PRO: Empiric treatment with PPIs is not appropriate without testing

How I Approach Laryngopharyngoesophageal Reflux (LPR)

The purpose of this article is to review the cornerstone and most recent literature regarding laryngopharynoesophageal reflux (LPR) including epidemiological characteristics, pathophysiology, symptoms, diagnosis, and management. The role of pepsin in the pathophysiology of LPR is highlighted in addition to new diagnostic modalities and pharmacologic therapies that target pepsin.

Proximal reflux: biochemical mediators, markers, therapeutic targets, and clinical correlations

Airway reflux is implicated in the pathophysiology of a wide range of adult and pediatric upper and lower airway diseases. However, the diagnosis of proximal reflux-associated disease remains challenging due to evolving clinical criteria and institutional and regional variances in diagnostic practices. Evidence suggests that nonacidic contents of reflux may serve as both pathologic mediators of and biomarkers for reflux in the upper airway. Furthermore, they offer potential pharmaceutical and surgical intervention targets and are the focus of novel clinical diagnostic tools currently under investigation.

Reflux finding score and reflux symptom index as potential predictors for proton pump inhibitor response in globus pharyngeus patients: A prospective study

OBJECTIVE

To evaluate the patient-reported reflux symptom index (RSI) and the doctors-reported Reflux finding score (RFS) as potential predictors for proton pump inhibitor (PPI) response in patients with suspected lower pharyngeal reflux, presenting with globus pharyngeus as their primary complaint.

METHODS

The research project was performed at the ENT department of Isala hospital Zwolle, the Netherlands. A before and after design was used for this single institution prospective exploratory study. 101 participants with globus pharyngeus symptoms as a primary complaint were included. All participants were assessed by an otorhinolaryngologist at enrollment and after eight weeks of esomeprazole use. Fiberoptic laryngoscopy was performed to document the RFS, and RSI questionnaires were self-administered by the participants. Our main outcome measurement was the patient- reported therapeutic response evaluation, that differentiated three categories: responders, partial responders and non-responders. For evaluation of the assessment tools, RFS > 7 and RSI > 13 were considered deviant.

RESULTS

Among the 101 participants, 43 (42.6%) were responders, 28 (27.7%) partial responders and 30 (29.7%) non-responders. Both baseline RSI > 13 and RFS > 7 were statistically significant associated with treatment response. Also, combined into RSI/RFS baseline categories, a significant overall association between baseline scores and patient-reported treatment response was found. Patients reported success rates for deviant RSI and RFS baseline scores were 76.6% and 96%, respectively. 95.5% of patients with both deviant RSI and RFS baseline scores, reported (partial) treatment response.

CONCLUSION

Both together, as well individually, pre-treatment RSI and RFS ratings can help predict treatment response of empirical PPI treatment in patients experiencing globus pharyngeus symptoms.

Pepsin: biomarker, mediator, and therapeutic target for reflux and aspiration

Extra-esophageal reflux is suspected to cause a wide range of clinical symptoms in the upper airways. Diagnosis and treatment has focused on acid, but realization of the role of nonacid reflux has resulted in research investigating the use of pepsin as a biomarker for gastric reflux and aspiration. Pepsin analysis can complement the use of questionnaires and office-based diagnosis and lessen the dependency on invasive and expensive diagnostic tests. Furthermore, pepsin as a first-line diagnostic biomarker has been shown to improve the accuracy of reflux diagnosis. In addition to its use as a diagnostic biomarker, pepsin has been shown to cause inflammation independent of the pH of the refluxate and thus despite acid suppression therapy. Research is ongoing to develop new therapies for airway reflux that specifically target pepsin.

The clinical characteristics of gastroesophageal reflux disease in patients with laryngeal symptoms who are referred to gastroenterology

The prevalence of gastroesophageal reflux disease (GERD) has increased recently in Asia-Pacific countries. However, little is known about its prevalence and clinical characteristics in GERD patients with atypical symptoms in Asia. The aim of this study was to investigate the clinical characteristics of GERD in patients who had laryngeal symptoms in Korea. Data were gathered retrospectively from patients who presented with atypical symptoms, such as throat discomfort, globus pharyngeus, hoarseness, and chronic cough. They underwent a 24-hour ambulatory intraesophageal pH monitoring and filled in a validated reflux questionnaire. Overall, 128 patients (36 men and 92 women) with laryngeal symptoms were included. Of these 128, 43 patients (34%) had erosive esophagitis or pathological reflux from 24-hour ambulatory pH monitoring, and 24 (19%) had a positive Bernstein test or positive symptom index from 24-hour pH monitoring. Sixty-one patients (48%) had no evidence of reflux esophagitis on upper endoscopy and pathological acid reflux on 24-hour pH monitoring. Fifty-six patients (44%) had weekly heartburn or regurgitation. Typical symptoms and dyspepsia were significantly more common in patients with GERD who had laryngeal symptoms than non-GERD. Fifty-two percent of patients had laryngeal symptoms that were associated with GERD. The presence of typical reflux symptoms and dyspepsia are risk factors for GERD in patients who present with laryngeal symptoms.

Extraesophageal Reflux: What Is the Best Parameter for pH-Monitoring Data Analysis from the Perspective of Patient Response to Proton Pump Inhibitors?

Objectives. To analyze the pH-monitoring records of patients with suspected extraesophageal reflux (EER) using three different parameters (number of refluxes (NOR), acid exposure time (AET), and reflux area index (RAI)), with a view to determining which type of analysis is best at selecting the patients who will respond to a proton pump inhibitor (PPI). Methods. Demographic data were obtained and the level of the complaint was assessed using the Visual Analogue Scale. A dual probe pH-monitoring study was conducted. NOR greater than six, AET more than 0.1%, and RAI higher than 6.3 mpH were taken to be the thresholds for EER. Subsequently the response to a 12-week PPI trial was analyzed. Results. A total of 81 patients were analyzed. The percentages of patients with substantial EER based on NOR, AET, and RAI were 36%, 28% and 26%, respectively. Statistically significant, often positive PPI trials were confirmed in the group identified as having substantial EER using all three types of analysis. When using AET and RAI, the significance was more pronounced (P = 0.012 and P = 0.013, resp.) in comparison with NOR (P = 0.033). Conclusions. Patients with EER diagnosed using AET or RAI will respond to PPI significantly often.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Classical reflux symptoms, hiatus hernia and overweight independently predict pharyngeal acid exposure in patients with suspected reflux laryngitis

BACKGROUND

Gastro-oesophageal reflux disease (GERD) has been associated with reflux laryngitis.

AIMS

To investigate the risk factors and the predictors of pharyngeal acid reflux (PAR) in Taiwanese patients with suspected reflux laryngitis.

METHODS

With referral from ENT physicians, 104 patients with symptoms and signs suggestive of reflux laryngitis completed a validated symptom questionnaire, an upper endoscopy exam and ambulatory 24-h pH tests with three sensors located at the hypopharynx, proximal and distal oesophagus. Patients with one or more episodes of PAR were considered abnormal.

RESULTS

Pharyngeal acid reflux was identified in 17% (18/104) of patients. In multivariate logistic regression analysis, PAR was independently associated with classical reflux symptoms [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI): 1.0-12.8], hiatus hernia (aOR = 6.7, 95% CI: 1.5-30.2) and overweight (aOR = 3.4, 95% CI: 1.0-11.0). In predicting PAR, classical reflux symptoms had a sensitivity of 78% and hiatus hernia had a specificity of 95%. With all three factors, the positive predictive value for PAR was 80%. Classical reflux symptoms included heartburn, chest pain, dyspepsia and acid regurgitation.

CONCLUSIONS

Classical reflux symptoms, hiatus hernia and overweight are independent risk factors that may predict pharyngeal acid reflux in patients with suspected reflux laryngitis.

Combined Dual Channel Impedance/pH-metry in Patients With Suspected Laryngopharyngeal Reflux

BACKGROUND/AIMS

Laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) such as globus sensation, hoarseness and chronic cough are becoming increasingly recognized. This study was aimed to investigate the diagnostic usefulness of combined dual channel multichannel intraluminal impedance (MII)/pH-metry in 'off-proton pump inhibitor (PPI)' patients with suspected laryngopharyngeal reflux.

METHODS

Ninety-eight patients with laryngopharyngeal symptoms of GERD were included. All patients were 'off-PPI' state for at least 2 weeks prior to the study, and underwent endoscopy and dual channel combined MII/pH-metry.

RESULTS

The mean age of the patients was 49.8 +/- 10.9 years and there were 44 males (44.9%). Fifty-three patients (54.1%) showed pathologic gastroesophageal reflux (GER). Combined dual channel MII/pH-metry achieved highest diagnostic yield of 49.0% and diagnostic yield of single channel combined MII/pH-metry was 37.8%. Addition of MII to standard pH-metry increased twofold of the diagnostic yield for detecting GER. Among 37 patients (37.8%) who had pathologic GER being detected by MII/pH-metry, 19 patients (19.4%) had nonacid GER (nonacid GER group) while 18 patients (18.4%) had acid GER (acid GER group). Pathologic GER group, as classified by MII/pH-metry showed more frequent globus sensation than nonpathologic GER group. Acid GER group had more proximal reflux than nonacid GER group, especially in the upright position.

CONCLUSIONS

In this study, combined dual channel MII/pH-metry showed the highest diagnostic yield for detecting GER. This technique can be performed primarily to accurately diagnose laryngopharyngeal reflux disease and exclude other causes of laryngopharyngeal symptoms.

Otolaryngological perspective on patients with throat symptoms and laryngeal irritation

The diagnosis of laryngopharyngeal reflux (LPR) is increasingly common in otolaryngology practice. Patients with nonspecific throat and voice symptoms, such as throat clearing, hoarseness, cough, sore throat, and globus, are frequently treated empirically with antireflux medication by otolaryngologists and primary care physicians. Physical findings such as laryngeal erythema, edema, and posterior laryngeal mucosal thickening are also frequently attributed to LPR. The literature has been inconsistent, with few prospective, randomized trials showing efficacy for this clinical practice. Because of the lack of specific signs and symptoms of LPR, clinicians should be aware of other potential causes for these clinical presentations. Recently published studies describe the association between allergy or asthma and many of the same symptoms attributed to reflux disease. Muscle tension dysphonia can also present with hoarseness and symptoms of throat irritation. Although LPR can cause the symptoms and signs described previously, it should not be the only diagnosis considered by the evaluating physician. Failure to consider other possible causes may result in unnecessary treatment and potential delay in diagnosis. This article discusses this topic, citing some of the pertinent literature published over the past 2 years.

Reflux and laryngitis: a systematic review

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Impact of different pH thresholds for 24-hour dual probe pH monitoring in patients with suspected laryngopharyngeal reflux

OBJECTIVES

The gold standard test for laryngopharyngeal reflux is 24-hour pH monitoring, which determines the reflux area index with a pH threshold of less than four (i.e. the reflux area index four). However, refluxed pepsin is able to cause laryngeal injury at pH levels above five.

STUDY DESIGN

Prospective study.

MATERIALS AND METHODS

In order to establish normative values for a reflux area index with a pH threshold of less than five (i.e. the reflux area index five), 29 healthy volunteers underwent pH monitoring. In 45 patients with suspected laryngopharyngeal reflux, reflux area index four and reflux area index five were determined by pH study.

RESULTS

In healthy volunteers, the reflux area index five was 72.6 (95th percentile). In 29 of 44 patients, laryngopharyngeal reflux was diagnosed due to a reflux area index four of greater than 6.3. However, the reflux area index five revealed laryngopharyngeal reflux in six more patients.

CONCLUSIONS

For exact analysis of pH monitoring results, two pH thresholds (less than four and less than five) must be considered. Further studies with a larger number of healthy volunteers are necessary in order to reveal normative values for the reflux area index five parameter.