A systematic review of proton-pump inhibitor therapy for laryngopharyngeal reflux

Change in Symptoms and Mucosal Findings after Proton Pump Inhibitor in Patients with Laryngopharyngeal Reflux

Introduction  Although there are several reports of endoscopic findings of the larynx and esophagus in laryngopharyngeal reflux (LPR) patients, little is known about the correlation between change in symptoms and laryngeal and esophageal mucosal findings after proton pump inhibitor (PPI) treatment. Objective  The present study aimed to evaluate the changes in symptoms and mucosal findings of the larynx and esophagus using transnasal esophagoscopy (TNE) after PPI medication and to analyze their relationship in LPR patients. Methods  The current prospective study included 36 patients who complained of LPR symptoms. Reflux Symptom Index (RSI), Reflux Finding Score (RFS), and modified Los Angeles classification using TNE were obtained pretreatment and 8 weeks after treatment with PPIs. Results  Data from 22 patients who completed all examinations were analyzed. The mean age was 52.8 years, and 4 patients were men. The most common symptom was a globus sensation (54.6%). Both RSI ( p <  0.001) and RFS ( p  < 0.001) were significantly improved after 8 weeks with PPI treatment. However, there was no correlation between improvement of RSI and RFS ( p  = 0.350). Thirteen patients showed improvement in esophageal findings. However, there was no significant association between improvement of esophageal findings and RSI ( p  = 0.350) or RFS ( p  = 0.376). Conclusion  Although PPI treatment improved LPR symptoms and endoscopic findings, the change in symptoms was not related to endoscopic mucosal findings in the larynx and esophagus.

[Treatment of laryngeal pathology associated with gastroesophageal reflux disease]

OBJECTIVE

To increase the effectiveness of the treatment of laryngeal pathology associated with gastroesophageal reflux disease (GERD), to determine the indications for the appointment of anti-inflammatory therapy to these patients.

MATERIAL AND METHODS

120 patients were examined and treated, 58 of them men and 62 women, aged 30 to 82 years with GERD-associated laryngeal pathology. Three groups of patients were formed, comparable in age and gender, in accordance with the type of pachydermia in interarytenoid region; type 1 (40 patients) - pachydermia did not go beyond the middle of the interarytenoid cartilage (according to G.F. Ivanchenko), less than 3 mm, without signs of perifocal inflammation; type 2 (40 patients) - pachydermia of large size, extending beyond the middle of the interarytenoid cartilage with a spread to the entire interarytenoid region (according to G.F. Ivanchenko), often in combination with hyperkeratosis or epithelial dysplasia; type 3 (30 patients) - pachydermia of large size in combination with severe perifocal inflammation. All patients received antireflux therapy. Each group is divided into two subgroups: patients who did not receive anti-inflammatory therapy, and patients who received anti-inflammatory therapy, the basis of which was inhalation with degassed alkaline mineral water, as well as according to indications acetylcysteine, benzyldimethylammonium chloride 0.01% or hydroxymethylquinoxalindioxide, with severe swelling of the mucous membrane - budesonide. All patients completed the questionnaire "Reflux Symptoms Scale" before and after treatment.

RESULTS

In group 2 patients (with type 2 pachydermia), the effectiveness of anti-inflammatory therapy was 75%. Of the 20 patients in this group, after inhaled therapy, 4 patients had pachydermia in interarytenoid region disappeared, 11 patients had type 1 pachydermia visualized, 5 (25%) patients had no pronounced dynamics. In group 3 patients (with type 3 pachydermia), the effectiveness of inhaled treatment was 100%, out of 15 patients after inhaled therapy, type 2 pachydermia was diagnosed in 8 patients, type 1 pachydermia - in 7 patients. In 4 patients, complex therapy led to the complete disappearance of reflux-associated laryngeal granulomas without surgical treatment. The effectiveness of inhaled therapy in relation to patient complaints after a month was 87%, while the effectiveness of treatment of patients without inhalation was 45%.

CONCLUSIONS

Indications for the appointment of inhaled anti-inflammatory therapy in patients with reflux-associated pathology of the larynx are the presence of complaints of hoarseness, dryness, tickling, lump in the throat and chronic cough, endolaryngoscopic signs of exacerbation of chronic inflammation of the mucous membrane of the posterior larynx.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

The acid test: Proton pump inhibitors in persistent throat symptoms: A systematic review of systematic reviews

INTRODUCTION

Proton pump inhibitors (PPIs) have evolved to become a frequent treatment option for patients with persistent throat symptoms. The evidence for their use in this context is, however, conflicting. This review assesses the quality of the published systematic reviews and meta-analyses evaluating PPIs in persistent throat symptoms.

METHODS

Following a literature search, systematic review were evaluated using the Reporting of Bias in Systematic Reviews (ROBIS) tool and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Outcome measures were analysed using the "checklist to operationalize measurement characteristics of patient-reported outcome measures."

RESULTS

10 systematic reviews were assessed. All but one were at high risk of bias. No review met the PRISMA checklist criteria. No identified PROM met the checklist requirements for validation. Significant methodological concerns include inappropriate selection of studies for inclusion, poor selection of outcome measures, a lack of appropriate bias assessments and inconsistent reporting of reviews.

CONCLUSION

The quality of evidence concerning the role of PPIs in persistent throat symptoms gives serious cause for concern. Collectively, nine studies at high risk of bias have been cited 714 times. Systematic reviews typically attract these high numbers of citations and, if their premises and conclusions do not withstand scrutiny, they are open to widespread misinterpretation, perpetuation of misunderstanding and negative clinical impact.

Proton Pump Inhibitors for the Treatment of Laryngopharyngeal Reflux. A Systematic Review

BACKGROUND

To give, if possible, an answer in the long-standing debate of the efficacy of proton pump inhibitors (PPIs) in treating laryngopharyngeal reflux (LPR) through published systematic reviews and meta-analyses.

METHOD

PubMed, Cochrane Library, and EMBASE were searched from 1984, the year the term LPR first appeared in the literature, until October 2018. Systematic reviews and meta-analyses comparing the treatment response of PPI therapy in patients with LPR were included in our study.

RESULTS

Nine eligible studies, two systematic reviews and seven meta-analyses, were identified and analyzed in our study. Three of these were published in 2006, one in 2007, one in 2013, and four in 2016. Five studies published before 2016 and one in 2016 showed no benefit from PPI therapy for LPR patients while the three remaining meta-analyses of 2016 showed a significant improvement in LPR symptoms but no significant difference in response rate and reflux finding scores (RFS) between PPI therapy and placebo treatment.

CONCLUSIONS

Based on the existing data, the use of PPI therapy for the treatment of LPR remains questionable. Six out of the nine systematic reviews/meta-analyses concluded that PPI therapy is not superior to placebo and three concluded that PPI therapy significantly improved LPR symptoms although they did not identify any difference in the post-treatment laryngoscopic findings. There is still a long way to go until we can give a definite answer to this question but in the meantime, the use of PPI therapy for the treatment of LPR will continue even though existing evidence is poor and weak, coming mainly from individual uncontrolled studies.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux

Importance

Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions.

Objective

To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions.

Design, Setting, and Participants

This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI).

Main Outcomes and Measures

Recorded change in the RSI after 6 weeks of treatment.

Results

Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68).

Conclusions and Relevance

Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Comparison of the effects of esomeprazole plus mosapride citrate and botulinum toxin A on vocal process granuloma

OBJECTIVES

Vocal process granulomas have a high tendency for persistence despite many treatment alternatives. Anti-reflux medications or botulinum toxin A injections are the main current therapies. There are no studies that compare the effects on vocal process granuloma of proton pump inhibitors plus prokinetic agents with botulinum toxin A injections.

STUDY DESIGN

Prospective cohort study.

METHODS

Adult patients reporting to our outpatient department complaining of trachyphonia and/or abnormal pharyngeal sensations who were found to have contact granulomas. Patients were divided into two groups according to the treatment: esomeprazole with mosapride citrate (n=26) or botulinum toxin A injection (n=20). The reflux symptom index and reflux finding score determined by electronic fibrolaryngoscopy were utilized to assess efficacy.

RESULTS

Forty-six patients were recruited (43 male; 3 female). The mean age (range) was 48.3years (38-69) and the body mass index was 23.51kg/m² (19.13-27.89). Laryngopharyngeal reflux disease diagnosed by RSI or RFS was found in 18 and 27 patients, respectively, and 18 diagnosed without laryngopharyneal reflux disease. Twenty patients (95%) were cured in the esomeprazole with mosapride citrate group and nine (45%) in the botulinum toxin A group. Eleven (55%) patients had recurrence after botulinum toxin A injection, with an average interval of 3.1months (range 1-6). The recorded symptoms after therapy resolved within 6months with a statistically significant improvement in the esomeprazole with mosapride citrate group.

CONCLUSIONS

Combined proton pump inhibitor plus prokinetic drug therapy plays a significant role in the treatment of vocal process granulomas or after surgery.