Prevalence and clinical significance of esophageal motility disorders in patients with laryngopharyngeal reflux symptoms

Chicago Classification Version 4.0 Improves Stratification of Ineffective Esophageal Motility Patients into Clinically Meaningful Subtypes: A Two-Center International Study

The 4th iteration of the Chicago Classification (CC v4.0) for esophageal motility disorders offers more restrictive criteria for the diagnosis of Ineffective Esophageal Motility (IEM) compared to version 3.0 (CC v3.0). In light of the updated criteria for IEM, we aimed to characterize and compare the patients who retained their IEM diagnosis to those who were reclassified as normal motility, and to evaluate the clinical impact of the newly introduced CC v4.0. We performed a retrospective case-control study. We included all individuals who underwent a high-resolution manometry (HRM) between 2020 and 2021 at two centers. Consecutive studies reported as IEM according to the CC v3.0 were reanalyzed according to the CC v4.0. We compared demographics, clinical, manometry, and pH-monitoring parameters. Out of 452 manometry studies, 154 (34%) met criteria for IEM as per the CC v3.0 (CC v3.0 IEM group). Of those, 39 (25%) studies were reclassified as normal studies according to the CC v4.0 (CC v4.0 normal group), while the remaining 115 studies (25% of the overall cohort) retained an IEM diagnosis (CC v4.0 IEM group). The CC v4.0 normal group had more recovered contractions during solid swallows (p = 0.01), less ineffective swallows (p = 0.04), and lower acid exposure time (p = 0.02) compared to the CC4.0 IEM group. Under CC v4.0 criteria, fewer patients are diagnosed with IEM. Those diagnosed with IEM had worse esophageal function and higher acid burden. Though further studies are needed to confirm these findings, our results indicate that CC v4.0 criteria restrict the IEM diagnosis to a more clinically meaningful population.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus

OBJECTIVE

The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.

METHODS

Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.

RESULTS

After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.

CONCLUSION

A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1614-1624, 2024.

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.

Relationship Between Esophageal Disease and Pulmonary Fibrosis

Esophageal disorders are prevalent among patients with chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). Gastroesophageal reflux disease (GERD) has been associated with IPF prevalence, severity, and respiratory decline. The pathophysiologic relationship between GERD and IPF is likely bidirectional, with aspiration of refluxate leading to lung inflammation and fibrosis, while the restrictive pulmonary physiology may contribute to altered transdiaphragmatic pressure gradient and increased reflux. Esophageal symptoms are frequently absent and do not predict esophageal dysfunction or pathologic reflux in patients with IPF, and objective diagnostic tools including upper endoscopy, ambulatory reflux monitoring, and high-resolution manometry are often needed. Impedance-based testing that identifies both weakly/non-acidic and acid reflux may provide important additional diagnostic value beyond pH-based acid testing alone. Novel metrics and maneuvers, including advanced impedance measures on impedance-pH study and provocative testing on HRM, may hold promise to future diagnostic advancements. The main treatment options include medical therapy with acid suppressants and anti-reflux surgery, although their potential benefits in pulmonary outcomes of IPF require further validations. Future directions of research include identifying phenotypes of IPF patients who may benefit from esophageal testing and treatment, determining the optimal testing strategy and protocol, and prospectively assessing the value of different esophageal therapies to improve outcomes while minimizing risks. This review will discuss the pathophysiology, evaluation, and management of esophageal diseases, particularly GERD, in patients with IPF, as informed by the most recent publications in the field, in hopes of identifying targets for future study and research.

Clinical Characteristics of Patients With Ineffective Esophageal Motility by Chicago Classification Version 4.0 Compared to Chicago Classification Version 3.0

Background/Aims

Chicago classification version 4.0 (CCv4.0) of esophageal motility disorders developed a more stringent diagnostic criteria for ineffective esophageal motility (IEM) than version 3.0. We studied the implications of the new diagnostic criteria on the prevalence of IEM, and clinically characterized and compared the population of patients who no longer meet diagnostic criteria for IEM to those who retain the diagnosis.

Methods

We included all consecutively performed high-resolution esophageal impedance manometries from 2014 to 2021. Three cohorts of patients with IEM were created: Patients with IEM by Chicago classification version 3.0 (CCv3.0; CC3 group), by CCv4.0 only (CC4 group), and by CCv3.0 who are now considered normal (Normal group). Demographics, manometric and reflux parameters, and clinical outcomes were compared.

Results

A total of 594 manometries were analyzed. Of those, 66 (11.1%) met criteria for IEM by CCv3.0 (CC3), 41 (62.0%) retained an IEM diagnosis using CCv4.0 criteria (CC4), while 25 (38.0%) patients no longer met criteria for IEM (Normal). The CC4 group had higher esophageal acid exposure, especially supine (% time - 18.9% vs 2.2%; P = 0.005), less adequate peristaltic reserve (22.0% vs 88.0%; P = 0.003), and higher Demeester score (49.0 vs 21.2; P = 0.017) compared to the Normal group. There was no difference in bolus clearance between the groups.

Conclusions

IEM under CCv4.0 has a stronger association with pathologic reflux, especially supine reflux, and inadequate peristaltic reserve, but impairment in bolus clearance is unchanged when compared with IEM diagnosed based on CCv3.0. Further studies are required to determine the implications of these findings on management strategies.

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.

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.

Correlation and Influencing Factors Between Laryngopharyngeal Reflux Disease and Sleep Status in Patients

Objective

To observe the correlation between laryngopharyngeal reflux disease (LPRD) and patients' sleep status, and to explore the related factors of LPRD.

Methods

Four hundred and sixteen patients who visited the otorhinolaryngology clinic in our hospital from June 2019 to June 2021 were selected as the research subjects. According to the scale of reflux symptom index, the subjects were divided into a patients group (120 patients) with an the reflux symptom index (RSI) > 13 and a control group (296 patients) with an RSI ≤ 13 according to the RSI scale score. General patient information was collected. The sleep state and emotional state of patients in the two groups were evaluated, and the related influencing factors for LPRD were also evaluated. The correlation between sleep state and depression in LPRD patients was analyzed.

Results

Four hundred and sixteen patients were divided into patients group and control group according to RSI score, the ratio of the two groups was 1:2.47. In the patients group, the common symptoms of RSI score and the top three of the total score were as follows: Foreign body sensation in throat in 112 patients, 438 points; Keep voice clear in 108 patients, 381 points; Excessive phlegm or nasal discharge reflux in 101 patients, 348 points. The PSQI and HADS scores in the patients group were higher than those in the control group (t = 19.990, 13.007, 14.690, P all <0.001). Logistic regression analysis showed that high-fat diet and high PSQI score were the risk factors for the development of LPRD (P = 0.012, P = 0.007). According to the PSQI score, the patients in the patients group were divided into 35 patients with abnormal PSQI score, 85 patients with normal PSQI score, and the HADS scores of those with abnormal PSQI score were all lower than those with normal PSQI score (P > 0.05). The PSQI score of the patients in the patients group was positively correlated with the HADS score (r = 0.714, P = 0.013).

Conclusion

Sleep disorder may lead to the occurrence or aggravation of anxiety and depression in patients with LPRD, and it is an independent risk factor for the development of LPRD. Clinical attention to the treatment of sleep disorders in patients with LPRD may be conducive to improving the efficacy of LPRD.

Bolus transit of upper esophageal sphincter on high-resolution impedance manometry study correlate with the laryngopharyngeal reflux symptoms

Laryngopharyngeal reflux symptom is a troublesome upper esophageal problem, and reflux symptom index (RSI) is commonly applied for the assessment of clinical severity. We investigated the relationship between the upper esophageal sphincter impedance integral (UESII) and RSI scores in this study. Totally 158 subjects with high-resolution esophageal impedance manometry (HRIM) with RSI questionnaire assessment were recruited. There are 57 (36.08%), 74 (46.84%), 21 (13.29%), and 6 (3.79%) patients were categorized as normal, ineffective esophageal motility disorder, absent contractility, and achalasia by HRIM examination, respectively. Subjects with RSI > 13 were noted to have lower UESII than others with RSI ≦ 13 (7363.14 ± 1085.58 vs. 11,833.75 ± 918.77 Ω s cm; P < 0.005). The ROC analysis yielded a UESII cutoff of < 2900 Ω s cm for the best prediction of subjects with RSI > 13 (P = 0.002). Both female gender and UESII cutoff of < 2900 Ω s cm were significant predictors of RSI > 13 in logistic regression analysis (OR = 3.84 and 2.83; P = 0.001 and 0.01; respectively). Lower UESII on HRIM study, indicating poor bolus transit of UES during saline swallows, is significantly associated with prominent laryngopharyngeal reflux symptoms scored by RSI score.