian version of RSS-12 is a valid and reliable self-administered questionnaire for assessing LPRD in Persian-speaking patients.

24-Hour Multichannel Intraluminal Impedance-pH in Proton Pump Inhibitor Nonresponders vs Responders in Patients With Laryngopharyngeal Reflux

OBJECTIVE

This study aimed to evaluate the characteristics of reflux in proton pump inhibitor (PPI) nonresponders vs responders in patients with laryngopharyngeal reflux (LPR) by using 24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring.

STUDY DESIGN

Prospective cohort study.

SETTING

A tertiary care otolaryngology clinic.

METHODS

Patients with typical LPR symptoms showing >1 proximal reflux episode were considered to have LPR and investigated prospectively. Patients were prescribed high-dose PPI twice daily and followed up for at least 2 months. Patients with LPR showing a ≥50% decrease in the follow-up reflux symptom index score during treatment periods as compared with pretreatment were defined as responders; others were defined as nonresponders. Various parameters in 24-hour MII-pH monitoring between nonresponders and responders with LPR were compared with Student's t test and receiver operating characteristic curve.

RESULTS

Eighty patients were diagnosed with LPR and categorized as nonresponders (n = 19) and responders (n = 61). Proximal all reflux time and proximal longest reflux time in various MII parameters were higher in responders than in nonresponders (P = .0040 and .0216, respectively). Proximal all reflux time >0.000517% was a better cutoff value to predict responders with LPR as compared with the proximal longest reflux time >0.61 minutes (sensitivity + specificity: 1.317 vs 1.291).

CONCLUSION

Proximal all reflux time in various 24-hour MII-pH monitoring parameters can be helpful to predict the response to PPI therapy in patients with LPR. These findings will help establish a personalized therapeutic scheme for patients with LPR.

Pharyngeal reflux episodes in patients with suspected laryngopharyngeal reflux versus healthy subjects: a prospective cohort study

PURPOSE

This study aimed to analyze pharyngeal reflux episodes in patients with suspected LPR versus healthy subjects using 24-h MII-pH monitoring.

METHODS

One hundred twenty-one patients who visited our clinic with a chief complaint of LPR-related symptoms and underwent 24-h MII-pH monitoring were enrolled prospectively. Also, 27 healthy subjects were enrolled and underwent 24-h MII-pH monitoring during the same period. We analyzed sensitivity, specificity, and accuracy comprehensively to determine appropriate cut-off values of pharyngeal reflux episodes in 24-h MII-pH monitoring to diagnose patients with LPR.

RESULTS

Twenty-nine of 121 patients with suspected LPR showed no pharyngeal reflux episodes, while 92 showed more than one pharyngeal reflux event. In contrast, the 22 healthy subjects showed no pharyngeal reflux episodes, three showed one reflux event, and two showed two reflux events. A cut-off value of ≥ 1 showed best accuracy reflected by combined sensitivity and specificity values, while ≥ 2 demonstrated better specificity with slight loss of sensitivity and slightly lower overall accuracy, suggesting cut-off value of ≥ 1 pharyngeal reflux episodes is a good clinical indicator.

CONCLUSION

A cut-off value of ≥ 1 in pharyngeal reflux episodes on 24-h MII-pH monitoring in patients with suspected LPR might be an acceptable diagnostic tool for LPR.

Sensitivity, Specificity, and Reproducibility of the Brazilian Portuguese Version of the Reflux Symptom Index

INTRODUCTION

The diagnosis of laryngopharyngeal reflux is controversial. There is currently no gold standard, so it relies mainly on suspicious clinical symptoms and videolaryngoscopic findings. Unfortunately these signs and symptoms are common to other causes of chronic laryngitis. Scoring systems have been proposed to reduce subjectivity in clinical diagnosis. The most widely used and accepted is the Reflux Symptom Index, which has already been translated into over 10 other languages.

OBJECTIVE

Study the psychometric properties of the Brazilian Portuguese version of the Reflux Symptom Index (Índice de Sintomas de Refluxo - ISR).

METHODS

One hundred and fifty-four adults, 88 with laryngopharyngeal reflux and 66 healthy controls, were studied over a 6-month period, responding to the ISR after thoroughly investigated on possible other causes of chronic laryngitis and the presence of gastroesophageal disease. Test and retest reliability was addressed by reapplying the score to a random subgroup of 101 subjects.

RESULTS

The ISR of subjects was significantly higher than that of controls (Student t test for independent samples, P < 0.001). The ISR also showed high temporal stability and reproducibility (ICC of 0.988 with a confidence interval of 0.982-0.992). The ISR at a cutoff of 13 points presented a sensitivity of 78.4%, a specificity of 95.4%, a false negative of 4.55%, a false positive of 21.59%, a positive predictive value of 95.83%, and a negative predictive value of 86.93%.

CONCLUSION

The ISR proved to be a valid and reliable diagnostic tool.

Proton Pump Inhibitor Ameliorates Taste Disturbance among Patients with Laryngopharyngeal Reflux: A Randomized Controlled Study

Patients with laryngopharyngeal reflux (LPR) were reported to suffer from hypogeusia that affects quality of life. Proton pump inhibitor (PPI) is a useful drug in the treatment of LPR, but its effect on hypogeusia is not known. We therefore assessed the effects of PPI or a histamine H2 receptor antagonist (H2 blocker) on hypogeusia among patients with LPR. Both PPI and H2 blocker could inhibit acid reflux. LPR was diagnosed with reflux finding score and reflux symptom index. The visual analogue scale (VAS) of taste disturbance symptoms and the gustatory tests were assessed before and 8 weeks after treatment with esomeprazole, a PPI (20 patients, aged 50.0 ± 1.7 years) or famotidine, a H2 blocker (20 patients, aged 47.1 ± 1.8 years). There were no significant differences in VAS scores and recognition thresholds for four basic tastes between the two groups before treatment. Only PPI therapy significantly decreased the VAS scores, suggesting the improvement of taste perception. Moreover, PPI therapy significantly decreased recognition thresholds for bitter taste in the anterior tongue (chorda tympani nerve area) and the thresholds in the posterior tongue (glossopharyngeal nerve area) for salty, sour, and bitter tastes. By contrast, H2-blocker therapy caused no significant changes of thresholds in the anterior tongue, but improved the threshold only for bitter in the posterior tongue, the value of which was however significantly higher than that in PPI group. In conclusion, PPI could ameliorate hypogeusia by improving bitter, salty, and sour tastes among patients with LPR.

Salivary epidermal growth factor concentrations in patients with Sjögren syndrome and laryngopharyngeal reflux

Sjögren syndrome was chosen as a clinical model to study acinar salivary deficiencies in the development of laryngopharyngeal reflux (LPR). The objective of this prospective cohort study was to compare salivary epidermal growth factor (EGF) concentrations of patients with Sjögren syndrome with and without LPR and gastroesophageal reflux disease (GERD) with normal controls. LPR was diagnosed with positive scores on the Reflux Symptom Index and Reflux and Reflux Finding Score, corroborated by esophagogastroduodenoscopy and/or 24-hour pH-metry. Salivary EGF concentrations of both unstimulated and mechanically stimulated saliva were established using enzyme-linked immunosorbent assay, and the significance level was set at 95%. Twenty-one patients and 19 controls were studied. All patients had LPR and 60% also had GERD. The mean salivary EGF concentration of unstimulated and stimulated saliva in the control group was 1,751.37 pg/ml and 544.76 pg/ml, respectively. Unstimulated and stimulated salivary EGF concentrations in the study group were 2,534.65 pg/ml and 920.69 pg/ml, respectively. These differences were not statistically significant. Body mass index, presence of erosive esophagitis, or severity of hyposalivation did not significantly influence salivary EGF concentrations. LPR and GERD are highly prevalent in patients with Sjögren syndrome. Unlike previous studies in which significant EGF deficiencies were found in patients with reflux laryngitis and GERD, patients with Sjögren syndrome seem to have reflux caused by a decrease in clearance capacity and not in specific salivary components.

Quantifying Laryngopharyngeal Reflux in Singers: Perceptual and Objective Findings

This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes. Twenty professional/semiprofessional singers completed the Reflux Symptom Index (RSI) and underwent oropharyngeal pH monitoring. Mild, moderate, or severe pH exposure was recorded during oropharyngeal pH monitoring. Correlations were performed to examine potential relationships between reflux symptoms and duration of LPR episodes. Symptom severity did not correlate with pH levels; however, we found a number of covariances of interest. Large sample sizes are necessary to determine if true correlations exist. Our results suggest that singers may exhibit enhanced sensitivity to LPR and may therefore manifest symptoms, even in response to subtle changes in pH. This study emphasizes the importance of sensitive and objective measures of reflux severity as well as consideration of the cumulative time of reflux exposure in addition to the number of reflux episodes.

The Role of Helicobacter pylori in Laryngopharyngeal Reflux

Objective The primary objective was to determine the prevalence of Helicobacter pylori among patients with laryngopharyngeal reflux. The secondary objective was determining if H pylori eradication leads to greater symptom improvement in patients with laryngopharyngeal reflux as compared with standard proton pump inhibitor therapy alone. Data Sources EMBASE, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, World Health Organization International Clinical Trials Registry Platform, European Union Clinical Trials Register, Cochrane Library databases of clinical trials, and ClinicalTrials.gov. Review Methods A systematic review was performed of studies assessing the diagnosis or treatment of H pylori among patients with laryngopharyngeal reflux. Randomized controlled trials, cohort studies, case-control studies, and case series were included. A meta-analysis of prevalence data and assessment of heterogeneity was performed on relevant studies. Results Fourteen studies were analyzed in the review, with 13 eligible for the meta-analysis. We determined that the prevalence of H pylori among patients with laryngopharyngeal reflux was 43.9% (95% confidence interval, 32.1-56.5). The heterogeneity of studies was high, with an overall I² value of 92.3%. We were unable to quantitatively assess findings for our secondary outcome, since H pylori identification and treatment were not the primary focus of the majority of studies. Conclusion There is a high rate of H pylori infection among patients with laryngopharyngeal reflux. The infection rate in North America and Western Europe has not been adequately studied. There is insufficient evidence to make a recommendation regarding the testing and treatment of H pylori infection among patients with laryngopharyngeal reflux.

Inhaled Corticosteroids and Voice Problems. What Is New?

BACKGROUND

Voice problems are the most common and most annoying local side effect of inhaled corticosteroids (ICS), affecting not only patients' treatment compliance but also their quality of life. The literature is very poor regarding prevalence, mechanism, prevention, and management of voice problems attributed to ICS use and especially for the new ICS, ciclesonide. Prevalence of dysphonia seems to be less common with the use of ciclesonide and beclomethasone dipropionate.

METHOD

We conducted a bibliography review based on recently published data, including data from the recently introduced ICS, ciclesonide, which are lacking in previous reviews.

RESULTS

Very little improvement, based on limited number of new papers published during previous years without any direct comparison between available ICS, has been made in our understanding of ICS local side effects.

CONCLUSION

Our understanding concerning basic information of ICS effects on voice still remains poor, and further investigation is needed to have a better understanding on epidemiology, predisposing factors, mechanisms, prevention, and treatment of voice problems attributed to ICS.

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.

Effect of Acid and Pepsin on Gene Expression in Laryngeal Fibroblasts

The aim of this study was to determine changes that momentary low pH with or without pepsin causes in gene expression in laryngeal fibroblasts. Cell cultures were established from human false vocal fold (FVF) and postcricoidal (PC) mucosae. Using a real-time polymerase chain reaction, we analyzed messenger RNA gene expression of growth factors (transforming growth factor β1, vascular endothelial growth factor, fibroblast growth factor 2), matrix metalloproteinases (MMP-1, MMP-2), and decorin in normal media, pH 4 media, and pH 5 media with and without pepsin. The FVF fibroblast gene expression differed substantially from the PC fibroblast gene expression. No significant interaction effects for acid and pepsin were found in the FVF culture, but in PC cultures we found a significant overexpression interaction effect for vascular endothelial growth factor, fibroblast growth factor 2, MMP-1, MMP-2, and decorin. These results imply that PC tissue is more sensitive than FVF tissue to the noxious effects of gastric contents. Furthermore, there appears to be a synergistic effect for acid and pepsin exposure in the posterior larynx.

Evaluation of a laryngopharyngeal reflux management protocol

PURPOSE

To evaluate the effectiveness of a protocol for management of patients with laryngopharyngeal reflux (LPR) in a multi-provider clinic.

MATERIALS AND METHODS

This is a retrospective cohort study of 188 patients treated for LPR. A standardized clinical protocol for diagnosis and management was instituted in 2012. Two cohorts were established: those managed according to the protocol, and those who were not. For patients managed with the LPR protocol, diagnosis was made using clinical judgment, guided by the Reflux Symptom Index (RSI) and Reflux Finding Score (RFS). Patients were treated with proton pump inhibitors (PPI) with the goal of weaning therapy after symptom resolution. Response to therapy was rated using a global rating scale with three response levels: no response, partial response, and complete response. The primary outcome measure was complete response to therapy and the secondary outcome measures were any response (complete or partial) and successful wean off PPI therapy.

RESULTS

The patients treated with the LPR protocol had higher rates of complete response (p<0.001). There was no statistically significant difference in rates of any response (complete or partial) between the two groups (p=0.08). Patients treated using the LPR protocol were more likely to be successfully weaned off PPI therapy (p=0.006).

CONCLUSIONS

The use of an LPR protocol improved treatment effectiveness in our clinic, highlighting the role of clinical protocols in reducing variability in care, thereby improving patient outcomes.

Salivary transforming growth factor alpha in patients with Sjögren's syndrome and reflux laryngitis

Introduction

Saliva plays a key role in the homeostasis of the digestive tract, through its inorganic components and its protein growth factors. Sjögren's syndrome patients have a higher prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux. Decreased salivary transforming growth factor alpha levels were observed in dyspeptic patients, but there have been no studies in patients with Sjögren's syndrome and laryngopharyngeal reflux.

Objective

To compare the salivary transforming growth factor alpha levels of patients with Sjögren's syndrome and laryngopharyngeal reflux to those of healthy controls.

Methods

This is a prospective controlled study. Twelve patients with Sjögren's syndrome and laryngopharyngeal reflux and 11 controls were prospectively evaluated. Spontaneous and stimulated saliva samples were obtained to establish salivary transforming growth factor alpha concentrations.

Results

The salivary transforming growth factor alpha levels of patients were significantly higher than those of healthy controls. Five patients with laryngopharyngeal reflux also had erosive esophagitis; their salivary transforming growth factor alpha levels were comparable to controls.

Conclusion

Salivary transforming growth factor alpha level was significantly higher in patients with Sjögren's syndrome and laryngopharyngeal reflux when compared to the control group.

A systematic review of proton-pump inhibitor therapy for laryngopharyngeal reflux

The author performed a MEDLINE literature search to identify and evaluate all randomized, placebo-controlled trials of the treatment of laryngopharyngeal reflux (LPR) with an oral proton-pump inhibitor (PPI) that have been published since 1966. Eight such trials that included a total of 358 patients were identified. These eight studies contained seven different definitions of LPR. Validity scores (maximum: 9) ranged from 5 to 9 (mean: 7.5). One study investigated low-dose once-daily therapy, two studies investigated low-dose twice-daily therapy, and five studies investigated high-dose twice-daily therapy. Outcomes measures were not consistent among studies, and most studies used unvalidated outcomes measures. Only two studies found that a PPI was significantly better than placebo-one in the low-dose twice-daily group and one in the high-dose twice-daily group. The author concludes that the current body of literature is insufficient to draw reliable conclusions about the efficacy of PPI therapy for the treatment of LPR.

Efficacy of super high dose proton pump inhibitor administration in refractory laryngopharyngeal reflux: a pilot study

OBJECTIVES

Proton pump inhibitors (PPIs) are the mainstay of current medical management for laryngopharyngeal reflux (LPR) but may be insufficient in managing some patients' disease. This study was designed to investigate the effectiveness of superdose PPI therapy in the improvement of 24-hour pH impedance studies and stroboscopy findings in patients with LPR refractory to standard dosing (BID PPI).

STUDY DESIGN

Retrospective chart review.

METHODS

This study examined 35 patients ranging from 20 to 76 years diagnosed with refractory LPR who were treated with super high dose PPIs. Reflux finding scores (RFS) obtained by three blinded raters and 24-hour pH impedance study scores were compared for patients on standard and then super high dose PPI regimens.

RESULTS

Statistical analysis of the stroboscopy evaluation revealed a modest but statistically significant decrease in the RFS scores for those patients on super high dose therapy, with good intrarater reliability. The DeMeester score showed no significant change between standard and super high dose regimens. The results of the 24-hour pH impedance monitoring showed no statistically significant decrease in acid reflux episodes despite an average of 7.6 fewer proximal acid reflux episodes.

CONCLUSION

Super high dose therapy seems to improve laryngeal signs of irritation as reflected by RFS. This improvement was not reflected in our patient population's severity of reflux while on super high dose therapy when compared with standard LPR therapy as measured by 24-hour pH impedance monitoring, although this finding may reflect selection bias. RFS and 24-hour pH impedance may be insufficiently sensitive to detect improvements in LPR with adequate treatment.

Edema of the interarytenoid mucosa seen on endoscopy is related to endoscopic-positive esophagitis (EE) and is an independent predictor of EE

BACKGROUND

Laryngopharyngeal reflux (LPR) is defined as the retrograde flow of gastric contents up through the esophagus to the larynx and hypopharynx; this is an extra-esophageal manifestation of gastroesophageal reflux disease (GERD). Although both LPR and GERD are caused by reflux of stomach contents, their clinical presentations and treatments differ.

PATIENTS AND METHODS

In the present study, we assessed esophago-gastroendoscopic findings related to GERD, specifically endoscopic-positive esophagitis (EE), laryngopharyngeal findings, and GERD symptoms on the 12-question frequency scale for the symptoms of gastroesophageal reflux disease (FSSG). Then, independent predictors of EE were analyzed, and relationships among EE, laryngopharyngeal findings, and patients' symptoms and characteristics were investigated.

RESULTS

Hiatal hernia (odds ratio [OR]: 2.70; 95% confidence interval [CI]: 1.17-6.23, P-value 0.019) and edema of theinterarytenoid mucosa (OR, 3.77; 95% CI, 1.26-16.3; P-value 0.035) were significantly related with EE and independent predictors of EE. However, patients' characteristics and the FSSG score had no significant relationship with EE; there was no relationship between patients' characteristics and EE, regardless of its severity.

CONCLUSIONS

Although LPR symptoms had no significant relationship with the findings of EE, hiatal hernia and edema of the interarytenoid mucosa were significantly related with EE and were considered to be independent predictors of EE.

Posterior laryngitis: a disease with different aetiologies affecting health-related quality of life: a prospective case-control study

BACKGROUND

Laryngo-pharyngeal reflux (LPR) is assumed to be the most common cause of posterior laryngitis (PL). Since LPR is found in healthy subjects, and PL patients are not improved by acid-reducing therapy, other aetiologies to PL must be considered. The aims of this study in PL were to investigate the prevalence of acid reflux in the proximal oesophagus and functional gastrointestinal symptoms, to analyse motilin levels in plasma, and to assess health-related quality of life (HRQOL) before and after treatment.

METHODS

Forty-six patients (26 women), with verified PL, median age 55 (IQR 41-68) years, were referred to oesophago-gastro-duodenoscopy and 24-h pH monitoring. Plasma motilin was analysed. The 36-item Short-Form questionnaire was completed at inclusion and at follow-up after 43±14 months, when also the Visual Analogue Scale for Irritable Bowel Syndrome was completed. Values were compared to controls. Treatment and relief of symptoms were noted from medical records.

RESULTS

Thirty-four percent had proximal acid reflux and 40% showed signs of distal reflux. Ninety-four percent received acid-reducing treatment, with total relief of symptoms in 17%. Patients with reflux symptoms had lower plasma motilin levels compared to patients without reflux symptoms (p = 0.021). The HRQOL was impaired at inclusion, but improved over time. Patients, especially men, had more functional gastrointestinal symptoms than controls.

CONCLUSIONS

This study indicates that a minority of patients with PL has LPR and is cured by acid-reducing therapy. Disturbed plasma motilin levels and presence of functional gastrointestinal symptoms are found in PL. The impaired HRQOL improves over time.

Esophageal motility, vagal function and gastroesophageal reflux in a cohort of adult asthmatics

BACKGROUND

Asthmatics are known to have esophageal hypomotility. Vagal hypofunction and prolonged intra-esophageal acidification cause esophageal hypomotility. The contribution of gastroesophageal reflux (GER) and vagal function to esophageal motility in asthmatics is unclear. We studied the relationship between esophageal motility, GER and vagal function in a cohort of adult asthmatics.

METHODS

Thirty mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory esophageal monitoring, manometry, autonomic function testing and GER symptom assessment. 27 asthmatics underwent gastroscopy. A vagal function score calculated from 3 tests (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) was correlated with esophageal function parameters.

RESULTS

Asthmatics (mean age 34.8 (SD 8.4), 60% female) had more frequent GERD symptoms than controls (mean age 30.9 (SD 7.7), 50% female). 10/27 asthmatics had esophageal mucosal damage, 22 showed hypervagal response, none had a hyperadrenergic response. 14 asthmatics had ineffective esophageal motility. Higher GERD-score asthmatics had significantly fewer peristaltic and more simultaneous contractions than controls, and higher esophageal acid contact times than those with lower scores. All reflux parameters were significantly higher and acid clearance time prolonged in asthmatics than controls (p < 0.001, Mann-Whitney U test). There was no correlation between vagal function score and esophageal function parameters.

CONCLUSIONS

A cohort of adult asthmatics was found to have peristaltic dysfunction and pathological GER, but otherwise normal esophageal motility. The peristaltic dysfunction seems to be associated with vagal hyperreactivity rather than vagal hypofunction.

Índice de sintomas do refluxo Faringo-Laríngeo: relação com os principais sintomas de refluxo gastresofágico, nível de uso de voz e triagem vocal

OBJETIVO: relacionar o Índice de Sintomas do Refluxo Faringo-Laríngeo - ISRFL com os principais sintomas do refluxo gastresofágico - RGE (azia/queimação e dor retroesternal), com o nível de uso da voz e com uma triagem vocal. MÉTODO: participaram deste estudo 179 voluntários maiores de 18 anos, 107 mulheres e 72 homens, classificados em dois grupos de acordo com o escore total do ISRFL, grupo positivo (escore total igual ou maior a 13 pontos) e negativo (abaixo deste). Os participantes foram questionados sobre a presença dos sinais característicos do refluxo gastresofágico (azia/queimação e/ou dor retroesternal), sobre a demanda de uso da voz (baixa/alta demanda) e submetidos à triagem vocal durante a entrevista. RESULTADOS: quanto ao ISRFL, 35 (19,6%) indivíduos compuseram o grupo positivo (escore médio de 20) e 144 (80,4%) o grupo negativo (média de 4,34 pontos). Os sintomas característicos do RGE foram maiores no grupo positivo: azia/queimação em 54,2% (19) verso 30,5% (44), dor retroesternal em 51,4% (18) verso 20,1% (29), sendo que 74,3% dos indivíduos do grupo positivo e apenas 43,1% do negativo apresentaram algum dos sintomas. Quanto à triagem vocal, 37,1% do grupo positivo e 13% do negativo falharam. Não houve diferença de demanda vocal auto-relatada entre os grupos. Foi encontrada associação estatística entre IRFL positivo, os sintomas de refluxo gastresofágico e fracasso na triagem vocal (p< 0,001). Não houve associação quanto ao uso da voz. CONCLUSÃO: o ISRFL positivo pode estar relacionado com os sinais do RGE e com a alteração na qualidade vocal percebida em triagem.

Reflux and aerodigestive tract diseases

Gastroesophageal reflux disease can present with a wide variety of extraesophageal symptoms. In particular, the type of disease characterized predominately by laryngopharyngeal reflux may be difficult to diagnose because of the absence of regurgitation or heartburn. The available battery of diagnostic tools is often insufficient to confirm a diagnosis of reflux, so the diagnosis is often made by elimination. In many cases, treatment with proton pump inhibitors will relieve symptoms and respiratory complications, despite the persistence of non-acidic reflux. Such treatment is often employed to "confirm" the diagnosis, as measured by patient response. Many diseases have been related to this condition in the literature. The authors review knowledge about these manifestations and their relationship with refluxed gastric content. Physiopathology, symptoms and treatment are reviewed in order to clarify our understanding of laryngopharyngeal reflux diseases and related manifestations.

[Extraesophageal reflux. Overview and discussion of a new method for pH monitoring]

BACKGROUND

Extraesophageal reflux disease often requires diagnosis and treatment by a phoniatry or ear, nose and throat specialist. The disease needs to be differentiated from gastroesophageal reflux disease.

OBJECTIVE

A new oropharyngeal pH measuring system with a single channel probe has recently been introduced. The aim of this study was to compare oropharyngeal pH-metry with the existing diagnostic methods for extraesophageal reflux disease and to present initial results in our own patients.

METHODS

A literature search for oropharyngeal pH-metry was performed in the databases NHS EED, HTA, DARE, Clinical trials, Cochrane reviews and Medline/PubMed. A selective literature search was also carried out on the problem of extraesophageal reflux disease.

RESULTS

Evaluation scales, trial proton pump inhibitor therapy or pH-metry, for example, can be used to diagnose extraesophageal reflux disease. pH-metry can be performed using a classical two-channel pH-metry system; a new oropharyngeal pH measuring system has recently been introduced. This new method has been evaluated in initial studies for normative data and has been compared to two-channel pH-metry. Prospective randomised studies to diagnose extraesophageal reflux disease with the new oropharyngeal pH-metry method are still lacking.

DISCUSSION

Oropharyngeal pH-metry has some potential advantages compared to classical two-channel pH-metry; however, a lot of questions remain unanswered. These will be discussed and illustrated with the help of a number of own patient case reports.

Ear, Nose, and Throat Manifestations during Pregnancy

Objective. The objective of this clinical review is to highlight the otolaryngological symptoms that occur in pregnancy. Where available, the authors discuss the current evidence of the etiology and management of the various presentations. While it is appreciated that many of these complaints are transient, their impact on the maternal quality of life can be significant, and therefore, medical practitioners should be aware of what to expect in order to provide reassurance to patients and also to safely manage such symptoms.

Data Sources. MEDLINE and EMBASE databases were searched for publications related to otolaryngology and pregnancy.

Review Methods. All literature was searched for and reviewed by 2 authors independently. Search results were then cross-examined, and any differences were settled by consensus.

Results. Pregnancy leads to circulatory changes and increased susceptibility to viral reactivation, and along with the exertion of parturition, it can lead to tinnitus, facial palsies, and deafness. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis and rhinitis. Increased progesterone and the increased intra-abdominal pressure of the growing fetus can lead to symptoms and sequelae of laryngopharyngeal reflux. Evidence for the treatment of pregnancy-induced symptoms is principally restricted to case reports and retrospective studies.

Conclusion. Recognition and understanding of pregnancy-related ear, nose, and throat complaints will allow otolaryngologists to reassure and manage these patients, improving their experience of the gestational period. High-quality evidence for their management is limited, with further research required.

Effect of pantoprazole in patients with chronic laryngitis and pharyngitis related to gastroesophageal reflux disease: clinical, proximal, and distal pH monitoring results

Few studies had evaluated the results of proton pump inhibitors on distal and proximal pH recording using a dual-channel probe. The aim of this study was to determine the clinical and pH-metric effect of treatment with pantoprazole 80 mg for 8 weeks in patients with ear, nose, and throat (ENT) manifestations of gastroesophageal reflux disease associated with pathological proximal acid exposure. We conducted a prospective open study. Patients included had to have chronic pharyngitis or laryngitis, and a pathological gastroesophagopharyngeal reflux. All patients received treatment with pantoprazole 80 mg daily for 8 weeks. One week after the end treatment, patients had a second ENT examination and a 24-hour pH monitoring using dual-channel probe. We included 33 patients (11 men, 22 women). A pathological distal acid reflux was found in 30 patients (91%). After treatment, the improvement of ENT symptoms was found in 51.5% of patients. Normalization of 24-hour proximal esophageal pH monitoring was observed in 22 patients (66%). After treatment, the overall distal acid exposure, the number of distal reflux events, and the number of reflux during more than 5 minutes were significantly decreased (respectively: 19.4% vs 7.2% [P < 0.0001], 62.7 vs 28.4 [P < 0.0001], and 10.4 vs 3.9 [P < 0.0001] ). Similarly, in proximal level, the same parameters were significantly decreased after treatment (respectively: 6.8% vs 1.6% [P < 0.0001], 32.6 vs 8.1 [P < 0.0001], and 3.4 vs 0.6 [P= 0.005] ). Treatment with pantoprazole reduced the frequency and severity of gastroesophagopharyngeal acid reflux in patients with chronic pharyngitis and laryngitis.

Development and validation of a laryngopharyngeal reflux questionnaire, the Pharyngeal Reflux Symptom Questionnaire

OBJECTIVE

To develop and validate the Pharyngeal Reflux Symptom Questionnaire (PRSQ), a comprehensive, disease-specific, self-administered questionnaire for laryngopharyngeal reflux (LPR) disease.

MATERIAL AND METHODS

The PRSQ was developed based on empirical evidence from a literature review and expert input from physicians and patients and tested in a pilot study. In this validation study, a total of 228 patients were included and classified according to the Reflux Symptom Index (RSI) cut-off score. Patients with an RSI score > 13 were defined as abnormal, i.e. having LPR disease (n = 102), and those with a score between 0 and 13 were defined as normal controls (n = 126). Psychometric properties of the PRSQ were evaluated by exploring the factor structure and by evaluating internal consistency and item convergent and discriminant validity. Convergent and discriminant validity were determined by using the Laryngopharyngeal Reflux-Health Related Quality of Life questionnaire (LPR-HRQL), the RSI and the Short Form-36.

RESULTS

The PRSQ was well accepted by the patients. Compliance was satisfactory and missing item rates were low. After item reduction, due to items not being conceptually relevant or scaling errors and/or low factor loadings, a construct was achieved with no scaling errors and high internal consistency (Cronbach's alpha 0.79-0.93). The correlations between the PRSQ and similar dimensions in the RSI and LPR-HRQL were generally strong. Discriminant validity was satisfactory as the questionnaire discriminated between patients with and without LPR disease.

CONCLUSION

The PRSQ showed good psychometric properties and may become a valuable instrument for assessing LPR disease.

Role of esophageal motility in the development of laryngopharyngeal reflux

AIM: To evaluate the role of esophageal motility in the development of laryngopharyngeal reflux.

METHODS: Esophageal manometry and 24-hour esophageal pH monitoring were performed in 22 patients suffering from reflux laryngitis (LPR group) caused by gastroesophageal reflux and 23 patients with typical gastroesophageal reflux symptoms (acid regurgitation and heartburn) but without laryngitis-related symptoms (GERD group).

RESULTS: The upper esophageal sphincter (UES) pressure and the contractile force of esophageal segment 8 cm above the lower esophageal sphincter (LES) in the LPR group were significantly lower than those in the GERD group (41.23 ± 19.61 mmHg vs 55.82 ± 20.51 mmHg, P = 0.009; 58.77 ± 30.84 mmHg vs 77.40 ± 36.12 mmHg, P = 0.035). No significant differences were noted in UES length, LES length, LES pressure and the contractile force of the remaining segments of the esophagus (3, 13, and 18 cm above LES) between the two groups. The incidence of pathological acid reflux in the LPR group was significantly lower than that in the GERD group (χ² = 3.979, P = 0.046).

CONCLUSION: UESP and the contractile force of the lower esophagus play an important role in preventing the development of laryngopharyngeal reflux.

Ambulatory 24-hour pharyngeal pH monitoring in healthy Korean volunteers

Pharyngeal pH monitoring is the standard diagnostic approach for laryngopharyngeal reflux (LPR). However, the normal values for Asian populations are still unknown. We evaluated the results of ambulatory 24-h pharyngeal pH monitoring in healthy volunteers to determine the normal reference values in the Korean population. Thirty healthy subjects underwent ambulatory 24-h pharyngeal pH monitoring with glass electrodes positioned 1 cm above the upper esophageal sphincter and 5 cm above the lower esophageal sphincter, based on esophageal manometry after upper gastrointestinal endoscopy. LPR occurred in about one half of the healthy volunteers without any significant association with age, gender and body mass index. Pharyngeal acid reflux occurred mainly in the upright position. At the 95th and 90th percentile, after the exclusion of mealtimes, the upper limits of normal (ULN) for pharyngeal acid exposure were 0.41% and 0.18%. The ULNs for the number of pharyngeal acid events were 12.8 and 5.0. The corresponding ULNs for the esophagus were 5.1% and 3.8% and 62.7 and 32.6. The findings of this study help establish the reference standards for LPR in Korean patients.

A more than 10-year prospective, follow-up study of esophageal and pharyngeal acid exposure, symptoms and laryngeal findings in healthy, asymptomatic volunteers

OBJECTIVE

To evaluate the development of pharyngeal and esophageal acid exposure, symptoms, and laryngeal findings in previously healthy subjects.

MATERIAL AND METHODS

Thirty-three subjects, previously included in a normative pH monitoring study, completed symptom questionnaires, a video laryngoscopic examination, and ambulatory 24-h pharyngeal and esophageal pH monitoring after a mean follow-up of 14 years.

RESULTS

Twenty-four subjects (15 F, 9 M, mean age 57 years) completed the study. The number of subjects with pathological esophageal reflux increased from 5 (21%) at baseline to 8 (33%) at follow-up (p=0.23), whereas the proportion with pharyngeal acid exposure of at least 0.1% decreased from 42% to 13% (p=0.04). Heartburn and/or regurgitation developed in 11 of the 24 (46%) subjects and airway symptoms in 10 (42%) subjects. Laryngeal pathology was found in 9 of 23 subjects (39%). Airway symptoms were equally common among subjects with and those without laryngeal findings or with and without pharyngeal reflux.

CONCLUSIONS

Esophageal acid exposure increases over time in previously symptom-free, healthy subjects. The increase in airway symptoms or laryngeal abnormalities is not directly related to increased acid exposure.

Gastroesophageal reflux monitoring: pH (catheter and capsule) and impedance

Diagnostic testing for GERD has evolved to include multi esophageal sites (distal, proximal and hypopharyngeal monitoring), wireless pH, and oropharyngeal devices. The versatility of the devices has increased our ability to better understand the role of acid reflux in various disorders involving reflux of acid. Wireless pH monitoring improves patient comfort and allows monitoring for gastroesophageal reflux events over several days. Ambulatory MII-pH monitoring is another exciting diagnostic tool, which is capable of detecting more than one type of reflux and achieves higher sensitivity and specificity to detect GERD than endoscopy or pH-metry. It is useful in patients with either typical or atypical reflux symptoms who are refractory to proton pump inhibitor (PPI) therapy. In this setting, MII-pH can be performed on PPI therapy to assess the efficacy of PPIs and the role of nonacid or acid reflux in persistent symptoms.

The integrity of esophagogastric junction anatomy in patients with isolated laryngopharyngeal reflux symptoms

BACKGROUND

Distortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms.

METHOD

In a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett's esophagus within each group.

RESULTS

There were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett's esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett's esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology.

CONCLUSION

This indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett's esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer.

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.

Hoarseness: is it really laryngopharyngeal reflux?

OBJECTIVE/HYPOTHESIS

This study will test the hypothesis that proton pump inhibitor (PPI) use is prevalent among patients referred for hoarseness and will assess the ultimate diagnosis and factors associated with patients' voice outcomes.

STUDY DESIGN

Retrospective review of patients in a tertiary care voice clinic.

METHODS

Patients with a primary diagnosis of hoarseness, who were taking or had taken PPIs in the previous 2 months and referred to a tertiary care voice clinic, were identified. The dosage and length of PPI administration, patient report of gastroesophageal reflux (GER), presence of findings suggesting muscle tension dysphonia (MTD), patient demographics, diagnosis, chronicity of symptoms, interventions, follow-up, and outcome were determined.

RESULTS

Of 299 patients, 264 met the inclusion criteria. The mean age was 47.2 years, with a range of 18 to 89 years, with 26.7% male and 73.3% female. Among patients referred for voice problems, 148 (56.1%) had previously tried PPIs or were currently on PPI treatment; 44 (29.7%) stopped taking their PPI because of continued hoarseness, and 104 (70.3%) had persistent hoarseness and associated throat complaints despite continued PPI treatment. Among patients who quit taking their PPI because of continued voice complaints, 79.5% did not have traditional GER symptoms of heartburn or regurgitation. The most common treatment after referral was voice therapy, with an overall voice therapy response rate of 62.7%.

CONCLUSIONS

PPI use is prevalent among patients referred because of persistent hoarseness. Whether patients have GER or MTD may influence patients' voice outcomes in response to PPI treatment.

Diagnosis and management of laryngopharyngeal reflux disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux has shown high prevalence and it is an interesting issue for otorhinolaryngologists, head and neck surgeons, and gastroenterologists. The present paper presents the most recent findings in diagnosis and management of laryngopharyngeal reflux.

RECENT FINDINGS

Clinical presentation of laryngopharyngeal reflux is widely varied and it may be manifested by a wide range of signs and symptoms. Other diseases that affect the larynx may also show the same signs and symptoms, such as, for example, vocal abuse, allergy, asthma, sinusitis, and smoking. Overvaluation of signs and symptoms related to reflux may be responsible for overdiagnosis of laryngopharyngeal reflux disease. The 24-hour dual-probe pH monitoring is considered the gold standard for the diagnosis of laryngopharyngeal reflux disease, and is essential in cases of pharyngolaryngeal complaints. The management of laryngopharyngeal reflux cases should be based on severity of symptoms, laryngoscopic findings, and frequency of reflux episodes. Proton-pump inhibitors are the preferred drugs for managing patients with laryngopharyngeal reflux and the best control can be achieved by prescribing high doses, twice a day. Patients that do not respond satisfactorily to clinical management are candidates for surgical fundoplication.

SUMMARY

Laryngopharyngeal reflux is characterized by a set of signs and symptoms resulting from extraesophageal manifestations of gastroesophageal reflux disease; however, this set of signs and symptoms may be related to other causes and the results of management, based on clinical presentation, vary widely and have low cure index.

Current knowledge, controversies and future directions in hyperfunctional voice disorders

Taking the preceding five papers in this special issue of the International Journal of Speech-Language Pathology as a starting point, this paper synthesizes key aspects of hyperfunctional voice disorders (HFVD). Aetiological and contributing factors, defining features, prevention, assessment and intervention are canvassed, while controversial issues and future directions in research and clinical practice are discussed. Despite disagreements and inconsistencies in terminology surrounding HFVD, there is broad agreement that musculoskeletal tension is the hallmark of these voice disorders. There is also reasonable consensus that the pathogenesis and persistence of HFVD are associated with multiple and overlapping factors, some of which are likely to interact in as yet unknown ways. In addition to dysregulated laryngeal muscle functioning, key processes in the psychosocial and sensory domains are canvassed as likely contributors to HFVD. Vocal fatigue is considered as an intriguing relative of HFVD, the role of laryngopharyngeal reflux is debated and the proposition that particular individuals are psychologically and/or physiologically predisposed to HFVD is discussed. New directions in assessment highlight the use of client-centred measures to consider insider perspectives of psychological factors, vocal effort and vocal fatigue. Emerging psychosocial and physical-manipulative interventions are emphasized and the future educational needs of voice care professionals are considered.

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.

Review article: The laryngological manifestations of reflux disease; why the scepticism?

BACKGROUND

Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment.

AIM

Proper understanding of laryngopharyngeal reflux disease (LPRD).

METHOD

Review of literature.

RESULTS

Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials.

CONCLUSIONS

LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.

Wireless upper esophageal monitoring for laryngopharyngeal reflux (LPR)

OBJECTIVES

To confirm feasibility of transnasal placement of a wireless pH-monitoring capsule in the upper esophagus, and to determine the positive predictive value of LPR and GERD signs and symptoms for diagnosis of LPR in patients with OSAHS.

STUDY DESIGN

Prospective, nonrandomized, IRB-approved study of 89 OSAHS patients with and without symptoms and signs of LPR.

METHODS

After complete history including QOL survey and fiberoptic laryngoscopy, patients underwent transnasal placement of the pH-monitoring capsule and wireless data collection for 24 hours.

RESULTS

77 of 89 consecutive patients underwent successful placement of wireless pH-monitoring capsule (86.5% success rate) and completed the study. 55 (71.4%) OSAHS patients had positive pH studies. 10.4% of these patients reported no symptoms or signs of LPR, indicating occult disease.

CONCLUSION

Success rates of placement, tolerability, morbidity, and complications are excellent. Wireless upper esophageal pH monitoring is safe and effective for diagnosing LPR in patients with OSAHS.

Prevalence of laryngopharyngeal reflux in a population with gastroesophageal reflux

OBJECTIVE

Laryngopharyngeal reflux (LPR) is a syndrome associated with a constellation of symptoms usually treated by ENT surgeons. It is believed to be caused by the retrograde flow of stomach contents into the laryngopharynx, this being a supra-esophageal manifestation of gastroesophageal reflux disease (GERD). It has been cited that LPR and GERD can be considered separate entities. Our hypothesis was that LPR is a supra-esophageal manifestation of GERD and therefore that patients with GERD should have a degree of symptoms suggestive of LPR because of the reflux of the gastric contents. We examined a population of patients with both upper gastrointestinal endoscopy and symptom-proven GERD and, using a questionnaire, looked at their existing symptoms to help assess the prevalence of LPR. We also looked at whether, with more severe GERD (suggestive of increased gastric content reflux), the degree of symptoms suggestive of LPR would be increased, as would be expected.

METHODS

A population of patients with endoscopically proven GERD were recruited and divided into groups depending on the severity of their reflux disease. A questionnaire was then administered that examined both LPR and GERD scoring criteria. The relationship between GERD and LPR was then analyzed.

RESULTS

We recruited 1,383 subjects with GERD; those with severe GERD had significantly higher LPR scores compared with those with mild (P < .01), moderate (P < .05), or inactive disease (P < .001).

CONCLUSIONS

The condition of LPR is likely to represent a supra-esophageal manifestation of GERD. This study examined a large number of patients with endoscopically proven GERD and has demonstrated a correlation between the severity of GERD and the prevalence of LPR. LPR and GERD are common and interlinked conditions. The subsequent prevalence of LPR in the population with GERD is therefore likely to be dramatically underestimated.

Hoarseness and misdirected swallowing in patients with hiatal hernia

The purpose of this study was to elucidate whether misdirected swallowing is an extra-laryngeal cause of hoarseness and investigate whether the prevalence of misdirected swallowing and hoarseness in patients with hiatal hernias differ from those with and without pathological gastroesophageal reflux (GER). One hundred and ninety eight patients with hiatal hernias diagnosed via esophageal manometry and pH-reflux test and 262 subjects in the general population who did not have a hiatal hernia at endoscopy, filled in a questionnaire about symptoms on hoarseness, misdirected swallowing, and heartburn. Hoarseness (35%), misdirected swallowing to the larynx (MSL; 35%), misdirected swallowing to the nose (MSN; 22%) and heartburn (85%) were significantly more common in patients with hiatal hernia than in controls (13, 5, 1, and 6%, respectively, P<0.001). MSL and MSN in the patient group were significantly interrelated (P<0.0001). Hoarseness and MSL were not significantly associated (P<0.076). Hoarseness and MSL were as common in the hernia group with normal GER, as in the group with pathological GER. There is a predisposition for hoarseness and MSL in patients with hiatal hernias, but the cause-and-effect relationship is unclear. Hoarseness does not seem to be caused by pathological GER.

Reflux and laryngitis: a systematic review

OBJECTIVES

To investigate and compare the prevalence of pharyngeal reflux (PR) events in normal controls and patients with clinically diagnosed reflux laryngitis.

METHOD

A systematic review of the literature was performed to identify all prospective studies on the results of 24-hour double-probe (pharyngeal and esophageal) pH monitoring in normal controls and in patients with symptoms and/or signs of reflux laryngitis.

RESULTS

Eleven relevant studies on 192 normal controls and 13 studies on 512 patients with reflux laryngitis were identified. One or more PR events were detected in 51 normal controls (22.9%; 95% CI, 13.9% to 33.3%) and in 154 of 422 patients (38.3%; 95% CI, 25.4% to 52.1%). There is no significant difference in the prevalence of PR events between normal controls and patients with reflux laryngitis (P = 0.079). In addition, the prevalence of PR events in patients with reflux laryngitis is much lower than reported in previous reviews on this subject.

CONCLUSION

This systematic review calculated that (1) only a minority of patients with clinically diagnosed reflux laryngitis will show PR events, and (2) there is no significant difference between the prevalence of PR events in patients with reflux laryngitis and healthy controls. At the moment, there is no reliable means to confirm reflux of gastric juice in patients with suspected reflux laryngitis. This diagnostic vacuum is fundamental and may pose important questions at the current concept of reflux of gastric juice as a common cause of laryngopharyngeal inflammation.

Exclusion of pH artifacts is essential for hypopharyngeal pH monitoring

BACKGROUND

Published yields of pH monitoring for suspected laryngopharyngeal reflux (LPR) vary greatly. Hypopharyngeal pH artifacts may be responsible for these inconsistencies.

OBJECTIVE

To determine the impact of potential artifacts on pH monitoring of the hypopharynx and esophagus.

METHODS

Patients with suspected LPR were prospectively studied. Single-catheter, triple-sensor pH monitoring was performed off antireflux therapy. Subjects recorded meal times and marked liquid swallows outside of meals on the data recorder. Results were analyzed by excluding six potential pH artifacts individually and all together. Positive pH test was defined as three or more reflux episodes in hypopharynx, total percent of time pH less than 4 was 1.0% or greater in the proximal esophagus, and total percent of time pH less than 4 was 4.2% or greater in the distal esophagus. Wilcoxon rank sum and chi-square tests were used.

RESULTS

Thirty-eight subjects (24 females; median age, 47 yr) completed the study. A total of 2,225 hypopharyngeal pH drops less than 4 were identified; 48% were short pH drops at less than 5 seconds, 17% within meal periods, 16% liquid swallows outside of meals, 16% isolated proximal pH drops, 12% pH out of range, and 5% pH drift. Eighty percent of the hypopharyngeal pH drops were at least one of the potential pH artifacts. The yield of the hypopharyngeal sensor was reduced by 45% (from 92% to 47%) after all potential pH artifacts were excluded. Yields of proximal and distal esophageal pH sensors were reduced by 19% and 8%, respectively, significantly less than the hypopharyngeal sensor (P < .01).

CONCLUSIONS

Patients should record all liquid swallows outside of meals. It is essential to exclude all potential artifacts for hypopharyngeal pH monitoring in patients with suspected LPR.

Efficacy of once-daily esomeprazole treatment in patients with laryngopharyngeal reflux evaluated by 24-hour pH monitoring

OBJECTIVE

Laryngopharyngeal reflux (LPR) is generally treated with twice-daily proton-pump inhibitor (PPI) therapy. In this study, the efficacy of esomeprazole 40 mg once-daily together with lifestyle modifications was determined by repeated 24-hour pH monitoring.

STUDY DESIGN AND SETTING

A prospective study. Forty-nine patients with suspected LPR underwent 24-hour pH monitoring. Twenty-seven of 49 patients with measurable abnormal proximal reflux reflected by a reflux area index (RAI)>6.3 were treated with esomeprazole 40 mg every day, and a second pH study was performed.

RESULTS

In 22 of 27 patients, everyday PPI treatment reduced the RAI. Four of 5 patients with no RAI reduction reported on symptomatic relief.

CONCLUSION

In a considerable number of patients with suspected LPR, pH monitoring reveals no abnormal proximal reflux. Esomeprazole 40 mg every day together with lifestyle modifications could reach adequate acid suppression in a large number of patients. Symptom improvement is also reported by patients without measurable effects of therapy.

Gastro-oesophageal reflux disease in chronic laryngitis: prevalence and response to acid-suppressive therapy

BACKGROUND

Gastro-oesophageal reflux is thought to cause chronic laryngitis through laryngopharyngeal reflux. Response of laryngitis to treatment with acid-suppressive therapy supports this causal link.

AIM

To determine the prevalence of gastro-oesophageal reflux disease in patients with chronic laryngitis and response to proton-pump inhibitor therapy.

METHODS

Patients with chronic laryngitis were recruited. The frequency and severity of reflux and laryngeal symptoms were scored and laryngitis graded by laryngoscopy. All patients underwent esophagogastroduodenoscopy and 24-h ambulatory pH monitoring before receiving lansoprazole 30 mg b.d. for 8 weeks.

RESULTS

The prevalence of gastro-oesophageal reflux disease was 65.6% (21 of 32). Based on positive pH test, the prevalence was 25% (eight of 32). The change in laryngeal symptom score and laryngitis grade was significantly higher in GERD compared with non-GERD patients (P = 0.010 for both). The proportion of patients with marked/moderate improvement in laryngeal symptoms were significantly higher in patients with reflux (14 of 21, 67%) compared to those without reflux (two of 11, 18%; P = 0.026).

CONCLUSIONS

The prevalence of gastro-oesophageal reflux disease amongst our patients with chronic laryngitis was high. The response to treatment with proton-pump inhibitors in patients with reflux disease compared to those without underlined the critical role of acid reflux in a subset of patients with chronic laryngitis.

Anatomy of reflux: a growing health problem affecting structures of the head and neck

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are sibling diseases that are a modern-day plague. Millions of Americans suffer from their sequelae, ranging from subtle annoyances to life-threatening illnesses such as asthma, sleep apnea, and cancer. Indeed, the recognized prevalence of GERD alone has increased threefold throughout the 1990s. Knowledge of the precise etiologies for GERD and LPR is becoming essential for proper treatment. This review focuses on the anatomical, physiological, neurobiological, and cellular aspects of these diseases. By definition, gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus; when excessive and damaging to the esophageal mucosa, GERD results. Reflux that advances to the laryngopharynx and, subsequently, to other regions of the head and neck such as the larynx, oral cavity, nasopharynx, nasal cavity, paranasal sinuses, and even middle ear results in LPR. While GERD has long been identified as a source of esophageal disease, LPR has only recently been implicated in causing head and neck problems. Recent research has identified four anatomical/physiological "barriers" that serve as guardians to prevent the cranial incursion of reflux: the gastroesophageal junction, esophageal motor function and acid clearance, the upper esophageal sphincter, and pharyngeal and laryngeal mucosal resistance. Sequential failure of all four barriers is necessary to produce LPR. While it has become apparent that GER must precede both GERD and LPR, the head and neck distribution of the latter clearly separates these diseases as distinct entities warranting specialized focus and treatment.

Performance and optimal technique for pharyngeal impedance recording: A simulated pharyngeal reflux study

BACKGROUND AND AIMS

Detection rate, influence of recording site, and subject posture for impedance monitoring of pharyngeal reflux of gastric contents remain unknown. We evaluated the ability of the impedance sensor for detection of various volumes of intrapharyngeal infusate at two sites and in two subject positions.

METHODS

Nineteen healthy subjects were studied using concurrent videoendoscopic, manometric, impedance, and pH recording.

RESULTS

Detection rate of simulated pharyngeal reflux events ranged between 87% and 100% for 1-4 mL. Detection rate for 0.1-1 mL volumes in the upright position was significantly higher (78-85%) when the impedance sensor was located at the proximal margin of the upper esophageal sphincter (UES) compared to 2 cm proximally (38-68%) (P < 0.001). With the sensor at 2 cm above the UES, the average detection rate for all volumes in the upright position was significantly less (P < 0.001) compared to the supine position (48%vs 84%). There was substantial variability in the magnitude of impedance changes induced by different infusates.

CONCLUSIONS

Impedance sensors can detect as small a volume as 0.1 mL and combined with a pH sensor can detect acidic and nonacidic liquid and mist reflux events. Sensor placement at the proximal margin of the UES yields the highest detection rate irrespective of subject posture compared to placement 2 cm proximally. Depending on the volume of refluxate and location of the impedance sensor, a substantial minority of simulated reflux events can be missed.