The impact of laryngopharyngeal reflux on patient-reported quality of life

Laryngopharyngeal reflux diagnosis: Factors associated with patient satisfaction

PURPOSE

To examine the patient experience of laryngopharyngeal reflux diagnosis and factors that contributed to perceived difficulty with the process.

MATERIALS AND METHODS

A 32-question anonymous survey was administered to individuals over 18 years old who reported a diagnosis of laryngopharyngeal reflux. The survey contained questions regarding demographics and individuals' experiences during the diagnostic workup along with the generic short patient experiences questionnaire. Percentages were calculated for all variables. Kendall rank correlation coefficient was performed to measure the strength and direction of association between laryngopharyngeal reflux workup and perceived difficulty with diagnosis.

RESULTS

Of the 232 respondents, 59.9 % reported difficulty with the diagnostic process. Strong positive correlations were found between perceived difficulty with laryngopharyngeal reflux diagnosis and the following factors: total number of physicians seen (τb = 0.483, p < 0.001), time from symptom onset (τb = 0.300, p < 0.001), and time from first physician visit (τb = 0.479, p < 0.001). Results from the generic short patient experiences questionnaire showed moderate negative correlations between perceived difficulty with diagnosis and the following factors: perceived competence of physician (τb = -0.228, p < 0.001), perception that the physician cared for the patient (τb = -0.253, p < 0.001), perceived interest the physician had in the patient (τb = -0.259, p < 0.001), and time interacting with the physician (τb = -0.226, p < 0.001).

CONCLUSIONS

Respondents report difficulty being diagnosed with laryngopharyngeal reflux. This correlates with increased time to receive a diagnosis, increased number of physicians seen, and factors related to the patient-physician relationship. Physicians can improve patient experience by focusing on clear communication with interactive patient appointments, and scheduling high yield diagnostic tests.

Validated Clinical Score to Predict Gastroesophageal Reflux in Patients With Chronic Laryngeal Symptoms: COuGH RefluX

BACKGROUND & AIMS

Discerning whether laryngeal symptoms result from gastroesophageal reflux is clinically challenging and a reliable tool to stratify patients is needed. We aimed to develop and validate a model to predict the likelihood of gastroesophageal reflux disease (GERD) among patients with chronic laryngeal symptoms.

METHODS

This multicenter international study collected data from adults with chronic laryngeal symptoms who underwent objective testing (upper gastrointestinal endoscopy and/or ambulatory reflux monitoring) between March 2018 and May 2023. The training phase identified a model with optimal receiver operating characteristic curves, and β coefficients informed a weighted model. The validation phase assessed performance characteristics of the weighted model.

RESULTS

A total of 856 adults, 304 in the training cohort and 552 in the validation cohort, were included. In the training phase, the optimal predictive model (area under the curve, 0.68; 95% CI, 0.62-0.74), was the Cough, Overweight/obesity, Globus, Hiatal Hernia, Regurgitation, and male seX (COuGH RefluX) score, with a lower threshold of 2.5 and an upper threshold of 5.0 to predict proven GERD. In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62-0.71), with 79% sensitivity and 81% specificity for proven GERD.

CONCLUSIONS

The externally validated COuGH RefluX score is a clinically practical model to predict the likelihood of proven GERD. The score classifies most patients with chronic laryngeal symptoms as low/high likelihood of proven GERD, with only 38% remaining as indeterminate. Thus, the COuGH RefluX score can guide diagnostic strategies and reduce inappropriate proton pump inhibitor use or testing for patients referred for evaluation of chronic laryngeal symptoms.

Quality of Life and Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is characterized by the reflux of gastric contents into the pharynx or larynx and often presents with symptoms including but not limited to cough, throat clearing, sore throat, globus, and dysphonia. Unlike gastroesophageal reflux disease (GERD), LPR is a relatively understudied syndrome, and knowledge regarding the diagnostic and treatment strategies, as well as the psychosocial impact continues to evolve. No singular test or procedure currently exists as a gold standard for LPR diagnosis. While laryngoscopy or pH monitoring may be positive, this does not exclude the contribution of non-gastroenterological processes. Prior research into psychosocial impact demonstrates a significant increase in symptom burden when comparing patients with laryngeal symptoms to controls and those with isolated GERD symptoms. However, these data are limited by the absence of physiologic data to correlate with the reported symptoms and survey responses. This knowledge gap highlights the need for further research to investigate the relationship between symptom burden and pathologic acid reflux on quality of life (QOL), anxiety, and depression. Ultimately, future studies to directly analyze these variables will help to guide treatment strategies and improve QOL in these patients.

Correlation of Esophageal Mean Nocturnal Baseline Impedance With Markers of Laryngopharyngeal Reflux

OBJECTIVES

Mean nocturnal baseline impedance (MNBI) is a measure of the esophageal epithelial barrier function calculated via high-resolution impedance manometry and can be used as a diagnostic tool and treatment response predictor for gastroesophageal reflux disease (GERD). However, its utility for laryngopharyngeal reflux (LPR) has been minimally studied. We aimed to investigate the relationship of MNBI between patients with suspected LPR, healthy controls, and their 24-h multichannel intraluminal impedance-pH (MII-pH) study results.

METHODS

Retrospective patient series analysis was performed of patients with suspected LPR and healthy controls who underwent 24-h MII-pH monitoring. MNBI values were calculated from impedance channels at the level of the hypopharynx, proximal esophagus, and distal esophagus. We compared these MNBI values between the subject groups with secondary analysis on MII-pH results, reflux symptom index, reflux findings score, DeMeester score, and salivary pepsin levels.

RESULTS

Twenty-three patients with suspected LPR and 14 healthy controls were enrolled. Decreased distal esophageal MNBI was found to be significantly decreased in patients with suspected LPR compared with healthy controls (p < 0.01) and in subjects with positive MII-pH studies compared to negative MII-pH studies (p < 0.01). There were no significant correlations of MNBI at the hypopharynx or proximal esophagus.

CONCLUSION

Distal esophageal MNBI has significant correlations with many phenotypic and biological markers of LPR. These findings indicate that MNBI has the potential to be applied to LPR, similar to its emerging use as a diagnostic tool and treatment response predictor for GERD.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

The Role of Empirical Treatment with Proton Pump Inhibitor as a Diagnostic Tool in Laryngopharyngeal Reflux

The presentations of laryngopharyngeal reflux (LPR) are diverse and include chronic hoarseness, sensation of foreign body in the throat, sore throat etc. 24 h pH monitoring considered the gold standard of investigation for LPR is costly, cumbersome and not readily available at all centers. Empirical trial of Proton pump inhibitor (PPI) as a diagnostic tool after assessment by Reflux Symptom Index (RSI) and Reflux Findings Score (RFS) is a cheaper, simple and readily available alternative. The objectives of the study were to determine clinical manifestations in patients presenting with LPR and to evaluate the role of empirical treatment with PPI as a diagnostic tool in LPR. 100 patients were divided into experimental group (RSI ≥ 13 and RFS ≥ 7) and control group (RSI < 13 and RFS < 7). Omeprazole trial was given to experimental group and assessed for RSI and RFS at 04 and 08 weeks. Statistical analysis was done within the group and between the groups. (1) The response rate to Omeprazole at 04 and 08 weeks interval (RSI<13 and/or RFS<7) was 60% and 76% respectively. (2) The response to Omeprazole given to the experimental group with RSI≥13 and RFS≥7 was significant at 04 weeks and 08 weeks duration (P<0.0001). RSI and RFS are good clinical tools to assess and diagnose patients with Laryngopharyngeal reflux. Based on the clinical diagnosis an empirical trial of a proton pump inhibitor (PPI) can be given to patients for duration of 02 months resulting in a good response.

Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux

BACKGROUND

The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR).

METHODS

This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI.

RESULTS

Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m² (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01).

CONCLUSION

This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).

An update on current treatment strategies for laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux (LPR) is a syndrome caused by reflux of gastric contents into the pharynx or larynx, which leads to symptoms of throat clearing, hoarseness, pain, globus sensation, cough, excess mucus production in the throat, and dysphonia. LPR is a challenging condition, as there is currently no gold standard for diagnosis or treatment, and thus this presents a burden to the healthcare system. Strategies for treatment of LPR are numerous. Medical therapies include proton pump inhibitors, which are first line, H2 receptor antagonists, alginates, and baclofen. Other noninvasive treatment options include lifestyle therapy and the external upper esophageal sphincter compression device. Endoscopic and surgical options include antireflux surgery, magnetic sphincter augmentation, and transoral incisionless fundoplication. Functional laryngeal disorders and laryngeal hypersensitivity can present as LPR symptoms with or without gastroesophageal reflux disease. Though there are minimal studies in this area, neuromodulators and behavioral interventions are potential treatment options. Given the complexity of these patients and numerous available treatment options, we propose a treatment algorithm to help clinicians diagnose and triage patients into an appropriate therapy.

Screening Test for LPRD: History Versus Video Laryngoscopy

Objective

To find a better screening test by correlating between history and video-laryngoscopy in patients with laryngopharyngeal reflux disease. To compare the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS).

Method

Patients with the signs and symptoms of LPRD were scored based on RSI. Those with RSI above 13 were included in study and evaluated further by videolaryngoscopy examination and rated according to RFS. The correlation between RSI and RFS was analysed.

Result

Out of the 107 patients included in study 55% were females. Among these patients positive RFS score (i.e. > 7) was seen in 58.3%. The average RSI was 18.22, and average RFS was 7.45. According to RSI the most common symptom was heartburn/indigestion (44.5%) and from RFS the most common finding was posterior commissure hypertrophy (95%). Correlation between RSI and total RFS was found to be 0.184 with a p value of 0.159 which was not significant.

Conclusion

LPRD is more common in females and in the middle age group. A correlation of RSI and RFS was not found to be significant suggesting that both should be used for diagnosis of LPRD instead of relying on only one. RFS and RSI are easy, quick and out patient based screening tools and when used together can be more reliable for LPRD diagnosis.

Validation of the Brazilian Portuguese Version of the Reflux Finding Score

INTRODUCTION

Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language.

OBJECTIVE

To validate the Brazilian Portuguese version of the RFS.

MATERIAL AND METHOD

For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested.

RESULTS

A statistically significant difference was observed in the mean RFS between patients with LPR (10.26 ± 3.58) and controls (5.52 ± 1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1 = 0.956; R2 =  0.948).

CONCLUSION

The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.

Does the Reflux Symptom Index Predict Increased Pharyngeal Events on HEMII-pH Testing and Correlate with General Quality of Life?

OBJECTIVES

To determine the ability of the reflux symptom index (RSI) to predict objective impedance and pH-probe testing, and to examine the relationship between disease-specific and general health status in patients diagnosed with laryngopharyngeal reflux (LPR).

METHODS

Adults presenting to a tertiary care academic center with a primary voice complaint completed the RSI and the Patient-Reported Outcomes Measurement Information System 10-item global health instrument (PROMIS). An RSI score ≥13 was considered abnormal. Objective testing for LPR was performed using hypopharyngeal-esophageal multichannel intraluminal impedance catheter with dual pH (HEMII-pH) testing; a positive test was defined as more than one pharyngeal impedance events over 24 hours. Spearman rho analyses were applied, and the sensitivity and specificity of the RSI to detect HEMII-pH findings were determined.

RESULTS

One hundred four patients underwent HEMII-pH testing. Mean scores were 16.7 (95%CI 15.1-18.3) for RSI. Sixty-three (60.6%) patients were diagnosed with LPR by HEMII-pH testing. RSI scores were moderately correlated with PROMIS physical (Spearman rho 0.43, P < 0.0001), social (Spearman rho 0.33, P < 0.0001) and mental health (Spearman rho 0.33, P < 0.0001) scores. The RSI has a sensitivity and specificity of 66.7% and 31.7%, respectively, for detecting pharyngeal events on HEMII-pH testing.

CONCLUSIONS

There is moderate sensitivity and lack of specificity of the RSI for detecting increased pharyngeal reflux events. Reflux-specific and general health status instruments are correlated. Further investigation could assess the diagnostic ability of RSI compared proximal reflux events on HEMII-pH, as well as whether health status instruments can be used to detect clinically meaningful change in the LPR population.

Temporal Association Between Respiratory Events and Reflux in Patients With Obstructive Sleep Apnea and Laryngopharyngeal Reflux

STUDY OBJECTIVES

The aim of the current study was to test the hypothesis that there is a temporal correlation between reflux episodes and respiratory events in patients with laryngopharyngeal reflux and obstructive sleep apnea.

METHODS

Adults with clinically diagnosed laryngopharyngeal reflux confirmed by two validated instruments (reflux symptom index ≥ 13 and reflux finding score ≥ 7) and obstructive sleep apnea (OSA) underwent full polysomnography with concomitant and synchronized multichannel intraluminal impedance-pH esophageal monitoring. The apnea-hypopnea and arousal indexes that occurred 15, 30, and 45 minutes before and after each reflux episode were recorded and compared to full-night apnea and hypopnea and arousal index.

RESULTS

We studied 27 patients (14 males, age 51.7 ± 9.1 years, body mass index 32.4 ± 4.2 kg/m²) with laryngopharyngeal reflux (reflux symptom index 16 ± 2 and reflux finding score 12 ± 3) and OSA (apnea-hypopnea index = 32.3 ± 28.4 events/h). We evaluated 102 reflux episodes. Almost half of the reflux episodes occurred while awake (43.1%) and only five reflux episodes (4.9%) occurred during an obstructive respiratory event. The apnea and hypopnea and arousal indexes 15, 30, and 45 minutes before and after reflux episodes were lower than full-night apnea and hypopnea and arousal indexes, respectively.

CONCLUSIONS

Among patients with well-established laryngopharyngeal reflux and OSA, there is no temporal association between reflux and obstructive respiratory events. Even though the data comprised a small sample size, it seems that a more complex mechanism is involved with these two highly prevalent diseases.

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.

Depression, Hematologic Parameters, and Blood Levels of Vitamin B12 in Patients With Laryngopharyngeal Reflux Under Use of Proton Pump Inhibitors

Objective

The objective of this study was to evaluate and correlate hematologic indices, vitamin B₁₂ levels, and depression in patients with suspected laryngopharyngeal reflux (LPR) treated with proton pump inhibitor (PPI).

Methods

This was a prospective study with a population (n = 23) consisted of patients with suspected LPR and treated with 2 daily doses of Omeprazole 40 mg (80 mg or full dose). The study volunteers performed a complete blood count and vitamin B₁₂ dosage before and after 3 and 6 months of treatment, as well as depression screening using the Center of Epidemiologic Studies-Depression (CES-D) questionnaire before and after 6 months of treatment. Scores greater than 16 were considered as suggestive of depression.

Results

The mean score on the CES-D scale of study participants at baseline significantly decreased after 6 months of treatment. A significant decrease was observed in the red blood cells count (RBC) after 6 months in relation to 3 months. Significant increases in mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) were observed from 3 months to 6 months in this study. Vitamin B₁₂ levels increased significantly between baseline and after 6 months of treatment.

Conclusion

Decreased scores on the CES-D scale were associated with increased MCV values, with no association with vitamin B₁₂ levels. However, vitamin B₁₂ levels also increased significantly after 6 months of treatment with PPI.

Association of Nasopharyngeal and Laryngopharyngeal Reflux with Postnasal Drip Symptomatology in Patients with and without Rhinosinusitis

Background

Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux.

Methods

Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3).

Results

Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055).

Conclusion

Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Are validated patient-reported outcomes used on children in pediatric otolaryngology? A systematic review

OBJECTIVES

Review the pediatric otolaryngology literature to 1) identify studies in which children completed patient-reported outcome (PRO) measures and 2) appraise the psychometric quality and validity of these PROs as they apply to pediatrics.

METHODS

In October 2016, a systematic review was performed by two reviewers on PubMed/MEDLINE and EMBASE for all otolaryngology-related studies that utilized PROs in children. Inclusion criteria included articles that required children (age<18) to complete PROs. Exclusion criteria included validation studies, reviews, and abstracts. Interreviewer agreement was determined using Cohen's kappa. Quality and rigor of validation testing for included PROs was determined using the COnsensus-based Standards for selection of health status Measurement Instruments.

RESULTS

Interrater agreement was very good (κ = 0.91; 95% CI, 0.85-0.98). Out of 316 articles retrieved, 11 met inclusion criteria. Eight PROs were identified. Six PROs were tested for validity and three of these PROs were tested for validity specifically within children. The most frequently utilized PRO was the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire. Two studies (18.2%) utilized PROs within the scope of their validation. Seven studies (63.6%) used PROs outside the scope of their validation. Two studies (18.2%) used non-validated PROs.

CONCLUSIONS

Patient-reported outcomes have become an integral part of research and quality improvement. There is a relative paucity of PROs directed towards children in pediatric otolaryngology and some studies utilized PROs that were not validated or not validated for use in this age group. Future efforts to design and validate more instruments may be warranted.

Quality of life, patient satisfaction, and disease burden in patients with gastroesophageal reflux disease with or without laryngopharyngeal reflux symptoms

BACKGROUND AND AIM

Patients with gastroesophageal reflux disease (GERD) have decreased health-related quality of life (HRQL). The quality of life in patients with laryngopharyngeal reflux (LPR) symptoms is also significantly impaired. However, the impact of LPR symptoms on HRQL in GERD patients has not been studied.

METHODS

A nationwide, random-sample, and face-to-face survey of 300 Korean patients with GERD was conducted from January to March 2013. Gastroesophageal reflux symptoms were assessed using the Rome III questionnaire, LPR symptoms using the reflux symptom index, and HRQL using the EuroQol five dimensions (EQ-5D) questionnaire. A structured questionnaire on patient satisfaction, sickness-related absences, and health-related work productivity was also used.

RESULTS

Among the 300 patients with GERD, 150 had LPR symptoms. The mean EQ-5D index was lower in patients with GERD and LPR symptoms than in those without LPR (0.88 vs 0.91, P = 0.002). A linear regression model showed that the severity of LPR symptoms was related to decreased HRQL and was independent of age, marital status, body mass index, or household income. The overall satisfaction rate regarding treatment was lower in patients with GERD and LPR (40.0% vs 69.1%, P = 0.040). GERD patients with LPR symptoms reported greater sickness-related absent hours per week (0.36 vs 0.02 h, P = 0.016) and greater percentages of overall work impairment than those without LPR (31.1% vs 20.8%, P < 0.001).

CONCLUSIONS

Gastroesophageal reflux disease patients with LPR symptoms have a poorer HRQL, a lower satisfaction rate, and a greater disease burden than those without LPR.

Quality-of-Life Impact of Non-Neoplastic Voice Disorders: A Meta-Analysis

Objectives:

We undertook to explore the relationship between non-neoplastic voice disorders and patients' quality of life.

Methods:

A PubMed search (1966 to 2003) for the terms Voice Handicap Index (VHI), Short Form-36 (SF-36), voice disorders, voice quality, treatment outcome, voice outcome, quality of life, and questionnaires was performed. Raw data were obtained whenever possible. Studies were analyzed by meta-analysis techniques.

Results:

Of 54 VHI studies identified, 11 were excluded, and of 21 SF-36 studies, 7 were excluded for incomplete data, non-English language, measuring malignant disease, or duplicate publication. Patients with neurologic and inflammatory or traumatic laryngeal disease had worse VHI scores than controls, and those with neurologic laryngeal disease had the most severe impairment (p <.001, Kruskal-Wallis analysis of variance; p <.05, Dunn's method of multiple comparisons). Those with neurologic laryngeal disease had worse SF-36 subdomain scores than did controls in 6 of 8 subdomains (p <.03, Kruskal-Wallis analysis of variance; p <.05, Dunn's method of multiple comparisons). Both patients with neurologic disease and patients with inflammatory or traumatic laryngeal disorders had changes in SF-36 subdomains similar to those of patients with other chronic disease states.

Conclusions:

Non-neoplastic voice disorders adversely impact patients' voice-related and general quality of life, and neurologic voice disorders have the greatest impact.

Validation and Cultural Adaptation of the Arabic Version of the Eating Assessment Tool (EAT-10)

BACKGROUND AND OBJECTIVES

The Eating Assessment Tool (EAT-10) is a 10-item self-administered questionnaire. It is a noninvasive tool to measure patients' perception of their swallowing problems. The purposes of the present study were to develop an Arabic version of the EAT-10 and to evaluate its validity, consistency, and reliability in the Arabic-speaking population with oropharyngeal dysphagia.

SETTING AND DESIGN

This was a prospective study carried out at the Communication and Swallowing Disorders Unit, King Saud University, Riyadh, Saudi Arabia.

SUBJECTS AND METHODS

The Arabic EAT-10 was administered to 138 patients with oropharyngeal dysphagia and 83 control subjects. Internal consistency and test-retest reliability were evaluated. Content and clinical validity were studied, and the EAT-10 results were compared across patients and control groups.

RESULTS

The Arabic EAT-10 showed excellent internal consistency (Cronbach's α = 0.92). Also, good test-retest reliability was found for the total scores of the Arabic EAT-10 (intraclass correlation = 0.73). There was a significant difference in Arabic EAT-10 scores between the oropharyngeal dysphagia group and the control group (p < 0.001).

CONCLUSION

This study demonstrated that the Arabic EAT-10 is a valid tool that can be used for screening of dysphagia-related problems in an Arabic-speaking population.

Self-Perception of Swallowing-Related Problems in Laryngopharyngeal Reflux Patients Diagnosed with 24-Hour Oropharyngeal pH Monitoring

Background and Objectives. Swallowing difficulty is considered one of the nonspecific symptoms that many patients with laryngopharyngeal reflux complain of. However, the relationship between laryngopharyngeal reflux and swallowing problems is not clear. The purpose of this work is to explore correlation between swallowing-related problems and laryngopharyngeal reflux (LPR) in a group of patients diagnosed with oropharyngeal pH monitoring and to study the effect of laryngopharyngeal reflux on the patients' self-perception of swallowing problems. Methods. 44 patients complaining of reflux-related problems were included in the study. Patients underwent 24-hour oropharyngeal pH monitoring and were divided into positive and negative LPR groups based on the pH monitoring results. All patient filled out the Dysphagia Handicap Index (DHI) and Reflux Symptom Index (RSI) questionnaires. Comparison was made between the positive and negative LPR groups regarding the results of the DHI and RSI ratings. Also, correlation between DHI scores, RSI scores, and pH monitoring results was studied. Results. Significant difference was reported between positive and negative LPR groups regarding DHI scores, RSI scores, and overall rating of swallowing difficulty. There was significant correlation demonstrated between DHI scores, RSI scores, and 24-hour oropharyngeal pH results. Conclusion. Laryngopharyngeal reflux appears to have a significant impact on patients' self-perception of swallowing problems as measured by DHI.

Long-term results of electrical stimulation of the lower esophageal sphincter for treatment of proximal GERD

INTRODUCTION

Electrical stimulation of the lower esophageal sphincter (LES) in gastroesophageal reflux disease (GERD) patients, using EndoStim(®) LES stimulation system (EndoStim BV, the Hague, Netherlands), enhances LES pressure, decrease distal esophageal acid exposure, improves symptoms, and eliminates the need in many patients for daily GERD medications.

AIM

To evaluate, in a post hoc analysis, the effect of LES stimulation on proximal esophageal acid exposure in a subgroup of patients with abnormal proximal esophageal acid exposure.

METHODS

Nineteen patients (median age 54 years; IQR 47-64; men-10) with GERD partially responsive to proton pump inhibitors (PPI), hiatal hernia ≤ 3 cm, esophagitis ≤ LA grade C underwent laparoscopic implantation of the LES stimulator. LES stimulation at 20 Hz, 215 μs, 5-8 m Amp sessions was delivered in 6-12, 30 min sessions each day. Esophageal pH at baseline and after 12-months of LES stimulation was measured 5 and 23 cm above the manometric upper border of LES.

RESULTS

Total, upright and supine values of median (IQR) proximal esophageal pH at baseline were 0.4 (0.1-1.4), 0.6 (0.2-2.3), and 0 (0.0-0.2) %, respectively, and at 12 months on LES-EST were 0 (0-0) % (p = 0.001 total and upright; p = 0.043 supine comparisons). 24-hour distal esophageal acid exposure improved from 10.2 (7.6-11.7) to 3.4 (1.6-7.0) % (p = 0.001). Seven (37%) patients had abnormal (>1.1%) 24-hour proximal acid exposure at baseline; all normalized at 12 months (p = 0.008). In these 7 patients, total, upright, and supine median proximal acid exposure values at baseline were 1.7 (1.3-4.1), 2.9 (1.9-3.7), and 0.3 (0-4.9) %, respectively, and after 12 months of LES-EST were 0 (0-0.0), 0 (0-0.1), and 0 (0-0) % (p = 0.018 total and upright; p = 0.043 supine comparisons). Distal esophageal pH for this group improved from 9.3 (7.8-17.2) at baseline to 3.2 (1.1-3.7) % at 12-months (p = 0.043). There were no GI side effects such as dysphagia, gas-bloat or diarrhea or device or procedure related serious adverse events with LES-EST. There was also a significant improvement in their GERD-HRQL scores.

CONCLUSION

LES-EST is associated with normalization of proximal esophageal pH in patients with GERD and may be useful in treating those with proximal GERD. The LES-EST is safe without typical side effects associated with traditional antireflux surgery.

Development of the Arabic Version of Dysphagia Handicap Index (DHI)

The Dysphagia Handicap Index (DHI) is a 25-item self-administered questionnaire. It is a noninvasive tool for measuring the handicapping effect of dysphagia on the physical, functional, and emotional aspects of people's lives. The purposes of the present study were to develop an Arabic version of the DHI and to evaluate its validity, consistency, and reliability in the normal Arabic population with oropharyngeal dysphagia. This was a prospective study that was carried out at the Communication and Swallowing Disorders Unit, King Saud University. The generated Arabic DHI was administered to 94 patients with oropharyngeal dysphagia and 98 control subjects. Internal consistency and test-retest reliability were evaluated. The results of the patients and the control group were compared. The Arabic DHI showed excellent internal consistency (Cronbach's α = 0.95). Also, good test-retest reliability was found for the total scores of the Arabic DHI (r = 0.9, p = 0.001). There was a significant difference between the DHI scores of the control group and those of the oropharyngeal dysphagia group (p < 0.001). This study demonstrated that the Arabic DHI is a valid tool for self-assessment of the handicapping effect of dysphagia on the physical, functional, and emotional aspects of patients and can be used by Arabic language speakers.

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

OBJECTIVE/HYPOTHESIS

To assess changes in the symptoms and quality of life (QOL) of patients diagnosed with laryngopharyngeal reflux (LPR) after proton pump inhibitor (PPI) treatment.

STUDY DESIGN

Prospective study.

METHODS

One hundred eighty patients diagnosed with LPR were evaluated. All patients were prescribed Lansoprazole (15 mg) twice daily for 12 weeks. The Reflux Symptom Index (RSI), Reflux Finding Score (RFS), Short-Form 36-Item Health Survey version 2.0 (SF-36), and LPR-health-related quality of life (HRQOL) were collected from each patient at the initial visit and at 4- and 12-week follow-up visits.

RESULTS

Significant improvement was observed in RSI and RFS scores after treatment. The LPR-HRQOL score also showed gradual improvement after PPI treatment in the voice, cough, throat clearing, swallowing, and overall impact of acid reflux. Although each domain of the SF-36 had a low score at the baseline visit, seven domains of the SF-36 had improved, except for the physical functioning domain.

CONCLUSIONS

We found that RSI, RFS, and most categories in the LPR-HRQOL and SF-36 improved 12 weeks after initiating PPI treatments. These findings indicate that PPI treatment for 3 months could improve the QOL of patients diagnosed with LPR.

Current concepts of otitis media in adults as a reflux-related disease

OBJECTIVE

To review the findings of otitis media in adults in relation to supraesophageal reflux of gastrointestinal contents and summarize current concepts.

DATA SOURCES

Literature published in English-language journals from 2001 to the present identified by searching electronic databases (MEDLINE and Web of Science).

STUDY SELECTION

Clinical articles that contained the terms reflux, ear, otitis media, and adult and relevant animal studies.

DATA EXTRACTION

Findings of searchable case reports and results of animal studies were included.

DATA SYNTHESIS

Current findings were reviewed for the following points: 1) proposed effect of reflux, 2) prevalence and characteristics, 3) risk factors, and 4) treatment.

CONCLUSION

Published literature concerning reflux and otitis media in adults is limited to clinical case series. Reflux is likely present in a significant number of adult cases with otitis media and may lead to Eustachian tube dysfunction in such subjects. Reflux in adult subjects with otitis media is potentially different from the physiologic events observed in children, but the causal link between them remains unclear. Evaluation of more cases that could be diagnosed as reflux-induced otitis media is necessary for better understanding of the disease entity.

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.

Laryngopharyngeal reflux: Current opinion

The increasing importance of LPR is being recognized day by day in ENT practice. LPR has a significant negative impact in the quality of lives of the patients. Although its impact is similar in some respects to that of laryngopharyngeal disease, LPR has a more significant impact on patient's social functioning and vitality.([23]) All ear, nose and throat practitioners need to be sensitised to the presence of LPR and the need for starting treatment wherever required. Lot of hitherto symptoms of unknown aetiology are being increasingly of treating patients with atypical reflux symptoms such as hoarseness (unexplained cause), globus, throat clearing, cough, etc., with antireflux therapy.([24]).

Gastroesophageal reflux and voice changes: objective assessment of voice quality and impact of antireflux therapy

BACKGROUND AND AIM

Voice-related complaints are the most common extraesophageal manifestation of gastroesophageal reflux disease (GERD). The aim of this study was to compare objectively measured voice parameters in normal subjects and patients with GERD and to assess the impact of antireflux surgery on these parameters in patients with reflux disease.

METHODS

Normal subjects and patients with reflux symptoms were asked to read a standardized, phonetically balanced text while the impedance across vocal cords was recorded using electroglottography. Irregularity in the voice frequency (CFx) and amplitude (CAx) as well as irregularity of the closed phase ratio of vocal cords (CQx) were calculated. These 3 voice parameters were compared between the normal subjects and patients with gastroesophageal reflux. In a subgroup of GERD patients who underwent antireflux surgery, electroglottography was repeated 3 months or later after surgery and the voice parameters were compared with preoperative values.

RESULTS

There were 55 normal subjects and 32 patients with GERD. Compared with normal subjects, GERD patients had a significantly higher irregularity in both voice frequency (P=0.04) and amplitude (P=0.03). The CQx did not differ significantly between the 2 groups (P=0.18). In 16 GERD patients who underwent surgery, a significant improvement in postoperative values was observed for both voice frequency (CFx: 48.4 vs. 30.4, P=0.002) and amplitude (CAx: 25.9 vs. 9.3, P=0.004).

CONCLUSIONS

There are measurable alterations in voice quality in patients with GERD when compared with normal subjects. Antireflux surgery improves the irregularity in both amplitude and frequency of voice in patients with reflux disease.

Prevalence of laryngopharyngeal reflux symptoms: comparison between health checkup examinees and patients with otitis media

OBJECTIVE

To investigate the prevalence of laryngopharyngeal reflux (LPR) symptoms in health checkup examinees and in patients with otitis media with effusion (OME) of undetermined etiology and the significance of age, body mass index (BMI), and pepsinogen (PG) concentration in middle ear effusions (MEEs).

STUDY DESIGN

Cross-sectional study.

SETTING

Health checkup and private clinics.

SUBJECTS AND METHODS

A total of 410 subjects who had undergone a health checkup were asked to respond to the reflux symptom index (RSI) to identify the distribution of the RSI score, and the results were compared with 62 patients with OME by BMI and PG concentration in the MEEs.

RESULTS

The RSI-positive (score >13) rate was 7.1% in the health checkup examinees. The highest rate was observed in men in their 40s, who had the highest average BMI. None of the men in their 80s were RSI positive. The RSI-positive rate in patients with OME was 21.0%. None of the male patients ≥ 70 years of age were RSI positive, whereas the average PG concentration was significantly higher in this group.

CONCLUSION

The prevalence of LPR symptoms evaluated by the RSI was significantly higher in OME patients than in the health checkup examinees; however, a similar pattern in which LPR symptoms were prominent in middle-aged men with a high BMI and much less in elderly men was observed. Middle-aged men with a high BMI might be diagnosed as having LPR disease based on the relevant symptoms. LPR findings would be more sensitive than symptoms in elderly men.

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII)

BACKGROUND

Laryngopharyngeal reflux (LPR) can cause atypical symptoms, asthma, and pulmonary fibrosis. The aim of this study was to establish the normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH (HMII).

METHODS

Asymptomatic subjects underwent endoscopy followed by 24-h HMII using a specialized impedance catheter configured to detect LPR before and after a 2-week course of proton pump inhibitors (PPI). Subjects were excluded if they had esophageal pathology or a positive DeMeester score. A cohort of 24 LPR patients who had a complete response to treatment was used for comparison with the normative data.

RESULTS

Forty subjects were enrolled. Thirty-four subjects completed one, and 25 completed both HMII testing periods off and on PPI. There was no difference in the total number of reflux events between off and on PPI [22 (8-32) and 24 (10-28), respectively, p = 0.89]. The 95th percentiles of LPR off and on PPI were 0 and 1, respectively. All patients with treatment responsive LPR had pre-treatment HMII values of LPR greater than the 95th percentile.

CONCLUSION

LPR events are rare in an asymptomatic population. One or more LPR events should be considered abnormal in patients with LPR symptoms regardless of whether there is a positive DeMeester score.

Management of laryngopharyngeal reflux with proton pump inhibitors

There is a lack of consistent guidelines and consensus for the diagnosis of laryngopharyngeal reflux (LPR). A therapeutic trial with a proton pump inhibitor (PPI) has been suggested to identify patients with LPR. This review focuses on the current difficulties in diagnosing the disease and examines the evidence for the effectiveness of PPI therapy in suspected reflux-related laryngeal symptoms. Additionally, mode of action, safety, and tolerability of PPIs are described. A total of 7 placebo-controlled trials were identified and included in the review. All studies evaluated the effect of a PPI on symptoms and objective laryngoscopic findings in suspected LPR. Data from these trials show that PPI therapy is no more effective than placebo in producing symptom relief in patients suspected of LPR. Symptoms, laryngoscopic findings, or abnormal findings on pH monitoring will not predict response to PPI therapy. High placebo response levels suggest a much more complex and multifactorial pathophysiology of LPR than simple acid reflux. Further studies are needed to characterize subgroups of patients with reflux-associated laryngeal symptoms that might benefit from treatment with PPI. Future studies should use validated patient reported outcome measures with endpoints that represent a predefined clinically meaningful change in symptom scores.

Establishment of a reflux esophago-laryngitis model in rats

BACKGROUND

To investigate the pathophysiology of reflux laryngitis, an experimental model is required.

AIM

The aim of this study is to establish an animal model of reflux esophago-laryngitis, modifying our previously reported model of chronic acid reflux esophagitis.

METHODS

The modified chronic acid reflux esophagitis (m-RE) group (n = 10), in which the duodenum was wrapped with 2.5 mm of Nelaton catheter, was not treated with any drugs. Also postoperatively, two treatment groups (n = 10 in each) received different dosages of rabeprazole (RPZ): 1.0 mg/kg/day (RPZ 1.0 group) or 10.0 mg/kg/day (RPZ 10.0 group). As a control group (n = 5), other rats underwent sham operation. The esophagus and larynx were resected on day 14 after the operation, and ulcer score of the esophagus was assessed. The epithelial thickness and leukocyte infiltration of the supraglottic and subglottic laryngeal mucosae were investigated. The number of interleukin (IL)-1β-positive cells was also counted and defined as the IL-1β labeling index.

RESULTS

In the m-RE group, the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of the supraglottic and subglottic laryngeal mucosae were increased compared with controls (P < 0.01). In the RPZ groups, not only the ulcer score of esophagus but also the epithelial thickness, leukocyte infiltration, and IL-1β labeling index of both the supraglottic and subglottic laryngeal mucosae were decreased dose-dependently relative to the m-RE group (P < 0.05).

CONCLUSIONS

Our modified chronic acid reflux esophagitis model proved useful in establishing a rat reflux esophago-laryngitis model, with both pathological laryngeal findings and reflux esophagitis shown to be improved by administration of a proton pump inhibitor.

Empirical treatment with pantoprazole as a diagnostic tool for symptomatic adult laryngopharyngeal reflux

OBJECTIVE

To determine the sensitivity and specificity of intensive empirical treatment with pantoprazole in diagnosing laryngopharyngeal reflux in adults.

STUDY DESIGN

This was a prospective, double-blind study.

SUBJECTS AND METHODS

Fifty-five patients with either a Reflux Symptom Index of more than 13 or a Reflux Finding Score of more than 7 were enrolled. All patients underwent 24-hour, double-probe pH monitoring before commencing pantoprazole 40 mg twice daily; both investigators and patients were blinded to pH monitoring results. The Reflux Symptom Index and Reflux Finding Score were reassessed during the second, third and fourth month of follow up.

RESULTS

The sensitivity of empirical pantoprazole treatment in diagnosing laryngopharyngeal reflux was 92.5 per cent. The specificity was 14.2 per cent, the positive predictive value 86 per cent and the negative predictive value 25 per cent. There was significant reduction in the total Reflux Symptom Index and Reflux Finding Score after the second, third and fourth month of treatment. There was no correlation between laryngopharyngeal reflux and body mass index.

CONCLUSION

Our results suggest that intensive empirical treatment with proton pump inhibitors is effective in diagnosing laryngopharyngeal reflux.

[Laryngectomised patients with voice prostheses: influence of supra-esophageal reflux on voice quality and quality of life]

INTRODUCTION

We conducted a prospective study to assess the influence of supra-esophageal reflux on voice quality and quality of life in patients who had undergone laryngectomy and prosthetic voice rehabilitation.

PATIENTS AND METHODS

We investigated 60 laryngectomised patients using 24-h dual-probe pH monitoring before and 6 months after oral anti-reflux treatment with proton pump inhibitors (PPIs). Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30. Voice quality was quantified using the voice handicap index (VHI10). Quality of life and voice quality parameters were then correlated with the severity of reflux disease.

RESULTS

Patients with physiological reflux area index (RAI) scores had a mean VHI10 score of 46.4 (±11.4). VHI scores were found to increase to up to 64.1 (±9.6) with reflux severity (p=0.025). Total quality of life scores ranged from 115.8 (±24.7) in patients with physiological RAI scores to 131.0 (±33.1) in patients with highly pathological RAI scores (p=0.007). After 6 months of treatment with PPIs, VHI scores improved to a total score of 57.5 (±20.6, p=0.003). Quality of life scores improved to 123.3 (±29.0, p=0.045).

CONCLUSION

Supra-esophageal reflux influences voice quality and quality of life in laryngectomised patients with voice prostheses. This can be explained, for example, by an increased incidence of periprosthetic leakage, the presence of edema in the pharyngo-esophageal segment (where speech is produced), and general reflux symptoms. Rigorous treatment with anti-reflux medications leads to an improvement in reflux parameters that can be assessed objectively (RAI) and in correlated quality of life and voice quality parameters. For this reason, we recommend rigorous oral treatment with PPIs in laryngectomised patients with a confirmed diagnosis of supra-esophageal reflux.

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.

Evaluation of upper abdominal symptoms using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease in patients with laryngopharyngeal reflux symptoms

BACKGROUND

The purpose of the study was to evaluate upper abdominal symptoms in laryngopharyngeal reflux (LPR) patients and changes in both upper abdominal and LPR symptoms before and after acid-suppression therapy.

METHODS

In 100 patients with LPR symptoms, upper abdominal and LPR symptoms were evaluated by using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) and the LPR symptom scoring system, respectively. In the 52 assessable patients, changes in these symptoms before and after acid-suppression therapy were evaluated.

RESULTS

Upper abdominal symptoms were reported by 96/100 LPR patients: 89 responded positively to at least one of the questions about acid reflux-related symptoms and 89 to at least one of those about dysmotility-like symptoms. There was poor correlation between positive rates to FSSG upper abdominal symptom questions and the frequency of reported laryngopharyngeal symptoms. There were significant reductions in the frequency of acid reflux-related symptoms, dysmotility-like symptoms, and laryngopharyngeal symptoms after acidsuppression therapy. The LPR symptom score decreased to less than half the pretreatment score in 25 subjects (therapeutic response group). The pretreatment frequency of dysmotility-like symptoms seemed to be higher in the nonresponse group than in the response group, although the difference was not significant. There was no significant difference between the two groups in the pretreatment frequency of acid reflux-related symptoms.

CONCLUSIONS

The majority of these Japanese LPR patients experienced some form of upper abdominal symptoms. The frequency of dysmotility-like symptoms was similar to that of acid reflux-related symptoms. The pretreatment frequency of dysmotility-like symptoms, but not of acid reflux-related symptoms, might be a predictor of patient response to acid-suppression therapy.

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.

Acid-suppression therapy offers varied laryngopharyngeal and esophageal symptom relief in laryngopharyngeal reflux patients

It is widely accepted that laryngopharyngeal reflux requires more aggressive and prolonged therapy than gastro-esophageal reflux disease. Otolaryngologists often observe that laryngopharyngeal symptoms, such as throat clearing, hoarseness, cough, and globus pharyngeus, are slower to resolve than esophageal symptoms, such as heartburn and regurgitation. The aim of this was to provide empirical evidence to support this observation and to carry out a detailed investigation of the differences between these symptoms. Forty-five patients with laryngopharyngeal and esophageal symptoms received acid-suppression therapy that involved the continuous administration of a proton-pump inhibitor for up to 6 months. We investigated the differences in response to acid-suppression therapy between patients suffering from laryngopharyngeal and esophageal symptoms, respectively, who received upper gastrointestinal endoscopy and were assayed for serum Helicobacter pylori antibodies. The significance of the rate of symptom improvement was estimated by Kaplan-Meier analysis and the logrank test. Laryngopharyngeal symptoms improved significantly more slowly than esophageal symptoms following acid-suppression therapy (49.8 vs. 78.3%, 60 days after the start of acid suppression; P = 0.003). These differences were observed both in patients with erosive esophagitis (P = 0.008) and in H. pylori-seronegative patients (P = 0.001).

Association of extraesophageal reflux disease and sinonasal symptoms: prevalence and impact on quality of life

OBJECTIVES

The purpose of this study was to investigate the prevalence of extraesophageal reflux disease symptoms and their association with sinonasal disorders within a general sample of adults in our community and to determine how these conditions affect perception of general health, sinus-related quality of life (QOL), and perception of reflux and digestive function.

STUDY DESIGN/METHODS

A community-dwelling sample of 1,878 adults completed symptom and QOL surveys in a two-stage prospective design: an initial screening questionnaire (n = 1,878) and disease-specific (sinus and reflux/digestion) and general health-related QOL instruments (n = 1,073). Demographic and response data were summarized and analyzed for prevalence and correlations among data sets.

RESULTS

Sinonasal symptoms were reported in 71% of subjects who completed the initial screening questionnaire, and reflux-related symptoms were reported by 59% of respondents. The co-occurrence of sinonasal and reflux symptoms was reported by 45% of respondents. Subjects with both sinonasal and reflux symptoms scored significantly worse on the disease-specific and general physical and mental QOL scales than subjects with only reflux or sinonasal symptoms or no symptoms.

CONCLUSIONS

Symptoms associated with inflammatory sinonasal disorders and gastroesophageal reflux disease are common in the general U.S. adult population and co-occur in the same individuals to a greater degree than can be attributed to chance alone. Co-occurrence was found to be associated with significant declines in both disease-specific and general physical and mental QOL. This finding has implications with regard to pathogenesis and treatment of these disorders.

Diagnosis and management of laryngopharyngeal reflux disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux should no longer be underestimated because of its negative impact on the lives of patients and its potentially dangerous long-term complications.

RECENT FINDINGS

Both laryngopharyngeal reflux and gastroesophageal reflux disease are caused by mucosal injury from acid and pepsin exposure, but the esophagus has intrinsic antireflux defenses that prevent mucosal injury (bicarbonate production, mucosal tissue resistance and esophageal motor function with acid clearance) whereas the pharynx and the larynx do not. Symptoms felt to be most related to reflux (>or= 95%) are throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in the throat) and voice-quality change, while the physical examination findings include (>or= 95%) arytenoid erythema, vocal-cord erythema and edema, posterior commissure hypertrophy, and arytenoid edema. In this regard, the reflux symptom index and the reflux finding score are very useful clinical tools. Patients are proposed an empirical therapeutic trial including behavioural and dietary recommendations and a 3-month twice-daily proton-pump inhibitor therapy. The proton-pump inhibitor should be taken 30-60 min before meals. Nonresponders undergo an assessment, ideally based on esogastroduodenoscopy and ambulatory multichannel intraluminal impedance and pH monitoring. Transnasal esophagoscopy in the outpatient setting is a safe alternative. When medical management fails, patients with demonstrable high-volume reflux and lower sphincter incompetence are often candidates for surgical intervention.

SUMMARY

The algorithm proposed by Ford has structured and confirmed our attitude on a day-to-day basis.

Epidemiology of gastroesophageal reflux disease in Tehran, Iran

BACKGROUND AND AIM

Epidemiological studies have indicated an increase in the prevalence of gastroesophageal reflux disease in Western countries; however, there is a lack of information about its prevalence in Iran. The aim of this study was to measure gastroesophageal reflux disease prevalence in a representative sample of the Tehran population in 1999.

METHODS

In a cross-sectional study, 700 people, with a male : female ratio of 1:1, were selected by stratified randomization based on the probability of 20% prevalence of gastroesophageal reflux disease and 3% error. They were divided equally into seven age groups. Heartburn and acid regurgitation were considered as the most common symptoms of gastroesophageal reflux disease. The severity and frequency of heartburn and the role of personal habits in the appearance of this symptom were determined. The prevalence of gastroesophageal reflux disease in samples was measured, and its actual prevalence in society was estimated.

RESULTS

Of 700 people, 350 were male and 350 were female. The major symptoms of gastroesophageal reflux disease were observed in 278 (39.7%) people. The prevalence of gastroesophageal reflux disease of smokers was twice that of non-smokers.

CONCLUSIONS

Gastroesophageal reflux disease is a serious and unresolved problem in Western countries, and its increasing prevalence correlates with an increasing prevalence of adenocarcinoma of distal esophagus. The prevalence of gastroesophageal reflux disease appears to be increasing in Iran also; therefore, it is recommended that major attention be paid to this disease.

Quality of Life in Laryngopharyngeal Reflux Patients

OBJECTIVES

To evaluate and compare quality of life (QL) parameters in patients with laryngopharyngeal reflux (LPR) versus healthy controls, to determine the impact of clinical signs to QL, and to assess changes in QL parameters after treatment.

STUDY DESIGN

Prospective, open, clinical study.

MATERIAL AND METHODS

One hundred outpatients with LPR and 109 healthy voice controls were enrolled. LPR patients underwent endoscopy and received omeprazole for 3 months. Results of endoscopy revealed 79 patients without esophagitis and 21 with, giving two subgroups of LPR patients. QL was evaluated using voice handicap index (VHI), hospital anxiety and depression scale, disability in social activities, and well-being in general (W-BVAS).

RESULTS

The mean scores for total VHI and functional, physical, and emotional functioning domain subscales were found to be significantly higher in LPR patients versus controls (P < .0001), with no difference among LPR subgroups. Abnormal anxiety was one third in both LPR subgroups versus 6.4% of controls (P < .001). Both LPR subgroups patients had significantly reduced social activities and significantly lower mean W-BVAS score than controls. LPR symptoms had a significant relation with all tested QL parameters, whereas laryngoscopic findings had a significant relation with VHI and W-BVAS only. All mean QL parameters scores improved after 3-month omeprazole treatment.

CONCLUSIONS

QL in LPR patients with or without esophagitis is impaired significantly in many aspects. Impairment of QL is more associated with symptoms than laryngoscopic findings. Treatment with omeprazole significantly improved QL in both LPR subgroups patients.