Is empirical treatment a reasonable strategy for laryngopharyngeal reflux? A contemporary review

Efficacy and safety of fexuprazan in patients with symptoms and signs of laryngopharyngeal reflux disease: a randomized clinical trial

PURPOSE

Laryngopharyngeal reflux disease (LPRD) is mainly treated with proton pump inhibitors (PPI) such as esomeprazole, which have shortcomings like delayed absorption and increased osteoporosis. Fexuprazan is a novel potent potassium-competitive acid blocker that inhibits gastric acid secretion with rapid onset and long duration of action. To assess the efficacy and safety of fexuprazan compared to esomeprazole in patients with LPRD.

METHODS

This prospective, randomized, double-blinded, multicenter, active-controlled trial was conducted in nine otolaryngologic clinics. Patients with reflux symptom index (RSI) ≥ 13 and reflux finding score (RFS) ≥ 7 were randomly assigned to the fexuprazan or esomeprazole groups, and received fexuprazan 40-mg or esomeprazole 40-mg once daily for 8 weeks. The outcomes were (1) mean change, change rate, and valid rate in RSI, RFS, and LPR-related questionnaires; and (2) adverse events.

RESULTS

A total of 136 patients (fexuprazan n = 68, esomeprazole n = 68) were followed up for ≥ 1 month. Each parameter significantly improved after 4 and 8 weeks in each group, with no significant differences between the two groups. For those with severe symptoms (RSI ≥ 18), the fexuprazan group (n = 32) showed more improvement in the mean change and change rate in the RSI than esomeprazole group (n = 31) after 4 weeks (p = .036 and .045, respectively). This phenomenon was especially observed in hoarseness and troublesome cough.

CONCLUSION

Fexuprazan improved symptoms and signs without no serious adverse events in patients with LPRD. In patients with severe symptoms, fexuprazan resulted in a faster symptom improvement than PPI.

TRIAL REGISTRATION

KCT0007251, https://cris.nih.go.kr/cris/search/detailSearch.do?seq=22100 .

Cost burden for healthcare and patients related to the unawareness towards laryngopharyngeal reflux

OBJECTIVE

To investigate the impact of physician unawareness towards laryngopharyngeal reflux (LPR) on healthcare costs.

METHODS

Patients with a confirmed LPR diagnosis were consecutively recruited from Belgian Hospitals. Demographics and clinical outcomes (impedance-pH testing features, reflux symptom score, and reflux sign assessment) were extracted. The past consultations and additional examinations dedicated to the investigation of laryngopharyngeal symptoms and findings without suspicion of LPR were collected. The estimated costs of consultations and procedures were those indicated in the National Health Insurance Institute's Charges for 2022. Part was reimbursed by the social security system, and the rest was paid by patients.

RESULTS

Seventy-six patients were recruited. Seventeen patients (22.4%) had no previous consultation or additional examination for their LPR-symptoms. The estimated mean (standard deviation) costs related to the unawareness of LPR for the healthcare system and patient, were 310.06 ± 370.49 €, and 54.05 ± 46.28 €, respectively. The highest estimated costs were related to gastroenterology consultations and procedures, which did not lead to a confirmation of LPR diagnosis. The total estimated cost for the Belgian healthcare system and patients (11,590,000 million), could range from 359 359 540 € to 1 078 078 620 €; and 62 643 950 € to 187 931 850 €, respectively. The estimated costs related to gastroenterology practice of patients with severe disease were significantly higher than patients with mild disease.

CONCLUSION

The unawareness of practitioners toward LPR leads to significant costs for healthcare system and patients. The teaching and awareness towards LPR need to be improved in medical schools and clinical practice.

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Effect of Laryngopharyngeal Reflux and Potassium-Competitive Acid Blocker (P-CAB) on the Microbiological Comprise of the Laryngopharynx

OBJECTIVE

To probe the microbiota composition progressing from healthy individuals to those with laryngopharyngeal reflux disease (LPRD) and subsequently undergoing potassium-competitive acid inhibitor (P-CAB) therapy.

STUDY DESIGN

Prospective case-control study.

SETTING

Academic Medical Center.

METHODS

Forty patients with LPRD and 51 patients without LPRD were recruited. An 8-week P-CAB therapy was initiated (post-T-LPRD), and 39 had return visits. In total, 130 laryngopharyngeal saliva samples were collected and sequenced by targeting the V3-V4 region of the 16S ribosomal RNA (rRNA) gene using an Illumina MiSeq. Amplicon sequence variants (ASVs) and clinical indices were analyzed.

RESULTS

Alpha and beta diversities were compared among the non-LPRD, LPRD, and post-T-LPRD groups, and the Observed_ASVs were not significantly different. At the same time, the Shannon and Simpson indices, unweighted Unifrac, weighted Unifrac, and binary Jaccard distance were significantly different between non-LPRD and LPRD groups. In addition, significant differences were found in the abundance of Streptococcus, Prevotella, and Prevotellaceae in the LPRD versus non-LPRD groups, and Neisseria, Leptotrichia, and Allprevotella in the LPRD versus post-T-LPRD groups. The genera model was used to distinguish patients with LPRD from those without, and a better receiver operating characteristic curve was formed after combining the clinical indices of reflux symptom index, reflux finding score, and pepsin, with an area under the curve of 0.960.

CONCLUSION

Laryngopharyngeal microbial communities changed after laryngopharyngeal reflux and were modified further after P-CAB treatment, which provides a potential diagnostic value for LPRD, especially when combined with clinical indices.

Exploring the Substantive Significance of Laryngoscopic Observations as Reliable Prognostic Indicators for the Therapeutic Efficacy in Cases of Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) can be defined as the regurgitation of gastric acid and peptic substances into the laryngeal and hypopharyngeal regions, even in the case of a singular occurrence. A substantial body of recent research underscores the significance of non-acid reflux as a notable contributor to LPR symptoms. This current investigation delves into the assessment of laryngoscopic observations in their predictive capacity regarding the therapeutic outcomes of empirically administered proton pump inhibitor (PPI) therapy in the context of LPR. In this study, 145 patients who had received a clinical diagnosis of laryngopharyngeal reflux (LPR) underwent rigorous laryngoscopic examinations. These patients were subsequently categorized into three distinct groups based on the Belafsky reflux findings score, which included the criteria for normal (scores ranging from 0 to 7), mild to moderate (scores ranging from 8 to 16), and moderate to severe (scores ranging from 17 to 26). Among the participants, 12 individuals from the normal group, 44 from the mild to moderate group, and 31 from the moderate to severe group reported experiencing a noteworthy alleviation of symptoms following a three-month period of proton pump inhibitor (PPI) therapy and lifestyle adjustments. It is important to note that these findings yielded statistically significant results. Preliminary laryngoscopic observations hold significant potential as predictors of favourable treatment outcomes in the context of empirical proton pump inhibitor (PPI) therapy for laryngopharyngeal reflux (LPR).

The Time-Point Distribution Characteristics of Laryngopharyngeal Reflux in Elderly Patients

OBJECTIVE

To identify the characteristics of the time-point distribution of the occurrence of hypopharyngeal-proximal reflux episodes (HREs) in elderly and younger patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Retrospective cohort study.

SETTING

Analysis of data from patients with LPR-related symptoms and 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH (24-hour HEMII-pH) monitoring from February 2017 to September 2022 at Sixth Medical Center of PLA General Hospital.

METHODS

Patients were divided into 2 age groups: the elderly group (>60 years) and the younger group (≤60 years). The time series of HREs and meals within 24 hours were analyzed based on HEMII-pH.

RESULTS

A total of 305 patients were included (126 elderly patients). In younger patients, except for nonacid-gas HREs, the incidence of the remaining types of HREs tended to increase within 2 hours after meals, especially after dinner. The incidence of all types of HREs pre- and postmeal was not significantly different in the elderly group (χ2  = 0.080, P = .777). The incidence of nighttime HREs in elderly patients was statistically higher than in younger patients (6.23% vs 3.96%, P = .030), particularly acid-/nonacid-liquid HREs.

CONCLUSION

HREs tend to increase within 2 hours after meals in younger LPR patients, except for nonacid-gas HREs. In elderly LPR patients, the incidence of all types of HREs pre- and postmeal were not significantly different, and nighttime fluid HREs was more prone to occur than in younger patients.

Tonghua Liyan granules in the treatment of Laryngopharyngeal reflux disease with stagnation of phlegm and qi syndrome: a randomized, double-blind, placebo-controlled study

Background: Laryngopharyngeal reflux disease (LPRD) is an extraesophageal syndromic manifestation of gastroesophageal reflux disease (GERD). Despite the increasing incidence of and concern about LPRD, treatment with proton pump inhibitors (PPIs) is unsatisfactory. Here, LPRD was treated with Tonghua Liyan (THLY) granules in combination with PPIs to evaluate treatment efficacy and possible adverse reactions. Methods: Seventy-six LPRD patients with stagnation of phlegm and qi syndrome (SPQS) were randomly divided into an experimental group and a control group. The experimental group received THLY granules combined with rabeprazole capsules. The control group received THLY granule placebo combined with rabeprazole capsules. A parallel, randomized, double-blind, placebo-controlled clinical trial was conducted with these two groups. The treatment cycle was 8 weeks. The reflux symptom index (RSI), clinical symptom score, salivary pepsin content, reflux finding score (RFS) and gastroesophageal reflux disease questionnaire (GerdQ) were used to evaluate clinical efficacy. The final efficacy rate was evaluated according to the RSI and clinical symptom score. Results: Compared with those at baseline, all the indicators in the experimental group and control group significantly improved (p < 0.01). In terms of the RSI, clinical symptom score, and RFS, the experimental group had a higher degree of improvement (p < 0.05), and the overall efficacy rate was higher (p < 0.05). In terms of the salivary pepsin concentration and GerdQ, there was no significant difference between the test group and the control group (p > 0.05). Both groups of safety indicators showed no abnormalities and did not cause any allergic reactions in the body. Conclusion: Compared with PPIs alone, THLY granules combined with PPIs are more effective in the treatment of LPRD patients with SPQS in terms of symptoms and signs. This combination treatment, because of its higher clinical efficacy and lack of obvious adverse reactions, is worthy of clinical promotion and further in-depth study. Clinical Trial Registration: www.chictr.org.cn, identifier ChiCTR2100046614.

Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision

OBJECTIVE

To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis.

METHODS

Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice.

RESULTS

Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05).

CONCLUSION

This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.

Personalized Treatments Based on Laryngopharyngeal Reflux Patient Profiles: A Narrative Review

OBJECTIVE

To review the current findings of the literature on the existence of several profiles of laryngopharyngeal reflux (LPR) patients and to propose personalized diagnostic and therapeutic approaches.

METHODS

A state-of-the art review of the literature was conducted using the PubMED, Scopus, and Cochrane Library databases. The information related to epidemiology, demographics, clinical presentations, diagnostic approaches, and therapeutic responses were extracted to identify outcomes that may influence the clinical and therapeutic courses of LPR.

RESULTS

The clinical presentation and therapeutic courses of LPR may be influenced by gender, age, weight, comorbidities, dietary habits and culture, anxiety, stress, and saliva enzyme profile. The clinical expression of reflux, including laryngopharyngeal, respiratory, nasal, and eye symptoms, and the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring profile of patients are important issues to improve in patient management. The use of more personalized therapeutic strategies appears to be associated with better symptom relief and cures over the long-term. The role of pepsin in LPR physiology is well-established but the lack of information about the role of other gastrointestinal enzymes in the development of LPR-related mucosa inflammation limits the development of future enzyme-based personalized diagnostic and therapeutic approaches.

CONCLUSION

Laryngopharyngeal reflux is a challenging ear, nose, and throat condition associated with poor therapeutic responses and a long-term burden in Western countries. Artificial intelligence should be used for developing personalized therapeutic strategies based on patient features.

Is empiric proton pump inhibition in patients with symptoms of extraesophageal gastroesophageal reflux justified?

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) has had a marked increase in Western countries with a paralleling interest in extraesophageal (EE) manifestations of GERD, including laryngopharyngeal reflux (LPR). There are considerable differences in clinical practice between gastroenterologists, otolaryngologists and pulmonologists.

METHODS

In this narrative review we address some of these controversies concerning EE manifestations of GERD and LPR.

RESULTS

It is disputed whether there is causal relationship between reflux and the numerous symptoms and conditions suggested to be EE manifestations of GERD. Similarly, the pathophysiology is uncertain and there are disagreements concerning diagnostic criteria. Consequently, it is challenging to provide evidence-based treatment recommendations. A significant number of patients are given a trial course with a proton pump inhibitor (PPI) for several months before symptoms are evaluated. In randomized controlled trials (RCTs) and meta-analyses of RCTs PPI treatment does not seem to be advantageous over placebo, and the evidence supporting that patients without verified GERD have any benefit of PPI treatment is negligible. There is a large increase in both over the counter and prescribed PPI use in several countries and a significant proportion of this use is without any symptomatic benefit for the patients. Whereas short-term treatment has few side effects, there is concern about side-effects after long-term use. Although empiric PPI treatment for suspected EE manifestations of GERD instead of prior esophageal 24-hour pH and impedance monitoring is included in several guidelines by various societies, this practice contributes to overtreatment with PPI.

CONCLUSION

We argue that the current knowledge suggests that diagnostic testing with pH and impedance monitoring rather than empiric PPI treatment should be chosen in a higher proportion of patients presenting with symptoms possibly attributable to EE reflux.

Current Treatment of Laryngopharyngeal Reflux

Objectives: Laryngopharyngeal reflux (LPR) is a complex syndrome characterized by the reflux of gastroduodenal contents into the pharynx or larynx, resulting in a range of symptoms, including chronic cough, throat clearing, pain, dysphagia, hoarseness, and dysphonia. Despite the lack of a gold standard for diagnosis or treatment, various strategies have been proposed to manage LPR. However, the effectiveness of these treatments is compromised by the lack of a uniform treatment protocol, which places a burden on patients, physicians, and the healthcare system. This study aims to systematically review the treatments of LPR and provide updated and useful clinical information to clinical physicians. Methods: The literature with an emphasis on LPR and related keywords is searched and reviewed in PubMed. Results: Treatment of LPR includes health education, lifestyle modification, dietary changes, medications, and surgery, as well as the emergence of a novel treatment method involving external upper esophageal sphincter compression devices. Conclusions: Currently, medication is the main treatment, supplemented with lifestyle and dietary changes, but there is still a lack of effective means for patients with drug-resistant or intolerant LPR. More high-quality and rigorous trials must continue to be conducted to determine the best treatment options and find novel treatments. Taking into account the complexity of LPR, this study proposes a simple algorithm to help clinicians with the initial management of this disease.

Oral and Inhaled Fosamprenavir Reverses Pepsin-Induced Damage in a Laryngopharyngeal Reflux Mouse Model

OBJECTIVE

More than 20% of the US population suffers from laryngopharyngeal reflux. Although dietary/lifestyle modifications and alginates provide benefit to some, there is no gold standard medical therapy. Increasing evidence suggests that pepsin is partly, if not wholly, responsible for damage and inflammation caused by laryngopharyngeal reflux. A treatment specifically targeting pepsin would be amenable to local, inhaled delivery, and could prove effective for endoscopic signs and symptoms associated with nonacid reflux. The aim herein was to identify small molecule inhibitors of pepsin and test their efficacy to prevent pepsin-mediated laryngeal damage in vivo.

METHODS

Drug and pepsin binding and inhibition were screened by high-throughput assays and crystallography. A mouse model of laryngopharyngeal reflux (mechanical laryngeal injury once weekly for 2 weeks and pH 7 solvent/pepsin instillation 3 days/week for 4 weeks) was provided inhibitor by gavage or aerosol (fosamprenavir or darunavir; 5 days/week for 4 weeks; n = 3). Larynges were collected for histopathologic analysis.

RESULTS

HIV protease inhibitors amprenavir, ritonavir, saquinavir, and darunavir bound and inhibited pepsin with IC50 in the low micromolar range. Gavage and aerosol fosamprenavir prevented pepsin-mediated laryngeal damage (i.e., reactive epithelia, increased intraepithelial inflammatory cells, and cell apoptosis). Darunavir gavage elicited mild reactivity and no discernable protection; aerosol protected against apoptosis.

CONCLUSIONS

Fosamprenavir and darunavir, FDA-approved therapies for HIV/AIDS, bind and inhibit pepsin, abrogating pepsin-mediated laryngeal damage in a laryngopharyngeal reflux mouse model. These drugs target a foreign virus, making them ideal to repurpose. Reformulation for local inhaled delivery could further improve outcomes and limit side effects.

LEVEL OF EVIDENCE

NA. Laryngoscope, 133:S1-S11, 2023.

The importance of laryngoscopic findings as predictors of the treatment outcomes of laryngopharyngeal reflux: a retrospective review of 143 cases

Background

Laryngopharyngeal reflux can be described as even a single episode of reflux of gastric acid peptic contents into the larynx and hypopharynx. A large number of new researches show non-acid reflux to be an important cause of LPR symptoms. The present study explores the role of laryngoscopic findings in predicting the treatment outcomes of empirical PPI therapy for LPR.

Methods

A total of 143 patients diagnosed clinically with LPR were evaluated by rigid laryngoscopy and classified into 3 groups based on the Belafsky reflux findings score, as normal (0–7), mild to moderate (8–16), and moderate to severe (17–26).

Results

Twelve out of 39 patients in the normal group, 44 out of 61 patients in the mild to moderate group, and 31 out of 43 patients in the moderate to severe group reported symptomatic improvement after 3 months of PPI therapy and lifestyle modifications. The results were statistically significant.

Conclusion

Pretherapy laryngoscopic findings can be an important predictor of successful treatment outcomes of empirical PPI therapy for LPR.

The role of pH-impedance monitoring in swallowing disorders

PURPOSE OF REVIEW

To review the current evidence about the usefulness and the place of pH study in the management of patients with swallowing disorders.

RECENT FINDINGS

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are found in approximately 30% of patients with esophageal or oropharyngeal dysphagia. Patients with suspected GERD may benefit from gastrointestinal endoscopy and proton pump inhibitors according to guidelines. The diagnosis of LPR in patients with oropharyngeal dysphagia is more controversial because there are no gold standard and diagnostic guidelines. The clinical diagnosis based on empirical therapeutic trial is a reasonable first-line strategy, but many dysphagic patients should not respond to treatment. These patients require hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH), which is the most effective examination providing important information on GERD and LPR features. At the HEMII-pH, GERD patients often report upright (daytime) and supine (nighttime) liquid acid esophageal events with significant esophageal distal acid exposure time. LPR patients have more frequently upright (daytime) gaseous weakly acid or nonacid pharyngeal reflux events without distal esophageal acid exposure abnormalities in many times. The features of reflux at the HEMII-pH may indicate a personalized treatment for dysphagic patients combining proton pump inhibitors, alginate/magaldrate or gastroprokinetic in cases of esophageal dysmotility.

SUMMARY

GERD and LPR are prevalent causes of dysphagia. The large number of reflux patients who do not respond to empirical treatment makes important the awareness of otolaryngologists about pH-impedance monitoring indication, features, and interpretation.

There is a Good Consistency Between Reflux Symptom Score-12 and Reflux Symptom Index in Chinese Population

OBJECTIVE

To investigate the consistency between the Reflux Symptom Score-12 (RSS-12) and Reflux Symptom Index (RSI) in Chinese people.

METHODS

Patients with symptoms of LPR from the outpatient otorhinolaryngology-head and neck surgery clinic were included. All included patients completed the RSS-12 and RSI. The patient with RSS-12>11 or RSI>13 suggested possible LPR. For the patients with RSI >13 or RSS-12>11, they were treated using diet recommendations and were prescribed a twice-daily pantoprazole for 12 weeks. The consistency between the RSS-12 and RSI was compared with the weighted Cohen's kappa statistic.

RESULTS

A total of 258 patients were included. The mean scores for RSS-12 and RSI were 13.21±17.31 and 12.86±6.15, respectively. The positive rate of LPR was 17.44% based on the RSI, and 24.42% based on the RSS-12. The kappa value between the RSS-12 and RSI was 0.736 (P < 0.001). Following 12 weeks of treatment, there was a significant reduction in both RSI and RSS-12. Based on the RSI, 73% of patients had a good treatment response, whereas according to the RSS-12, 85% of patients had a good treatment response.

CONCLUSION

There is a good consistency between RSS-12 and RSI, meaning that the RSS-12 is a feasible LPR initial screening tool. The RSS-12 provides a more comprehensive evaluation of reflux symptoms and treatment effect than RSI in patients with LPR.

Best Practices in Treatment of Laryngopharyngeal Reflux Disease: A Multidisciplinary Modified Delphi Study

BACKGROUND

Laryngopharyngeal reflux (LPR) is a common otolaryngologic diagnosis. Treatment of presumed LPR remains challenging, and limited frameworks exist to guide treatment.

METHODS

Using RAND/University of California, Los Angeles (UCLA) Appropriateness Methods, a modified Delphi approach identified consensus statements to guide LPR treatment. Experts independently and blindly scored proposed statements on importance, scientific acceptability, usability, and feasibility in a four-round iterative process. Accepted measures reached scores with ≥ 80% agreement in the 7-9 range (on a 9-point Likert scale) across all four categories.

RESULTS

Fifteen experts rated 36 proposed initial statements. In round one, 10 (27.8%) statements were rated as valid. In round two, 8 statements were modified based on panel suggestions, and experts subsequently rated 5 of these statements as valid. Round three's discussion refined statements not yet accepted, and in round four, additional voting identified 2 additional statements as valid. In total, 17 (47.2%) best practice statements reached consensus, touching on topics as varied as role of empiric treatment, medication use, lifestyle modifications, and indications for laryngoscopy.

CONCLUSION

Using a well-tested methodology, best practice statements in the treatment of LPR were identified. The statements serve to guide physicians on LPR treatment considerations.

Clinical Update Findings about pH-Impedance Monitoring Features in Laryngopharyngeal Reflux Patients

Purpose: The diagnosis of laryngopharyngeal reflux (LPR) is commonly based on non-specific symptoms and findings and a positive response to an empirical therapeutic trial. The therapeutic response is, however, unpredictable, and many patients need pH-impedance monitoring to confirm the diagnosis. Methods: A review of the recent literature was conducted in PubMED, Scopus, and Embase about the pH-study features of LPR patients. A summary of last evidence was proposed. Results: The awareness of otolaryngologists about indications and interpretation of pH-impedance monitoring is low. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is the most reliable examination determining the type and composition of hypopharyngeal reflux events (HRE) and the LPR features. The use of HEMII-pH is important to confirm the diagnosis in selected patients because non-specificity of symptoms and findings. There are no international consensus guidelines for the LPR diagnosis at the HEMII-pH. However, most studies supported the occurrence of >1 acid/weakly acid/nonacid HRE as diagnostic threshold. HREs are more frequently gaseous, weakly/nonacid compared with reflux events of gastroesophageal reflux. HREs occurred as daytime and upright, which does not support the value of double proton pump inhibitors or bedtime alginate. Oropharyngeal pH-monitoring is another approach reporting different sensitivity and specificity outcomes from HEMII-pH. The use of Ryan score for the LPR diagnosis at the oropharyngeal pH monitoring may be controversial regarding the low consideration of alkaline HREs. Conclusions: The awareness of otolaryngologists about HEMII-pH indication, features, and interpretation is an important issue regarding the high prevalence of LPR in outpatients consulting in otolaryngology. The HEMII-pH findings may indicate a more personalized treatment considering type and occurrence time of HREs.

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux

OBJECTIVE

Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD.

METHODS

Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction.

RESULTS

Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001).

CONCLUSION

In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF.

LEVEL OF EVIDENCE

Level 4.

Effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases: physiopathology and therapeutic targets

PURPOSE

Laryngopharyngeal reflux disease (LPRD) is a general term for the reflux of gastroduodenal contents into the laryngopharynx, oropharynx and even the nasopharynx, causing a series of symptoms and signs. Currently, little is known regarding the physiopathology of LPRD, and proton pump inhibitors (PPIs) are the drugs of choice for treatment. Although acid reflux plays a critical role in LPRD, PPIs fail to relieve symptoms in up to 40% of patients with LPRD. The influence of other reflux substances on LPRD, including pepsin, bile acid, and trypsin, has received increasing attention. Clarification of the substances involved in LPRD is the basis for LPRD treatment.

METHODS

A review of the effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases was conducted in PubMed.

RESULTS

Different reflux substances have different effects on LPRD, which will cause various symptoms, inflammatory diseases and neoplastic diseases of the laryngopharynx. For LPRD caused by different reflux substances, 24-h multichannel intraluminal impedance combined with pH-metry (MII-pH), salivary pepsin, bile acid and other tests should be established so that different drugs and treatment courses can be used to provide patients with more personalized treatment plans.

CONCLUSION

This article summarizes the research progress of different reflux substances on the pathogenesis, detection index and treatment of LPRD and lays a theoretical foundation to develop target drugs and clinical diagnosis and treatment.

How to Understand and Treat Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.

Multitime point pepsin testing can double the rate of the diagnosis of laryngopharyngeal reflux

OBJECTIVE

To study the value of multitime point salivary pepsin testing (MTPSPT) for the diagnosis of laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective noncontrolled.

METHODS

For patients who met the enrollment criteria, the reflux symptom index (RSI) and reflux finding score (RFS) were calculated and salivary pepsin testing was performed. The pepsin test was performed every hour from 7:00 a.m. to 6:00 p.m. by collecting fresh saliva samples. A single positive test result was needed for the diagnosis of LPR. The consistency in the diagnosis of LPR between the two methods was compared with the weighted Cohen's kappa statistic.

RESULTS

A total of 204 patients were included. The kappa value between the two methods was 0.566 (p = .00). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MTPSPT were 76.43%, 85.94%, 92.24%, and 62.5%, respectively. We also compared a single pepsin measure at 7 a.m. with the screening results based on the RSI and RFS, and found a much lower kappa agreement value (0.223, p = .00). The sensitivity, specificity, PPV, NPV, and false-negative rate of pepsin testing at 7 a.m. (fasting) were 37.86%, 92.18%, 91.38%, 40.41%, and 58.57%, respectively.

CONCLUSION

The use of the result of a single salivary pepsin test in the morning yields a relatively higher rate of missed diagnosis of LPR, and multitime point testing through a day increased the accuracy and sensitivity of detection of LPR twofold compared to a single morning fasting sample.

LEVEL OF EVIDENCE

3.

Chronic Course, Weaning, and Awareness of Patients With Reflux Toward Proton Pump Inhibitor Therapy

OBJECTIVES

To assess the feasibility of middle-term proton pump inhibitor (PPI) weaning in patients with laryngopharyngeal reflux (LPR) and evaluate patient awareness of PPI adverse events.

METHODS

We conducted a cross-sectional study of 100 LPR patients treated with an association of diet, PPIs, and alginate. Patients were followed from September 2016 to May 2020. At the end of the initial 3-to-6 months therapeutic period, LPR patients were weaned from PPIs and instructed to respect diet and stress management over the long-term. The 3-year symptom recurrence rate, PPI use, and patient awareness of PPI adverse events were assessed.

RESULTS

Sixty-seven patients completed the evaluation. Twenty-seven patients (40.3%) reported a chronic course of LPR-symptoms, requiring chronic or occasional PPI use. LPR symptom recurrence occurred 1-to-2 or 3-to-5 times yearly in 8.9% and 20.9% of patients, respectively. Recurrences were managed by short-term diet, alginate, or PPI intake. The remaining patients (29.9%) did not report middle-term LPR recurrence. The 3-year weaning rate of occasional or chronic use of PPIs was 64.2%. Among participants, 26.8% were aware of PPI-related adverse events, most frequently through physicians (33%), online sources (17%), and friends or family (17%). Nonresponder patients were significantly more aware of PPI adverse events than responders (P = 0.029). PPI-attributed adverse events occurred in 29.8% of patients.

CONCLUSION

Sixty-four percent of LPR patients treated with PPIs were weaned at 3-year posttreatment time. Different forms of LPR may exist regarding symptom relief, recurrences, and chronic course.

Management of Laryngopharyngeal Reflux Around the World: An International Study

OBJECTIVE

To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR).

METHODS

An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment.

RESULTS

A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR.

CONCLUSIONS

LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world.

LEVEL OF EVIDENCE

N.A. Laryngoscope, 131:E1589-E1597, 2021.

Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians

Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.