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Dwyer CD, Fein M, Gordon L, Kridgen S, Roth D, Winston J, Carroll TL. Temporary Vocal Fold Augmentation Outcomes for Refractory Chronic Cough with Concurrent Nonparalytic Glottic Insufficiency due to Vocal Fold Atrophy. J Voice 2024:S0892-1997(24)00232-7. [PMID: 39107214 DOI: 10.1016/j.jvoice.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Determine the effect of temporary vocal fold augmentation on refractory chronic cough (RCC) in patients with glottic insufficiency (GI) due to vocal fold atrophy. METHODS Retrospective electronic chart review was conducted for patients with a diagnosis of bilateral vocal fold atrophy and RCC undergoing vocal fold augmentation with carboxymethylcellulose (CMC). Patients with vocal fold immobility were excluded, and cough must have been present for at minimum 8weeks. VHI-10, CSI, and RSI scores along with subjective overall patient report of chronic cough improvement were collected. RESULTS A total of 28 patients underwent 30 vocal fold augmentation procedures with CMC. All had undergone extensive cough work-up and treatment trials prior to their augmentation procedure. From chart review, 13 overall subjectively reported satisfactory improvement in their cough, 5 reported partial improvement, and 7 reported no improvement in their cough. An uncertain effect on cough was documented in 5 (either patient was uncertain or no mention of cough symptom in the interval chart history note). For those subjects with both pre- and post-augmentation data, mean preaugmentation CSI: 22.08± 6.8 (n = 13); VHI-10: 13.6± 8.9 (n = 18); RSI: 22.4± 7.5 (n = 17). Mean postaugmentation CSI was 20.7± 9.2 (n = 13); VHI-10: 15.2± 8.2 (n = 18); RSI: 21.1± 5.8 (n = 17). Mean pre-post change in CSI was -1.4± 5.1 (P = 0.175, n = 13, range -10 to +6). CONCLUSIONS Vocal fold augmentation seems to provide subjective cough improvement in some patients with concurrent GI due to vocal fold atrophy and RCC. It can be offered as a diagnostic trial, on which further augmentation may be offered, for patients with persistent cough despite prior work-up and treatment trials. Further controlled prospective studies are needed to identify factors that are predictive of successful cough improvement following vocal fold augmentation, as well as the effect of durable augmentation in those patients who had improvement with a diagnostic trial.
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Affiliation(s)
- Christopher D Dwyer
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Mira Fein
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Lindsey Gordon
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Samantha Kridgen
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Douglas Roth
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Jennifer Winston
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts
| | - Thomas L Carroll
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Boston, Massachusetts.
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Miles ER, Krishna PD, Dehom S, Hahn R, LaTour D, Murry T, Crawley BK. Voice and Airway Outcomes of Montgomery T-tube Placement in Laryngotracheal Stenosis. J Voice 2022:S0892-1997(22)00161-8. [PMID: 35859059 DOI: 10.1016/j.jvoice.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe voice and airway outcomes and complications experienced by patients with laryngotracheal stenosis following Montgomery T-tube placement. METHODS Retrospective chart review of all patients with laryngotracheal stenosis and Montgomery T-tube placement treated at a tertiary referral center from 2012 to 2021. RESULTS Eighteen patients met criteria with laryngotracheal stenosis, seven including the level of the glottis and 11 without glottal involvement. Eleven were completely aphonic before T-tube placement and the remainder had severe dysphonia. There was improvement of Voice Handicap Index-10, Reflux Symptom Index, and GRBAS grade following T-tube placement in patients compared to their preoperative values. Improvement of grade was greater in patients without glottal involvement. Complications of chronic indwelling T-tube included granulation in 14 patients (78%), tracheitis in two patients (11%), and mucus plugging in three patients (17%) with one T-tube related mortality. Five patients were eventually decannulated, six returned to tracheostomy tube, and seven retained the T-tube at last follow-up (average: 30 months, range: 4-80 months). CONCLUSIONS Montgomery T-tube placement improves voice in patients with severe dysphonia secondary to laryngotracheal stenosis with and without glottal involvement though the degree of improvement is greater in patients without glottal involvement. T-tube can help reestablish long-term laryngotracheal continuity in patients with no other surgical options. The potential benefits in phonation should be weighed against the possibility of rare but serious adverse events.
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Affiliation(s)
- Ethan R Miles
- School of Medicine, Loma Linda University, Loma Linda, California.
| | - Priya D Krishna
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda Voice and Swallowing Center Loma Linda University, Loma Linda, California
| | - Salem Dehom
- School of Nursing, Loma Linda University, Loma Linda, California
| | - Rachel Hahn
- School of Medicine, Loma Linda University, Loma Linda, California
| | - Donn LaTour
- School of Medicine, Loma Linda University, Loma Linda, California
| | - Thomas Murry
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda Voice and Swallowing Center Loma Linda University, Loma Linda, California
| | - Brianna K Crawley
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda Voice and Swallowing Center Loma Linda University, Loma Linda, California
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Shires CB, Dewan K. Is there Really a Lump in My Throat? The Incidence and Implication of Vocal fold Abnormalities in Patients Presenting with Globus. J Voice 2022:S0892-1997(22)00141-2. [PMID: 35794058 DOI: 10.1016/j.jvoice.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To identify the prevalence of vocal fold abnormalities in patients with a primary complaint of globus sensation. Secondly, to determine the relationship between globus, vocal fold abnormality, and patient-reported quality of life questionnaire score. STUDY DESIGN Retrospective chart review. METHODS A retrospective chart review was performed to identify all new patients evaluated at a tertiary academic care laryngology practice between January 2018 and December 2018 presenting with a chief complaint of globus. Variables of interest include age, gender, laryngeal symptoms, self-reported quality-of-life questionnaire results, and laryngostroboscopy findings. Questionnaires selected for this investigation include the reflux symptom index (RSI), eating assessment tool-10 (EAT-10), and voice handicap index-10 (VHI-10). RESULTS Two hundred twenty-eight subjects with an average age of 54 ±17 years, were categorized based on one of three laryngostroboscopic findings: absence of vocal fold abnormality, vocal fold paresis/paralysis (motion abnormality), or a vocal fold mass lesion. Fifty percent of patients reporting globus had a normal laryngeal exam, and 50% had a mass lesion or motion abnormality. Twenty five percent had vocal fold motion abnormality (paresis, paralysis, or supraglottic squeeze); 19% had a mass lesion; and 3% had both a lesion and motion abnormality. The average self-reported survey scores were compared among the three groups. Patients with dysphonia had a significantly higher VHI-10 (P = 0.00), and a significantly higher RSI (P = 0.00) than those without dysphonia. Those patients with dysphagia had significantly higher EAT-10 (P = 0.00) and RSI (P = 0.02) scores than those who did not have dysphagia. Patients with vocal fold motion abnormality had significantly higher VHI-10 than those with normal vocal fold mobility (P = 0.02) CONCLUSIONS: Identifying the etiology of globus presents a significant challenge to laryngologists. Data presented here suggest that vocal fold abnormalities may contribute to the sensation of globus and should therefore be considered in the differential when managing these patients.
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Affiliation(s)
| | - Karuna Dewan
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University, Shreveport, Louisiana.
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Distinct Clinical Physiologic Phenotypes of Patients With Laryngeal Symptoms Referred for Reflux Evaluation. Clin Gastroenterol Hepatol 2022; 20:776-786.e1. [PMID: 34022451 PMCID: PMC8715518 DOI: 10.1016/j.cgh.2021.05.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Heterogeneous presentations and disease mechanisms among patients with laryngeal symptoms account for misdiagnosis of laryngopharyngeal reflux (LPR), variations in testing, and suboptimal outcomes. We aimed to derive phenotypes of patients with laryngeal symptoms based on clinical and physiologic data and to compare characteristics across phenotypes. METHODS A total of 302 adult patients with chronic laryngeal symptoms were prospectively enrolled at 3 centers between January 2018 to October 2020 (age 57.2 ± 15.2 years; 30% male; body mass index 27.2 ± 6.0 kg/m2). Discriminant analysis of principal components (DAPC) was applied to 12 clinical and 11 physiologic variables collected in stable condition to derive phenotypic groups. RESULTS DAPC identified 5 groups, with significant differences across symptoms, hiatal hernia size, and number of reflux events (P < .01). Group A had the greatest hiatal hernia size (3.1 ± 1.0 cm; P < .001) and reflux events (37.5 ± 51; P < .001), with frequent cough, laryngeal symptoms, heartburn, and regurgitation. Group B had the highest body mass index (28.2 ± 4.6 kg/m2; P < .001) and salivary pepsin (150 ± 157 ng/mL; P = .03), with frequent cough, laryngeal symptoms, globus, heartburn, and regurgitation. Group C frequently reported laryngeal symptoms (93%; P < .001), and had fewest esophageal symptoms (9.6%; P < .001) and reflux events (10.7 ± 11.0; P < .001). Group D commonly reported cough (88%; P < .001) and heartburn. Group E (18%) was oldest (62.9 ± 14.3 years; P < .001) and distinguished by highest integrated relaxation pressure. CONCLUSIONS DAPC identified distinct clinicophysiologic phenotypes of patients with laryngeal symptoms referred for reflux evaluation: group A, LPR and gastroesophageal reflux disease (GERD) with hiatal hernia; group B, mild LPR/GERD; group C, no LPR/No GERD; group D, reflex cough; and group E, mixed/possible obstructive esophagogastric junction. Phenotypic differences may inform targeted clinical trials design and improve outcomes.
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Snow G, Dhar SI, Akst LM. How to Understand and Treat Laryngopharyngeal Reflux. Gastroenterol Clin North Am 2021; 50:871-884. [PMID: 34717876 DOI: 10.1016/j.gtc.2021.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Grace Snow
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Shumon I Dhar
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Lee M Akst
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA.
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Zhang J, Li J, Zhang Y, Nie Q, Zhang R, Wang X, Jiang X, Wu Y, Wu R, Bi X, Cui X, Song H, Ran T, Li L. Multitime point pepsin testing can double the rate of the diagnosis of laryngopharyngeal reflux. Laryngoscope Investig Otolaryngol 2021; 6:1389-1394. [PMID: 34938879 PMCID: PMC8665477 DOI: 10.1002/lio2.700] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Jinhong Zhang
- Department of OtolaryngologySchool of Medicine, South China University of TechnologyGuangzhouChina
- Department of OtolaryngologyThe Sixth Medical Center of PLA General Hospital of BeijingBeijingChina
| | - Jinrang Li
- Department of OtolaryngologySchool of Medicine, South China University of TechnologyGuangzhouChina
- Department of OtolaryngologyThe Sixth Medical Center of PLA General Hospital of BeijingBeijingChina
| | - Yanping Zhang
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Qian Nie
- Department of OtolaryngologyThe Sixth Medical Center of PLA General Hospital of BeijingBeijingChina
| | - Ran Zhang
- Department of OtolaryngologyThe Sixth Medical Center of PLA General Hospital of BeijingBeijingChina
| | - Xiaoyu Wang
- Department of OtolaryngologyThe Sixth Medical Center of PLA General Hospital of BeijingBeijingChina
| | - Xingwang Jiang
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Yingying Wu
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Runze Wu
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Xinxin Bi
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Xiaohuan Cui
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Hui Song
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Taotao Ran
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Lina Li
- Department of OtolaryngologyThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
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Sikavi DR, Cai JX, Carroll TL, Chan WW. Prevalence and clinical significance of esophageal motility disorders in patients with laryngopharyngeal reflux symptoms. J Gastroenterol Hepatol 2021; 36:2076-2082. [PMID: 33373479 DOI: 10.1111/jgh.15391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/12/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Esophageal motor dysfunction may underlie impaired bolus/refluxate clearance in laryngopharyngeal reflux (LPR). However, the prevalence of esophageal dysmotility and its correlation with reflux parameters and symptoms in LPR is not well established. The aim of this study was to evaluate the prevalence of coexisting esophageal dysmotility among patients with suspected LPR. METHODS This was a retrospective cohort study of 194 consecutive patients with LPR symptoms referred for high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing at a tertiary center in March 2018 to August 2019. Validated symptom surveys were prospectively collected at time of testing, including Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, dominant symptom intensity, and 12-Item Short-Form Health Survey. HRM findings were categorized using Chicago Classification v3.0. RESULTS Abnormal findings on HRM were identified in 84 (43.3%) patients, with ineffective esophageal motility (n = 60, 30.9%) as the most common diagnosis. A disorder of esophagogastric junction outflow or a major disorder of peristalsis was identified in 26 (13.4%) patients, including 2 (1%) with achalasia and 7 (3.6%) with jackhammer esophagus. Reflux burden (distal, proximal, or pharyngeal) on combined hypopharyngeal-esophageal multichannel intraluminal impedance and pH testing did not differ across HRM findings. Patients reporting esophageal symptoms were more likely to have a primary motility disorder (odds ratio 2.34, P = 0.04). However, no significant differences in Reflux Symptom Index, Gastroesophageal Reflux Disease Questionnaire, or 12-Item Short-Form Health Survey were noted across HRM diagnoses. CONCLUSION Esophageal motility disorders are prevalent among patients with LPR symptoms, including up to one in seven with esophagogastric junction outflow or major peristaltic disorder. Patients with abnormal motility more likely report esophageal symptoms. Clinicians should be aware of these coexisting conditions, particularly in those with refractory symptoms.
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Affiliation(s)
- Daniel R Sikavi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer X Cai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas L Carroll
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Dwyer CD, Leclerc AA, Schneider SL, Young VN, Rosen CA. Creation and Implementation of the UCSF Laryngeal Symptom Diary for Trial Vocal Fold Injection. J Voice 2020; 36:707-718. [PMID: 32873434 DOI: 10.1016/j.jvoice.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Patient recollection of their trial vocal fold injection outcomes is crucial in determining future treatment. This study aims to assess a new clinical tool, the UCSF Laryngeal Symptom Diary, for its ease of use, clinical value in patient symptom tracking, and utility for long-term decision-making following trial vocal fold injection. MATERIALS AND METHODS In this prospective cohort study, consecutive patients undergoing trial vocal fold injection between June 2019 and January 2020 completed the UCSF Laryngeal Symptom Diary. Patients rated standardized and customized laryngeal symptoms weekly. Upon follow-up, a survey pertaining to the diary was completed by both the patient and treating laryngologist. RESULTS A total of 29 patients opted to participate and were provided with the UCSF Laryngeal Symptom Diary. The diary was returned by 82.3% (n = 24/29) of patients. Mean time to follow up was 5.98 weeks. Survey participation rate was 93.1% (n = 27/29). From the patients' perspective, 66.7% (n = 18/27) found the diary useful in following their symptom evolution. Treating laryngeal surgeon noted excellent concordance between diary entries and patient's overall injection benefit (91.7%, n = 22/24). The diary was useful in clinician-recommendation of subsequent treatment options in 70.8% (n = 17/24) of patients. CONCLUSION The UCSF Laryngeal Symptom Diary is a patient friendly clinical tool for trial vocal fold injection that facilitates patient tracking of symptom evolution and helps guide treating clinicians in subsequent treatment planning.
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Affiliation(s)
- Christopher D Dwyer
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, UCSF Voice and Swallowing Center, University of California, San Francisco, San Francisco, California
| | - Andrée-Anne Leclerc
- Division of Otolaryngology-Head and Neck Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Sarah L Schneider
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, UCSF Voice and Swallowing Center, University of California, San Francisco, San Francisco, California
| | - VyVy N Young
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, UCSF Voice and Swallowing Center, University of California, San Francisco, San Francisco, California
| | - Clark A Rosen
- Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, UCSF Voice and Swallowing Center, University of California, San Francisco, San Francisco, California.
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Kavookjian H, Irwin T, Garnett JD, Kraft S. The Reflux Symptom Index and Symptom Overlap in Dysphonic Patients. Laryngoscope 2020; 130:2631-2636. [PMID: 32027383 DOI: 10.1002/lary.28506] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 12/23/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS The Reflux Symptom Index (RSI) is a validated quality-of-life instrument that quantifies symptoms associated with laryngopharyngeal reflux (LPR). Many dysphonic patients are managed empirically for reflux. In this study, we examine responses to the RSI in patients with dysphonia attributable to a variety of pathologies. STUDY DESIGN Retrospective cohort study. METHODS This is an institutional review board-approved study. All patients presented to a tertiary care voice center January 2011 to June 2016 with the chief complaint of dysphonia. Patients were analyzed by 1) diagnosis and 2) treatment modality: surgery, medicine, or voice therapy (VT). Data collected included pre- and postintervention RSI and Voice Handicap Index, demographic, and clinical information. Statistical analysis was performed using SPSS. RESULTS Five hundred forty-six dysphonic patients were included. One hundred forty required surgery, 155 were treated with VT alone, and 251 were medically managed (MM). Prior to therapy, 63.4% of surgery patients, 62.5% of VT patients, and 74.6% of MM patients had an abnormal RSI with a score greater than 13. The most common diagnosis for each group was vocal cord paresis/paralysis (surgery), vocal fold atrophy (VT), and LPR (MM). There was a statistically significant improvement in RSI after treatment for each group. CONCLUSIONS In patients with dysphonia, pretreatment RSI scores were elevated for a variety of laryngeal pathologies. Scores often improved with directed treatment, regardless of etiology. This highlights the symptom overlap between reflux and nonreflux causes of dysphonia, and the importance of a comprehensive workup for patients with voice complaints. LEVEL OF EVIDENCE 4 Laryngoscope, 130:2631-2636, 2020.
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Affiliation(s)
- Hannah Kavookjian
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Missouri, U.S.A
| | - Thomas Irwin
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Missouri, U.S.A
| | - James D Garnett
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Missouri, U.S.A
| | - Shannon Kraft
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Missouri, U.S.A
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10
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Borges LF, Chan WW, Carroll TL. Dual pH Probes Without Proximal Esophageal and Pharyngeal Impedance May Be Deficient in Diagnosing LPR. J Voice 2019; 33:697-703. [DOI: 10.1016/j.jvoice.2018.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/13/2018] [Indexed: 12/12/2022]
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12
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Gaviscon® Advance alone versus co-prescription of Gaviscon® Advance and proton pump inhibitors in the treatment of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol 2018; 275:2515-2521. [PMID: 30062580 DOI: 10.1007/s00405-018-5079-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/26/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Management of laryngopharyngeal reflux (LPR) typically comprises alginates and proton pump inhibitors (PPIs) alone or in combination, yet evidence to support any particular treatment regimen is lacking. We sought to evaluate the efficacy of Gaviscon® Advance alone versus co-prescription with a PPI in treating LPR. METHODS One hundred consecutive LPR patients with a reflux symptom index (RSI) score > 10 attending our joint voice clinic (JVC) were studied prospectively. All were treated with Gaviscon® Advance four times daily. If patients had been started on a PPI prior to their JVC attendance, this was optimised to a twice-daily dosing regimen and continued. RSI scores were recorded at first attendance and 3 months post-treatment via postal questionnaire. Scores were analysed using t tests and Levene's test for equality of variances. RESULTS Follow-up RSI scores were returned by 72 patients, 39 of whom were treated with Gaviscon® Advance only (group A) and 33 with Gaviscon® Advance + PPI (group B). Mean pre-treatment RSI scores were similar between groups [group A: 19.2, 95% confidence interval (CI) ± 2.4; group B: 21.3, 95% CI ± 3.2 (p = 0.65)]. No significant differences were observed with respect to 3-month post-treatment RSI scores [group A: 9.9, 95% CI ± 2.8; group B: 12.6, 95% CI ± 4.2 (p = 0.82)] and change in RSI scores [group A: 9.3, 95% CI ± 3.0; group B: 8.7, 95% CI ± 2.9 [p = 0.75]). CONCLUSIONS Gaviscon® Advance alone is effective in treating symptoms of LPR, while co-prescription with a high-dose PPI offers no additional benefit.
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Lechien JR, Huet K, Khalife M, Fourneau AF, Finck C, Delvaux V, Piccaluga M, Harmegnies B, Saussez S. Gender differences in the presentation of dysphonia related to laryngopharyngeal reflux disease: a case-control study. Eur Arch Otorhinolaryngol 2018; 275:1513-1524. [DOI: 10.1007/s00405-018-4951-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/22/2018] [Indexed: 12/31/2022]
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Carroll TL, Faudoa E, Van Doren M. Evaluation of a Shorter Follow-up Time to Capture Benefit of a Trial Vocal Fold Augmentation. J Voice 2018; 33:169-175. [PMID: 29373176 DOI: 10.1016/j.jvoice.2017.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Trial vocal fold injection (TVFI) is employed diagnostically for patients with subtle glottic insufficiency to explore potential for improvement. Clinical experience demonstrates the time to and length of peak benefit of the TVFI is variable. Previous studies collected data 4 weeks or more after TVFI. The aim of this study was to compare subjectively successful and unsuccessful TVFI patient groups. It is hypothesized that patients with subjectively reported success will also have significant improvements in Voice Handicap Index-10 (VHI-10), phase closure percentage, and aerodynamic measures 2 weeks after trial augmentation. METHODS/DESIGN Subjects with glottic insufficiency were included in this retrospective review if they underwent office-based, per-oral vocal fold injection augmentation specifically for trial purposes. Patients were divided into "successful" and "unsuccessful" groups based on their subjective experience during the 2-week post-TVFI period. VHI-10, subjective report, phase closure evaluation using frame-by-frame analysis, and aerodynamic data were collected pre- and 2 weeks post-TVFI. RESULTS Of the subjects, 15 of 23 (65%) reported a successful subjective improvement of their symptom, whereas 8 (35%) were unsuccessful (only partial improvement or no improvement). The number of subjects with an improvement in VHI-10 by 5 or more points was not significantly different between groups. The number of subjects that demonstrated complete, long phase closure was significantly higher in the successful group (P = 0.021). CONCLUSIONS The understanding of how to more precisely determine the success of TVFI remains incomplete. Subjective improvement of successful TVFI was captured with basic clinical questioning, yet the VHI-10 was unable to confidently demonstrate this reported success 2 weeks after TVFI.
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Affiliation(s)
- Thomas L Carroll
- Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Elizabeth Faudoa
- Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maxine Van Doren
- Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Litts JK, Fink DS, Clary MS. The effect of vocal fold augmentation on cough symptoms in the presence of glottic insufficiency. Laryngoscope 2017; 128:1316-1319. [DOI: 10.1002/lary.26914] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/24/2017] [Accepted: 08/19/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Juliana K. Litts
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAurora Colorado U.S.A
| | - Daniel S. Fink
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAurora Colorado U.S.A
| | - Matthew S. Clary
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAurora Colorado U.S.A
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16
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Carroll TL, Werner A, Nahikian K, Dezube A, Roth DF. Rethinking the laryngopharyngeal reflux treatment algorithm: Evaluating an alternate empiric dosing regimen and considering up-front, pH-impedance, and manometry testing to minimize cost in treating suspect laryngopharyngeal reflux disease. Laryngoscope 2017; 127 Suppl 6:S1-S13. [PMID: 28842999 DOI: 10.1002/lary.26806] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/22/2017] [Accepted: 06/27/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES/HYPOTHESIS Empiric proton pump inhibitor (PPI) trials for laryngopharyngeal reflux (LPR) are common. A majority of the patients respond to acid suppression. This work intends to evaluate once-daily, 40 mg omeprazole and once-nightly, 300 mg ranitidine (QD/QHS) dosing as an alternative regimen, and use this study's cohort to evaluate empiric regimens prescribed for LPR as compared to up-front testing with pH impedance multichannel intraluminal impedance (MII) with dual pH probes and high-resolution manometry (HRM) for potential cost minimization. STUDY DESIGN Retrospective cohort review and cost minimization study. METHODS A chart review identified patients diagnosed with LPR. All subjects were treated sequentially and outcomes recorded. Initial QD/QHS dosing increased after 3 months to BID if no improvement and ultimately prescribed MII and HRM if they failed BID dosing. Decision tree diagrams were constructed to determine costs of two empiric regimens and up-front MII and HRM. RESULTS Ninety-seven subjects met the criteria. Responders and nonresponders to empiric therapy were identified. Seventy-two subjects (74%) responded. Forty-eight (67% of responders and 49% of all) improved with QD/QHS dosing. Forty-nine (51%) subjects escalated to BID dosing. Twenty-four subjects (33% of responders and 25% of all) improved on BID therapy. Twenty-five subjects (26%) did not respond to acid suppression. Average weighted cost was $1,897.00 per patient for up-front testing, $3,033.00 for initial BID, and $3,366.00 for initial QD/QHS. CONCLUSIONS An alternate QD/QHS regimen improved the majority who presented with presumed LPR. Cost estimates demonstrate that the QD/QHS regimen was more expensive than the initial BID high-dose PPI for 6 months. Overall per-patient cost appears less with up-front MII and HRM. LEVEL OF EVIDENCE 4. Laryngoscope, 127:S1-S13, 2017.
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Affiliation(s)
- Thomas L Carroll
- Department of Surgery, Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | | | | | - Aaron Dezube
- Tufts Medical School, Boston, Massachusetts, U.S.A
| | - Douglas F Roth
- Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts, U.S.A
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17
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Lechien JR, Finck C, Huet K, Khalife M, Fourneau AF, Delvaux V, Piccaluga M, Harmegnies B, Saussez S. Impact of age on laryngopharyngeal reflux disease presentation: a multi-center prospective study. Eur Arch Otorhinolaryngol 2017; 274:3687-3696. [DOI: 10.1007/s00405-017-4671-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/08/2017] [Indexed: 01/18/2023]
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18
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Neto L, Meyer D. A Joyful Noise: The Vocal Health of Worship Leaders and Contemporary Christian Singers. J Voice 2017; 31:250.e17-250.e21. [DOI: 10.1016/j.jvoice.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/16/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022]
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19
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Francis DO, Patel DA, Sharda R, Hovis K, Sathe N, Penson DF, Feurer ID, McPheeters ML, Vaezi MF. Patient-Reported Outcome Measures Related to Laryngopharyngeal Reflux: A Systematic Review of Instrument Development and Validation. Otolaryngol Head Neck Surg 2016; 155:923-935. [PMID: 27554511 PMCID: PMC5639324 DOI: 10.1177/0194599816664330] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/22/2016] [Accepted: 07/25/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Patient-reported outcome (PRO) measures are often used to diagnose laryngopharyngeal reflux (LPR) and monitor treatment outcomes in clinical and research settings. The present systematic review was designed to identify currently available LPR-related PRO measures and to evaluate each measure's instrument development, validation, and applicability. DATA SOURCES MEDLINE via PubMed interface, CINAHL, and Health and Psychosocial Instrument databases were searched with relevant vocabulary and key terms related to PRO measures and LPR. REVIEW METHODS Three investigators independently performed abstract review and full text review, applying a previously developed checklist to critically assess measurement properties of each study meeting inclusion criteria. RESULTS Of 4947 studies reviewed, 7 LPR-related PRO measures (publication years, 1991-2010) met criteria for extraction and analysis. Two focused on globus and throat symptoms. Remaining measures were designed to assess LPR symptoms and monitor treatment outcomes in patients. None met all checklist criteria. Only 2 of 7 used patient input to devise item content, and 2 of 7 assessed responsiveness to change. Thematic deficiencies in current LPR-related measures are inadequately demonstrated: content validity, construct validity, plan for interpretation, and literacy level assessment. CONCLUSION Laryngopharyngeal reflux is often diagnosed according to symptoms. Currently available LPR-related PRO measures used to symptomatically identify suspected LPR patients have disparate developmental rigor and important methodological deficiencies. Care should be exercised to understand the measurement characteristics and contextual relevance before applying these PRO measures for clinical, research, or quality initiatives.
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Affiliation(s)
- David O Francis
- Department of Otolaryngology, Bill Wilkerson Center, Nashville, Tennessee, USA
- Center for Surgical Quality and Outcomes Research, Nashville, Tennessee, USA
- Vanderbilt Evidence-Based Practice Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhyanesh A Patel
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rohit Sharda
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kristen Hovis
- Department of Otolaryngology, Bill Wilkerson Center, Nashville, Tennessee, USA
| | - Nila Sathe
- Vanderbilt Evidence-Based Practice Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David F Penson
- Center for Surgical Quality and Outcomes Research, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research and Education Coordination Center, Veteran's Administration Tennessee Valley Health System, Nashville, Tennessee, USA
| | - Irene D Feurer
- Center for Surgical Quality and Outcomes Research, Nashville, Tennessee, USA
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa L McPheeters
- Vanderbilt Evidence-Based Practice Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Population Health Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael F Vaezi
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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20
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Carroll TL, Nahikian K, Asban A, Wiener D. Nissen Fundoplication for Laryngopharyngeal Reflux After Patient Selection Using Dual pH, Full Column Impedance Testing. Ann Otol Rhinol Laryngol 2016; 125:722-8. [DOI: 10.1177/0003489416649974] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives: Prior studies demonstrate inconsistent diagnostic strategies for laryngopharyngeal reflux disease (LPR) patients who are offered laparoscopic Nissen fundoplication (Nissen). Superior symptom resolution outcomes are demonstrated in patients with accompanying typical gastroesophageal reflux (GERD) symptoms. This study aims to evaluate the efficacy of selecting patients with LPR complaints for Nissen using full column, dual pH impedance catheters (multichannel intraluminal impedance catheters [MII]). Methods: All patients who underwent Nissen for management of LPR symptoms refractory to at least 3 months of twice daily (BID) proton pump inhibitor (PPI) therapy with reflux symptom index (RSI) of 13 or higher and who had demonstrable reflux on MII were included. Pre- and (minimum) 16 week post-Nissen RSI scores as well as LPR-specific complaints were collected. Results: Eleven patients met criteria. Nine subjects (5 female, 4 male) had complete data. All 9 (100%) achieved improvement in RSI. The average pre-Nissen RSI was 31.7, and average post-Nissen RSI was 10 ( P < .001). Six (67%) subjects dropped below an RSI of 13. Seven subjects (78%) had resolution of their primary LPR symptom, and 6 (67%) subjects had resolution of all LPR symptoms. Conclusions: Patients with LPR who are selected using dual pH and full column impedance are likely to demonstrate improvement in RSI following Nissen.
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Affiliation(s)
| | - Kael Nahikian
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ammar Asban
- University of California San Francisco, California, USA
| | - Daniel Wiener
- Brigham and Women’s Hospital, Boston, Massachusetts, USA
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21
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Schneider GT, Vaezi MF, Francis DO. Reflux and Voice Disorders: Have We Established Causality? CURRENT OTORHINOLARYNGOLOGY REPORTS 2016; 4:157-167. [PMID: 28163985 DOI: 10.1007/s40136-016-0121-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A trend of attributing abnormal voice changes to reflux has gained momentum among medical professionals over the last few decades. Evidence supporting the connection between reflux and voice and the use of anti-reflux medication in patients with dysphonia is conflicting and deserves careful examination. In the current health care environment, it is important that medical decisions be based on science rather than anecdote and practice patterns. The goal of this review is to investigate the evidence linking reflux and voice changes. Specifically, this association will be examined in the context of the Bradford-Hill criteria to determine what evidence exists for a causal relationship between this exposure (reflux) and outcome (voice change).
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Affiliation(s)
- G Todd Schneider
- Vanderbilt Voice Center, Department of Otolaryngology, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David O Francis
- Vanderbilt Voice Center, Department of Otolaryngology, Bill Wilkerson Center, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Center for Population Sciences, and Evidence-based Practice Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
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22
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Francis DO, Vaezi MF. Should the Reflex Be Reflux? Throat Symptoms and Alternative Explanations. Clin Gastroenterol Hepatol 2015; 13:1560-6. [PMID: 25264272 DOI: 10.1016/j.cgh.2014.08.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/23/2014] [Indexed: 02/07/2023]
Abstract
Although laryngopharyngeal reflux, also known as extraesophageal reflux (EER), was codified more than 25 years ago, it has not been characterized fully. There is no sensitive and specific diagnostic test, and its symptoms often are nonspecific and overlap with those of other conditions commonly seen in primary care and specialist practices. Otolaryngologists have an important role in the evaluation and management of these patients--they must investigate persistent reflux-attributed symptoms by direct visualization of the upper airway and larynx, and, in some circumstances, the esophagus. It is of utmost importance to rule out the possibility of malignancy, which often presents with symptoms similar to those of EER. Once cancer is excluded, many benign upper airway conditions also can masquerade as, and often incorrectly are attributed to, EER. Although reflux is a potential etiologic factor for upper-airway symptoms, it is important not to reflexively blame reflux. We discuss other etiologies that should be considered carefully for persistent symptoms.
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Affiliation(s)
- David O Francis
- Vanderbilt Voice Center, Department of Otolaryngology, Bill Wilkerson Center, Center for Surgical Quality and Outcomes Research, Institute for Medicine and Public Health, Nashville, Tennessee.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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