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

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.

Low Antioxidant Enzyme Levels and Oxidative Stress in Laryngopharyngeal Reflux (LPR) Patients

OBJECTIVE

Laryngopharyngeal reflux disease (LPR) is a characterized by symptoms different from gastroesophageal reflux disease (GERD). LPR can causes chronic mucosal inflammation which may lead to an increase in cytokine production, and a systemic decrease in antioxidant enzyme levels. Our aim in this study is to evaluate antioxidant enzyme levels in patients with LPR.

METHODS

Reflux Symptom Index (RSI) questionnaire, extraesophageal symptom questionnaire which is included in RSI and Reflux Finding Score (RFS) evaluation with 70° rigid laryngoscope were performed to patients who applied to the otolaryngology clinic with a typical LPR complaint, and 60 patients who had an RSI score above 13 and an RFS score above 7 were included in the study. Thirty people consisting of healthy volunteers were included in the control group. Antioxidant enzyme SOD, GSH-Px and CAT levels were measured in the blood serum of the patients and compared with the control group. Results obtained from biochemical tests were expressed as mean ± SE. Descriptive statistical methods (mean ± standard error) were used for the independent t test for the control and study group. P < 0.05 was considered statistically significant.

RESULTS

In the LPR group, 28 (46%) were women, 32 (53%) were men, and age range was 21-60, average age was 36.45 ± 1.147.There was no significant difference between LPR and control group in terms of age, gender and Body Mass Index (BMI). In the LPR group, the lowest score for RSI was 14 and the highest score was 39. The average RSI was 23.67. RFS ranges from 8-22. The mean RFS was 13.50. A highly significant statistical correlation was observed between RSI and total RFS (P < 0.001). There was a significant difference between the antioxidant enzyme levels of the control group and the LPR group. Antioxidant enzyme levels of the control group were SOD 274.10 ± 26.836 U / L, GSH-Px 174.20 ± 20.699 µU / mL and CAT 42.2898 ± 20.699 KU / L. Antioxidant enzyme level results of the LPR group were SOD 147 ± 14.022 U / L (P < 0.01), GSH-Px 88.28 ± 9.113 µU / mL (P < 0.01) and CAT 12.67 ± 0.799 KU / L (P < 0.001). The RSI results ranges from 4 to 39 and the RFS from 8 to 22. Antioxidant enzyme levels demonstrated fairly consistent reliability with individual variables from both RFS and RFS. There was also a highly significant statistical correlation between RSI and RFS.

CONCLUSION

We found that the antioxidant enzymes SOD, GPX and catalase enzyme levels were significantly lower in LPR patients. Treatment modalities to reduce oxidative stress (OS) in LPR should be investigated.

Clinical Manifestations and Treatment Outcome of Laryngopharyngeal Reflux on Larynx and Symptom-Sign Correlation

To evaluate various clinical signs and symptoms of Laryngopharyngeal reflux on the Larynx along with treatment outcome and to establish symptom-sign correlation. Prospective interventional study. 50 patients with symptoms and signs of LPR were enrolled in the study and were followed up for 9 months. Patients were evaluated with a 70° Hopkins rigid laryngoscope and the Reflux Symptom Index and Reflux Finding Score scales were used to grade the sign and symptoms and to diagnose LPR and to compare pre and post-treatment conditions. Patients were given treatments including PPI and diet modification. The most common laryngeal symptom based on the RSI score was sore throat (40%). Other common symptoms were hoarseness of voice (30%) and cough (20%). The most common laryngeal sign based on RFS (Reflux finding score) was Posterior Commissure Hypertrophy (40%). The other common signs were Pseudosulcus (30%), Vocal cord oedema (20%), and Granulomas (10%). Out of the 50 patients, 21 patients (42%) had an RFS score of less than 7. Rest 29 patients (58%) had RFS scores of more than 7. Out of these 29 patients, 19 patients (65.52%) had partial relief from symptoms after 3 weeks of treatment and were advised to take treatment for 3 more weeks, and rest 10 (34.48%) patients were completely unresponsive to treatment. The improvement in symptoms does not always manifest in improvement in signs and there is no correlation between the symptoms and signs of LPR.

Treating and Managing Laryngopharyngeal Reflux Disease in the Over 65s: Evidence to Date

Purpose

The clinical presentation and therapeutic outcomes of elderly patients may be different from those in younger populations, leading to additional diagnostic and therapeutic difficulties. The present study reviewed the findings on the epidemiology, and clinical, diagnostic, and therapeutic outcomes of elderly patients with laryngopharyngeal reflux (LPR).

Methods

A PubMed, Cochrane Library, and Scopus literature search was conducted on the epidemiological, clinical, diagnostic, and therapeutic findings of elderly LPR patients.

Findings

The prevalence of LPR in the elderly population remains unknown. From a clinical standpoint, older LPR patients report overall lower symptom scores and related quality-of-life outcomes at the time of the diagnosis. The required treatment time to obtain symptom relief appears to be longer in older compared with younger patients. Particular attention needs to be paid to prolonged medication use because the elderly population is characterized by polypharmacy and there is a higher risk of proton-pump inhibitor (PPI) interactions and adverse events. The plasma clearance of most PPIs is reduced with age, which must be considered by practitioners in the prescription of antireflux therapy.

Conclusion

The clinical presentation and treatment efficacy of elderly LPR patients differ from those in younger patients. Practitioners need to carefully consider the risk of drug interactions and adverse events in elderly patients.

Dysphonia in Performers: Prevalence of Vocal Lesions and Voice Emergencies in a Private Otorhinolaryngology Practice

OBJECTIVE

To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.

STUDY DESIGN

Retrospective study of professional singers and actors who presented for a vocal evaluation.

SUBJECTS AND METHODS

A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).

RESULTS

A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P<0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).

CONCLUSION

Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

The Effects of Empiric Antireflux Treatment on Laryngopharyngeal and Gastroesophageal Reflux Disease

Objectives:

This study aims to investigate the effects of empiric lansoprazol therapy on laryngopharyngeal (LPR) and gastroesophageal (GOR) reflux symptoms and laryngological findings.

Methods:

Sixty-seven patients with suspected LPR related symptoms were prospectively analyzed in this study. Following eleven symptoms were asked to patients using LPR symptom questionnaire; sore throat, throat burning, throat clearing, globus sensation, cough, halitosis, dysphonia, dysphagia, postnasal dripping, vocal fatigue and sputum. GOR symptoms were evaluated with the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) questionnaire consist of twelve symptoms. Posterior larynx, arytenoids and interarytenoid area were evaluated with a 70° endoscope. Erythema, edema and nodularity were graded separately using 4 point severity scale to examine laryngeal signs. All patients were treated using 30 mg lansoprazole once daily for four weeks. After the end of medication, symptoms and laryngoscopic signs were evaluated again with the same method. The pretreatment and posttreatment values were compared with statistical analyses.

Results:

There was a statistically significant decrease in LPR symptom scores and total scores of FSSG. The severity of nodularity in the posterior larynx, arytenoids and interarytenoid area was improved after treatment. There was no statistically significant difference in erythema on each area larynx. Edema in the posterior larynx and interarytenoid area was improved but there was no change on the edema of arytenoids.

Conclusion:

A short period of empiric antireflux treatment has a significant improving effect on all LPR symptoms and most of GOR symptoms. However, it was insufficient on laryngeal signs. Further research is needed to investigate longer times of treatment for the complete resolution of symptoms and signs.

Prevalence and clinical predictors of LPR among patients diagnosed with GERD according to the reflux symptom index questionnaire

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) is a common condition that can lead to significant morbidity. Laryngopharyngeal reflux (LPR) is a distinct clinical entity that can occur simultaneously with GERD, necessitating additional treatment measures. The degree of overlap and clinical predictors of LPR among patients with GERD remains unknown. We aim to measure the prevalence of LPR in patients with GERD and identify clinical predictors.

PATIENTS AND METHODS

We performed a cross-sectional study involving patients with confirmed GERD according to the GERD questionnaire (GerdQ) using the reflux symptom index (RSI). Data on demographics, comorbidities, past and current medications, and GERD-related lifestyle measures were documented. The prevalence of LPR was calculated. Linear and logistic regression analyses were conducted to correlate GerdQ and RSI, and to identify clinical predictors of LPR, respectively.

RESULTS

A total of 80 patients with confirmed GERD were consecutively recruited and surveyed. Mean age was 43 (±16) and 60% were females. The majority of patients were Saudis (51%) and only 24% were smokers. The mean duration of GERD was 7 (±4.4) years and the average body mass index (BMI) was 36 ± 22. Sixty-six percent of the patients consumed coffee on regular basis. On simple and multiple linear regression analyses, a strong, positive correlation was observed between the GerdQ and RSI scores (coefficient = 1.13, 95%CI = 0.39-1.86), and ipratropium bromide inhaler was positively associated with RSI scores (coefficient = 13.12, 95%CI = 0.16-26.09). LPR was identified in 57 patients (71%). On simple and multiple logistic regression analyses, GerdQ scores (OR = 1.78, 95%CI = 1.13-2.80), BMI (OR = 1.07, 95%CI = 1.01-1.14), duration of GERD in years (OR = 1.42, 95%CI = 1.04-1.93), and the type of gender (OR = 49.67, 95%CI = 1.32-1870) appeared to increase the risk of LPR, whereas coffee consumption (OR = 0.0005, 95%CI = 1.82e-06, 0.13) appeared to be negatively associated with LPR.

CONCLUSIONS

Contradictory to what is frequently reported, LPR commonly occurs and positively correlates with GERD. Several modifiable clinical predictors of LPR might exist, which highlight the importance of performing a complete clinical assessment of the patients with reflux symptoms.

How uncomplicated total thyroidectomy could aggravate the laryngopharyngeal reflux disease?

Swallowing, voice disorders, throat discomfort and subjective neck discomfort are usually reported by patients with a known thyroid nodule and are correlated to nodular thyroid disease itself. Moreover, in endemic goitrous areas, total thyroidectomy (TT) is the most frequently performed surgical procedure. We are used to relate swallowing, voice and throat discomfort to the mechanical effects of nodular goiter or to thyroidectomy itself, but in both these cases the relationship between symptoms and the thyroid mass or its removal is not always clear or easily demonstrated. How can we explain the persistence of local neck symptoms after TT? And how can TT worsen the dysphagic or dysphonic disorders attributed to the goiter's effect over the surrounding structures? During these years, many articles have analyzed the relationship between the thyroid disease and the laryngopharyngeal reflux, finding more and more evidences of their consensuality, leading to important new management considerations and notable medico-legal implications; if the reason of local neck symptoms is not the thyroid disease, we have to study and specially cure the reflux disease, with specific test and drugs. Therefore, the aim of our study, relying on the published literature, was to investigate how, in demonstrated presence of reflux laryngopharyngitis in patients with nodular goiter and local neck symptoms before and after uncomplicated TT, the surgery could influence our anti-reflux mechanism analyzing the anatomical connection as well as the functional coordination; can we play a part in the post-operative persistence of swallowing and voice alterations and throat discomfort?

Influence of smoking isolated and associated to multifactorial aspects in vocal acoustic parameters

INTRODUCTION

Smoking affect voice quality in a long period of time, but other factors may compromise it, such as professional using of voice, habits, alcohol dependence and GERD. The aim was associate the influence of these factors on vocal parameters.

STUDY DESIGN

Contemporary cohort study with cross-sectional.

MATERIALS AND METHODS

Eighty adults of 35 to 60 years old had participated in this study, they had been divided into two groups, smokers (GF) and control (GC). There was application of questionnaire and voices were recorded. Praat software has been used for voice assessment and Man-Whitney, chi-square and logistic regression has been used for statistical analysis.

RESULTS

The GF had a higher incidence of alcohol dependence, coughing, throat clearing and professional voice using. Respecting to the acoustic parameters: noise-to-harmonic ratio (NHR), jitter and shimmer, the GF presented higher values. Relating these data to the questionnaire, it's noticed that female gender have influence over all acoustic parameters, GERD have influence over jitter and smoking can affect fundamental frequency, jitter, shimmer and NHR.

CONCLUSION

Smoking interferes in acoustics parameters isolated and associated with alcohol dependence, GERD, cough, throat clearing, gender and professional using of voice.

Laryngopharyngeal reflux: diagnosis, treatment, and latest research

Introduction Laryngopharyngeal reflux (LPR) is a highly prevalent disease and commonly encountered in the otolaryngologist's office.

Objective To review the literature on the diagnosis and treatment of LPR.

Data Synthesis LPR is associated with symptoms of laryngeal irritation such as throat clearing, coughing, and hoarseness. The main diagnostic methods currently used are laryngoscopy and pH monitoring. The most common laryngoscopic signs are redness and swelling of the throat. However, these findings are not specific of LPR and may be related to other causes or can even be found in healthy individuals. Furthermore, the role of pH monitoring in the diagnosis of LPR is controversial. A therapeutic trial with proton pump inhibitors (PPIs) has been suggested to be cost-effective and useful for the diagnosis of LPR. However, the recommendations of PPI therapy for patients with a suspicion of LPR are based on the results of uncontrolled studies, and high placebo response rates suggest a much more complex and multifactorial pathophysiology of LPR than simple acid reflux. Molecular studies have tried to identify biomarkers of reflux such as interleukins, carbonic anhydrase, E-cadherin, and mucin.

Conclusion Laryngoscopy and pH monitoring have failed as reliable tests for the diagnosis of LPR. Empirical therapy with PPIs is widely accepted as a diagnostic test and for the treatment of LPR. However, further research is needed to develop a definitive diagnostic test for LPR.

Salivary Concentration of Epidermal Growth Factor in Adults with Reflux Laryngitis before and after Treatment

Objectives:

The diagnosis of laryngopharyngeal reflux (LPR) is controversial. There is no correlation between the number of reflux episodes and the severity of the inflammatory response at the esophagus or the laryngopharyngeal segment. Some authors have suggested that decreased salivary epidermal growth factor (EGF) concentrations in patients with gastroesophageal reflux disease and LPR point to a breakdown in the local defenses. Our objective was to establish whether treatment of the disease influences low salivary EGF concentrations.

Methods:

The spontaneous whole saliva of 20 adults with LPR was sampled at a tertiary teaching hospital before and after a 16-week course of full-dose proton pump inhibitor and compared to that of 12 healthy controls. Salivary EGF concentrations were established with a commercially available enzyme-linked immunosorbent assay kit.

Results:

Although the mean salivary EGF concentrations were higher before treatment than after treatment and control of the disease (25,083 versus 19,359 pg/mL), this difference was not statistically significant (p = 0.065). The mean salivary EGF concentration of healthy control subjects was significantly higher (54,509 pg/mL; p < 0.0001).

Conclusions:

Both before and after treatment, patients with reflux laryngitis present lower salivary EGF concentrations than healthy control subjects, suggesting a primary deficit in their protective mechanisms.

Transition zone defect associated with the response to proton pump inhibitor treatment in patients with globus sensation

BACKGROUND AND AIM

Few data describing short-term proton pump inhibitor (PPI) treatment in patients with globus sensation exist. The aim of this study was to evaluate the use of high-resolution manometry (HRM) for predicting the response to PPI treatment in patients with globus sensation.

METHOD

A total of 41 patients with globus sensation were treated with PPIs for 4 weeks and were classified as positive and negative responders. HRM topographical plots were analyzed for relevant manometric parameters. In addition, clinical and HRM data of 20 patients with typical gastroesophageal reflux disease (GERD) not presenting globus symptom were analyzed.

RESULTS

Of the 41 patients, 19 (46%) were clinically diagnosed with GERD. The proportion of patients with favorable symptomatic improvement was higher in patients with GERD than in those without reflux (P=0.046). Positive and negative responders to PPI treatment did not differ in upper esophageal sphincter and proximal esophageal contraction. In globus patients with GERD, the temporal and spatial dimension of the transitional zone were greater among negative responders than among PPI-positive responders (P=0.010 and P=0.011). Regarding GERD patients without globus, there was no significant difference in transition zone defect according to PPI responsiveness. By receiver operating characteristic curve analysis, 2.1 cm and 1.1 s were found to be the spatial and temporal transitional zone dimensions that best differentiated positive and negative responders.

CONCLUSION

In patients with GERD-related globus, there were larger transition zone defect in the negative responders compared with the PPI-positive responders.

Reflux and aerodigestive tract diseases

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

Globus pharyngeus: A review of its etiology, diagnosis and treatment

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.

Pepsin promotes proliferation of laryngeal and pharyngeal epithelial cells

OBJECTIVE/HYPOTHESIS

Laryngopharyngeal reflux (LPR) is thought to be a significant risk factor for laryngeal squamous cell carcinoma (SCC), but causality has never been proven. It is accepted that chronic reflux into the esophagus can induce metaplastic changes in esophageal mucosa with subsequent increased risk of esophageal adenocarcinoma, but no similar associations have been established for LPR and laryngopharyngeal SCC. The objective of this study was to test the hypothesis that reflux of pepsin into the laryngopharynx can promote carcinogenesis.

STUDY DESIGN

Translational research study.

METHODS

Normal human laryngeal primary epithelial cell cultures and hypopharyngeal FaDu SCC cells were exposed to human pepsin and analyzed by Human Cancer PathwayFinder and miRNA Superarrays, flow cytometry, and Western blot to determine the effect of pepsin on carcinogenesis. Laryngeal biopsy specimens taken from cancer patients and normal control subjects were analyzed for the presence of pepsin by Western blot.

RESULTS

Microarray analysis demonstrated that pepsin significantly altered the expression of 27 genes implicated in carcinogenesis and also affected the expression of 22 microRNAs known to be altered in human head and neck cancers. Pepsin increased proliferation in both FaDu SCC cells and cultured normal laryngeal epithelial primary cells by increasing S phase distribution on flow cytometry analysis in a time- and dose-dependent manner. Furthermore, pepsin was detected in 60% (3/5) human laryngeal cancer biopsies, absent in all (0/5) normal control specimens.

CONCLUSIONS

These data support a role for refluxed pepsin in the promotion of epithelial proliferation and carcinogenesis of the larynx and pharynx.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomarkers and laryngopharyngeal reflux

Laryngopharyngeal reflux is a controversial but increasingly made diagnosis used in patients with a collection of often non-specific laryngeal symptoms. It is a clinical diagnosis, and its pathophysiology is currently poorly understood. Previous reflux research has focused on injurious agents, acid, pepsin and biomarker expression. Failure of intrinsic defences in the larynx may cause changes in laryngeal epithelia, particularly alterations in carbonic anhydrases and E-cadherin. Carbonic anhydrase III levels vary in the larynx in response to laryngopharyngeal reflux, depending on location. Expression of E-cadherin, a known tumour suppressor, is reduced in the presence of reflux. Mucin expression also varies according to the severity of reflux. Further research is required to define the clinical entity of laryngopharyngeal reflux, and to identify a definitive mechanism for mucosal injury. Understanding this mechanism should allow the development of a comprehensive model, which would enable future diagnostic and therapeutic interventions to be developed.

Reflux symptom index and reflux finding score in otolaryngologic practice

OBJECTIVES

To evaluate whether patients with abnormal Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) benefit from proton pump inhibitor (PPI) therapy.

STUDY DESIGN

Open, multicenter, prospective longitudinal cohort study.

METHODS

Patients with suspected reflux-associated laryngologic symptoms were evaluated by 40 community practice otolaryngologists using RSI and RFS. Patients were treated with pantoprazole 40-80 mg/d for 8-12 weeks if RSI was greater than 9 and RFS greater than 7. Pre- and posttherapeutic RSI and RFS were compared using Wilcoxon signed rank test and additionally controlled with the symmetry test of Bowker.

RESULTS

A total of 1044 patients were included over a period of 20 months. Median total score of RSI before therapy was 12 and decreased to 3 (P≪0.001). Median total score of RFS before therapy was 16 and decreased to 6 (P≪0.001). Assessment of the treatment effect by otolaryngologists and patients was judged as being excellent in at least 50%. In 2% of the patients, gastrointestinal side effects were documented.

CONCLUSION

RSI and RSF are easy to administer in the routine care of patients suspected of having laryngopharyngeal reflux. Patients identified by positive results of these tests have a high likelihood of excellent improvement after 8-12 weeks of PPI treatment. By implementation of RFS and RSI in daily use, most patients may not need time-consuming and cost-intensive examinations in the first-line assessment of LPR. These examinations can be reserved for nonresponders, and uncontrolled prescription of PPIs can be restricted.

Loss of alkalization in proximal esophagus: a new diagnostic paradigm for patients with laryngopharyngeal reflux

INTRODUCTION

Cervical esophageal pH monitoring using a pH threshold of <4 in the diagnosis of laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of cervical esophageal exposure to gastric juice. The aim of this study was to define normal values for the percent time the cervical esophagus is exposed to a pH ≥7 and to use the inability to maintain this as an indicator for diagnosis of LPR.

MATERIAL AND METHODS

Fifty-nine asymptomatic volunteers had a complete foregut evaluation including pH monitoring of the cervical esophagus. Cervical esophageal exposure to a pH <4 was calculated, and the records were reanalyzed using the threshold pH ≥7. The sensitivity of these two pH thresholds was compared in a group of 51 patients with LPR symptoms that were completely relieved after an antireflux operation.

RESULTS

Compared to normal subjects, patients with LPR were less able to maintain an alkaline pH in the cervical esophagus, as expressed by a lower median percent time pH ≥ 7 (10.4 vs. 38.2, p < 0.0001). In normal subjects, the fifth percentile value for percent time pH ≥ 7 in the cervical esophagus was 19.6%. In 84% of the LPR patients (43/51), the percent time pH ≥ 7 were below the threshold of 19.6%. In contrast, 69% (35/51) had an abnormal test when the pH records were analyzed using the percent time pH < 4. Of the 16 patients with a false negative test using pH < 4, 11 (69%) were identified as having an abnormal study when the threshold of pH ≥ 7 was used.

CONCLUSION

Normal subjects should have a pH ≥7 in cervical esophagus for at least 19.6% of the monitored period. Failure to maintain this alkaline environment is a more sensitive indicator in the diagnosis of the LPR and identifies two thirds of the patients with a false negative test using pH <4.

Heterotopic gastric mucosal patch of the esophagus is associated with higher prevalence of laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux (LPR) is common in clinical practice. Heterotopic gastric mucosal patch of the proximal esophagus (HGMP) is reported to cause LPR symptoms. This study assessed the prevalence of LPR symptoms and correlation with the size of HGMP. Four hundred and sixty-two patients undergoing endoscopy were carefully questioned regarding LPR symptoms experienced in the previous 12 weeks. The size of the HGMP was assessed and documented during endoscopy. Clinicopathological classifications were assigned (types I-V) accordingly. HGMP [median one patch (range 1-3), median size 15 mm [3-35] was detected in 26 (19 HGM type I and 7 HGM type II] patients giving a prevalence of 5.6%. Among the indications, there were significantly more LPR symptoms as referral indications among patients with HGMP. There were no significant differences in the endoscopic findings. On specific enquiries, significantly more HGMP patients had experienced any LPR symptoms (73.1 vs. 25.9%, p < 0.001) specifically chronic cough (p = 0.002), throat discomfort/hoarseness (p < 0.001), globus sensation (p = 0.004), regurgitation (p < 0.001). HGMP patients also had more heartburn (p = 0.001). Larger HGMP (≥ 15 mm) was only associated with more chronic cough (p = 0.022). In conclusion, patients with HGMP have significantly more LPR symptoms. However, most were mild and detected through specific enquiries. Interestingly, the size of HGMP did not significantly affect the prevalence of LPR symptoms.

Proximal esophageal pH monitoring: improved definition of normal values and determination of a composite pH score

BACKGROUND

Patients with respiratory and laryngeal symptoms are commonly referred for evaluation of reflux disease as a potential cause. Dual-probe pH monitoring is often performed, although data on normal acid exposure in the proximal esophagus are limited because of the small number of normal subjects and inconsistent placement of the proximal pH sensor in relation to the upper esophageal sphincter. We measured proximal esophageal acid exposure using dual-probe pH and calculated a composite pH score in a large number of asymptomatic volunteers to better define normal values.

STUDY DESIGN

Eighty-one normal subjects free of reflux, laryngeal, or respiratory symptoms were recruited. All had video esophagraphy to exclude hiatal hernia. Esophageal pH monitoring was performed using 1 of 3 different dual-probe catheters with sensors spaced 10, 15, or 18 cm apart. The standard components of esophageal acid exposure were measured, excluding meal periods. A composite pH score for the proximal esophagus was calculated using these components.

RESULTS

The final study population consisted of 59 (49% male) subjects, with a median age of 27 years. All had normal distal esophageal acid exposure and no hiatal hernia. The 95(th) percentile values for the percent time the pH was < 4 for the total, upright, and supine periods were 0.9%, 1.2%, and 0.4%, respectively. The 95(th) percentile for the number of reflux episodes was 24 and for the calculated proximal esophageal composite pH score was 16.4.

CONCLUSIONS

In a large population of normal subjects, we have defined the normal values and calculated a composite pH score for proximal esophageal acid exposure. The total percent time pH < 4 was similar to previously published normal values, but the number of reflux episodes was greater.

A comparison of rating scales used in the diagnosis of extraesophageal reflux

OBJECTIVE

To evaluate the level of agreement between reflux area index scores, the reflux symptom index (RSI), and the reflux finding score (RFS). Inter- and intrarater reliability of the RFS was assessed. A criterion of pH 5 was used to evaluate its effects on agreement.

STUDY DESIGN

Adult participants were enrolled in this prospective study.

METHODS

Eighty-two participants (72 patients and 10 controls) completed the RSI, videoendoscopy, and 24-hour pH probe monitoring. The reflux area index for extraesophageal reflux (EER) events was calculated at pH 4 and 5. Two speech-language pathologists and one otolaryngologist independently rated 36 endoscopic examinations using the RFS through a web-based system. A repeated rating of six examinations was completed.

RESULTS

Chi-square revealed poor agreement between the diagnostic tools, regardless of which pH criterion was used. Intraclass correlation coefficients revealed fair interrater reliability of the RFS and moderate intrarater reliability. Independent-sample t tests for the RFS and reflux area index (RAI) scores failed to identify patients from normal controls.

CONCLUSIONS

The results of this study highlight the lack of agreement among the current available diagnostic tools for EER. Raters were not in agreement regarding the presence and severity of physical findings of EER. Results support the need for greater consensus among the clinical tools used in the diagnosis of EER. Physical rating scales may overidentify patients and would benefit from uniform scales and training. Assessing EER occurring at pH 5 may also yield important diagnostic information. Further research is needed to verify normative RAI cutpoints.

Gastroesophageal reflux disease and the airway-essentials for the surgeon

Gastroesophageal reflux disease (GERD) has many protean manifestations. Some of the most vexing have to do with the airway. GERD affects the tracheobronchial tree directly, leading to aspiration pneumonia and asthma, or exacerbating existing pulmonary disease, such as asthma or chronic obstructive pulmonary disease. In addition to the respiratory manifestation of GERD, there are unique pharyngeal and laryngeal manifestations. These include voice hoarseness, throat-clearing, chronic cough, globus, and “post-nasal drip”. Linking these symptoms to GERD is challenging and frequently the diagnosis is that of exclusion. Despite proton pump inhibitor therapy being the mainstay of treatment, with anti-reflux surgery being reserved for intractable cases, there is no definitive evidence of the superiority of either.

Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care--a 5-year follow-up

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be associated with laryngo-respiratory symptoms (LRS) such as chronic cough, asthma or laryngeal symptoms.

AIM

To analyse the long-term clinical course of LRS in a large population with GERD and LRS.

METHODS

ProGERD is a prospective multicentre cohort study of 6215 adult out-patients with GERD. At baseline, the prevalence of LRS was assessed. Initial standardized treatment was esomeprazole for up to 8 weeks. After 5 years of follow-up, patients were interviewed for LRS and a multivariate analysis was performed with resolved vs. persistent symptoms for chronic cough, asthma and laryngeal symptoms.

RESULTS

In all, 2886 patients (46.4%) were available for analysis at baseline and at 5 years. The prevalence of chronic cough and laryngeal disorders had decreased while the prevalence of asthma had increased. Resolution of LRS was independent of clinical reflux characteristics or PPI medication.

CONCLUSIONS

In a large population with GERD, only few patients reported persistent LRS over 5 years. Resolution of LRS was independent of the stage of GERD and PPI treatment. Accordingly, data on the direction of causality between GERD and LRS are lacking and the strength of the association between the two must remain controversial.

[Postoperative care in operative laryngology]

The postoperative care after phonosurgery and laryngologic procedures from the physician's view comprises control of wound healing and confirmation of restitution of the vocal folds or the larynx. The physician manages the patient's behaviour, prescribes medication if necessary and provides advice on measures to promote healing, such as voice rest and work incapacity. Basic knowledge on wound healing is an aid for deciding at which point in time voice rest and work incapacity can be ended. Professional voice users need a specifically tailored line of conduct during the period of voice rehabilitation. The documentation includes the organic findings and the vocal function.

The diagnosis and management of globus: a perspective from Japan

PURPOSE OF REVIEW

The etiology of globus is multifactorial and its management is controversial. Recent findings in the etiology and diagnosis of globus are discussed, and a subjective opinion on its management is presented.

RECENT FINDINGS

Although there is considerable debate concerning the role of gastroesophageal reflux disease (GERD) in patients with globus, the globus symptom score has been shown to be significantly higher in patients with GERD than in those without GERD. This definite association between GERD and globus leads to the practical division of patients with globus into two groups: the GERD/laryngopharyngeal reflux (LPR)-induced and non-GERD/LPR groups. When the presence of GERD or LPR or both is established in patients with globus, management of this condition should be considered. Owing to limitations in the technology for the detection of GERD/LPR, precise discrimination between the two groups is still difficult. For practical purposes, empirical approaches for targeting GERD in patients with globus appear to be justified. A 24 h pH-metry/multichannel intraluminal impedance test may increase the detection of reflux events in patients with globus.

SUMMARY

A practical approach for dividing patients with globus into GERD/LPR-induced and non-GERD/LPR groups is introduced.