Evaluation of gastroesophageal reflux in patients with laryngotracheal stenosis

Involvement of Laryngopharyngeal Reflux in Select Nonfunctional Laryngeal Diseases: A Systematic Review

Objectives

To investigate the existing published evidence supporting the role of laryngopharyngeal reflux (LPR) in the development of the select nonfunctional laryngeal diseases of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections

Data Sources

PubMed, Cochrane Library, and Scopus.

Review Methods

A systematic review was performed by 3 independent investigators for studies providing information about the prevalence and role of LPR in the development of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed with PRISMA criteria.

Results

Of the 64 relevant publications, 27 clinical and 4 basic science studies were included. Ten studies used objective reliable examinations for LPR diagnosis (eg, dual- or triple-probe or oropharyngeal pH monitoring, multichannel intraluminal impedance–pH monitoring, or pepsin detection). According to the bias analysis and the results of studies, the association between LPR and laryngotracheal stenosis, leukoplakia, laryngeal papillomatosis, or vocal fold granuloma remains poorly demonstrated. There is a notable heterogeneity among included studies regarding their inclusion criteria, diagnostic methods, and clinical outcome evaluation. Although some experimental findings support the involvement of bile salts and other gastroduodenal proteins active in alkaline pH, no included clinical studies assessed the role of nonacid and mixed reflux through multichannel intraluminal impedance–pH monitoring.

Conclusion

The involvement of LPR in the development of leukoplakia, laryngotracheal stenosis, vocal fold granuloma, and laryngeal papillomatosis is currently not demonstrated. The potential relationship between LPR and these select nonfunctional laryngeal diseases must be confirmed through future clinical and experimental studies considering acid, nonacid, and mixed LPR.

Management of Laryngopharyngeal Reflux in Asia

OBJECTIVES

This study was conducted to investigate the current practices of Asian otolaryngologists for laryngopharyngeal reflux (LPR).

METHODS

An online survey about LPR was sent to 2,000 members of Asian otolaryngological societies, and a subgroup analysis was performed between Western and Eastern Asian otolaryngologists. The survey was conducted by the Laryngopharyngeal Reflux Study Group of Young Otolaryngologists of the International Federation of Oto-rhino-laryngological Societies.

RESULTS

Among approximately 1,600 Asian otolaryngologists, 146 completed the survey (62 from Western Asian countries, 84 from Eastern Asian countries). A substantial majority (73.3%) of the otolaryngologists considered LPR and gastroesophageal reflux disease to be different diseases. The symptoms thought to be closely related to LPR were coughing after lying down, throat clearing, and globus sensation. The findings thought to be closely related to LPR were posterior commissure granulations and hypertrophy, arytenoids, and laryngeal erythema. The respondents indicated that they mostly diagnosed LPR (70%) after an empirical therapeutic trial of proton pump inhibitors (PPIs). Although multichannel intraluminal impedance-pH (MII-pH) monitoring is a useful tool for diagnosing nonacid or mixed LPR, 78% of Asian otolaryngologists never or very rarely used MII-pH. Eastern Asian otolaryngologists more frequently used once-daily PPIs (64.3% vs. 45.2%, P=0.021), whereas Western Asian otolaryngologists preferred to use twice-daily PPIs (58.1% vs. 39.3%, P=0.025). The poor dietary habits of patients were considered to be the main reason for therapeutic failure by Asian otolaryngologists (53.8%). Only 48.6% of Asian otolaryngologists considered themselves to be adequately knowledgeable and skilled regarding LPR.

CONCLUSION

Significant differences exist between Western and Eastern Asian otolaryngologists in the diagnosis and treatment of LPR. Future consensus statements are needed to establish diagnostic criteria and therapeutic regimens.

Duodenogastroesophageal reflux and its effect on extraesophageal tissues: A review

We conducted a literature review to identify elements of duodenogastroesophageal reflux (DGER)—namely pancreatic fluids, hydrochloric acid, pepsin, and bile—as to the effects each has when refluxed to the extraesophageal structures. Further, we wished to acquaint clinicians with the possibilities that, in addition to hydrochloric acid, the other components of DGER are likewise contributing to disease in the extraesophageal areas. Our review included studies that have indicated reflux of the above mentioned components of DGER to the pharynx, larynx, tracheobronchial tree, oral cavity, nasopharynx, nose and sinuses, eustachian tube, and middle ear. Findings demonstrate that injury to the upper aerodigestive tract can occur from a variety of substances secreted from the stomach and duodenum. Treatment for DGER is nonspecific. We conclude that patients with an incomplete response to acid suppression may have significant involvement of pepsin, bile, or both. Future studies are needed to clarify the importance of these elements and to suggest more precise treatments.

Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux

OBJECTIVES

To investigate the current trends in management of laryngopharyngeal reflux (LPR) among young European otolaryngologists and general practitioners (GP).

METHODS

An international survey was sent to European general practitioners and all otolaryngologists under 45 years old from the 2017 IFOS meeting. This survey was conducted by the LPR Study Group of YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies).

RESULTS

Among the 2500 attendees, 230 European otolaryngologists (response rate = 9%) completed the survey; an additional 70 GPs also completed the survey. GPs did not differentiate between gastroeosophageal reflux disease (GERD) and LPR, overstating GERD-related symptoms (ie, heartburn and regurgitations) in LPR clinical presentation and relying on gastrointestinal endoscopy for LPR diagnosis. Otolaryngologists also believe that GERD-related symptoms are prevalent in LPR. Knowledge of nonacid and mixed LPR and use of multichannel intraluminal impedance-pH monitoring are still limited in both groups. A therapeutic dichotomy exists between groups: GPs mainly use a 4-week once daily empiric proton pump inhibitors (PPIs) trial, while otolaryngologists use PPIs twice daily for a longer therapeutic period ranging from 8 to 12 weeks. More than 50% of GPs and otolaryngologists believe that they are not adequately knowledgeable and skilled about LPR.

CONCLUSION

The majority of GPs and otolaryngologists do not believe themselves to be sufficiently informed about LPR, leading to different practice patterns and grey areas. The elaboration of international recommendations in the management of reflux is needed to improve practices.

Pharyngeal pH Probe Findings in Patients with Postnasal Drainage

Background

Patients commonly present with complaints of postnasal drainage (PND). This study reports the pharyngeal pH probe findings in patients without rhinitis/rhinosinusitis who present with complaints of PND.

Methods

This is a prospective study of patients presenting with PND but no historical or endoscopic evidence of rhinitis/rhinosinusitis. Twenty-four-hour pharyngeal pH probe studies were done on 32 consecutive patients and compared with historical controls.

Results

There were a total of 32 patients with PND (mean age, 54 years) and 51 controls (mean age, 49 years). The proportion of patients with positive pH probe studies was higher in PND (28.1%) versus controls (17.6%) but did not reach statistical significance (p = 0.27). However, when comparing the mean number of pharyngeal acid exposure events, patients with PND had significantly more events (1.6) than controls (0.3; p < 0.002). In addition, the mean acid exposure time was significantly higher in PND (0.18%) versus controls (0.01%; p < 0.004).

Conclusion

The proportion of patients with PND displaying positive pharyngeal 24 pH probe studies is not significantly greater than controls. However, patients with PND do exhibit a statistically greater degree of pharyngeal acid exposure as compared with controls. Additional research is required to delineate the role of pharyngeal reflux in patients with PND.

Risk Factors for Adult Laryngotracheal Stenosis: A Review of 74 Cases

Objectives:

We sought to identify risk factors for and review our experience in the management of adult acquired laryngotracheal stenosis (LTS) at an academic urban medical center.

Methods:

A retrospective review of all patients given a diagnosis of acquired LTS between 1997 and 2005 was performed. Seventy-four patients with LTS were identified. Demographic information, medical and surgical history, surgical procedures performed, and outcomes were collected. A control group of 106 patients admitted over the same time period with respiratory distress but without LTS was identified. The data collected for both groups were analyzed by Fisher's exact test and logistic regression analysis.

Results:

Demographically, the control group was not significantly different from the LTS group. Patients who had a previous tracheostomy were 10.99 times more likely to develop LTS than control patients (95% confidence interval [CI], 4.68 to 25.80). Patients irradiated for carcinomas of the oropharynx and larynx were 5.95 times more likely to develop LTS than control patients (95% CI, 1.87 to 18.91). Those previously intubated for more than 48 hours were 3.91 times more likely to develop LTS than control patients (95% CI, 1.91 to 8.02). Finally, patients who were intubated for any non-airway surgery were found to be 2.07 times more likely to develop LTS (95% CI, 1.09 to 3.93).

Conclusions:

Prolonged intubation, tracheostomy, previous non-airway surgery, and irradiation for oropharyngeal and laryngeal tumors are risk factors for LTS. Multiple surgical procedures are often required for treatment. Mitomycin C did not significantly improve decannulation rates.

Synchronous airway lesions in children: an analysis of characteristics and comorbidities

OBJECTIVES

To analyze the characteristics and the associated medical co-morbidities in children with synchronous airway lesions (SALs) found during rigid bronchoscopy.

METHODS

Retrospective case series and chart review of patients who were found to have more than one airway lesion after undergoing airway evaluation via rigid endoscopy at a tertiary care pediatric hospital between 2001 and 2011. Patient demographics, presence of associated non-airway pathologies, and the number and types of airway lesions were collected. For analysis, airway lesions were classified based on the anatomical subsites involved (supraglottic, glottic, subglottic, tracheal and bronchial).

RESULTS

Out of 592 rigid bronchoscopies performed, there were 73 cases with SALs (12.3%). Of these, only 20% of patients were term infants without associated congenital anomalies. Over 70% of patients with SALs have combinations of lesions involving the trachea, subglottis and supraglottis. Neurological anomalies and GERD were both independently associated with a three-time increase in the odds of having synchronous involvement of these three anatomical subsites (OR 3.15, 95% CI 1.06-9.41; OR 3.0, 95% CI 1.05-8.50, respectively). Glottic lesions were present in 28.7% of patients. Prematurity and cardiac anomalies were both associated with tendency of doubling the odds of glottic lesions (OR 2.34, 95% CI 0.84-6.52; OR 2.0, 95% CI 0.76-5.60, respectively). Overall, almost 10% of newly diagnosed lesions in context of SALs required an additional intervention.

CONCLUSIONS

The majority of patients with SALs are either born prematurely or have associated congenital anomalies. In SAL patients with associated neurological anomalies or GERD, the lesions are more likely to be localized to the supraglottis, subglottis and trachea whereas prematurity and cardiac anomalies could both be increasing the odds of a glottic lesion. High suspicious index should be kept in mind when rigid bronchoscopy is performed to not miss an associated lesion.

Non-malignant central airway obstruction

The most common causes of non-malignant central airway obstruction are post-intubation and post-tracheostomytracheal stenosis, followed by the presence of foreign bodies, benign endobronchial tumours and tracheobronchomalacia. Other causes, such as infectious processes or systemic diseases, are less frequent. Despite the existence of numerous classification systems, a consensus has not been reached on the use of any one of them in particular. A better understanding of the pathophysiology of this entity has allowed us to improve diagnosis and treatment. For the correct diagnosis of nonspecific clinical symptoms, pulmonary function tests, radiological studies and, more importantly, bronchoscopy must be performed. Treatment must be multidisciplinary and tailored to each patient, and will require surgery or endoscopic intervention using thermoablative and mechanical techniques.

Respiratory manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is highly associated with a range of respiratory symptoms, arising from a variety of etiologies. The following commentaries on respiratory manifestations of GERD address evidence for a role of a vagally mediated bronchoconstriction reflex in the development of asthma; the direct effects of airway obstruction on lower esophageal sphincter (LES) pressure and reflux episodes; the mechanisms by which reflux may play roles in chronic cough and airway stenosis; the limited efficacy of laparoscopic antireflux surgery (LARS) in improving GERD-related respiratory symptoms; the search for a marker for microaspiration and reflux-induced airway disease; and the potential of proton pump inhibitor (PPI) treatment for patients presenting with asthma and GERD.

The "forgotten zone": acquired disorders of the trachea in adults

The upper airway is generally defined as the air passage segment that extends between the naso- or oropharynx and the carina. The longest segment of the upper airway—the trachea—begins at the inferior portion of the larynx and extends to the branch point of the main carina. The trachea has the potential to be a “forgotten zone” in differential diagnoses, as pathological processes involving this portion may not receive prominent clinical consideration in disorders presenting with respiratory symptoms and signs. Unlike the oropharynx, this anatomical area is beyond visualization on routine inspection; unlike the mediastinum and lung fields, it is a potential “blind spot” on initial, plain radiographic examination of the chest. Nonetheless, the adult trachea is affected by a number of primary disorders and is also a target organ of a variety of systemic diseases. This review will focus on both primary and systemic diseases involving the adult trachea with specific attention to their clinical manifestations and diagnostic hallmarks.

Endoscopic management of idiopathic tracheal stenosis

BACKGROUND

Idiopathic tracheal stenosis (ITS) is a rare condition representing a difficult therapeutic challenge. Endoscopic management is a therapeutic option but long-term results are not established. The aim of this retrospective multicenter study was to analyze long-term outcome after endoscopic management of ITS.

METHODS

Nine institutions involved in interventional bronchoscopy were contacted and asked to identify ITS endoscopically treated. A standard form was used to report the main characteristics and long-term outcome after endoscopic management.

RESULTS

Twenty-three patients, 96% women, aged 45±16 years, were endoscopically treated for ITS. Time between first symptoms and diagnosis was 19±18 months. Bronchoscopy showed a weblike (61%) or complex (39%) stenosis, located in the upper part of the trachea, mainly in the cricoid area. Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient. The follow-up after endoscopic management was 41±34 months. The ITS recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14±16 months. The treatment of recurrence (n=13) included endoscopic management in 12 cases.

CONCLUSIONS

Endoscopic management of ITS provides a safe and efficient therapeutic option but late recurrences are frequent and require long-term follow-up.

Flexible laryngoscopy-guided pharyngeal pH monitoring in infants

OBJECTIVE

To evaluate flexible laryngoscopy-guided pharyngeal pH probe monitoring as an alternative accurate and practical pharyngeal pH probe placement technique to eliminate the need for radiographs and esophageal manometry for pharyngeal pH monitoring in infants with extraesophageal reflux disease (EERD).

MATERIALS AND METHODS

Infants with suspected laryngopharyngeal acid reflux (LPR) who underwent pharyngoesophageal pH monitoring were included. Data analysis included description of the flexible laryngoscopy-guided pharyngoesophageal pH monitoring technique and pharyngoesophageal pH monitoring findings, including the number of acid reflux episodes and percent acid exposure time.

RESULTS

Six infants (3 boys, 3 girls, age range, 2 wk-7.5 mo) with suspected LPR underwent pharyngoesophageal pH monitoring. Flexible laryngoscopy was used, under direct vision, to guide pH probe placement in the laryngopharyngeal region. The esophageal pH probe was located 5 cm distal to the pharyngeal pH probe. All infants tolerated the procedure. Of the six infants, four had pharyngeal acid reflux, and six had esophageal acid reflux. The number of acid reflux episodes ranged from 4 to 81 in the pharynx and from 5 to 173 in the esophagus. The percentage of acid exposure time was between 0% and 1.2% in the pharynx and between 0.1% and 1.5% in the esophagus.

CONCLUSION

With the aid of flexible laryngoscopy, a pH probe can be placed in the laryngopharyngeal region in infants undergoing pharyngeal pH monitoring. Findings documented that not all esophageal acid reflux reach the pharynx. Flexible laryngoscopy-guided pharyngeal pH probe placement can be used to detect LPR in infants with EERD.

Perceptual voice analysis of patients with subglottic stenosis

OBJECTIVES

To characterize the perceptual assessment of vocal quality in subglottic stenosis (SGS) patients and to identify risk factors for dysphonia.

STUDY DESIGN AND SETTING

Retrospective review, academic center.

METHODS

Perceptual voice assessment using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain); patient characteristics determined for 31 SGS cases.

RESULTS

The mean GRBAS (0 to 3 scale, 0 = normal quality) for SGS patients at their initial visit was G(1.4)R(1.2)B(0.5)A(0.5)S(1.1). For males vs females: G(2.1 vs 1.1)R(2.0 vs 0.8)B(1.0 vs 0.4)A(1.0 vs 0.3)S(1.7 vs 0.9). The Grade (P < 0.03), Breathiness (P < 0.04), and Asthenia (P < 0.02) assessments were significantly more dysphonic in patients with multilevel stenosis; vocal fold motion impairment (VFMI) also impacted overall Grade (P < 0.01). Overall Grade (P < 0.002), Roughness (P < 0.007), and Breathiness (P < 0.006) were significantly worse in patients with prior airway surgery.

CONCLUSION

SGS patients demonstrate a mild to moderate change in perceptual voice characteristics with males in this series being more affected than females. Negative risk factors include multiple stenoses, VFMI, and previous airway surgery.

SIGNIFICANCE

This is the first systematic report of perceptual voice assessment in subglottic stenosis. SGS patients have notable degrees of dysphonia with identifiable risk factors.

Prevalence of gastroesophagopharyngeal acid reflux events: an evidence-based systematic review

OBJECTIVES

To identify variables contributing to discrepant gastroesophagopharyngeal acid reflux (GEPR) findings and to critically assess the prevalence of GEPR in healthy individuals and patients with reflux laryngitis (RL).

STUDY DESIGN

Quantitative systematic review.

METHODS

Pharyngeal pH monitoring studies of healthy individuals and patients with RL were identified through a MEDLINE search of publications between 1966 and 2003. Pooled results of the measured pharyngeal acid exposure characteristics and the prevalence of GEPR events were analyzed. Statistical comparisons were performed using a chi 2 test.

RESULTS

The study included 181 controls and 184 RL patients. Subjects' age ranged from 19 to 85 years. Gastroesophagopharyngeal acid reflux events were detected at 1, 2, and 4 cm above upper esophageal sphincter (UES) and 0.5 cm below arytenoids, with varying rates. The prevalence of GEPR ranged from 0% to 83% in controls and 27% to 86% in RL. After excluding the healthy subjects with abnormal esophageal acid exposure, prevalence of GEPR decreased from 35% to 17% (P<or=.002). Gastroesophagopharyngeal acid reflux in RL was significantly more prevalent than in the entire group of controls as well as in controls without abnormal esophageal acid exposure (P<or=.001).

CONCLUSIONS

The prevalence of GEPR in controls and patients with RL varies in the studied 4 areas above the UES. The percentage of the subjects with GEPR increased as the probe was located more closely to the UES. Differences in demographic characteristics of the subjects, interventions used to select subjects, and pharyngeal pH monitoring techniques were identified as factors possibly contributing to inconsistent pharyngeal pH monitoring findings. The documented differences in methodology of existing studies make comparison of the studies difficult.

Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux

We report a meta-analysis of a series of studies in which 24-hour ambulatory pH monitoring was performed in 1) normal subjects, 2) the normal control subjects in studies of laryngopharyngeal reflux (LPR), and 3) the patients with LPR in these controlled studies. The statistical analysis utilized the fixed-effects model by Mantel-Haenszel and the random-effects mixed model. There were 16 studies from the past 12 years that fulfilled the inclusion criteria. They involved 793 subjects (264 normal and 529 with LPR). The numbers of positive pharyngeal reflux events for normal subjects and for patients with LPR differed with a p value of <.0001. There was also a significant difference in the mean percentage of acid exposure times between normal subjects and patients with LPR (p = .003). We conclude that the upper probe gives accurate and consistent information in normal subjects and patients with LPR. The numbers of reflux events and acid exposure times are most important in distinguishing normal subjects from patients with LPR. The technology and methodology of probe testing is quite reliable and is consistent on a worldwide basis.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux

Gastro-oesophageal reflux disease (GERD) has been associated with a variety of supra-oesophageal symptoms, including asthma, laryngitis, hoarseness, chronic cough, frequent throat clearing and globus pharyngeus. GERD may be overlooked as the underlying mechanism for these symptoms because typical GERD symptoms may be absent, despite abnormal oesophageal acid exposure. Two basic mechanisms linking GERD with laryngeal symptoms have been proposed: direct contact of gastric acid with the upper airway, in some cases due to micro-aspiration, and a vagovagal reflex triggered by acidification of the distal portion of the oesophagus. Gastro-oesophageal reflux (GER) during sleep is believed to be an important mechanism for the development of supra-oesophageal complications of GERD, such as asthma and idiopathic pulmonary fibrosis (IPF). Several physiological changes during sleep, including prolonged oesophageal acid contact time, decreased upper oesophageal sphincter pressure, increased gastric acid secretion, decreased salivation, decreased swallowing and a decrease in conscious perception of acid, render an individual more susceptible to reflux-induced injury. Supra-oesophageal symptoms often improve in response to aggressive acid-suppressive therapy. However, many unanswered questions remain regarding the appropriate approach to diagnosis and treatment of patients with GERD-related supra-oesophageal symptoms. In this article we review the relationship between supra-oesophageal symptoms and GERD and, where possible, highlight the evidence supporting the role of night-time reflux as a contributing factor to these symptoms.

Laryngopharyngeal Reflux: Trends in Diagnostic Interpretation Criteria

Laryngopharyngeal reflux (LPR) is becoming recognized as a clinical entity with a variety of presentations distinct from those of gastroesophreflux disease (GERD). However, much uncertainty remains as to what is considered pathologic versus physiologic reflux. The aim of the study was to determine the normal range of pharyngeal reflux (PR) occurring in healthy adults based on pH-monitoring parameters utilized in the DeMeester scoring system for GERD. We have reviewed the current pool of prospective literature examining ambulatory dual-channel pH-monitoring study data derived from hypopharyngeal proximal probes in normal adults. From our review we have identified trends in several monitoring parameters based on the DeMeester scoring system for GERD. Our discussion recognizes and accepts the limitations imposed by small sample sizes and the number of healthy individuals that would be required to determine the general adult physiologic range of PR. We also explore the possible need for separate normal PR reference intervals based on age or gender disparities. Additional discussion and the summary address future directions for LPR research notably, (1) identification of the most appropriate research paradigm for LPR (i.e., pH 4 vs. 5), (2) establishing reproducibility for the appropriate LPR research paradigm, and (3) complementary modalities to ambulatory dual-channel pH monitoring for the study of acid and nonacid bolus movement within the esophagus

Prevalence of extraesophageal reflux in patients with symptoms of gastroesophageal reflux

OBJECTIVES

To compare the prevalence of extraesophageal reflux (EER) in patients with heartburn, posterior laryngitis (PL), and in healthy controls. Study design and setting A retrospective and prospective study including a total of 101 subjects who underwent 24-hour dual-probe pH monitoring.

RESULTS

52% of the subjects with heartburn had EER. No significant differences were found between the PL and heartburn groups for any pharyngeal reflux parameters. However, supine pharyngeal reflux was significantly more prevalent in heartburn patients with GERD than in PL patients and healthy controls (P < 0.05). Significant positive correlation (P < 0.01) was found between the percentage of time pH <4 in the pharynx and in the distal esophagus.

CONCLUSION

EER occurs in the majority of heartburn patients who are lacking laryngeal symptoms. Abnormal distal esophageal acid exposure makes the occurrence of EER more likely.

SIGNIFICANCE

EER appears to be a continuum without clear-cut differences between the groups.

Fundoplication for laryngopharyngeal reflux disease

BACKGROUND

Laryngopharyngeal reflux (LPR) disease arises from the effects of refluxed gastric contents on the proximal aerodigestive tract. LPR patients are often lumped into the category of "atypical" reflux. LPR symptoms are hoarseness, globus, cough, and pharyngitis. Severe disease is associated with subglottic stenosis and laryngeal cancer. Treatment includes lifestyle modifications and medications. The role of fundoplication for LPR has yet to be defined.

STUDY DESIGN

Forty-one patients underwent fundoplication for LPR. They were prospectively followed with three outcomes measures: The Reflux Symptom Index, a laryngoscopic grading scale (Reflux Finding Score), and a reflux-based specific quality-of-life scale.

RESULTS

Average early followup was at 4 months and late followup was at 14 months. The Reflux Symptom Index improved by 5.4 early (p < 0.05) and 6.5 late (p < 0.05). Improvement between early and late periods approached significance (p < 0.09). Reflux Finding Score improved 3.8 (p < 0.05) early and 4.4 (p < 0.05) late. The Quality of Life Index improved 0.6 early and 2.3 (p < 0.05) late. By Reflux Symptom Index criteria, 26 patients were improved early versus 35 late (p < 0.05). Factors associated with poor outcomes were structural laryngeal changes in five patients (p < 0.05) and no response to proton pump inhibitors in six patients (p < 0.05).

CONCLUSIONS

Fundoplication augments treatment of LPR. Improvement of symptoms continues past the first 4 months. Laryngoscopy is critical in patient selection because selected findings are associated with outcomes, diagnosis, and management.

Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms

OBJECTIVE

To determine whether the presence of laryngopharyngeal reflux symptoms is associated with the presence of esophageal adenocarcinoma (EAC).

BACKGROUND

Most patients diagnosed with EAC have incurable disease at the time of detection. The majority of these patients are unaware of the presence of Barrett's esophagus prior to cancer diagnosis and many do not report typical symptoms of gastroesophageal reflux disease (GERD). This suggests that the current GERD symptom-based screening paradigm may be inadequate. Data support a causal relation between complicated GERD and laryngopharyngeal reflux symptoms. We theorize that laryngopharyngeal reflux symptoms are not recognized expeditiously, resulting in chronic esophageal injury and an unrecognized progression of Barrett's esophagus to EAC.

METHODS

This is a case-comparison (control) study. Cases were patients diagnosed with EAC (n = 63) between 1997 and 2002. Three comparison groups were selected: 1) Barrett's esophagus patients without dysplasia (n = 50), 2) GERD patients without Barrett's esophagus (n = 50), and 3) patients with no history of GERD symptoms or antisecretory medication use (n = 56). The risk factors evaluated included demographics, medical history, lifestyle variables, and laryngopharyngeal reflux symptoms. Typical GERD symptoms and antisecretory medication use were recorded. Multivariate analysis of demographics, comorbid risk factors, and symptoms was performed with logistic regression to provide odds ratios for the probability of EAC diagnosis.

RESULTS

The prevalence of patients with laryngopharyngeal reflux symptoms was significantly greater in the cases than comparison groups (P = 0.0005). The prevalence of laryngopharyngeal reflux symptoms increased as disease severity progressed from the non-GERD comparison group (19.6%) to GERD (26%), Barrett's esophagus (40%), and EAC patients (54%). Symptoms of GERD were less prevalent in cases (43%) when compared with Barrett's esophagus (66%) and GERD (86%) control groups (P < 0.001). Twenty-seven percent (17 of 63) of EAC patients never had GERD or laryngopharyngeal reflux symptoms. Fifty-seven percent of EAC patients presented without ever having typical GERD symptoms. Chronic cough, diabetes, and age emerged as independent risk factors for the development of EAC.

CONCLUSIONS

Symptoms of laryngopharyngeal reflux are more prevalent in patients with EAC than typical GERD symptoms and may represent the only sign of disease. Chronic cough is an independent risk factor associated with the presence of EAC. Addition of laryngopharyngeal reflux symptoms to the current Barrett's screening guidelines is warranted.

The endoscopic radiofrequency approach to management of GERD

PURPOSE OF REVIEW

Endoscopic treatment has been recently introduced as a new option for treating gastroesophageal reflux disease. In this article the authors review the radiofrequency approach known as the Stretta procedure, as more evidence has linked reflux to upper airway disease.

RECENT FINDINGS

Since 1968, when laryngeal disorders were linked to gastroesophageal reflux disease, more upper airway diseases such as chronic laryngitis, subglottic stenosis, and even laryngeal carcinoma were found to be occasionally caused by extraesophageal reflux. Most otolaryngologists treat these patients with proton pump inhibitors, which improve symptoms in two thirds of patients. Antireflux surgery remains the treatment of choice, relieving symptoms in more than 90% of patients. Endoscopic treatment has recently emerged as an option for treatment of gastroesophageal reflux disease. The Stretta procedure delivers radiofrequency energy to the gastroesophageal junction. This has proved to be effective in controlling reflux by inhibiting transient, inappropriate lower esophageal sphincter relaxation, increasing postprandial lower esophageal spincter pressure, and decreasing lower esophageal sphincter compliance. Stretta is among the earliest endoscopic technologies to be approved by the Food and Drug Administration for the treatment of reflux. It has the longest term follow-up published to this date, and the most durable effect. It is performed under intravenous sedation on an outpatient basis and has a low incidence of complications.

SUMMARY

The Stretta procedure is an endoscopic, noninvasive modality for the treatment of gastroesophageal reflux disease. It should be considered in the treatment of reflux-related upper airway diseases.

Gastroesophageal reflux and the upper airway

EER is a disorder commonly seen in otolaryngologic practice and differs from GERD in its clinical manifestations, pathophysiology, and response to treatment. Its association with numerous disorders in children should lead otolaryngologists to consider this diagnosis in all patients with voice, airway, and swallowing complaints.

Laryngopharyngeal reflux identified using a new catheter design: defining normal values and excluding artifacts

OBJECTIVE

To define normal values for laryngopharyngeal reflux using an improved catheter design with adjustable electrode placement for pH monitoring.

STUDY DESIGN

Cohort study of normal volunteers.

METHODS

The setting was an institutional-based gastroenterology practice. Subjects included 20 healthy volunteers with no history of laryngeal, pharyngeal, or reflux symptoms. These included 10 men and 10 women (mean age, 33 y; age range, 26-49 y). Ambulatory 24-hour triple-electrode monitoring of pH in distal esophagus, proximal esophagus, and pharynx using new bifurcated probe was performed. The distal electrode was placed 5 cm above the lower esophageal sphincter, with the proximal two electrodes straddling the upper sphincter. The main outcome measure was the number of true pharyngeal reflux episodes.

RESULTS

Sixteen of 20 subjects had no episodes, and 2 subjects had only one episode of pharyngeal reflux. The two subjects exceeding this value (8 and 15 episodes, respectively) had abnormal distal and proximal esophageal reflux. Artifacts for pharyngeal reflux due to acidic meals or "pseudoreflux" were excluded. Subject tolerance of this new probe was excellent.

CONCLUSION

The triple-electrode bifurcated adjustable pH probe provides a well-tolerated technique to identify true hypopharyngeal acid reflux episodes. When artifacts produced by meals and pseudoreflux are excluded, 90% of normal subjects show no episodes or a single episode over a 24-hour period.

Perspectives in laryngopharyngeal reflux: an international survey

OBJECTIVES

Although data exists to support the relationship between laryngopharyngeal reflux (LPR) and laryngitis, there is variability among otolaryngologists regarding the methods and criteria used to make the diagnosis. This study was undertaken to discern the current attitudes and practices of a select cohort of otolaryngologists in regards to LPR.

METHODS

Four hundred fifteen surveys were mailed to members of the American Broncho-Esophagological Association. Survey recipients were asked to rate patient symptomatology and physical examination findings in terms of their relationship to LPR and their preferred laryngeal visualization procedure in terms of clinical use and diagnostic accuracy. The role and validity of adjunctive diagnostic tests were also surveyed.

RESULTS

Survey response rate was 38%. Symptoms felt to be most related to reflux were: throat clearing (98.3%), persistent cough (96.6%), heartburn/dyspepsia (95.7%), globus sensation (94.9%), and voice quality change (94.9%). The physical examination findings felt to be most related to reflux included: arytenoid erythema (97.5%), vocal cord erythema (95.7%) and edema (95.7%), posterior commissure hypertrophy (94.9%), and arytenoid edema (94.0%). Fiberoptic laryngoscopy was the most commonly performed diagnostic visualization procedure (75.7%) and was also considered to be most sensitive and specific (45.0%). The most commonly ordered adjunctive test was a double pH probe (37.2%), which was also felt to be the most sensitive and specific adjunctive test (75.9%).

CONCLUSION

A polling of a select group of otolaryngologists demonstrated agreement in the criteria used to diagnose reflux laryngitis, although some variability exists. The development of objective guidelines for the diagnosis of LPR is a critical initial step toward evaluating the manifestations and therapeutic interventions for this disease process.

Outcomes of acid suppressive therapy in patients with posterior laryngitis

OBJECTIVE

To evaluate the results of acid suppressive therapy (AST) in posterior laryngitis (PL) patients with and without documented pharyngeal acid reflux (PAR).

METHODS

The charts of all patients with PL who received AST and who had undergone pharyngeal pH monitoring were reviewed. Results of AST in patients with PL with and without documented PAR were evaluated by laryngeal examination, symptom scores, and self-reported overall benefit.

RESULTS

Thirty-nine patients with PL had received AST and undergone pharyngeal pH monitoring. Follow-up ranged from 2 to 27 months. Laryngeal findings were improved in patients with and without PAR. Pretreatment total symptom scores were significantly greater than that of posttreatment in patients with and without documented PAR. Overall benefit from AST was reported by the majority of PL patients with and without documented PAR.

CONCLUSION

These findings support the use of AST to reduce or eliminate signs and symptoms in PL regardless of documentation of PAR.

Ambulatory pH monitoring methodology

Twenty-four-hour ambulatory double-probe pH monitoring is the current "gold standard" for the evaluation of gastroesophageal and extraesophageal reflux. The following article seeks to characterize some of the areas of controversy and describes the methodology of ambulatory pH monitoring used at the Center for Voice Disorders of Wake Forest University.

Laryngopharyngeal reflux: state of the art diagnosis and treatment

Gastroesophageal reflux has been implicated in the pathogenesis of a wide variety of otolaryngologic disorders. Patients with otolaryngologic disorders associated with gastroesophageal reflux infrequently have the classic symptoms of gastroesophageal reflux, such as heartburn. Clinical presentation of laryngopharyngeal reflux is commonly characterized by chronic intermittent symptoms. A meticulous synthesis of the information obtained from a complete otolaryngologic examination, diagnostic tests, and response to treatment is essential for the efficient management of patients with otolaryngologic disorders associated with laryngopharyngeal reflux.