Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms

Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score

OBJECTIVE

The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR).

METHODS

Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests.

RESULTS

Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001). When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%.

CONCLUSION

The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review

Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.

The utility of a symptom model to predict the risk of oesophageal cancer

OBJECTIVE

To assess whether extra-oesophageal symptoms are predictive of oesophageal malignancy.

METHODS

A prospective, single-centre cross-sectional questionnaire study at a tertiary referral unit for oesophageal cancer using the Comprehensive Reflux Symptoms Scale (CReSS) questionnaire tool. Respondents with oesophageal malignancy were compared with historical cohorts undergoing airway examination or upper gastrointestinal endoscopy and found to have benign diagnoses. We developed a model for predicting oesophageal cancer using linear discriminant analysis and logistic regression, assessed by Monte Carlo cross validation.

RESULTS

Respondents with oesophageal malignancy (n = 146; mean age 70.5; male: female, 71:29) were compared with those undergoing airway examination (n = 177) and upper gastrointestinal endoscopy (n = 351), found to have benign diagnoses. No single questionnaire item, or group of co-varying items (factors), reliably discriminated oesophageal cancer from other diagnoses. Individual items which suggested higher risk of oesophageal malignancy included dysphagia (area under the curve (AUC) 0.68), low appetite (AUC 0.66), and early satiety (AUC 0.58). Conversely, throat pain (AUC 0.38), bloating (AUC 0.38) and heartburn (AUC 0.37) were inversely related to cancer risk. A forward stepwise regression analysis including a subset of 12 CReSS questionnaire items together with age and sex derived a model predictive of oesophageal malignancy in this cohort (AUC 0.89).

CONCLUSION

We demonstrate a model comprised of 12 questionnaire items and 2 demographic parameters as a potential predictive tool for oesophageal malignancy diagnosis in this study population. Translating this model for predicting oesophageal malignancy in the general population is a valuable topic for future research.

The Validity and Reliability of the Reflux Finding Score

Laryngopharyngeal reflux (LPR) disease is common. The incidence of newly diagnosed cases has increased substantially due to awareness and development of new diagnostic measurements. The reflux finding score (RFS) and reflux symptom index (RSI) are believed to be useful in the assessment process, including after the initiation of therapy. However, many authors have suggested concerns about the reliability and validity of the RFS.

OBJECTIVE

To evaluate the validity and reliability of the RFS.

METHODS

Ninety-two patients diagnosed with LPR who had undergone 24-hour pH-Impedance tests were included. All patients underwent stroboscopy and 24-Hour pH-Impedance monitoring within thirty days. Fifty-nine patients filled out a RSI prior to stroboscopic exam. The RFS was determined by four blinded observers: one otolaryngology resident, two laryngology fellows, and one laryngologist. Stroboscopic images were reviewed again one year later to assess intrarater reliability. RFS and RSI were correlated with 24-hour pH Impedance testing.

RESULTS

The Kappa value between reviewers was 0.479. The percent agreement of the four observers for total RFS was 74.04%.The percent agreement between reviewers for subglottic edema was 78.77%; for ventricular obliteration was 65.55%; for erythema/hyperemia was 69.62%, for vocal fold edema was 68.32%; for diffuse laryngeal edema was 66.86%, for posterior commissure hypertrophy was 73.54%; for granuloma/granulation was 96.80%; for thick endolaryngeal mucus was 72.81%. The intrarater reliability of the four observers for total RFS was 67.5% with an intrarater reliability range of 50%-90%. The intrarater reliability for subglottic edema was 85% with a range of 70%-100%; for ventricular obliteration was 77.50% with a range of 70%-90%; for erythema/hyperemia was 65.00% with a range of 50%-90%; for vocal fold edema was 52.50% with a range of 30%-70%; for diffuse laryngeal edema was 62.50% with a range of 20%-80%; for posterior commissure hypertrophy was 52.50% with a range of 10%-80%; for granuloma/granulation was 100%; for thick endolaryngeal mucus was 55.00% with a range of 10%-90%. There was no correlation between RFS and any parameter of the 24-Hr pH-Impedance Test. RSI had a significant correlation with number of upright events (r value of 0.271, R² of 0.0733 and P-value of 0.037), total symptoms experienced (r value of 0.0.267, R² of 0.0715 and P-value of 0.041), and symptom correlation score (r value of -0.297, R² of 0.0884 and P-value of 0.022).

CONCLUSION

Many authors have expressed concerns about the reliability and validity of the RFS. In our study we found a fair/substantial interrater reliability, and a modest intra-rater reliability. We found no correlation between the RFS and 24-Hr pH Impedance testing. This study suggests that the concerns about the validity and reliability of the RFS may be warranted. This widely used clinical score should be interpreted with caution and further research and refinement should be considered.

The Association between the Risk of Esophageal Cancer and Type 2 Diabetes Mellitus: An Updated Meta-Analysis

Background

A large amount of publications had reported the association between incidence of esophageal cancer (EC) and type 2 diabetes mellitus (T2DM) in the past decade. However, those papers' results are inconsistent on relationships between T2DM the incidence of EC. Therefore, the objective of this meta-analysis was to determine the relationship between T2DM and the risk of EC (including 2 histological types, esophageal adenocarcinoma [EADC] and esophageal squamous cell carcinoma [ESCC]).

Method

We finally extracted 19 articles though Pubmed, Embased, and Cochrane library. Those identify extraction date including 14,312 cases and 24,959,067 control records and then mixed the relative risks (RRs) and corresponding 95% confidence intervals (95%CIs) through STATA.

Results

We observed that there are significantly positive correlation between T2DM and EC risk (RR = 1.28, 95% CI: 1.05-1.57, P = 0.015).Also, our study showed positive correlation between T2DM and EADC (esophageal adenocarcinoma) risk (RR = 1.28, 95% CI: 1.05-1.57, P < 0.001). What's more, subgroup analysis based on ethnicity represented the Caucasian is more susceptible to EC (RR = 1.28 ,95% CI: 1.10-1.49, P = 0.001).

Conclusion

Those results offer a recent epidemiological and integrated evidence to ascertain the correlations between T2DM and incidence of EC. Those results take public health implications on preventing T2DM and then depress the occurrence of EC. Our study also provides referenced information for the prevention. However, some data is still insufficient, and more research should be carried out.

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.

A Study on the Correlation Between Endoscopic Findings and Symptoms of Gastroesophageal Reflux Disease (GERD)

Background Gastroesophageal reflux disease is a common disorder affecting a large section of the community. In addition, the numerous complications of chronic gastroesophageal reflux disease (GERD) necessitate adequate diagnosis and treatment of this common entity. Thus, to analyze the spectrum of GERD on the basis of symptoms and endoscopic findings along with the contributory effects of various risk factors including obesity, this specific study has been carried out. Study design A descriptive type of observational study was conducted on the patients visiting the outpatient department (OPD) at Acharya Vinoba Bhave Rural Hospital (AVBRH), affiliated with Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, Maharashtra. The clinical symptoms, suspected risk factors, and endoscopic findings of the patients were studied, assessed, and correlated. Methods and material Patients, more than 18 years of age complaining of a minimum of two typical symptoms of GERD for at least one month, were included in the study. Demographic data, clinical symptomatology, and personal history of the patients were noted. All the patients were subjected to esophagogastroduodenoscopy, and findings were recorded. Correlation and analysis were done on clinical and endoscopic findings. Statistical analysis This descriptive study has been conducted after the approval of the Ethics Committee Department of Medical Education, Jawaharlal Nehru Medical College, Deemed University, Sawangi (DMIMS(DU)/IEC/Sept-2019/8403). The outcomes were recorded and analyzed at the end of the study using a Microsoft Excel Spreadsheet (version 16.40, Microsoft Corporation, Redmond, Washington, USA). Results and conclusion A total of 100 patients were included in the study. A number of male patients (58%) were more than that of female patients. Most of the patients were in the age group of 30-60 years (70%). The most common symptoms were epigastric pain (78%), regurgitation (71%), and heartburn (63%). Forty-five percent of the patients had erosive lesions suggestive of reflux esophagitis on endoscopic evaluation.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study

OBJECTIVES

Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology.

DESIGN

A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite.

MAIN OUTCOME MEASURES

Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival.

RESULTS

Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P < .0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P < .02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa.

CONCLUSIONS

An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

Diabetes in relation to Barrett's esophagus and adenocarcinomas of the esophagus: A pooled study from the International Barrett's and Esophageal Adenocarcinoma Consortium

BACKGROUND

Diabetes is positively associated with various cancers, but its relationship with tumors of the esophagus/esophagogastric junction remains unclear.

METHODS

Data were harmonized across 13 studies in the International Barrett's and Esophageal Adenocarcinoma Consortium, comprising 2309 esophageal adenocarcinoma (EA) cases, 1938 esophagogastric junction adenocarcinoma (EGJA) cases, 1728 Barrett's esophagus (BE) cases, and 16,354 controls. Logistic regression was used to estimate study-specific odds ratios (ORs) and 95% CIs for self-reported diabetes in association with EA, EGJA, and BE. Adjusted ORs were then combined using random-effects meta-analysis.

RESULTS

Diabetes was associated with a 34% increased risk of EA (OR, 1.34; 95% CI, 1.00-1.80; I2  = 48.8% [where 0% indicates no heterogeneity, and larger values indicate increasing heterogeneity between studies]), 27% for EGJA (OR, 1.27; 95% CI, 1.05-1.55; I2  = 0.0%), and 30% for EA/EGJA combined (OR, 1.30; 95% CI, 1.06-1.58; I2  = 34.9%). Regurgitation symptoms modified the diabetes-EA/EGJA association (P for interaction = .04) with a 63% increased risk among participants with regurgitation (OR, 1.63; 95% CI, 1.19-2.22), but not among those without regurgitation (OR, 1.03; 95% CI, 0.74-1.43). No consistent association was found between diabetes and BE.

CONCLUSIONS

Diabetes was associated with increased EA and EGJA risk, which was confined to individuals with regurgitation symptoms. Lack of an association between diabetes and BE suggests that diabetes may influence progression of BE to cancer.

There is no correlation between signs of reflux laryngitis and reflux oesophagitis in patients with gastro-oesophageal reflux disease symptoms

The objective of the present study was to determine if there is correlation between signs of reflux laryngitis (RL) and reflux oesophagitis (RE) in patients with gastro-oesophageal reflux disease (GORD) symptoms. Laryngeal photography obtained from patients during oesophagogastroduodenoscopy were examined by two otolaryngologists experienced in the field of extra-oesophageal reflux regarding the presence and severity of RL. The presence of RE was evaluated by gastroenterologist. Smokers, heavy drinkers and patients with bronchial asthma were excluded from the statistical analysis. A total of 681 patients were analysed. RL was diagnosed in 367 (53.9%) cases, of whom 182 patients had mild, 118 moderate and 67 severe (Reflux Finding Score > 7) RL. RE was diagnosed in 103 (28.1%) patients with RL and in 80 (25.7%) patients without RL. Neither the difference between the overall group of patients with RL and those without (OR 1.141, 95% CI 0.811-1.605, p = 0.448), nor the differences between the respective subgroups of patients with mild, moderate and severe RL and those without RL were statistically significant. The OR and 95% CI for mild, moderate and severe RL were 1.042, 95% CI 0.712-1.526, p = 0.834, 1.182, 95% CI 0.764-1.831, p = 0.453 and 1.0, 95% CI 0.566-1.766, p = 0.999 respectively. It can be concluded that there is no correlation between RL and RE in patients with GORD symptoms.

Oesophageal causes of dysphagia localised only to the pharynx: Implications for the suspected head and neck cancer pathway

OBJECTIVES

Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx-localised dysphagia (PLD) and the location of the underlying disease processes.

DESIGN

A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis.

MAIN OUTCOME MEASURES

Information about patient demography and presenting symptoms were recorded. The incisor-to-pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy.

RESULTS

The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid-thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio-oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight-change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy.

CONCLUSIONS

Pharynx-localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight-loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio-oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio-oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux

Importance

Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions.

Objective

To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions.

Design, Setting, and Participants

This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI).

Main Outcomes and Measures

Recorded change in the RSI after 6 weeks of treatment.

Results

Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68).

Conclusions and Relevance

Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Diabetes mellitus carries a risk of esophageal cancer: A meta-analysis

BACKGROUND

Many studies have showed that diabetes mellitus (DM) might be a risk factor for certain types of cancers. However, there are still inconsistent results on the effects of DM on the risk of esophageal cancer (EC). The objective of this study is to investigate the association and to quantify the correlation between DM and EC by a meta-analysis.

METHODS

The initial search identified 339 articles. Those publications that did not report the exact number of EC cases were removed. Finally, 13 meaningful studies were extracted from the databases of PubMed, MEDLINE, and Web of Science. All pooled analyses of risk ratios (RRs) and 95% confidence intervals (CIs) were assessed by a random-effect or fixed-effect model. Subgroup analysis was implemented on the basis of the sex or ethnicity. I value was used to assess heterogeneity, and funnel plot analysis was for publication bias.

RESULTS

The result showed that there was a positive correlation between type 2 diabetes mellitus (T2DM) and EC risk (RR = 1.28, 95% CI: 1.12-1.47, P < .001). Subgroup analysis based on gender showed that male was an important risk factor for EC (RR = 1.53, 95% CI: 1.44-1.62, P < .001), but female was not (RR = 1.23, 95% CI: 0.41-3.69, P = .71). In addition, subgroup analysis based on ethnicity showed that DM was significantly correlated to EC in North America subjects (RR = 1.39, 95% CI: 1.31-1.47, P < .001), and in Europe subjects (RR = 1.37, 95% CI: 1.02-1.83, P = .04), whereas no correlation was found in Asian subjects (RR = 0.98, 95% CI: 0.50-1.95, P = .96). Furthermore, DM had a correlation to an increased risk of esophageal adenocarcinoma (EAC) (RR = 1.43, 95% CI: 1.35-1.51, P < .001).

CONCLUSION

This meta-analysis indicates that DM is positively correlated to EC. However, the results should be interpreted with caution because of the limitations on potential clinical confounding factors in each study included in this meta-analysis.

Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease

OBJECTIVES/HYPOTHESIS

Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization.

STUDY DESIGN

Retrospective cohort review and cost minimization study.

METHODS

A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM.

RESULTS

Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS.

CONCLUSIONS

An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:S1-S13, 2017.

The elevated preoperative fasting blood glucose predicts a poor prognosis in patients with esophageal squamous cell carcinoma: The Fujian prospective investigation of cancer (FIESTA) study

Diabetes as a latent risk factor for cancer has been extensively investigated, while its postoperative prognosis for esophageal cancer is rarely reported. We therefore sought to assess whether the elevated fasting blood glucose before surgery was associated with poor survival in esophageal cancer patients by eliciting a subset of data from the ongoing Fujian prospective investigation of cancer (FIESTA) study. Over 15-year follow-up, 2535 patients receiving three-field lymphadenectomy were assessable. Only patients with esophageal squamous cell carcinoma (ESCC) (n=2396) were analyzed due to the lower prevalence of the other histological types. In ESCC patients, the follow-up duration ranged from 0.5 to 180 months (median 38.2 months). The median survival time (MST) was remarkably shorter in males than in females (80.7 vs. 180+ months, Log-rank test: P<0.001). In males, the survival was worse in patients with diabetes than those without (MST: 27.9 vs. 111.1 months, Log-rank test: P<0.001). In females, the survivor was improved in patients with diabetes (MST: 71.5 months), but was still worse than patients without diabetes (MST: 180+ months, Log-rank test: P<0.001). The overall multivariate hazard ratio for per unit increment in fasting blood glucose was 1.11 (95% confidence interval or CI: 1.09-1.14, P<0.001) and 1.08 (95% CI: 1.03-1.13, P=0.002) in males and females, respectively. Further survival tree analysis consolidated the discrimination ability of fasting blood glucose for the survival of ESCC patients. Taken together, our findings convincingly demonstrated that the elevated preoperative fasting blood glucose can predict poor survival of ESCC patients, especially in males.

Association between diabetes and esophageal cancer, independent of obesity, in the United States Veterans Affairs population

In the past 30 years, the incidence of esophageal adenocarcinoma (EAC) has increased more rapidly than any other cancer in the United States. The prevalence of obesity and diabetes mellitus has drastically increased as well. We explored the potential association between obesity, diabetes mellitus, and EAC. By means of retrospective interrogation of an administrative database from fiscal year 2005-2009, we identified two cohorts. The cancer cohort was defined as patients with adenocarcinoma of the distal esophagus or gastric cardia. The comparison cohort contained patients with gastroesophageal reflux disorder (GERD; diagnosis coupled with a procedure code for fundoplication). Patient data, including demographic measures, diagnoses of obesity, diabetes mellitus, dyslipidemia, alcohol abuse, and nicotine dependence were examined. A logistic regression model identified risk factors for development of EAC. The sample included 2,836 patients identified as having either EAC (1,704) or fundoplication with GERD (1,132). Although slightly higher percentages of the benign cohort were obese, the cancer cohort had more diabetics (30.8% vs. 14.8%; chi-square = 94.5; P < 0.0001). In a logistic regression analysis adjusting for comorbidity and lifestyle factors, diagnosis of diabetes mellitus was significantly associated with esophageal cancer as opposed to GERD without cancer (OR = 2.2; 95% confidence interval [CI] 1.7-2.8). Nicotine dependence was also identified as a risk factor (OR = 1.7; 95% CI 1.4-2.0). We identified a potential association between diabetes mellitus and adenocarcinoma of the esophagus or gastric cardia. This association appears to be independent of obesity. Additionally, nicotine dependence was identified as a risk factor for EAC.

High Prevalence of Laryngopharyngeal Reflux Disease in Patients With Lumbar Kyphosis

OBJECTIVE

To evaluate the relationship between laryngopharyngeal reflux disease and presence of lumbar kyphosis.

STUDY DESIGN

A cross-sectional study.

METHODS

We included 20 patients with lumbar kyphosis and 31 control subjects. A diagnosis of laryngopharyngeal reflux disease and gastroesophageal reflux disease was made if the Reflux Symptom Index score was ≥13 and if the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease was ≥8, respectively. We compared the prevalence of the two reflux diseases, frequent reflux symptoms, and demographic factors between the two groups.

RESULTS

There was no significant difference in demographic factors between the two groups. Five (25%) of 20 patients with lumbar kyphosis had a Reflux Symptom Index ≥13 compared with one (3.2%) of 31 controls. Seven (35.0%) of 20 patients had a Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease ≥8 compared with three (9.7%) of 31 controls. A comparison of the prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease showed a significant difference between patients with kyphosis and controls (P value = 0.029 and 0.036, respectively). In Reflux Symptom Index, heartburn, hoarseness, and a swallowing problem were significantly frequent symptoms in the kyphosis group compared with the control group.

CONCLUSIONS

The prevalence of laryngopharyngeal reflux disease and gastroesophageal reflux disease was significantly higher in patients with lumbar kyphosis than in controls. Therefore, otolaryngologists and orthopedic surgeons should be aware that patients with lumbar kyphosis are likely to have gastroesophageal reflux disease and also laryngopharyngeal reflux disease.

Laryngopharyngeal reflux disease in the Greek general population, prevalence and risk factors

Background

To assess the prevalence of laryngopharyngeal reflux (LPR) in the Greek general population and its risk factors.

Methods

Questionnaire based epidemiological, adult participants’ survey. The Reflux Symptom Index (RSI) was used for the assessment of LPR prevalence. The RSI questionnaire was completed by 340 (183 male and 157 female) randomly selected subjects. Subjects with RSI score ≥13 were considered as LPR patients and those with RSI score <13 were considered as non LPR subjects.

Results

The prevalence of LPR in the general Greek population was found to be 18.8 % with no statistically significant difference between the two genders (p > 0.05). The age group of 50–64 years showed the higher prevalence rate. Tobacco smoking and alcohol consumption were found to be related with LPR. No reported concomitant disease or medication was found to be related with LPR.

Conclusions

LPR prevalence in the Greek general population was found to be 18.8 %. Tobacco smoking and alcohol consumption were found to be related with LPR.

Changing Patterns in Reflux Care

Objectives:

To compare patterns of laryngopharyngeal reflux (LPR) diagnosis and management over time by American Broncho-Esophagological Association (ABEA) members.

Methods:

American Broncho-Esophagological Association members completed an online questionnaire focused on LPR evaluation and management in 2012; responses were compared to a 2002 survey.

Results:

Four hundred twenty-six members were emailed, of whom 63 (14.8%) responded. In both time periods, throat clearing, heartburn, globus, arytenoid edema, and erythema were considered highly related to LPR. Management in 2012 differed as respondents more commonly treated LPR empirically (82.6% vs 56.3%, P = .036). When adjunctive testing was ordered, dual pH probe were less frequently utilized in 2012 (61.5% vs 78.3%, P = .029). Either esophagogastroduodenoscopy (EGD) or transnasal esophagoscopy (TNE) was used more often in 2012 compared to EGD alone in 2002 (63.8% vs 42.4%, P = .020). Dual pH probe was regarded as the most sensitive and specific evaluation for LPR in both surveys, while the perceived sensitivity/specificity of EGD in 2012 was half that reported in 2002 (28.0% vs 56.3%, P = .003).

Conclusion:

Attitudes of ABEA members toward empiric treatment and adjunctive tests have changed between 2012 and 2002. While pH probe testing remains the test regarded as most sensitive/specific for evaluation of LPR, empiric management has become more common. Meanwhile, EGD use has increased despite a significant decrease in its perceived sensitivity/specificity.

Impact of Otolaryngology in the diagnosis of early oesophageal malignancy

INTRODUCTION

A large number of patients present in Otolaryngology clinics with vague upper gastro intestinal symptoms, some potentially originating from the oesophagus. In the United Kingdom there is no consensus for investigation protocols. The concern is that diagnosis of early oesophageal malignancy can be delayed with detrimental effects to the prognosis of the patient. The aim of this paper is to attempt to establish the impact of Ear Nose and Throat (ENT) work up in the diagnostic pathway of these patients.

METHODS

Retrospective analysis of case notes of newly diagnosed oesophageal carcinoma over a 15 month period.

RESULTS

Sixty five patients with a new diagnosis of oesophageal carcinoma were identified from the upper GI cancer network. A cohort of 7 patients was initially referred to ENT with related symptoms. Delays occurred at different stages during the course of their diagnostic pathways. Only 2 patients were diagnosed from ENT prior to referral to upper GI.

CONCLUSION

We support the creation of one stop clinics incorporating the use of transnasal oesophagoscopy. The current literature is discussed.

Transnasal oesophagoscopy: diagnostic and management outcomes in a prospective cohort of 257 consecutive cases and practice implications

OBJECTIVES

To determine the success rate, patient tolerability and impact of introducing transnasal oesophagoscopy on clinical practices.

DESIGN

Prospective cohort with review of electronic patient records for outcomes.

SETTING

UK tertiary centre Otolaryngology Department.

PARTICIPANTS

The cohort comprised of two hundred and fifty-seven patients, 128 females (50%) and 129 males (50%) with an age range of 20-91 years; mean age 59 years (sd 13.6).

MAIN OUTCOME MEASURES

Success rates, indications, findings and outcomes of patients undergoing transnasal oesophagoscopy and impact on rigid examinations of the pharynx and oesophagus were also considered.

RESULTS

Transnasal oesophagoscopy has a high success rate of 97%; it is well tolerated by patients, and poor views are uncommon. Pathology was detected in 44% of patients. The most common indications for transnasal oesophagoscopy were unexplained throat symptoms (50%) and dysphagia (25%). Common positive findings were hiatus hernia (7%), Barrett's oesophagus (5%), dysmotility (5%) and oesophageal candidiasis (5%). Following transnasal oesophagoscopy, 59% of patients were discharged to their referring clinician, 17% continued to undergo otolaryngology follow-up, and 13% were referred to our gastrointestinal colleagues. Following the introduction of transnasal oesophagoscopy, there was a reduction in the number of rigid examinations of the pharynx and oesophagus in the subsequent years, despite an increase in total referrals.

CONCLUSIONS

Transnasal oesophagoscopy is a well-tolerated procedure that allows otolaryngologists to make management decisions on common referrals swiftly in the clinic setting avoiding unnecessary investigations, follow-up and referral.

CARING (CAncer Risk and INsulin analoGues): the association of diabetes mellitus and cancer risk with focus on possible determinants - a systematic review and a meta-analysis

Background:

Patients suffering from diabetes mellitus (DM) may experience an increased risk of cancer; however, it is not certain whether this effect is due to diabetes per se.

Objective:

To examine the association between DM and cancers by a systematic review and meta-analysis according to the PRISMA guidelines.

Data Sources:

The systematic literature search includes Medline at PubMed, Embase, Cinahl, Bibliotek.dk, Cochrane library, Web of Science and SveMed+ with the search terms: “Diabetes mellitus”, “Neoplasms”, and “Risk of cancer”.

Study Eligibility Criteria:

The included studies compared the risk of cancer in diabetic patients versus non-diabetic patients. All types of observational study designs were included.

Results:

Diabetes patients were at a substantially increased risk of liver (RR=2.1), and pancreas (RR=2.2) cancer. Modestly elevated significant risks were also found for ovary (RR=1.2), breast (RR=1.1), cervix (RR=1.3), endometrial (RR=1.4), several digestive tract (RR=1.1-1.5), kidney (RR=1.4), and bladder cancer (RR=1.1). The findings were similar for men and women, and unrelated to study design. Meta-regression analyses showed limited effect modification of body mass index, and possible effect modification of age, gender, with some influence of study characteristics (population source, cancer- and diabetes ascertainment).

Limitations:

Publication bias seemed to be present. Only published data were used in the analyses.

Conclusions:

The systematic review and meta-analysis confirm the previous results of increased cancer risk in diabetes and extend this to additional cancer sites. Physicians in contact with patients with diabetes should be aware that diabetes patients are at an increased risk of cancer.

Evaluation of a 4-protein serum biomarker panel-biglycan, annexin-A6, myeloperoxidase, and protein S100-A9 (B-AMP)-for the detection of esophageal adenocarcinoma

BACKGROUND

Esophageal adenocarcinoma (EAC) is associated with a dismal prognosis. The identification of cancer biomarkers can advance the possibility for early detection and better monitoring of tumor progression and/or response to therapy. The authors present results from the development of a serum-based, 4-protein (biglycan, myeloperoxidase, annexin-A6, and protein S100-A9) biomarker panel for EAC.

METHODS

A vertically integrated, proteomics-based biomarker discovery approach was used to identify candidate serum biomarkers for the detection of EAC. Liquid chromatography-tandem mass spectrometry analysis was performed on formalin-fixed, paraffin-embedded tissue samples that were collected from across the Barrett esophagus (BE)-EAC disease spectrum. The mass spectrometry-based spectral count data were used to guide the selection of candidate serum biomarkers. Then, the serum enzyme-linked immunosorbent assay data were validated in an independent cohort and were used to develop a multiparametric risk-assessment model to predict the presence of disease.

RESULTS

With a minimum threshold of 10 spectral counts, 351 proteins were identified as differentially abundant along the spectrum of Barrett esophagus, high-grade dysplasia, and EAC (P<.05). Eleven proteins from this data set were then tested using enzyme-linked immunosorbent assays in serum samples, of which 5 proteins were significantly elevated in abundance among patients who had EAC compared with normal controls, which mirrored trends across the disease spectrum present in the tissue data. By using serum data, a Bayesian rule-learning predictive model with 4 biomarkers was developed to accurately classify disease class; the cross-validation results for the merged data set yielded accuracy of 87% and an area under the receiver operating characteristic curve of 93%.

CONCLUSIONS

Serum biomarkers hold significant promise for the early, noninvasive detection of EAC.

Extraesophageal presentations of GERD: where is the science?

This article reviews the evaluation and management of patients with suspected extraesophageal manifestations of gastroesophageal reflux disease, such as asthma, chronic cough, and laryngitis, which are commonly encountered in gastroenterology practices. Otolaryngologists and gastroenterologists commonly disagree upon the underlying cause for complaints in patients with one of the suspected extraesophageal reflux syndromes. The accuracy of diagnostic tests (laryngoscopy, endoscopy, and pH- or pH-impedance monitoring) for patients with suspected extraesophageal manifestations of gastroesophageal reflux disease is suboptimal. An empiric trial of proton pump inhibitors in patients without alarm features can help some patients, but the response to therapy is variable.

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.

A cross-sectional analysis of the prevalence of Barrett esophagus in otolaryngology patients with laryngeal symptoms

BACKGROUND

Populations at risk for esophageal adenocarcinoma remain poorly defined. Laryngeal symptoms can be secondary to laryngopharyngeal reflux (LPR) and can occur without associated gastroesophageal reflux symptoms such as heartburn and regurgitation.

GOAL

We sought to determine the prevalence of Barrett esophagus (BE) in otolaryngology patients with laryngeal symptoms±typical gastroesophageal reflux disease (GERD) symptoms.

STUDY

We performed a cross-sectional study of otolaryngology clinic patients who reported laryngeal symptoms. Symptoms, medications, and exposure histories were obtained. Unsedated transnasal endoscopy was performed. Suspected BE was biopsied and confirmed histologically. Risk factors and prevalence of BE were assessed.

RESULTS

Two hundred ninety-five patients were enrolled [73% male, median age 60 y (interquartile range 51 to 68 y)]. The overall prevalence of BE was 11.8% (n=33). Antisecretory medication use was present in 56% (n=156) of patients at enrollment. Compared with patients without BE, patients with BE were more likely to be male (P=0.01) and to report occupational lung injury (P=0.001). Duration, but not severity of laryngeal symptoms, significantly increased the odds of BE (odds ratio, 5.64; 95% confidence interval, 1.28-24.83; for a duration of symptoms >5 y). Of patients with BE, 58% (n=19) had coexisting LPR and GERD symptoms and 30% (n=10) had only LPR symptoms. Presence and size of hiatal hernia and length of columnar-lined esophagus were significant risk factors for BE.

CONCLUSIONS

Long-standing laryngeal symptoms are associated with the presence of BE in otolaryngology patients. Patients with chronic laryngeal symptoms and no identifiable ear, nose, or throat etiology for those symptoms may benefit from endoscopic screening regardless of whether typical GERD symptoms are present.

Globus Pharyngeus: Effectiveness of Treatment with Proton Pump Inhibitors and Gabapentin

Objectives:

This study was performed to investigate the effectiveness of treatment of globus pharyngeus with proton pump inhibitors, gabapentin, or both.

Methods:

The subjects all presented with globus pharyngeus during the years 2006 to 2011. The inclusion criteria included a chief (primary) complaint of globus pharyngeus; a trial of proton pump inhibitor therapy for at least 2 months and/or a trial of gabapentin for at least 2 weeks; and at least 1 follow-up visit. We reviewed 331 charts; 87 patients met the criteria. The response to treatment was graded as none, partial, or complete.

Results:

Seventy-seven percent of all patients had improvement. Sixty-seven percent of patients had a partial or complete response from aggressive reflux management. Sixty-six percent of patients who had a trial of gabapentin reported improvement. Eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin.

Conclusions:

A majority of patients with globus pharyngeus can be helped by treating reflux or neuralgia. A trial of gabapentin should be considered for patients who do not respond or only partially respond to reflux management.

Transnasal esophagoscopy

Since the mid 1900s, esophagoscopy has been performed under sedation or general anesthesia. With transnasal esophagoscopy (TNE), there has been a return to awake, in-office esophagoscopy. Technologic advances have allowed the advent of a ultrathin, flexible esophagoscope that is introduced transnasally, allowing esophagoscopy to be performed in unsedated patients. TNE correlates with conventional esophagoscopy (sedated, flexible esophagoscopy) in diagnostic capacity. Over time, as the benefits of TNE have become elucidated, the procedure has gained wider acceptance and continues to have its role in patient care defined.

Barrett's esophagus: review of diagnosis and treatment

Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.

Barrett's esophagus in Latinos undergoing endoscopy for gastroesophageal reflux disease symptoms

Previous studies comparing the prevalence of Barrett's esophagus in Latinos and non-Latino whites are inconsistent. The aim of the study is to compare the prevalence of Barrett's esophagus in Latinos and non-Latino whites and to determine risk factors associated with Barrett's esophagus. Between March 2005 and January 2009, consecutive Latino and non-Latino white patients who underwent endoscopy for primary indication for symptoms of gastroesophageal reflux disease were identified by examining the internal endoscopy database at Los Angeles County + USC Medical Center. Barrett's esophagus was defined by columnar-lined distal esophagus on endoscopy confirmed by intestinal metaplasia on histology. Clinical features and endoscopic findings were retrospectively reviewed. The mean age of the 663 patients was 50 ± 12 years, 30% were male, and 92% were Latino. Compared with non-Latino whites, Latinos had more females (72% vs. 46%; P = 0.0001) and more Helicobacter pylori infection (53% vs. 24%; P = 0.003) but less tobacco use (7% vs. 17%; P = 0.01). Overall, 10% (68/663) of all patients had Barrett's esophagus whereas the prevalence was 10% (62/611) among the Latinos and 12% (6/52) among the non-Latino whites (OR 0.9, 95% CI 0.4-2.1; P = 0.75). One patient in the Latino group had high-grade dysplasia. On multivariate analysis, male gender (AOR 2.3, 95% CI 1.4-4.1; P = 0.002), diabetes (AOR 2.2, 95% CI 1.1-4.5; P = 0.03), and age ≥55 years (AOR 2.2, 95% CI 1.3-3.8; P = 0.006) were independently associated with Barrett's esophagus; Latino ethnicity remained nonsignificant (AOR 1.1, 95% CI 0.4-2.7; P = 0.88). In Latinos undergoing endoscopy for gastroesophageal reflux disease symptoms, the prevalence of Barrett's esophagus was 10%, comparable with non-Latino white controls as well as the prevalence previously reported among Caucasians. In addition to established risk factors, diabetes was associated with Barrett's esophagus.

Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease

OBJECTIVES

At the cellular level, tissue-bound pepsin is fundamental to the pathophysiologic mechanism of reflux disease, and although the thresholds for laryngeal damage in laryngopharyngeal reflux and for esophageal damage in gastroesophageal reflux disease differ, both forms of damage are due to pepsin, which requires acid for its activation. In addition, human pepsin remains stable at pH 7.4 and may be reactivated by hydrogen ions from any source. Thus, most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability. The purposes of these in vitro studies were to investigate whether artesian well water containing natural bicarbonate (pH 8.8) might irreversibly denature (inactivate) human pepsin, and to establish its potential acid-buffering capacity.

METHODS

Laboratory studies were performed to determine whether human pepsin was inactivated by pH 8.8 alkaline water. In addition, the buffering capacity of the alkaline water was measured and compared to that of the two most popular commercially available bottled waters.

RESULTS

The pH 8.8 alkaline water irreversibly inactivated human pepsin (in vitro), and its hydrochloric acid-buffering capacity far exceeded that of the conventional-pH waters.

CONCLUSIONS

Unlike conventional drinking water, pH 8.8 alkaline water instantly denatures pepsin, rendering it permanently inactive. In addition, it has good acid-buffering capacity. Thus, the consumption of alkaline water may have therapeutic benefits for patients with reflux disease.

Diabetes and risk of esophageal and gastric adenocarcinomas

Diabetes has been consistently associated with an increased risk of liver, pancreas and endometrial cancer and has been implicated as a risk factor for esophageal and gastric cancers, although this association has been less well studied. We sought to determine the role of diabetes in the etiology of esophageal, gastric cardia and distal gastric adenocarcinomas (DGAs). This analysis included patients with esophageal adenocarcinoma (EA) (n = 209), gastric cardia adenocarcinoma (GCA) (n = 257) and DGA (n = 382), and 1,309 control participants from a population-based case-control study conducted in Los Angeles County. The study included non-Hispanic whites, African Americans, Hispanics and Asian Americans. The association of diabetes with the three tumor types was estimated using polytomous logistic regression. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated. Nine percent of control participants and 13% of the case patients reported a history of diabetes. After adjustment for age, gender, race, birthplace, education, cigarette smoking status and body mass index, diabetes was associated with an increased risk of EA (OR, 1.48; 95% CI, 0.94-2.32; p = 0.089) and DGA (OR, 1.47; 95% CI, 1.01-2.15; p = 0.045), but was not associated with risk of GCA (OR, 0.96; 95% CI, 0.59-1.55; p = 0.87). However, the association between diabetes and risk of DGA was statistically significant only among patients for whom we interviewed their next of kin. Our study further investigated the association between diabetes and adenocarcinomas of the esophagus and distal stomach.

[The possibilities of reflux disease diagnosis by the ear, nose and throat specialist]

Reflux disease has gained in importance over the last decade since we know that many of the symptoms and diseases of the upper aerodigestive tract might be associated with reflux. However, a distinction needs to be made between extraesophageal reflux (EER) and gastroesophageal reflux disease (GERD). There are several techniques available for the diagnosis of EER. Furthermore, there are various pH monitoring devices to determine acid contamination of the larynx and the pharynx. In addition, flexible transnasal esophagoscopy is a practicable technique for the rapid examination of reflux, its cause as well as the diagnosis of reflux-induced mucosal changes in the esophagus. The present article describes the instruments used for the diagnosis of reflux against the background of our own experience and the international literature.

Aurora kinase A (AURKA) and never in mitosis gene A-related kinase 6 (NEK6) genes are upregulated in erosive esophagitis and esophageal adenocarcinoma

Gastroesophageal reflux disease is a risk factor for esophageal adenocarcinoma yet studies that have investigated the relationship between erosive esophagitis and esophageal adenocarcinoma have usually focused on symptom-related evidence or polymorphisms. There are no epigenetic gene expression studies on this topic. In this study, we aimed to evaluate the relationship between erosive esophagitis and esophageal adenocarcinoma to identify whether there is a genetic predisposition for esophageal adenocarcinoma. The Human Epigenetic Chromatin Modification Enzyme RT(2) Profiler(™) PCR array (PAHS-085A) was used to detect the expression of 84 key genes encoding enzymes. This was carried out prospectively for samples from 60 patients (20 patients as a control group, 20 patients with erosive esophagitis and 20 patients with esophageal adenocarcinoma). AURKA, AURKB, NEK6 were expressed at significantly higher levels in esophageal adenocarcinoma compared to the control group. MBD2 was expressed at significantly lower levels in the esophageal adenocarcinoma group compared to the control group. AURKA, AURKC, HDAC9 and NEK6 were expressed at significantly higher levels in erosive esophagitis compared to the control group. There was no difference in upregulated gene expression between the erosive esophagitis and esophageal adenocarcinoma. MBD2 was significantly downregulated in esophageal adenocarcinoma compared to erosive esophagitis. NEK6 and AURKA were significantly upregulated in esophageal adenocarcinoma and erosive esophagitis compared to the control group. This is a novel study on the genetic predisposition for erosive esophagitis and esophageal adenocarcinoma. AURKA and NEK6 are two promising genetic markers for erosive esophagitis and esophageal adenocarcinoma.

Risk factors for laryngopharyngeal reflux

The aim of this study was to evaluate the demographic and clinicopathologic characteristics of gastroesophageal reflux disease (GERD) with and without laryngopharyngeal reflux (LPR) to determine the risk factors for the occurrence of LPR in patients with GERD. This is a retrospective study of GERD patients with and without LPR. From the outpatient computer program of our hospital we randomly enrolled 45 GERD patients with LPR into the first group and another 45 GERD patients without LPR to the second group. Medical records of the patients in both groups were examined. All patients underwent upper gastrointestinal system endoscopy. LPR was confirmed by laryngoscopy, and LPR-related laryngoscopy scoring. Non-erosive GERD (NERD), erosive GERD (ERD) and Barrett's esophagus (BE) were diagnosed by endoscopy and histopathology. Various clinical parameters including status of Helicobacter pylori (H. pylori) infection, topography of gastritis were analyzed. For therapy, lansoprazole in a dosage of 30 mg BID for at least 8 weeks were given to all patients in both groups. GERD patients with and without LPR were compared according to demographic, clinic, endoscopic and histopathological parameters. The results revealed that patients with LPR were younger than the patients without LPR (38.7 ± 10.2 years and 43.8 ± 11.5 years; p = 0.08); however, there was no statistical significance. Patients without LPR showed no gender predilection (55% male) while LPR patients showed male preponderance (71% male). In LPR group, 11 patients (24%) had NERD, while 28 (62%) and 6 (13%) patients had ERD and BE, respectively. Twenty-seven (60%) patients without LPR were diagnosed as NERD, 15 patients (33%) without LPR had ERD and only 3 patients (6.6%) showed the histological findings of BE. The patients in LPR group had higher body mass index. Hiatal hernia was more frequent in the patients with LPR (53%) than in the patients without LPR (24%) (p = 0.005). LPR patients had longer duration of reflux symptoms than the patients without LPR (p = 0.04). H. pylori status was not different in both groups but the patients without LPR had more corpus gastritis than the patients with LPR. Eight weeks of lansoprazole treatment was successful in 71% of patients with LPR, and 86% of patients without LPR. We concluded that male gender, hiatal hernia, longer duration of symptoms, high BMI, having ERD and BE seems as risk factors for the occurrence of LPR in patients with GERD. H. pylori status did not have any effect on the development of LPR. Corpus dominant gastritis may have a protective role against the development of LPR. Proton pump inhibitor therapy is less effective in patients with LPR.

Risk of esophageal cancer in diabetes mellitus: a meta-analysis of observational studies

OBJECTIVE

Inconsistent findings from observational studies have prolonged the controversy over the effects of history of diabetes mellitus (DM) on the risk of esophageal cancer (EC). We conducted a meta-analysis of epidemiologic studies to evaluate the association of a history of DM with the risk of EC.

METHODS

We identified studies by a literature search of MEDLINE (from 1 January 1966) and EMBASE (from 1 January 1974), through 28 Feburary 2011, and by searching the reference lists of pertinent articles. Summary relative risks (SRRs) with 95% confidence intervals (CIs) were calculated with a random-effects model. All statistical tests were two-sided.

RESULTS

A total of 17 studies (6 case-control studies and 11 cohort studies) fulfilled the inclusion and exclusion criteria. Compared with non-diabetic individuals, diabetic individuals had a modestly increased risk of EC (SRRs 1.30, 95% CI: 1.12-1.50), with significant heterogeneity among studies (p = 0.042). In stratified analysis, the SRRs of EC were 1.28 (1.10-1.49) for diabetic men and 1.07 (95% CI, 0.71-1.62) for diabetic women, respectively. In addition, DM was associated with an increased risk of esophageal adenocarcinoma (SRR 2.12, 95% CI 1.01-4.46). There was no significant publication bias (p = 0.127 for Begg's adjusted rank correlation test and p = 0.629 for Egger's regression test).

CONCLUSION

These findings support the hypothesis that men with diabetes may have a modestly increased risk of EC, while diabetic women were not the case.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

Endoscopic management of Barrett esophagus

Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.

The Challenge of Protocols for Reflux Disease

Objectives. Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are very common and controversial diseases. The authors have previously reviewed clinical practice guidelines (CPGs) on reflux disease, and these major consensus statements differ on what constitutes ideal management. The aim is to critically review existing protocols for reflux based on CPG recommendations and to present a refined protocol that may be further used to develop a critical pathway for reflux in ambulatory medical practice.

Study Design. Literature review with discussion.

Methods. A PubMed search was used to identify current clinical protocols or algorithms for reflux disease, and the principal elements of each were compared.

Results. Of the 828 articles identified in the search, 11 met the search criteria. Together with 4 articles previously identified, 15 were analyzed. All protocols discuss the important role of empiric therapy, although with differences in use. Only 5 protocols (33%) were based on systematic review such as CPGs. Eight protocols (53%) used alarm symptoms to prompt a workup. For these patients, upper endoscopy was by far the most common diagnostic method. The use of other modalities varies significantly between protocols. The authors propose a standard protocol based on patient risk factors that employs CPG recommendations and may be used for critical pathway outcomes measures.

Conclusion. There are major differences between existing protocols for reflux disease in the literature, reflecting many clinical controversies. Outcomes of different protocols have not been extensively studied. The authors propose a new protocol that is a synthesis of those reviewed and based on risk stratification.

Globus pharyngeus and extraesophageal reflux: simultaneous pH <4.0 and pH <5.0 analysis

OBJECTIVES/HYPOTHESIS

Weakly acid refluxes seem to play an important role in the pathogenesis of extraesophageal reflux. The aim of this study was to evaluate how proportional representation of patients with extraesophageal reflux in a group of patients with globus pharyngeus changes when we use both pH <4.0 as well as pH <5.0 as a pathological threshold for an extraesophageal reflux episode.

STUDY DESIGN

Prospective pH monitoring study of 46 patients.

METHODS

Patients with pure globus pharyngeus lasting more than 3 months were included in the study. The pH monitoring was performed (Smit technique) with double probes (fixed distance of 15 cm). The recorded data using only pH <4.0 and using both pH <4.0 along with pH <5.0 as thresholds for extraesophageal reflux episode were analyzed simultaneously. The reflux area index 4 >6.3 and reflux area index 5 >72.6 were considered as clear pathological extraesophageal reflux.

RESULTS

Extraesophageal reflux was proven in 23.9% patients with pure globus pharyngeus when standard analysis using only pH <4.0 was used as pathological threshold. If both pH <4.0 and pH <5.0 were used as the pathological threshold, clear extraesophageal reflux was found in four more (8.7%) patients.

CONCLUSIONS

This study indicates the possible role of weakly acid extraesophageal reflux episodes in some patients with globus pharyngeus. Other studies on this issue, including the use of biological markers such as signs of inflammation, are warranted.

Advances in endoscopic diagnosis and treatment of Barrett's esophagus

Barrett's esophagus (BE) is defined as abnormal specialized columnar metaplasia with intestinalization in place of the normal squamous esophageal epithelium. Gastroesophageal reflux disease is a known risk factor for BE; nonetheless BE is also detected in asymptomatic individuals. Other risk factors for BE include smoking, male gender, age over 50 and obesity. Patients diagnosed with BE (without dysplasia) are recommended to undergo endoscopic surveillance every 3-5 years. Advances in imaging techniques (such as narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy) have the potential to improve the detection of dysplasia and early cancer, thus making surveillance a more cost-effective endeavor. Patients with high grade dysplasia (HGD) and early cancer have a high rate of progression to invasive adenocarcinoma and traditionally these patients were treated with esophagectomy. The rapid advancement of endoscopic therapeutic techniques along with a low risk of complications have made endoscopic therapy an acceptable alternative to an esophagectomy in patients with HGD and early cancer. Several endoscopic treatment techniques such as endoscopic mucosal resection, multipolar electrocoagulation, photodynamic therapy, argon plasma coagulation, cryotherapy, and radiofrequency ablation have been studied for endoscopic treatment.

Meta-analyses of the effect of symptoms of gastroesophageal reflux on the risk of Barrett's esophagus

OBJECTIVES

Esophageal adenocarcinoma (EAC) is a devastating disease that has risen in incidence over the past several decades. Barrett's esophagus (BE) is an associated premalignant lesion. Current preventative efforts rely on endoscopic screening of individuals with gastroesophageal reflux disease (GERD) symptoms and surveillance endoscopy for those with BE. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that studies of higher-quality design show weaker associations of GERD with BE, and that GERD is only weakly associated with short-segment Barrett's esophagus (SSBE).

METHODS

We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histological confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest-quality sampling design was defined a priori by both cases and controls identified among unselected research volunteers ("research design") rather than by patients selected for endoscopy for clinical indications ("clinical design"), which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q P<0.20 and the inconsistency index (I(2); 25% low, 50% moderate, and 75% high). Heterogeneity of results can reflect significant differences in study design or effect modification by strata of outcomes.

RESULTS

Systematic review identified 13,392 citations. Evaluation identified 108 potentially relevant journal articles, of which 26 met eligibility. Of these, 14 studies identified cases of BE and controls based on clinical indication ("clinical design"), and 6 used the "research design." The remaining six studies identified cases of BE from patients undergoing endoscopy for clinical indication and controls among patients without known BE ("cases clinical/controls research"). The summary odds ratio (OR) for the association of GERD with BE from all studies was 2.90 (95% confidence interval (CI), 1.86-4.54), but the results were very heterogeneous (P=0.0001; I(2)=89%). When stratified by BE length and sampling design, the studies with clinical design showed substantial, but heterogeneous, associations with SSBE (OR, 2.38; 95% CI, 1.21-4.70; P=0.02; I(2)=62%), and stronger and homogeneous association with long-segment BE (LSBE; fixed effects OR, 2.96; 95% CI, 1.69-5.19; P=0.25; I(2)=25%). In the research study design, stratifying by length of BE resolved the heterogeneity and showed a strong association between GERD and LSBE (fixed effects OR, 4.92; 95% CI, 2.01-12.0; P=0.30; I(2)=19%) and no association with SSBE (fixed effects OR, 1.15; 95% CI, 0.763-1.73; P=0.84; I(2)=0%). Funnel plots showed potential evidence for bias against dissemination of small negative studies.

CONCLUSIONS

In the highest-quality studies, GERD symptoms are not associated with SSBE, but increased the odds of LSBE by fivefold. GERD symptoms can serve as a reliable predictor of LSBE, but not SSBE. If SSBE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and alternative methods of selection for screening need to be developed.

Screening for Barrett's Esophagus

Barrett's esophagus (BE) increases the risk for development of esophageal adenocarcinoma. Because of the rapid rise in incidence of esophageal adenocarcinoma, screening for BE with subsequent surveillance when found has been proposed as a method of early detection. Sedated endoscopy, however, is too expensive for wide spread screening. As a result, other techniques including unsedated transnasal esophagoscopy and capsule esophagoscopy have been proposed to expand screening programs.

Laryngopharyngeal reflux: a prospective analysis of a 34 item symptom questionnaire

OBJECTIVES

Laryngopharyngeal reflux is increasingly diagnosed, but both its symptoms and relationship to gastro-oesophageal reflux disease remain confused.

AIMS

(i) To assess symptoms in potential laryngopharyngeal reflux patients according to a comprehensive symptom list based on both a gastro-oesophageal reflux questionnaire and a laryngopharyngeal reflux questionnaire. (ii) To assess whether there are statistically discrete symptom clusters which might map to specific syndromes e.g. globus pharynges.

DESIGN

Prospective single cohort questionnaire survey.

METHODS

A 34-item questionnaire comprising all symptoms identifiable on (i) the original 25-item Gastroesophageal Symptom Assessment Scale (GSAS) and (ii) the nine Reflux Symptom Index (RSI) items, 'unbundled' as necessary, were administered to 62 ENT clinic attenders. Descriptive, correlation and cluster analysis was performed.

RESULTS

All but two of the combined 34-symptom list were endorsed by at least 20% of 62 patients. Certain symptoms which the Reflux Symptom Index groups as a single item were only weakly correlated. No specific symptom clusters were identified.

CONCLUSIONS

Neither the most popular 'lower' oesophageal (GSAS) nor the 'throat' reflux (RSI) questionnaire adequately captures the full range of potential reflux symptoms regularly encountered in otolaryngology patients: inadequate evaluation of patients' symptoms may have contributed to the ongoing uncertainty about the role of acid or pepsin suppression. A more comprehensive reflux questionnaire is needed to characterise the true reflux correlations of laryngopharyngeal symptoms, and offer a symptom-specific measure of response to placebo and anti-reflux therapy.

Transnasal esophagoscopy findings: interspecialty comparison

INTRODUCTION

Otolaryngologists implement transnasal esophagoscopy (TNE) to assess esophageal pathology. Previous studies using TNE are largely retrospective and deal with select patient populations. The prevalence of esophageal pathology in patients presenting with throat symptoms to an otolaryngology voice center is presently unknown.

OBJECTIVE

To assess the prevalence of esophageal pathology in this population and determine the interobserver variability of the findings reviewed by an otolaryngologist and a gastroenterologist.

STUDY DESIGN

A prospective study.

SETTING

This study was conducted in a laryngology/voice subspecialty clinic.

SUBJECTS AND METHODS

Fifty patients with throat symptoms presenting to the voice center were asked prospectively to undergo TNE. The findings were videotaped and reviewed by an otolaryngologist and a gastroenterologist blinded to the patients' presenting complaint.

RESULTS

Hoarseness was the most common presenting symptom (68%). According to the gastroenterologist, the prevalence of esophageal findings was: z-line irregularity suspicious for Barrett esophagus (12%), esophagitis (10%), hiatal hernia (32%), and esophageal stricture (10%). The percent agreement for a normal study was 72 percent. The percent agreement for various pathological findings were as follows: Barrett esophagus 86 percent, esophagitis 88 percent, hiatal hernia 76 percent, and esophageal stricture 96 percent. For an abnormal study, the percent agreement was 80 percent.

CONCLUSION

Esophageal abnormalities are common in patients presenting to a voice subspecialty clinic.

Laryngopharyngeal reflux: current concepts and questions

PURPOSE OF REVIEW

Laryngopharyngeal reflux is a widely recognized disorder. Yet, decades after its initial description, debate persists regarding pathophysiology, diagnosis, and treatment. This review addresses current literature on laryngopharyngeal reflux and identifies areas of controversy and future opportunities for research.

RECENT FINDINGS

Despite numerous research efforts, the diagnosis and treatment of laryngopharyngeal reflux remain elusive and unproven. Acid-induced changes in laryngopharyngeal mucosa have been confirmed by histologic evidence. However, the implications of this for laryngeal symptoms and signs are unclear. Diagnosis remains controversial, confounded by lack of standardization and accepted, evidence-based norms. Whereas treatment is generally believed by clinicians to be effective in alleviating symptoms and signs attributed to laryngopharyngeal reflux, incontrovertible data confirming efficacy are scarce. Confounding the issues further, there are numerous studies that purport to show that various widely used treatments are not effective, although the scientific merit of virtually all of these studies has been challenged.

SUMMARY

Laryngopharyngeal reflux remains a controversial diagnosis. Treatment with proton pump inhibitors persists despite weak evidence supporting or refuting their utility, and well designed studies are needed to understand diagnosis, treatment, pathyophysiology, and long-term health consequences of laryngopharyngeal reflux and its treatment.