Validity and Reliability of the Reflux Sign Assessment

Digestive Biomarkers of Laryngopharyngeal Reflux: A Preliminary Prospective Controlled Study

OBJECTIVE

To investigate the digestive enzymes and biomarkers in the saliva of patients with laryngopharyngeal reflux (LPR) and asymptomatic individuals.

STUDY DESIGN

Prospective controlled study.

SETTING

Multicenter study.

METHODS

Patients with LPR at the hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and asymptomatic individuals were consecutively recruited from January 2020 to April 2023 from 2 University Hospitals. The saliva of patients (off PPIs) and asymptomatic individuals was collected to measure pH, elastase, bile salts, cholesterol, gastric, and pancreatic lipases. Anxiety, symptoms, and findings were studied through perceived stress scale (PSS), reflux symptom score (RSS), and reflux sign assessment (RSA).

RESULTS

Sixty-seven LPR patients and 57 asymptomatic individuals completed the evaluations. LPR patients reported higher PSS, RSS, and RSA than asymptomatic individuals. The mean saliva pH was more alkaline in LPR patients (7.23: 95% confidence interval [CI]: 7.08, 7.38) compared to controls (6.13; 95% CI: 5.95, 6.31; P = .001). The mean concentration of elastase was higher in patients (51.65 µg/mL; 95% CI: 44.47, 58.83 µg/mL) versus asymptomatic individuals (25.18 µg/mL; 95% CI: 21.64, 28.72 µg/mL; P = .001). The saliva cholesterol reported higher concentration in healthy individuals (3.43 mg/dL; 95% CI: 3.21, 3.65 mg/dL) compared to patients (1.16 mg/dL; 95% CI: 1.05, 1.27 mg/dL; P = .001). The saliva pH, and elastase concentration were significantly associated with the baseline RSS, while saliva cholesterol was negatively associated with the severity of RSS and RSA.

CONCLUSION

Cholesterol, bile salts, and elastase are biomarkers of LPR and should be considered to develop future non-invasive saliva device for the detection of LPR.

Association Between Helicobacter pylori and Laryngopharyngeal Reflux Disease: A Systematic Review and Meta-Analysis

BACKGROUND

It is controversial that Helicobacter pylori (H pylori) is involved in the pathogenesis or development of laryngopharyngeal reflux disease (LPRD).

OBJECTIVE

To investigate the potential association between LPRD and H pylori infection.

MATERIAL AND METHODS

A systematic review was performed of studies assessing the diagnosis or treatment of LPRD among patients with H pylori infection. Data sources are PubMed/MEDLINE, EMBASE[Ovid], Cochrane Library, and Web of Science, and ClinicalTrials.gov.

RESULTS

Fifteen studies were analyzed in the review, with all eligible for the meta-analysis. A significant association between H pylori infection and LPRD was detected for higher rates of H pylori infection in patients with LPRD than in non-LPRD patients (relative risk (RR), 1.35; 95% CI, 1.12-1.63; P = 0.002), and H pylori-positive patients had a higher prevalence of LPRD than H pylori-negative patients (RR, 1.19; 95% CI, 1.07-1.31; P = 0.001). The prevalence of H pylori among patients with LPRD was 49% (95% CI, 36-61), the prevalence of H pylori among patients with non-LPRD was 35% (95% CI, 23-49).

CONCLUSION AND SIGNIFICANCE

The limited evidence indicated the association between LPRD risk and increased H pylori infection. Different population races, diagnostic approach to LPRD, variant H pylori testing methods, age and sex may contribute to the heterogeneity. Further well-designed studies regarding the efficacy of H pylori eradication in the treatment of LPRD are strongly recommended in the future.

Narrative review of relationship between chronic cough and laryngopharyngeal reflux

Gastroesophageal reflux disease (GERD) as a possible cause of chronic cough is known for decades. However, more than 75% of patients with extraoesophageal symptoms do not suffer from typical symptoms of GERD like pyrosis and regurgitations and have negative upper gastrointestinal endoscopy. For such a condition term laryngopharyngeal reflux (LPR) was introduced and is used for more than two decades. Since the comprehensive information on relationship between chronic cough and LPR is missing the aim of this paper is to summarize current knowledge based on review of published information during last 13 years. Laryngopharyngeal reflux is found in 20% of patients with chronic cough. The main and recognized diagnostic method for LPR is 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, revealing reflux episodes irritating the upper and lower respiratory tract mucosa. The treatment of LPR should be initiated with dietary and lifestyle measures, followed by proton pump inhibitor (PPI) therapy and other measures. Despite progress, more research is needed for accurate diagnosis and targeted therapies. Key areas for exploration include biomarkers for diagnosis, the impact of non-acid reflux on symptom development, and the efficacy of new drugs. Further studies with a focused population, excluding other causes like asthma, and using new diagnostic criteria for LPR are essential. It's crucial to consider LPR as a potential cause of unexplained chronic cough and to approach diagnosis and treatment with a multidisciplinary perspective.

Translation and validation of the Korean Version of the Reflux Symptom Score

OBJECTIVES

To assess the validity and reliability of the Korean version of the reflux symptom score (K-RSS).

MATERIALS AND METHODS

The English version of the RSS was translated into Korean and completed by 77 people (44 and 33 people in the patient group and control group, respectively). They completed the K-RSS (K-RSS-1) and reflux symptom index (RSI) questionnaires and answered questions about age, sex, underlying disease, smoking history, and alcohol and coffee consumption. They completed the K-RSS once more (K-RSS-2) after 1 - 2 weeks. Internal consistency was evaluated using Cronbach's α and test-retest reliability using the intraclass correlation coefficient (ICC). External validity was evaluated using the Spearman rank test between the RSI and K-RSS. The Mann-Whitney U test was used to assess internal validity by comparing the K-RSS-1 scores between the patient and control groups.

RESULTS

The most common symptoms were globus sensation, throat clearing, and throat pain. The K-RSS reported high internal consistency (α = 0.894). The ICC for the total score was 0.883, indicating excellent test-retest reliability. According to the Spearman analysis, there was a significant correlation between the total score of the K-RSS and that of the RSI (rs = 0.902; P < 0.001), demonstrating strong external validity. Furthermore, the patient group showed significantly higher values than the control group in all K-RSS scores, suggesting high internal validity.

CONCLUSION

The K-RSS is a patient-reported outcome questionnaire with excellent criterion-referenced validity and ideal reliability.

Diagnostic Value of Fasting and Bedtime Saliva Pepsin Measurements in Laryngopharyngeal Reflux

BACKGROUND

The pepsin test is an emerging non-invasive diagnostic approach for laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of multiple salivary pepsin tests for detecting LPR.

METHODS

Patients with suspected LPR and asymptomatic individuals were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) and fasting and bedtime saliva collections to measure oral pepsin. The sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values were calculated considering fasting, bedtime, and the highest values of the pepsin tests at ≥16, ≥36, ≥45, and ≥100 ng/mL cutoffs.

RESULTS

The pepsin test was adequately performed in 147 LPR patients and 32 controls. The pepsin tests were 81.6%, 74.8%, and 61.5% sensitive at cutoffs of ≥16, ≥45, and ≥100 ng/mL, respectively. The PPVs were 93.0%, 94.0%, and 94.8%, respectively. The highest specificity (81.8%) was found for the fasting pepsin test at a cutoff of 100 ng/mL. The highest sensitivity (81.6%) was found by considering the highest measured pepsin test at the ≥16 ng/mL threshold. The measurement of fasting saliva pepsin was associated with the highest sensitivity and specificity value. At ≥16 ng/mL, 27 patients had negative findings, indicating that 18.4% (27/147) of the true positive cases were missed by considering the highest pepsin test. The receiver operating characteristic curve reported that a cutoff of 21.5 was 76.9% sensitive and 62.5% specific, while the PPV and NPV were 91.1% and 38.2%, respectively.

CONCLUSIONS

The consideration of the highest concentration of the fasting and bedtime saliva pepsin collections at a cutoff of 21.5 was associated with the best detection rate and sensitivity of the pepsin tests.

The sensitivity of laryngeal findings in predicting high-grade dysplasia in patients with vocal fold leukoplakia undergoing office-based biopsies: A retrospective analysis of 100 cases

Objective

To investigate the sensitivity of laryngeal findings in predicting high-grade dysplasia/carcinoma in situ (CIS) and squamous cell carcinoma (SCC) in patients with vocal fold leukoplakia.

Methods

A retrospective review of the medical records and video recordings of the laryngeal examination of patients with vocal fold leukoplakia who underwent un-sedated office-based laryngeal biopsy in a tertiary referral center between January 2022 and August 2023 was conducted. Laryngeal findings included the size, surface, projection, and edges of the lesion. Vocal fold leukoplakia was classified according to the WHO as benign, low-grade dysplasia, high-grade dysplasia/CIS, and squamous cell carcinoma.

Results

Seventy patients with 100 vocal fold leukoplakia were included. Size was found to have the highest sensitivity with an AUC of 0.730 (95% CI [0.618-0.842], p = 0.002) followed by surface and projection with AUCs of 0.672 (95% CI [0.548-0.795], p = 0.019) and 0.675 (95% CI [0.546-0.804], p = 0.017), respectively. Furthermore, the odds of diagnosing high-risk lesions (high-grade dysplasia/CIS and SCC) were the greatest when the lesion was large and rough (OR = 10.28; 95% CI [3.08-34.36]).

Conclusion

The morphological features of vocal fold leukoplakia may assist the physician in predicting the risk of malignancy. Large and rough lesions were more likely to harbor high-grade dysplasia/CIS and SCC compared to small and smooth lesions.

A Study of the Diagnostic Value of the Sign and Symptom Questionnaires for Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the diagnostic value of symptom questionnaires, sign questionnaires, and the combination of 2 questionnaires for laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

Prospective, single-centered.

SETTING

Seventy-seven patients who were hospitalized in the Department of Otolaryngology-Head and Neck Surgery from October 2022 to April 2023 were included.

METHODS

Included patients completed the RSS, RSI, RSA, and RFS questionnaires and underwent 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH). The RSS, RSI, RSA, RFS, RSS+RSA, RSS+RFS, RSI+RSA, RSI+RFS, and RSI+RFS diagnostic value were compared using Cohen's k test and receiver operating characteristic analysis.

RESULTS

Based on the 24 hours HEMII-pH results, 52 patients had LPRD, and 25 patients did not have LPRD. The Kappa values of RSS, RSI, RSA, RFS, RSS+RSA,2 RSS+RFS, RSI+RSA, and RSI+RFS with the 24 hours HEMII-pH monitoring results were 0.565, 0.442, 0.318, 0.431, 0.517, 0.631, 0.451, and 0.461, respectively. The RSS+RFS questionnaire had the highest AUC of 0.836 (95% confidence interval [CI] 0.762-0.909) and the RSA questionnaire had the lowest AUC (AUC = 0.665, 95% CI 0.560-0.790). The sensitivity of RSS was the highest (98%), the specificities of RSS+RFS and RSI+RFS were the highest (96%), and the specificity of RSS was the lowest (52%). RSS+RFS had a sensitivity of 75%, second only to RSS and RFS (76%).

CONCLUSION

Among the 8 methods, the RSS combined with the RFS had the highest concordance with 24 hours HEMII-pH monitoring results and AUC values when screening for LPRD.

Usefulness of pepsin saliva measurement for the detection of primary burning mouth syndrome related to reflux

OBJECTIVES

To study the diagnostic value of salivary pepsin tests for detecting laryngopharyngeal reflux (LPR) in patients with primary burning mouth syndrome (BMS).

METHODS

Patients with BMS and asymptomatic individuals were consecutively recruited from September 2018 to June 2023. Patients underwent hypopharyngeal-esophageal impedance pH-monitoring (HEMII-pH) and saliva collections to measure pepsin. Stomatology evaluation was carried out to exclude other causes of BMS. Oral, pharyngeal and laryngeal signs and symptoms were evaluated with Reflux Sign Assessment (RSA) and Reflux Symptom Score (RSS). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin test were calculated considering the highest values of pepsin tests at ≥ 16, ≥ 36, and ≥ 100 ng/mL cutoffs. Receiver operating characteristic curve (ROC) was evaluated.

RESULTS

Forty-nine patients with both BMS and LPR at the HEMII-pH and 21 asymptomatic individuals were recruited. Pepsin test was 83.7%, 79.6%, and 71.4% sensitive at cutoffs ≥ 16, ≥ 36, and ≥ 100 ng/mL, respectively. The ROC analysis reported that a threshold of ≥ 21.5 ng/mL was associated with sensitivity, specificity, PPV and NPV of 81.6%, 81.0%, 90.1% and 65.4%, respectively. The severity score of burning mouth symptom was significantly associated with the saliva pepsin concentration (rs = 0.263; p = 0.029) and the oral RSA (rs = 0.474; p = 0.007).

CONCLUSION

Pepsin test is a valuable diagnostic approach for detecting LPR in patients with BMS. Patients with high level of saliva pepsin reported more severe burning mouth symptoms. Future studies are needed to confirm the role of LPR in the primary BMS.

The Relation Between Endoscopic and Subjective Laryngopharyngeal Reflux Signs, Vocal Tract Discomfort, Voice Handicap, and Voice Disorder Type: Same Yet Different?

OBJECTIVES

This study aimed to investigate the relation between subjective voice-related symptoms and endoscopic findings in patients with different etiology of voice disorder and vocally healthy subjects with and without laryngopharyngeal reflux (LPR).

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

The study involved 149 participants (106 female, 43 male) including 125 with various voice disorders (functional, structural, and neurogenic) and 24 vocally healthy individuals. For self-rating the German versions of the Voice Handicap Index (VHI), Vocal Tract Discomfort (VTD) Scale, and Reflux Symptom Index (RSI) were applied, while endoscopic evaluations utilized the Reflux Finding Score (RFS) and Reflux Sign Assessment (RSA). Statistical analyses incorporated ANOVA with Bonferroni posthoc tests to identify group variations. Correlations between VTD Scale, VHI, RSI, RFS, and RSA were evaluated using Pearson's correlation coefficient. To examine test sensitivity and specificity for the VTD Scale and RSA, we performed a receiver operating characteristics analysis. Youden's-Index was applied to determine the cut-off-value with best discriminatory abilities. The diagnosis of LPR was assumed when the criteria of RFS > 7 AND RSI > 13 was met.

RESULTS

Significant differences for all voice diagnosis groups and vocally healthy individuals for RFS and all three self-rating questionnaires were found. Moreover, there was significant correlation between VTD Scale and VHI and RSI as well as RSI and RFS, which was moderate, negative in the group of persons with LPR. However, there was no significant difference for RSA results between the vocally healthy or any diagnosis group.

CONCLUSION

Thus, the RFS may be more suitable to predict reflux and voice-related symptoms. The VTD Scale is a useful instrument in screening voice disorders but also LPR and can therefore be used as a tool for decision-making when transferring to a specialist.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians

INTRODUCTION

To update the European guidelines for the assessment of voice quality (VQ) in clinical practice.

METHODS

Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.

RESULTS

Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases.

CONCLUSION

The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Personalized Treatments Based on Laryngopharyngeal Reflux Patient Profiles: A Narrative Review

OBJECTIVE

To review the current findings of the literature on the existence of several profiles of laryngopharyngeal reflux (LPR) patients and to propose personalized diagnostic and therapeutic approaches.

METHODS

A state-of-the art review of the literature was conducted using the PubMED, Scopus, and Cochrane Library databases. The information related to epidemiology, demographics, clinical presentations, diagnostic approaches, and therapeutic responses were extracted to identify outcomes that may influence the clinical and therapeutic courses of LPR.

RESULTS

The clinical presentation and therapeutic courses of LPR may be influenced by gender, age, weight, comorbidities, dietary habits and culture, anxiety, stress, and saliva enzyme profile. The clinical expression of reflux, including laryngopharyngeal, respiratory, nasal, and eye symptoms, and the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring profile of patients are important issues to improve in patient management. The use of more personalized therapeutic strategies appears to be associated with better symptom relief and cures over the long-term. The role of pepsin in LPR physiology is well-established but the lack of information about the role of other gastrointestinal enzymes in the development of LPR-related mucosa inflammation limits the development of future enzyme-based personalized diagnostic and therapeutic approaches.

CONCLUSION

Laryngopharyngeal reflux is a challenging ear, nose, and throat condition associated with poor therapeutic responses and a long-term burden in Western countries. Artificial intelligence should be used for developing personalized therapeutic strategies based on patient features.

Association between oropharyngeal ph-monitoring, pepsin saliva concentration and degree of apnea-hypopnea index of obstructive sleep apnea

OBJECTIVE

To investigate the association between obstructive sleep apnea (OSA) and laryngopharyngeal reflux (LPR) through oropharyngeal pH-monitoring and pepsin saliva measurements.

DESIGN

Prospective uncontrolled study.

METHODS

Patients with sleep disturbances and reflux symptoms underwent polysomnography, 24-h oropharyngeal pH-monitoring and saliva pepsin collections. The prevalence of LPR was investigated in OSA patients according to oropharyngeal pH-monitoring and pepsin measurements. A correlation analysis was performed between pH-monitoring findings, pepsin saliva levels, reflux symptom score-12 (RSS-12), reflux sign assessment (RSA), Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale, Pichot and arousal findings.

RESULTS

Thirty-seven patients completed the evaluations. LPR was detected in 34/37 (92%) and 29/34 (85%) patients at the oropharyngeal-pH monitoring and pepsin test, respectively. OSA was detected in 30 patients (81%). Among them, LPR was detected in 28/30 (93%) cases. Pharyngeal reflux events mainly occurred nighttime/supine in OSA patients. Both Ryan score and supine reflux time at pH < 6.5 were significantly associated with BMI and the RSA sub- and total scores (p < 0.02). Tongue-base hypertrophy score was positively associated with the number of micro-arousals (p = 0.027); the supine percent of pH < 6.5 (p = 0.030); morning (p = 0.030) and bedtime pepsin saliva measurements (p = 0.037). The bedtime pepsin saliva level was significantly associated with Ryan Score (p = 0.047); AHI (p = 0.017) and the sleep saturation < 90% time (p = 0.040). The saliva level of the morning pepsin was associated with a shortest paradoxical sleep phase (p = 0.013).

CONCLUSION

OSA patients may have high prevalence of pharyngeal reflux events at the oropharyngeal pH-monitoring and high pepsin saliva measurements. Oropharyngeal pH-monitoring should be useful for the correlation between reflux and sleep findings in OSA patients. Future large cohort controlled studies are needed to determine the prevalence of LPR in OSA and healthy individuals.

Variability and accuracy of multiple saliva pepsin measurements in laryngopharyngeal reflux patients

OBJECTIVE

To study the variability and diagnostic value of multiple salivary pepsin measurements in the detection of laryngopharyngeal reflux (LPR).

METHODS

Patients with LPR symptoms were consecutively recruited from December 2019 to Augustus 2022. Twenty-one asymptomatic individuals completed the study. The diagnostic was confirmed with hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH). Patients collected three saliva samples during the 24-h testing period. Symptoms and findings were studied with reflux symptom score-12 and reflux sign assessment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin measurements were calculated considering morning, post-lunch and post-dinner samples. The consistency and relationship between HEMII-pH, pepsin measurements, and clinical features were investigated.

RESULTS

Morning, post-lunch and post-dinner saliva pepsin concentrations were measured in 42 patients. Pepsin measurements were 64.9%, 59.5%, and 59.0% sensitive for morning, post-lunch and post-dinner collections at cutoff ≥ 16 ng/mL. Considering the highest concentration of the three pepsin saliva collections, the accuracy, sensitivity, specificity and PPV were 70.5%, 73.0%; 66.7% and 78.9%, respectively. Morning pepsin measurements reported higher consistency, sensitivity, and specificity than post-dinner and post-lunch pepsin measurements.

CONCLUSION

The collection of several saliva pepsin samples improves the detection rate of LPR. In case of high clinical LPR suspicion and negative pepsin test, a HEMII-pH study could provide further diagnostic information.

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.

Diagnostic Value of Pepsin Measurements in Dysphonia Attributed to Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the diagnostic value of pepsin test in detecting laryngopharyngeal reflux (LPR) in patients with suspected LPR-induced dysphonia.

METHODS

Dysphonic and non-dysphonic patients with LPR at the 24-hour hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were recruited from January 2019 to November 2022. Patients collected saliva/sputum samples to measure pepsin concentrations. Symptoms and findings were studied through reflux symptom score (RSS) and reflux sign assessment (RSA). Voice quality was assessed with maximum phonation time, GRBAS, voice handicap index (VHI), and acoustic parameters at baseline and 3-month post-treatment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin tests for dysphonia-related to LPR were calculated at ≥16 ng/mL cutoff. The relationship between HEMII-pH, clinical features, voice quality outcomes, and pepsin measurement was investigated.

RESULTS

Sixty-seven patients with LPR at the HEMII-pH completed the evaluations accounting for 30 patients consulting for dysphonia. Dysphonic patients reported higher RSS than non-dysphonic patients. RSS, RSA, laryngeal findings, VHI, and grade of dysphonia significantly improved from baseline to 3-month posttreatment. Pepsin test detected LPR in 73% of dysphonic cases. The pepsin test was 73.3 sensitive and 18.9 specific when considering the highest pepsin level of morning, postlunch, and postdinner sputum collections. Sensitivity, specificity, PPV, and NPV varied regarding the time of sputum collections. There was a strong significant association between the concentration of the morning pepsin test and the severity of laryngeal RSA score (P = 0.018). The morning pepsin saliva test concentration was predictive of the 3-month otolaryngological RSS (P = 0.014).

CONCLUSION

Pepsin test is a sensitive but poorly specific diagnostic approach for patients with dysphonia attributed to LPR. Multiple pepsin measurements may increase the sensitivity and predictive value of pepsin test. Future large-cohort studies are needed to investigate the accuracy of pepsin test in this population.

Laryngopharyngeal Reflux Patient Changes during the COVID-19 Quarantine

Background and Objective: To examine the effects of the lockdown on diet adherence and stress levels in patients with laryngopharyngeal reflux (LPR). Materials and Methods: Patients with a positive LPR diagnosis at the hypopharyngeal-esophageal impedance-pH monitoring were treated from a pre- to lockdown period with a 3-month high-protein, low-fat, alkaline, plant-based diet, with behavioral changes, and an association of pantoprazole (20 MG/d) and alginate (Gaviscon 3/d). The following patient-reported outcomes questionnaire and findings instrument were used: Reflux Symptom Score-12 (RSS-12) and Reflux Sign Assessment (RSA). At the posttreatment time, patients were invited to evaluate the impact of lockdown on diet adherence and stress management with a predefined grid of foods and beverages and the perceived stress scale (PSS), respectively. Results: Thirty-two patients completed the evaluations. RSS-12 and RSA significantly improved from baseline to 3-month posttreatment. Most patients experienced mild-to-severe stress levels at the end of the lockdown. The level of stress substantially increased in 11 patients (34%) due to the lockdown, while it did not change in 11 patients (44%). In 11 cases (34%), patients reported that the adherence to the anti-reflux diet was better than initially presumed thanks to the lockdown period, while 44% (N = 14) reported that the lockdown did not impact the adherence to a diet. PSS and RSS-12 were significantly correlated at the end of the pandemic (rs = 0.681; p < 0.001). The increase in stress level was positively associated with the lack of adherence to diet (rs = 0.367; p = 0.039). Conclusions: During the lockdown, the diet habits of LPR patients were improved in one-third and unchanged in 44% of cases. The stress level was increased in one-third of patients, which was associated with an increase in symptom scores.

The Persian Version of Reflux Sign Assessment Scale: Validity and Reliability for the Examination of Patients with Laryngopharyngeal Reflux Disease

OBJECTIVES/HYPOTHESIS

The non-specificity of signs associated with laryngopharyngeal reflux disease (LPRD) makes the diagnosis challenging. This study aimed to evaluate the psychometric properties of the Persian version of reflux sign assessment (RSAp) in LPRD.

STUDY DESIGN

This was a methodological study.

METHODS

The prefinal version of RSAp was developed in a forward and backward translation protocol. It was completed by a speech-language pathologist (SLP) and an otolaryngologist for 20 LPRD patients to provide a final version. The final version was completed by a SLP (rater 1) for 42 LPRD patients and 42 healthy people. To study intra and inter-rater reliability, the RSAp was recompleted after 21 days by rater 1 and another SLP (rater 2), respectively. For construct validity, the reflux finding score and reflux symptom index was completed in the patients.

RESULTS

There were significant differences in the subscales and total scores of RSAp between the patient and healthy groups (P < 0.001). The Cronbach's alpha of the total score was 0.76 and 0.72 for rater 1 and 2, respectively. Concordance correlation coefficient and intraclass correlation coefficient values for all scores showed excellent intra and inter-rater reliability. The total score had a significant positive correlation with the scores of reflux finding score and reflux symptom index (rp = 0.813, P < 0.001 and rp = 0.811, P < 0.001 respectively).

CONCLUSIONS

The current study indicated the RSAp is a valid and reliable scale for the examination of the vocal tract in LPRD. The RSAp can be used as a useful tool in clinical and research settings for Persian LPRD patients.

Saliva pepsin measurements in the detection of gastroesophageal reflux disease in laryngopharyngeal reflux patients: a cohort study

OBJECTIVE

To study the diagnostic value of salivary pepsin measurement (Peptest) for detecting gastroesophageal reflux disease (GERD) in laryngopharyngeal reflux (LPR) patients.

METHODS

Patients with reflux symptoms were consecutively recruited from January 2020 to November 2022. Patients benefited from hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH), fasting and bedtime saliva collections to measure pepsin. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were evaluated for GERD and LPR patients considering the highest values of pepsin tests at ≥ 16, ≥ 75, and ≥ 216 ng/mL cutoffs. The relationship between HEMII-pH, endoscopic and clinical findings, and pepsin measurements was studied.

RESULTS

Saliva was collected in 109 LPR patients and 30 individuals with both LPR and GERD. The total number of pharyngeal reflux events was significantly higher in GERD-LPR patients compared with LPR patients (p = 0.008). The mean fasting and bedtime pepsin saliva concentrations were similar between groups. The sensitivity of Peptest in LPR patients was 30.5%, 70.2%, and 84.0% at cutoffs ≥ 16, ≥ 75 and ≥ 216 ng/mL. In GERD-LPR group, Peptest was 80.0%, 70.0%, and 30.0% sensitive. At cutoff 16 ng/mL, Peptest reported PPV of 20.7% and 94.8% in LPR-GERD and LPR groups, respectively. NPV were 73.9% and 8.7% in GERD-LPR and LPR groups, respectively. The consistency analysis between Peptest and HEMII-pH was not significant. Peptest was significantly associated with the number of acid pharyngeal reflux events (r_s = 0.182; p = 0.032).

CONCLUSION

Pepsin saliva measurements appear to be not a reliable diagnostic tool for the detection of GERD in LPR patients. Future studies are needed to determine the place of Peptest in laryngopharyngeal reflux and gastroesophageal reflux diseases.

Pediatric Laryngopharyngeal Reflux: An Evidence-Based Review

Purpose: Pediatric laryngopharyngeal reflux (P-LPR) is associated with the development of common otolaryngological symptoms and findings. In the present study, the findings about epidemiology, clinical presentation, diagnostic and therapeutic outcomes of pediatric population were reviewed. Methods: A PubMed, Cochrane Library, and Scopus literature search was conducted about evidence-based findings in epidemiology, clinical presentation, diagnostic and therapeutic outcomes of P-LPR. Findings: The prevalence of LPR remains unknown in infant and child populations. The clinical presentation depends on age. Infants with LPR symptoms commonly have both gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux and related digestive, respiratory and ear, nose and throat symptoms. The GERD prevalence appears to decrease over the growth, and the clinical picture is increasingly associated with LPR symptoms and findings without GERD. The prevalence of LPR and proximal acid and nonacid esophageal reflux events may be high in some prevalent otolaryngological conditions (chronic otitis media, laryngolomalacia and apnea). However, the lack of use of hypopharyngeal–esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) limits the establishment of etiological associations. Proton pump inhibitors are less effective in P-LPR patients compared to GERD populations, which may be related to the high prevalence of weakly or nonacid reflux events. Conclusions: Many gray areas persist in P-LPR and should be not resolved without the establishment of diagnostic criteria (guidelines) based on HEMII-pH. The unavailability of HEMII-pH and the poor acid-suppressive therapeutic response are all issues requiring future investigations. Future controlled studies using HEMII-pH and enzyme measurements in ear, nose or throat fluids may clarify the epidemiology of P-LPR according to age and its association with many otolaryngological conditions.

A Prospective Controlled Study Investigating Odor Identification in Laryngopharyngeal Reflux

OBJECTIVE

To psychophysically evaluate olfaction in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective controlled study.

SETTING

Tertiary medical center.

METHODS

From January 2021 to January 2022, patients with LPR diagnosed with hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring underwent psychophysical evaluation of the sense of smell. Reflux symptoms and findings were assessed with the Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA). Nasal symptoms were assessed through the Sino-Nasal Outcome Test 22 (SNOT-22). From pre- to posttreatment, patients underwent identification Sniffin' Sticks test and olfactory cleft examination. Clinical outcomes were compared between LPR patients and healthy individuals.

RESULTS

In total, 107 patients and 76 healthy individuals completed the evaluations. LPR patients reported significant higher RSS, RSA, and SNOT-22 scores. Psychophysical olfactory evaluations were significantly lower in reflux patients compared with controls, while there were no significant differences in olfactory cleft score. RSS and RSA significantly improved from baseline to 3 months posttreatment. SNOT-22, olfactory cleft endoscopy scale, and psychophysical olfactory evaluations did not change throughout treatment. Patients with higher number of acid pharyngeal reflux events reported lower psychophysical olfactory scores (P = .025).

CONCLUSION

LPR disease was associated with low odor identification results in patients without olfactory cleft abnormalities. The sense of smell did not improve after 3-month therapy. Future controlled studies using threshold, discrimination, and identification testing are needed.

Laryngopharyngeal reflux induced sleep-related laryngospasm

BACKGROUND

Sleep-related laryngospasm (SRL) has been defined as the sustained closure of the vocal cords during sleep. Studies have suggested that it is a rare manifestation of laryngopharyngeal reflux (LPR). Difficulties in diagnosing SRL and LPR have led to the condition being under-recognised in the clinical setting.

AIMS

The aim of this study was to determine if LPR was the cause of the SRL symptoms seen in our patients.

METHODS

A retrospective chart assessment of patients with SRL. Patients with risk factors for LPR were identified. These included smoking status, alcohol intake, a history of dyspepsia or history of gastroesophageal reflux disease, a history of late-night eating and a history of eating spicy or fatty foods before bed. A clinical diagnosis based on the history and response to management was made for the diagnosis of LPR. All were advised to refrain from late meals and those with signs of nasopharyngitis were commenced on proton pump inhibitor therapy.

RESULTS

Nineteen patients (mean age ± SD: 57.21 ± 15.18) were included in the study. All had at least one risk factor for LPR. Ten (52.6%) had signs of nasopharyngitis on nasendoscopy. Following treatment, 17 (89.5%) reported no further SRL symptoms at 1-year follow-up.

CONCLUSION

SRL is a largely unknown and under-diagnosed condition. We believe this study provides supportive evidence for the causal relationship between LPR and SRL.

Usefulness, acceptation and feasibility of electronic medical history tool in reflux disease

OBJECTIVES

To investigate usefulness, feasibility, and patient satisfaction of an electronic pre-consultation medical history tool (EPMH) in laryngopharyngeal reflux (LPR) work-up.

METHODS

Seventy-five patients with LPR were invited to complete electronic medical history assessment prior to laryngology consultation. EPMH collected the following parameters: demographic and epidemiological data, medication, medical and surgical histories, diet habits, stress and symptom findings. Stress and symptoms were assessed with perceived stress scale and reflux symptom score. Duration of consultation, acceptance, and satisfaction of patients (feasibility, usefulness, effectiveness, understanding of questions) were evaluated through a 9-item patient-reported outcome questionnaire.

RESULTS

Seventy patients completed the evaluation (93% participation rate). The mean age of cohort was 51.2 ± 15.6 years old. There were 35 females and 35 males. Patients who refused to participate (N = 5) were > 65 years old. The consultation duration was significantly lower in patients who used the EPMH (11.3 ± 2.7 min) compared with a control group (18.1 ± 5.1 min; p = 0.001). Ninety percent of patients were satisfied about EPMH easiness and usefulness, while 97.1% thought that EPMH may improve the disease management. Patients would recommend similar approach for otolaryngological or other specialty consultations in 98.6% and 92.8% of cases, respectively.

CONCLUSION

The use of EPMH is associated with adequate usefulness, feasibility, and satisfaction outcomes in patients with LPR. This software is a preliminary step in the development of an AI-based diagnostic decision support tool to help laryngologists in their daily practice. Future randomized controlled studies are needed to investigate the gain of similar approaches on the traditional consultation format.

The role of pH-impedance monitoring in swallowing disorders

PURPOSE OF REVIEW

To review the current evidence about the usefulness and the place of pH study in the management of patients with swallowing disorders.

RECENT FINDINGS

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are found in approximately 30% of patients with esophageal or oropharyngeal dysphagia. Patients with suspected GERD may benefit from gastrointestinal endoscopy and proton pump inhibitors according to guidelines. The diagnosis of LPR in patients with oropharyngeal dysphagia is more controversial because there are no gold standard and diagnostic guidelines. The clinical diagnosis based on empirical therapeutic trial is a reasonable first-line strategy, but many dysphagic patients should not respond to treatment. These patients require hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH), which is the most effective examination providing important information on GERD and LPR features. At the HEMII-pH, GERD patients often report upright (daytime) and supine (nighttime) liquid acid esophageal events with significant esophageal distal acid exposure time. LPR patients have more frequently upright (daytime) gaseous weakly acid or nonacid pharyngeal reflux events without distal esophageal acid exposure abnormalities in many times. The features of reflux at the HEMII-pH may indicate a personalized treatment for dysphagic patients combining proton pump inhibitors, alginate/magaldrate or gastroprokinetic in cases of esophageal dysmotility.

SUMMARY

GERD and LPR are prevalent causes of dysphagia. The large number of reflux patients who do not respond to empirical treatment makes important the awareness of otolaryngologists about pH-impedance monitoring indication, features, and interpretation.

Do Otolaryngologists Over- or Underestimate Laryngopharyngeal Reflux Symptoms and Findings in Clinical Practice? A Comparison Study between the True Prevalence and the Otolaryngologist-Estimated Prevalence of Symptoms and Findings

Purpose: To investigate the prevalence of symptoms and signs of laryngopharyngeal reflux (LPR) and to compare them with the otolaryngologist-estimated prevalence of the most common LPR-related symptoms and signs. Methods: The prevalence of LPR symptoms and signs was determined through the clinical data of 403 patients with a positive LPR diagnosis on hypopharyngeal−esophageal multichannel intraluminal impedance pH monitoring. The otolaryngologist-estimated prevalence was assessed through an international survey investigating the thoughts of 824 otolaryngologists toward LPR symptom and sign prevalence. The determination of potential over- or underestimation of LPR symptoms and findings was investigated through a data comparison between the ‘true’ prevalence and the ‘estimated prevalence’ of symptoms and findings by otolaryngologists. Results: The prevalence of breathing difficulties, coated tongue, and ventricular band inflammation was adequately evaluated by otolaryngologists. The prevalence of hoarseness, throat pain, odynophagia, dysphagia, throat clearing, globus sensation, excess throat mucus, tongue burning, heartburn, regurgitations, halitosis, cough after eating or lying down, and troublesome cough was overestimated by otolaryngologists (p < 0.01), while the prevalence of chest pain was underestimated as an LPR symptom. Most laryngeal signs, e.g., arytenoid/laryngeal erythema, inter-arytenoid granulation, posterior commissure hypertrophy, retrocricoid edema/erythema, and endolaryngeal sticky mucus, were overestimated (p < 0.01). The occurrence of anterior pillar erythema and tongue tonsil hypertrophy was underestimated by participants. Conclusion: Most laryngopharyngeal reflux symptoms and laryngeal signs were overestimated by otolaryngologists, while some non-laryngeal findings were underestimated. Future studies are needed to better understand the reasons for this phenomenon and to improve the awareness of otolaryngologists toward the most and least prevalent reflux symptoms and signs.

Sensitivity, Specificity, and Predictive Values of Laryngopharyngeal Reflux Symptoms and Signs in Clinical Practice

OBJECTIVE

To investigate the sensitivity (SE), specificity (SP), and positive and negative predictive value (PPV and NPV) of symptoms and signs of laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective controlled.

SETTING

University medical center.

METHODS

Patients presenting with LPR symptoms and signs were consecutively included after diagnosis confirmation through 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring. Healthy individuals were recruited to compose a control group. Symptoms and signs were evaluated with the reflux symptom score and reflux sign assessment. The SE, SP, PPV, and NPV of symptoms and signs were assessed.

RESULTS

The study included 403 patients with LPR and 144 healthy individuals. Throat clearing, globus sensation, heartburn, and excess throat mucus were symptoms with the highest SE (67.5%-69.7%), SP (12.5%-20.8%), and NPV (48.3%-49.2%). The combination of throat clearing, heartburn, globus sensation, and excess throat mucus led to a high SE (96.0%) and NPV (85.2%). Anterior pillar erythema, tongue tonsil hypertrophy, and posterior commissure hypertrophy resulted in the highest SE (75.5%-83.5%). The highest SP was found for uvula erythema/edema, epiglottis erythema, and interarytenoid granulatory tissue (97.1%-97.2%). The association of nonendoscopic signs (anterior pillar erythema, uvula erythema/edema, and coated tongue) had an SE and SP of 80.1% and 47.2%, respectively. The association of throat clearing, heartburn, globus, anterior pillar erythema, and uvula erythema/edema had the highest SE (98.8%), SP (33.3%), PPV (94.3%), and NPV (70.6%).

CONCLUSION

LPR symptoms and signs reported low SP and NPV. The SE, SP, PPV, and NPV may be maximized with the association of throat clearing, heartburn, globus sensation, anterior pillar erythema, and uvula erythema/edema.

Best Practices in Treatment of Laryngopharyngeal Reflux Disease: A Multidisciplinary Modified Delphi Study

BACKGROUND

Laryngopharyngeal reflux (LPR) is a common otolaryngologic diagnosis. Treatment of presumed LPR remains challenging, and limited frameworks exist to guide treatment.

METHODS

Using RAND/University of California, Los Angeles (UCLA) Appropriateness Methods, a modified Delphi approach identified consensus statements to guide LPR treatment. Experts independently and blindly scored proposed statements on importance, scientific acceptability, usability, and feasibility in a four-round iterative process. Accepted measures reached scores with ≥ 80% agreement in the 7-9 range (on a 9-point Likert scale) across all four categories.

RESULTS

Fifteen experts rated 36 proposed initial statements. In round one, 10 (27.8%) statements were rated as valid. In round two, 8 statements were modified based on panel suggestions, and experts subsequently rated 5 of these statements as valid. Round three's discussion refined statements not yet accepted, and in round four, additional voting identified 2 additional statements as valid. In total, 17 (47.2%) best practice statements reached consensus, touching on topics as varied as role of empiric treatment, medication use, lifestyle modifications, and indications for laryngoscopy.

CONCLUSION

Using a well-tested methodology, best practice statements in the treatment of LPR were identified. The statements serve to guide physicians on LPR treatment considerations.

Acute, Recurrent, and Chronic Laryngopharyngeal Reflux: The IFOS Classification

OBJECTIVE

To investigate the clinical patterns and disease evolution of laryngopharyngeal reflux (LPR) patients.

METHODS

Patients with LPR diagnosed by hypopharyngeal-esophageal impedance-pH monitoring were prospectively followed in three medical centers. Symptoms and findings were assessed with reflux symptom score (RSS) and reflux sign assessment (RSA). Patients were treated with 3-to 9-month diet and combination of proton pump inhibitors, alginate or magaldrate. Patients were followed for 3 years to determine the clinical evolution of symptoms over time. LPR that did not recur was defined as acute. Recurrent LPR consisted of reflux with one or several recurrences yearly despite successful treatment. Chronic LPR was reflux with a chronic course of symptoms. Predictive indicators of clinical evolution were investigated.

RESULTS

One hundred forty patients and 82 healthy individuals completed the evaluations. Among patients, 41 (29.3%), 57 (40.7%), and 42 (30.0%) had acute, recurrent, or chronic LPR respectively. Baseline quality of life-RSS (QoL-RSS) and RSS total scores were significantly higher in chronic LPR patients. The post-treatment decrease of QoL-RSS and RSS of acute LPR patients were significantly faster as compared to recurrent and chronic patients. QoL-RSS >5 reported adequate sensitivity (94.2) and specificity (75.3). QoL-RSS thresholds defined acute (QoL-RSS = 6-25), recurrent (QoL-RSS = 26-38), and chronic (QoL-RSS > 38) LPR.

CONCLUSION

Baseline QoL-RSS may predict the clinical course of LPR patients: acute, recurrent, or chronic. A novel classification system that groups patients according to the longevity, severity, and therapeutic response of symptoms was proposed: the International Federation of Otorhinolaryngological Societies Classification of LPR.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:1073-1080, 2023.

Reflux Finding Score Using HD Video Chromoendoscopy: A Diagnostic Adjunct in Suspected Laryngopharyngeal Reflux?

OBJECTIVE

To explore the use of real-time virtual chromoendoscopy (i-scan) in characterizing the mucosal changes present in subjects with suspected laryngopharyngeal reflux (LPR) and to compare the inter-rater and intra-rater agreement of Reflux Finding Scores (RFS) from both laryngologists and general otolaryngologists (ORL) observing exams using both white light endoscopy (WLE) and i-scan.

METHODS

This is a cross-sectional study that included 66 subjects: 46 symptomatic and 20 asymptomatic of suspected LPR based on the reflux symptom index (RSI). Subjects underwent flexible video laryngoscopic evaluation of the larynx utilising both WLE and i-scan during one continuous exam. Subjects also underwent 24-hour oropharyngeal pH-monitoring (Dx-pH). Two laryngologists and two general otolaryngologists evaluated the anonymized videos independently using RFS. Dx-pH results were interpreted using the pH graph, report and RYAN score. Subjects were then designated into one of three groups: no reflux, acid reflux and alkaline reflux.

RESULTS

For the symptomatic group, no mucosal irregularities or early mucosal lesions were observed except in one subject who had granulation tissue. The mean RFS using WLE and i-scan were, respectively: 11.8 (SD 6.1) and 11.3 (SD 5.6) in symptomatic and 7.3 (SD 5.7) and 7.3 (SD 5.2) in asymptomatic group. The inter-rater agreement of RFS using WLE and i-scan for both groups were good with intraclass correlation, ICC of 0.84 and 0.88 (laryngologists); and 0.85 and 0.81 (ORL). The intra-rater agreement among all four raters were good to excellent and similar for both WLE and i-scan (ICC of 0.80 to 0.99). 47 of 66 subjects had evidence of LPR on Dx-pH results which more specifically showed 39 subjects had "acid reflux" and 8 had "alkaline reflux". Sixteen subjects demonstrated a positive RYAN score but showed none were significantly correlated with their RFS.

CONCLUSIONS

This study reports the first utilization of real-time video chromoendoscopy with i-scan technology through high-definition flexible endoscopes to attempt to characterize laryngopharyngeal findings in patients suspected of having LPR. Both general otolaryngologists and laryngologists were equally capable of reliably calculating the RFS using both WLE and i-scan, however no significant improvement in agreement or change in RFS was found when i-scan technology was employed.

LEVEL OF EVIDENCE

Level 2.

Does hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring for the diagnosis of laryngopharyngeal reflux have to be 24 h?

PURPOSE

To investigate the diagnostic value of combined multi-timepoint salivary pepsin testing (MTPSPT) and hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) for laryngopharyngeal reflux (LPR) and whether an appropriate reduction in the duration of HEMII-pH would affect the accuracy of diagnosis of LPR.

METHODS

Recruited patients were studied with both MTPSPT and HEMII-pH. The diagnosis of LPR was based on the occurrence of > 1 reflux event and/or positive results on any of the MTPSPT. The diagnostic value of combined diagnosis was studied through combining a breakdown of the 24-h HEMII-pH finding and the results of the MTPSPT. The diagnostic value was expressed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

Based on 24-h HEMII-pH and MTPSPT, the positive rate of LPR was 83.33% and 74.69%, respectively. According to the combined diagnosis, the positive rate of LPR was 90.74%. The sensitivity and specificity of the combined diagnosis both were 89.51% and 100%, when the HEMII-pH intervals were 7 a.m.-6 p.m. and 7 a.m.-7 p.m., respectively. However, when the monitoring time was extended to 8 p.m. and bedtime, the sensitivity, specificity, PPV and NPV of the combined diagnosis both were 100%.

CONCLUSIONS

The combination of MTPSPT and HEMII-pH increased the sensitivity and accuracy of diagnosis of LPR. For patients with positive MTPSPT results, the duration of HEMII-pH can be appropriately shortened to reduce patient sufferings.

Prevalence of Laryngopharyngeal Symptoms in Patients With Gastroesophageal Reflux Disease Refractory to Medical Therapy Undergoing Esophagogastroduodenoscopy

OBJECTIVE

Casting more information on the link between GERD and LPR by investigating the prevalence of laryngopharyngeal symptoms in patients with severe GERD refractory to medical treatment.

DESIGN

Prospective Study METHODS: Fifty patients with typical GERD symptoms presenting for EGD were recruited. All patients filled the GERD-Health-Related Quality of Life (HRQL) questionnaire and were screened for LPR using the Reflux Symptom Score questionnaire. All patients were also evaluated for the presence of hiatal hernia, esophagitis, inlet patch, gastritis (erosive vs. non erosive), polyps, intestinal metaplasia and or Helicobacter pylori infection. Laryngeal images were taken during EGD and evaluated using the Reflux Sign Assessment (RSA).

RESULTS

A total of 50 patients were recruited for this study. The prevalence of heartburn was the highest (90%). The mean score of GERD-HRQL was 30.76±15.09. The mean RSS score was 70.96±46.08. Laryngeal examination was documented in 49 patients. the most common finding was edema (34.7%) followed by redness (28.6%). The mean RSA score for the total group was 21.15±8.04. There was a strong correlation between RSS score and GERD-HQRL score. There was no significant correlation between the RSS and any of the EGD findings (P > 0.05). There was no significant correlation between RSA and GERD-HRQL scores or any of the EGD findings (P > 0.05). However, there was a significant correlation between total RSA and RSS scores (rho=0.287, P = 0.04).

CONCLUSION

The suggested high prevalence of LPRD should alarm the treating physician to the need for a thorough otolaryngologic examination in patients presenting with severe GERD, particularly those in whom the LPR symptoms may be masked by the typical symptoms of GERD.

Clinical Update Findings about pH-Impedance Monitoring Features in Laryngopharyngeal Reflux Patients

Purpose: The diagnosis of laryngopharyngeal reflux (LPR) is commonly based on non-specific symptoms and findings and a positive response to an empirical therapeutic trial. The therapeutic response is, however, unpredictable, and many patients need pH-impedance monitoring to confirm the diagnosis. Methods: A review of the recent literature was conducted in PubMED, Scopus, and Embase about the pH-study features of LPR patients. A summary of last evidence was proposed. Results: The awareness of otolaryngologists about indications and interpretation of pH-impedance monitoring is low. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is the most reliable examination determining the type and composition of hypopharyngeal reflux events (HRE) and the LPR features. The use of HEMII-pH is important to confirm the diagnosis in selected patients because non-specificity of symptoms and findings. There are no international consensus guidelines for the LPR diagnosis at the HEMII-pH. However, most studies supported the occurrence of >1 acid/weakly acid/nonacid HRE as diagnostic threshold. HREs are more frequently gaseous, weakly/nonacid compared with reflux events of gastroesophageal reflux. HREs occurred as daytime and upright, which does not support the value of double proton pump inhibitors or bedtime alginate. Oropharyngeal pH-monitoring is another approach reporting different sensitivity and specificity outcomes from HEMII-pH. The use of Ryan score for the LPR diagnosis at the oropharyngeal pH monitoring may be controversial regarding the low consideration of alkaline HREs. Conclusions: The awareness of otolaryngologists about HEMII-pH indication, features, and interpretation is an important issue regarding the high prevalence of LPR in outpatients consulting in otolaryngology. The HEMII-pH findings may indicate a more personalized treatment considering type and occurrence time of HREs.

Acoustic measurements are useful therapeutic indicators of patients with dysphonia-related to reflux

OBJECTIVES

The objective is to study the usefulness of acoustic measurements as therapeutic outcomes for patients with dysphonia related to laryngopharyngeal reflux (LPR).

METHODS

From September 2019 to April 2021, 120 patients with LPR at the hypopharyngeal-esophageal multichannel intraluminal impedance pH-monitoring (HEMII-pH) were prospectively recruited from three University Hospitals. They were divided in two groups regarding the presence of dysphonia. The treatment consisted of a combination of diet, proton-pump inhibitors, magaldrate and alginate for 3-6 months. The following clinical and acoustic evaluations were studied regarding groups at baseline, 3- and 6-month posttreatment: reflux symptom score (RSS), reflux sign assessment (RSA), percent jitter, percent shimmer and noise-to-harmonic ratio (NHR).

RESULTS

A total of 109 patients completed the evaluations, accounting for 49 dysphonic and 60 non-dysphonic individuals. HEMII-pH, gastrointestinal endoscopy, baseline clinical and acoustic features were comparable between groups. RSS and RSA significantly improved from pre- to 3-month posttreatment in both groups. Jitter, Shimmer and NHR significantly improved from pre- to 3-month posttreatment in dysphonic patients, without additional 3- to 6-month posttreatment changes. Acoustic parameters did not change throughout treatment in patients without dysphonia.

CONCLUSION

Acoustic measurements may be an interesting indicator of treatment in LPR patients who reported dysphonia. In this group of individuals, the evolution of acoustic parameters was consistent with the evolution of symptoms and findings.

Laryngopharyngeal Reflux: Evolution and Predictive Value of Symptoms and pH-Impedance Features on Clinical Evolution

OBJECTIVES

To investigate the features of patients with laryngopharyngeal reflux (LPR) who did not respond to medical treatment.

STUDY DESIGN

Prospective uncontrolled study.

SETTING

Multicenter study.

METHODS

Patients with LPR at 24-hour HEMII-pH monitoring (hypopharyngeal-esophageal multichannel intraluminal impedance-pH) were prospectively recruited from 3 European university centers. Patients were treated with 3- to 6-month medication (proton pump inhibitor and alginate) and categorized as mild to moderate responders, high responders, or nonresponders according to Reflux Symptom Score (RSS) changes at 6 months posttreatment. The predictive value of the following outcomes was studied: epidemiologic data, HEMII-pH, gastrointestinal endoscopy findings, baseline RSS and Reflux Sign Assessment, and early therapeutic response (6-week RSS).

RESULTS

A total of 148 patients completed the evaluations, accounting for 40 mild to moderate responders (20%-60% RSS changes), 76 high responders (>60% RSS changes), and 32 nonresponders. Nonresponders presented more often with hiatal hernia and lower esophageal sphincter insufficiency when compared with mild to moderate and high responders (P = .032). Baseline otolaryngologic, digestive, and respiratory RSS and the number of pharyngeal reflux events at the HEMII-pH were predictive of the 6-month therapeutic response (P < .05). The early therapeutic response (6 weeks posttreatment) was predictive of the 6-month treatment response.

CONCLUSION

Hiatal hernia and baseline and 6-week RSS were the most predictive indicators of therapeutic effectiveness in patients with LPR.

Is Diet Sufficient as Laryngopharyngeal Reflux Treatment? A Cross-Over Observational Study

OBJECTIVES/HYPOTHESIS

To investigate the efficacy of low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet as single treatment for patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Cross-over observational study.

METHODS

Patients with LPR diagnosis at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH-monitoring were prospectively recruited from the reflux clinic of three University Hospitals. Patients were instructed to follow low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet for 6 to 12 weeks. Pre- to post-treatment symptom and finding changes were evaluated with reflux symptom score (RSS) and reflux sign assessment. Findings were compared to those of a control period where patients did not receive any treatment or diet. Diet was evaluated with refluxogenic diet score (REDS).

RESULTS

Fifty patients completed the study (19 males). Otolaryngological, digestive, and total RSS scores significantly improved from baseline to 6-week post-diet, while there were no significant changes during the control period. At 6-week post-diet, 37 (74%) patients reported significant symptom improvement or relief. Among them, symptoms continued to improve from 6 to 12 weeks in 27 cases, corresponding to a diet success rate of 54%. The REDS was predictive of the baseline RSS (P = .031).

CONCLUSION

Low-fat, low-quick-release sugar, high-protein, alkaline, and plant-based diet is an alternative cost-effective therapeutic approach for patients with LPR. Patients with higher REDS reported higher baseline symptom score.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

A simple qualitative scale for diagnosis of laryngopharyngeal reflux: high correlations with pH measurements and disease severity. The usefulness of the Warsaw Scale in LPR diagnostics compared to other diagnostic tools

Purpose

Diagnosis and monitoring of laryngopharyngeal reflux (LPR) is a constant challenge in otolaryngological practice, chiefly because there are no specific symptoms characteristic of the disease. In this paper, we present the validation of a simple, 6-level qualitative scale to gauge the clinical findings of LPR. It has been previously published in Polish as the Warsaw Scale.

Methods

In the study, we enrolled 100 patients with voice problems who had registered in our clinic, and we performed an extended battery of diagnostic tests for LPR, together with 24-h pH monitoring.

Results

The Warsaw Scale significantly outperformed other instruments in both predicting LPR status and correlating with pH measurements. Moreover, the rating provided by the scale showed a strong association with patient-reported symptoms.

Conclusion

The data indicate that the Warsaw Scale could be used as an affordable, consistent, and effective diagnostic and monitoring tool for LPR.

Diagnostic Value of the PeptestTM in Detecting Laryngopharyngeal Reflux

BACKGROUND

The Peptest^TM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR.

METHODS

Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes.

RESULTS

Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively.

CONCLUSIONS

A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.

Influence of Age and Sex on Clinical and Therapeutic Features of Laryngopharyngeal Reflux

OBJECTIVE

To explore the influence of age and sex on the clinical presentation and therapeutic response of patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective study.

SETTING

Prospective multicenter study of 271 patients with a diagnosis of LPR confirmed by impedance-pH monitoring.

METHODS

Patients were prescribed 6 months of diet changes and a combination of pantoprazole and/or alginate depending on the results of their impedance-pH results. The Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were collected at baseline and at 3 and 6 months posttreatment. Data were explored according to sex and age.

RESULTS

A total of 237 patients completed the evaluations (138 females). On the RSS, patients of the oldest group (>60 years) had lower symptom scores (throat pain, ear pain, odynophagia, chest pain, tongue burning, nausea, halitosis, and indigestion) and lower quality-of-life scores than younger individuals. RSS and RSA outcomes significantly improved from pretreatment to 3 months posttreatment in all groups. Scores on the RSS and RSA continued to improve from 3 to 6 months posttreatment in the elderly group. Females with LPR had a higher score on the RSS at baseline as compared with males. On the RSS, scores significantly improved after 3 months in males and females; however, they continued to improve from 3 to 6 months in the female group.

CONCLUSION

Age and sex may influence the clinical presentation and pre- to posttreatment evolution of symptoms and findings. Age and sex differences could be considered in future therapeutic approaches to guide more effective personalized treatment plans for patients with LPR.

Atypical Clinical Presentation of Laryngopharyngeal Reflux: A 5-Year Case Series

Background: Laryngopharyngeal reflux (LPR) is a common disease in otolaryngology characterized by an inflammatory reaction of the mucosa of the upper aerodigestive tract caused by digestive refluxate enzymes. LPR has been identified as the etiological or favoring factor of laryngeal, oral, sinonasal, or otological diseases. In this case series, we reported the atypical clinical presentation of LPR in patients presenting in our clinic with reflux. Methods: A retrospective medical chart review of 351 patients with LPR treated in the European Reflux Clinic in Brussels, Poitiers and Paris was performed. In order to be included, patients had to report an atypical clinical presentation of LPR, consisting of symptoms or findings that are not described in the reflux symptom score and reflux sign assessment. The LPR diagnosis was confirmed with a 24 h hypopharyngeal-esophageal impedance pH study, and patients were treated with a combination of diet, proton pump inhibitors, and alginates. The atypical symptoms or findings had to be resolved from pre- to posttreatment. Results: From 2017 to 2021, 21 patients with atypical LPR were treated in our center. The clinical presentation consisted of recurrent aphthosis or burning mouth (N = 9), recurrent burps and abdominal disorders (N = 2), posterior nasal obstruction (N = 2), recurrent acute suppurative otitis media (N = 2), severe vocal fold dysplasia (N = 2), and recurrent acute rhinopharyngitis (N = 1), tearing (N = 1), aspirations (N = 1), or tracheobronchitis (N = 1). Abnormal upper aerodigestive tract reflux events were identified in all of these patients. Atypical clinical findings resolved and did not recur after an adequate antireflux treatment. Conclusion: LPR may present with various clinical presentations, including mouth, eye, tracheobronchial, nasal, or laryngeal findings, which may all regress with adequate treatment. Future studies are needed to better specify the relationship between LPR and these atypical findings through analyses identifying gastroduodenal enzymes in the inflamed tissue.

Prevalence and Features of Laryngopharyngeal Reflux in Patients with Primary Burning Mouth Syndrome

OBJECTIVES/HYPOTHESIS

To investigate the prevalence and features of laryngopharyngeal reflux (LPR) in patients with primary burning mouth syndrome (BMS).

STUDY DESIGN

Prospective uncontrolled study.

METHODS

Patients who visited our Departments of Otolaryngology-Head and Neck and Maxillofacial surgery with BMS were prospectively recruited from September 2018 to September 2020. Patients benefited from dental, maxillofacial, otolaryngological examinations, and hypopharyngeal-esophageal impedance pH-monitoring (HEMII-pH). Oral, pharyngeal, and laryngeal findings and symptoms were rated with Reflux Sign Assessment (RSA) and Reflux Symptom Score-12 (RSS-12). Patients were treated with a combination of diet, pantoprazole, and alginate.

RESULTS

From the 81 included patients, 76 reported >1 pharyngeal reflux events (93.8%), accounting for 35 (46.1%), 24 (31.6%), and 17 (22.3%) acid, mixed, and nonacid LPR, respectively. Thirty-two patients had both LPR and gastroesophageal reflux disease (GERD). Thirty-eight patients benefited from pepsin saliva measurement, which was positive in 86.8% of cases. The mean scores of mouth/tongue burning, RSS-12, and RSA significantly improved from pre- to post-treatment (P < .004). At 3-month post-treatment, 62.5% of patients reported an improvement of mouth/tongue burning score. Patients with both GERD and LPR reported higher baseline RSS-12 and RSA scores.

CONCLUSION

Acid, weakly acid, and nonacid LPR may be involved in the development of BMS. The use of an appropriate treatment considering the reflux features is associated with an improvement of symptoms and findings.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Involvement of Laryngopharyngeal Reflux in Ocular Diseases: A State-of-the-Art Review

BACKGROUND

Laryngopharyngeal reflux-associated symptoms embrace a wide variety of head and neck manifestations. Its participation in eye disorders has recently been postulated, and there is currently no consensus in this regard. The aim of this manuscript is to review the role of reflux in the development of ocular signs and symptoms, and its physio-pathological mechanisms.

METHODS

A systematic approach based on the preferred reporting Items for a systematic review and meta-analysis checklist with a modified population, intervention, comparison, and outcome framework was used to structure the review process of studies that evaluated the possible association, with clear diagnostic methods, of laryngopharyngeal reflux and ocular signs and symptoms. Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through the meta-searcher Trip Database with the keywords: reflux, laryngitis, laryngopharyngeal, gastroesophageal, ocular, eye, symptoms, signs, conjunctivitis, keratitis, dacryocystitis, dry eye.

RESULTS

Seven studies met the inclusion criteria, in which the primary acquired nasolacrimal duct obstruction and the ocular surface disease were evaluated. The local increase of eye pepsin concentration (>2.5 ng/mL) may affect ocular surface though its direct proteolytic activity and the local expression of proinflammatory cytokines. The H. Pylori, with a similar mechanism to reach the lacrimonasal duct, would be associated with the release of proinflammatory and vasoactive substances that would lead to a mucosa injury and chronic inflammation. Ocular Surface Disease Index seems to correlate directly with the reflux severity, with cut-off of 41.67 score as predictor for disease.

DISCUSSION

The role of laryngopharyngeal reflux in the development of ocular disorders has not yet been demonstrated and data are limited and heterogeneous. It seems theoretically conceivable that pepsin may reach lachrymal duct area through hypopharyngeal-nasal gaseous reflux events. Future studies using objective testing for diagnosis and pepsin detection into the tear and nasal mucosa are needed in order to explore this potential relationship.

Chronic Course, Weaning, and Awareness of Patients With Reflux Toward Proton Pump Inhibitor Therapy

OBJECTIVES

To assess the feasibility of middle-term proton pump inhibitor (PPI) weaning in patients with laryngopharyngeal reflux (LPR) and evaluate patient awareness of PPI adverse events.

METHODS

We conducted a cross-sectional study of 100 LPR patients treated with an association of diet, PPIs, and alginate. Patients were followed from September 2016 to May 2020. At the end of the initial 3-to-6 months therapeutic period, LPR patients were weaned from PPIs and instructed to respect diet and stress management over the long-term. The 3-year symptom recurrence rate, PPI use, and patient awareness of PPI adverse events were assessed.

RESULTS

Sixty-seven patients completed the evaluation. Twenty-seven patients (40.3%) reported a chronic course of LPR-symptoms, requiring chronic or occasional PPI use. LPR symptom recurrence occurred 1-to-2 or 3-to-5 times yearly in 8.9% and 20.9% of patients, respectively. Recurrences were managed by short-term diet, alginate, or PPI intake. The remaining patients (29.9%) did not report middle-term LPR recurrence. The 3-year weaning rate of occasional or chronic use of PPIs was 64.2%. Among participants, 26.8% were aware of PPI-related adverse events, most frequently through physicians (33%), online sources (17%), and friends or family (17%). Nonresponder patients were significantly more aware of PPI adverse events than responders (P = 0.029). PPI-attributed adverse events occurred in 29.8% of patients.

CONCLUSION

Sixty-four percent of LPR patients treated with PPIs were weaned at 3-year posttreatment time. Different forms of LPR may exist regarding symptom relief, recurrences, and chronic course.

Impact of subspecialty training on management of laryngopharyngeal reflux: results of a worldwide survey

OBJECTIVE

To study the management of laryngopharyngeal reflux (LPR) among the subspecialties of practicing otolaryngology-head and neck surgeons and their trainees.

METHODS

A survey was sent to over 8000 otolaryngologists (OTOHNS) over 65 countries, utilizing membership lists of participating otolaryngological societies. The outcomes were answers to questions regarding LPR knowledge and practice patterns, and included queries about its definition, prevalence, clinical presentation, diagnosis, and treatment.

RESULTS

Of the 824 respondents, 658 practiced in one specific otolaryngologic subspecialty. The symptoms and findings thought to be the most related to LPR varied significantly between subspecialists. Extra-laryngeal findings were considered less by laryngologists while more experienced OTOHNS did not often consider digestive complaints. Compared with colleagues, otologists, rhinologists and laryngologists were less aware of the involvement of LPR in otological, rhinological and laryngological disorders, respectively. Irrespective of subspecialty, OTOHNS consider symptoms and signs and a positive response to empirical therapeutic trial to establish a LPR diagnosis. Awareness regarding the usefulness of impedance pH-studies is low in all groups. The therapeutic approach significantly varies between groups, although all were in agreement for the treatment duration. The management of non-responder patients demonstrated significant differences among laryngologists who performed additional examinations. The majority of participants (37.1%) admitted to being less than knowledgeable about LPR management.

CONCLUSIONS

LPR knowledge and management vary significantly across otolaryngology subspecialties. International guidelines on LPR management appear necessary to improve knowledge and management of LPR across all subspecialties of otolaryngology.

[Current possibilities and challenges in the diagnosis of laryngopharyngeal reflux]

Laryngopharyngeal reflux (LPR) is defined as backflow of gastral or gastroduodenal content into the upper aerodigestive tract and characterized by a variety of unspecific symptoms such as chronic cough, globus sensation, or mucus hypersecretion. Due to the lack of a gold standard and the heterogeneity of studies, the diagnosis of LPR is still problematic and challenging. However, in patients with characteristic symptoms and endoscopic findings, with an increased reflux symptom index, a pathologic reflux finding score (RFS), pathologic 24 h esophageal or oropharyngeal pH monitoring, and without any other underlying condition, the diagnosis of LPR is probable. In the following review, we critically discuss the abovementioned methods as well as more recent tools such as measurements of pepsin concentrations in the saliva for diagnosis of LPR.

Does Pepsin Saliva Concentration (Peptest™) Predict the Therapeutic Response of Laryngopharyngeal Reflux Patients?

OBJECTIVE

To study the profile and the therapeutic response of patients with laryngopharyngeal reflux (LPR) at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) according to the initial pepsin saliva concentration.

METHODS

From January 2018 to January 2020, patients with positive LPR diagnosis at the HEMII-pH were consecutively recruited from 3 European Hospitals. Saliva pepsin concentration (Peptest™) was measured during the HEMII-pH testing period and patients were classified into 2 groups: negative versus positive Peptest. The clinical outcomes, that is, gastrointestinal and HEMII-pH findings, reflux symptom score-12 (RSS-12), and 3-month therapeutic response, were compared between groups.

RESULTS

A total of 124 patients completed the study. Among them, 30 patients had negative Peptest. Pharyngeal reflux events occurred outside 1-hour post-meal time in 74.0%, after the meals in 20.5% and nighttime in 5.5%. The pepsin saliva level was not significantly associated with the reflux events preceding the sample collection. Patients with positive Peptest had better improvement of RSS-12 digestive and respiratory subscores and oral, pharyngeal, and laryngeal findings compared with patients with negative Peptest.

CONCLUSION

Patients with high saliva pepsin concentration had no stronger gastrointestinal, HEMII-pH, or clinical outcomes compared with those with low or undetectable saliva pepsin concentration.

Management of laryngopharyngeal reflux in Brazil: a national survey

INTRODUCTION

Studies assessing the management of laryngopharyngeal reflux by otolaryngologists have reported an important heterogeneity regarding the definition, diagnosis, and treatment, which leads to discrepancies in the management of the patient. Information about the current knowledge and practices of Brazilian otolaryngologists in laryngopharyngeal reflux is lacking.

OBJECTIVE

To investigate the trends in management of laryngopharyngeal reflux disease among Brazilian otolaryngologists.

METHODS

A survey was sent by email to the members of the Brazilian Association of Otolaryngology-Head Neck Surgery. This survey has initially been conducted by the laryngopharyngeal reflux study group of young otolaryngologists of the International Federation of Otolaryngological Societies.

RESULTS

According to the survey responders, the prevalence of laryngopharyngeal reflux was estimated to be 26.8% of patients consulting in otolaryngology and the most common symptoms were globus sensation, throat clearing, cough and stomach acid reflux. Nasal obstruction, Eustachian tube dysfunction, acute and chronic otitis media, vocal fold nodules and hemorrhage were considered not associated with laryngopharyngeal reflux by the majority of responders. About 2/3 of Brazilian otolaryngologists based the diagnosis of laryngopharyngeal reflux on the assessment of both symptoms and findings and a positive response to empiric therapeutic trials. Proton pump inhibitor utilized once or twice daily, was the most commonly used therapeutic scheme. Only 21.4% of Brazilian otolaryngologists have heard about nonacid and mixed laryngopharyngeal reflux and the awareness about the usefulness of multichannel intraluminal impedance pH monitoring (MII-pH) was minimal; 30.5% of responders did not consider themselves as well-informed about laryngopharyngeal reflux.

CONCLUSION

Although the laryngopharyngeal reflux-related symptoms, main diagnostic and treatment approaches referred by Brazilian otolaryngologists are consistent with the literature, the survey identified some limitations, such as the insufficient awareness of the role of laryngopharyngeal reflux in many otolaryngological conditions and of the possibility of non-acid or mixed reflux in refractory cases. Future studies are needed to establish international recommendations for the management of laryngopharyngeal reflux disease.

Management of Laryngopharyngeal Reflux Around the World: An International Study

OBJECTIVE

To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR).

METHODS

An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment.

RESULTS

A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR.

CONCLUSIONS

LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world.

LEVEL OF EVIDENCE

N.A. Laryngoscope, 131:E1589-E1597, 2021.

Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians

Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.

Laryngopharyngeal Reflux in Hypertrophic Laryngeal Diseases

OBJECTIVES

To evaluate the characteristics of laryngopharyngeal reflux (LPR) in patients with different hypertrophic laryngeal diseases and to explore the relationship between LPR and these diseases.

METHODS

A retrospective analysis was performed. The clinical data of 154 patients were collected. According to their diagnoses, patients were divided into 3 groups. Group 1 included 49 patients with vocal cord polyps. Group 2 contained 52 patients with vocal cord leukoplakia. Group 3 included 53 patients with laryngeal carcinoma. The reflux symptom indexes (RSIs), reflux finding scores (RFSs), and Ryan scores of all patients were evaluated and compared.

RESULTS

Patients with vocal cord polyps were the youngest of the 3 groups, and those with laryngeal carcinoma were the oldest. A male preponderance emerged in each group. In total, 128 patients (83.12%) had positive RSI/RFS values and 60 (60/146, 41.1%) patients had positive Ryan scores. The positive RSI/RFS rates of both groups 1 and 2 (89.80% and 92.16%, respectively) were significantly higher than that of group 3 (69.81%). Moreover, the positive Ryan score rates in both groups 1 and 2 (39.58% and 53.85%, respectively) were significantly higher than that of group 3 (28.26%).

CONCLUSIONS

Laryngopharyngeal reflux occurs in many patients with vocal cord polyps, vocal cord leukoplakia, and vocal cord carcinoma, indicating that LPR may be important in the pathogenesis of these diseases. Laryngopharyngeal reflux occurs more common in patients with vocal cord polyps and leukoplakia and less common in those with laryngeal carcinoma, suggesting the role of LPR on these diseases may be different.