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

Transoral Laser Microsurgery and Transoral Robotic Surgery in Aging Patients: A State-of-The-Art Review

Purpose

In the present study, the findings related to the epidemiology, clinical presentation, and therapeutic outcomes of elderly patients treated with transoral laser microsurgery (TOLM) and transoral robotic surgery (TORS) for supraglottic laryngeal squamous cell carcinoma (LSCC) have been reviewed.

Methods

A PubMed, Cochrane Library, and Scopus literature search was conducted according to the PRISMA statements. Critical literature analysis was carried out considering the last advancement in TOLS and TORS, and their related surgical, functional, and survival outcomes.

Findings

The mean age of patients with supraglottic LSCCs has progressively increased in the past decades. The data on postoperative complications in elderly patients with LSCC are heterogeneous and contradictory. The thought of the age-related high risk of complications was based on open supraglottic laryngectomy (SGL), but not on TOLM and TORS findings, which do not support an age-related increase of most postoperative complications. The only complication that could be associated with age is aspiration. The adequate selection of patients undergoing TOLM or TORS, and the pre- to postoperative evaluation of swallowing function can prevent this risk. The OS of elderly patients treated with TOLM or TORS SGL could be lower compared to younger patients. However, the disease-free survival was not influenced by age, highlighting the role of comorbidities and intercurrent diseases in the presumed lower survival. The survival analysis could definitively consider the physiological age rather than the chronological age to investigate the impact of age on survival outcomes.

Conclusion

The current literature supports an important place of TOLM and TORS in managing cT1-T3 supraglottic LSCC. The preoperative geriatric, nutritional, and swallowing evaluations are important for ensuring an adequate selection of patients treated with TORS or TOLM SGL.

Laryngopharyngeal Reflux in Patients Who Received or Declined Nissen Fundoplication

OBJECTIVE

To evaluate whether Robotic or Laparoscopic Nissen Fundoplication (LNF) improves voice outcomes and symptoms in patients with Laryngopharyngeal Reflux (LPR) compared to patients who were candidates for surgery but elected to receive treatment with antireflux medical management alone.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted of patients who visited the office of the senior author, received a diagnosis of LPR, and were candidates for LNF. Patients were categorized into two groups: those who received LNF surgery (Nissen-received, n = 50) and those who declined surgery (Nissen-declined, n = 54). Reflux Finding Scores (RFS) collected pre- and post-treatment were compared between groups. 24-hour pH-impedance results also were evaluated pre- and post-treatment.

RESULTS

24-hour pH-impedance testing from patients in the Nissen-received group showed a statistically significant decrease in six recording categories at the proximal sensor and five at the distal sensor, pre- to post-Nissen fundoplication. Proximal sensor categories included: (1) total reflux, (2) supine reflux, (3) acidic reflux, (4) weakly acidic reflux, (5) upright reflux, and (6) total postprandial reflux. Distal sensor categories included: (1) total reflux, (2) weakly acidic reflux, (3) supine reflux, (4) upright reflux, and (5) upright weakly acidic reflux. There were statistically significant differences in the changes from pre- to post-intervention when comparing between the Nissen-received and Nissen-declined groups at three proximal and three distal recordings. The proximal recording categories were (1) total reflux, (2) upright reflux, and (3) upright weakly acidic reflux, and the distal sensor categories were (1) upright reflux, (2) upright weakly acidic reflux, and (3) weakly acidic reflux. The Nissen-received group demonstrated statistically significant improvements in total RFS score, as well as the subcategory score of erythema, from pre- to post-Nissen fundoplication. There were statistically significant differences in the subcategory scores of erythema and diffuse laryngeal edema when comparing the changes from pre- to post-intervention between the Nissen-received and Nissen-declined groups.

CONCLUSION

LNF provides improved LPR control compared with treatment with antireflux medication alone.

Laryngopharyngeal Reflux Pathophysiology, Clinical Presentation, and Management: A Narrative Review

Laryngopharyngeal reflux (LPR) is a common and often misinterpreted clinical entity responsible for various symptoms affecting the upper aerodigestive tract. This narrative literature review aims to review the pathophysiology, symptoms, and management of LPR, emphasizing the emerging understanding of gastric content reflux in aerodigestive tissue irritation. Understanding the pathophysiology of LPR will allow general practitioners and specialists to accurately recognize and treat a condition that causes substantial morbidity in the affected patients. Using evidence-based findings from randomized controlled trials, clinical studies, and meta-analyses, the present investigation aims to outline and unify previous research into LPR. A review of anatomical structures, pathogenic mechanisms, endoscopic findings in LPR, and clinical manifestations and treatment options are also discussed. Though controversy around the diagnosis and management of LPR persists, emerging research in cellular damage and diagnostic tools promises to provide increasingly accurate and reliable modalities for characterizing LPR. Hopefully, future research will unify the field and provide overarching guidelines for both primary care and specialists. The present investigation provides an integrated perspective on LPR, a clinically prevalent and complex disease.

Characterization of Laryngopharyngeal Reflux in the Elderly Population

INTRODUCTION

Laryngopharyngeal reflux (LPR) often is not diagnosed due to its presentation without heartburn. The aim of this study was to analyze the signs and symptoms of elderly patients undergoing treatment for LPR using subjective as well as objective measures including strobovideolaryngoscopies, 24-hour pH studies, and manometry to highlight appropriate considerations for diagnosis and treatment.

METHODS

This was a retrospective review of patients with laryngopharyngeal reflux who were seen from January 2010 to February 2021 in the practice of the senior author (Robert T. Sataloff) who had undergone 24-hour pH testing, and for whom all data were available. Patients aged 60 years and older were considered elderly and compared to patients younger than 40 and between the ages of 40 and 59. However, patients in their 60s, 70s, and 80s were evaluated and compared separately. Objective reflux findings, 24-hour pH studies, and manometry were compared between groups.

RESULTS

Two hundred and eighty-eight patients being treated for LPR were included, 100 of whom were over the age of 60. While 94.1% of patients younger than 40 had a chief complaint of hoarseness, 71% percent of those aged 60 and older complained of hoarseness. Patients aged 60 and older were more likely to present with no voice complaint as their age increased (P = 0.001). Lower esophageal sphincter residual pressure was 12.15 ± 6.28 in elderly patients compared to 4.90 ± 3.38 in patients younger than 40 (P < 0.001). Upper esophageal sphincter (UES) basal pressure was decreased in elderly patients at 83.84 ± 50.53 compared to 105.92 ± 51.49 in patients younger than 60 or younger (P = 0.029). Older patients in their 70s and 80s also had lower UES basal pressures at 75.79 ± 47.66 and 63.45 ± 14.50 (P = 0.003). Additionally, while 71.4% of patients younger than 40 had normal esophageal motility (Chicago classification v4), only 40% of elderly patients had normal esophageal motility (P < 0.001). More severe ventricular obliteration also was present in elderly patients compared to non-elderly patients (P = 0.032), and thick endolaryngeal mucus was less likely to be present in elderly patients (P = 0.007). Reflux finding score differed between age groups with patients aged less than 40 scoring 14.78 ± 2.5, 40-59 year olds scoring 15.83 ± 2.13 and patients 60 and older scoring 15.48 ± 2.43 (P = 0.018).

CONCLUSION

Elderly patients diagnosed with LPR have different presentations of the disease compared with younger patients.

A combined treatment for patients with dry eye and associated laryngopharyngeal reflux: a real-life approach

AIM

To evaluate the efficacy and tolerability of administering a combined therapy in patients with dry eye syndrome (DES) and associated laryngopharyngeal reflux (LPR).

METHODS

The study was retrospective, open, observational, and conducted in a real-life setting. Patients had pathological symptom assessment in dry eye (SANDE) and reflux symptom index (RSI) at baseline. Patients were re-assessed after 1mo and at the end of treatment. The treatment consisted of a three-month course based on the combined therapy: Gastroftal eye drops, one drop three times a day, and Gastroftal tablets, two tablets after lunch and two tablets after dinner. Tear break-up-time (TBUT) test, Schirmer test, RSI, and SANDE questionnaire were evaluated.

RESULTS

The study included 253 patients. The mean age was 58±11.19y. TBUT test score and Schirmer's test significantly increased (both P<0.001) after 1mo and at the end of treatment. The RSI score and SANDE scores significantly decreased (both P<0.001) after 1mo and at the end of treatment.

CONCLUSION

The current, retrospective, and open study shows that combined therapy using Gastroftal eye drops and tablets could represent a valuable option in managing patients with DES associated with LPR.

Reliability and Validity of the Chinese Version of Reflux Symptom Score

OBJECTIVE

To evaluate the reliability, validity and clinical value of the Chinese version of reflux symptom score (RSS) (RSS in Chinese).

METHODS

This was a prospective study that contained 42 healthy volunteers and 135 possible laryngopharyngeal reflux disease (LPRD) patients. Reflux symptom index, reflux finding score, oropharyngeal pH monitoring (Dx-pH monitoring), and RSS of each patient were performed. RSS was performed again after 1 week. Confirmed LPRD patients were treated with proton pump inhibitor (PPI) for 8 weeks. And RSS was performed again after treatment. The reliability and validity of RSS was evaluated.

RESULTS

The Cronbach's α coefficient of the Chinese version of RSS was 0.772, which indicated good internal reliability. The results of test-retest found all P values were less than 0.05, which supported good external reliability. The comparison of the results of RSS with oropharyngeal pH monitoring discovered a diagnostic coincidence rate of 83.70% and a positive predictive value of 84.96%, which showed good criterion validity. After 8 weeks treatment of PPI, RSS decreased significantly (pretreatment 84.79 ± 42.50，post-treatment 20.11 ± 22.82, P < 0.001), indicating good responsiveness to change of RSS. The score of quality of life impact of suspected LPRD patients was obviously higher than that of healthy volunteers (t = 7.153, P < 0.001). All patients and volunteers agreed that RSS in Chinese can evaluate their symptoms well.

CONCLUSION

RSS in Chinese had good internal and external reliability, good criterion validity and good responsiveness to change. The content and method of evaluation of RSS in Chinese was better and more comprehensive. RSS in Chinese could be a new instrument to evaluate LPRD in China.

Current Treatment of Laryngopharyngeal Reflux

Objectives: Laryngopharyngeal reflux (LPR) is a complex syndrome characterized by the reflux of gastroduodenal contents into the pharynx or larynx, resulting in a range of symptoms, including chronic cough, throat clearing, pain, dysphagia, hoarseness, and dysphonia. Despite the lack of a gold standard for diagnosis or treatment, various strategies have been proposed to manage LPR. However, the effectiveness of these treatments is compromised by the lack of a uniform treatment protocol, which places a burden on patients, physicians, and the healthcare system. This study aims to systematically review the treatments of LPR and provide updated and useful clinical information to clinical physicians. Methods: The literature with an emphasis on LPR and related keywords is searched and reviewed in PubMed. Results: Treatment of LPR includes health education, lifestyle modification, dietary changes, medications, and surgery, as well as the emergence of a novel treatment method involving external upper esophageal sphincter compression devices. Conclusions: Currently, medication is the main treatment, supplemented with lifestyle and dietary changes, but there is still a lack of effective means for patients with drug-resistant or intolerant LPR. More high-quality and rigorous trials must continue to be conducted to determine the best treatment options and find novel treatments. Taking into account the complexity of LPR, this study proposes a simple algorithm to help clinicians with the initial management of this disease.