Treatment of laryngopharyngeal reflux disease: A systematic review

Mucosal integrity of the larynx and hypopharynx and the response to proton pump inhibitors in patients with laryngopharyngeal reflux

PURPOSE

To evaluate whether impairment of integrity of laryngeal and hypopharyngeal mucosa in laryngopharyngeal reflux (LPR) could be related to response to proton pump inhibitors (PPIs).

METHODS

Chronic hoarseness with Reflux Finding Score (RFS) > = 7 was evaluated using the Reflux Disease Questionnaire (RDQ) and Reflux Symptoms Index (RSI). Upper endoscopy was performed and samples of the laryngeal posterior commissure were collected to evaluate ex vivo laryngeal mucosal integrity by transepithelial resistance (TER) using Ussing chamber. In vivo, hypopharyngeal integrity was measured using intraluminal impedance. Clinical responders scored < 13 and had a drop of at least 50% in the initial RSI after 8 weeks of pantoprazole.

RESULTS

Eighteen patients completed the protocol, Esophagitis was detected in 28% of the patients, and one patient presented acid exposure above 6%. After treatment, 66.67% responded to PPI. Laryngeal basal TER and TER drops after the weakly acidid challenge showed no difference between PPI responders and non-responders. Hypopharyngeal basal impedance was similar between the groups. After acid exposure test, there was a lower impedance in non-responders.

CONCLUSION

In laryngopharyngeal reflux, hypopharyngeal mucosal integrity was lower in PPI non-responders. These preliminary results suggest that the weaker laryngopharyngeal mucosa in refractory LPR may require new therapies aimed at improving barrier function.

LEVEL OF EVIDENCE

N/A.

Development of a Machine Learning Model to Predict Therapeutic Responses in Laryngopharyngeal Reflux Disease

OBJECTIVES

Laryngopharyngeal reflux disease (LPRD) is a challenging condition requiring effective treatment. Thus, understanding the factors that influence therapeutic response in LPRD is crucial. This study leverages machine learning models to predict the therapeutic responses and identify the key influencing factors in LPRD.

METHODS

Patients with typical LPRD symptoms showing more than one pharyngeal reflux episode on 24-hour multichannel intraluminal impedance (MII)-pH monitoring were collected retrospectively from two independent otolaryngologic clinics. Patients who were prescribed proton pump inhibitor therapy and followed up for at least 2 months were included. Patients who showed a ≥50% decrease in the follow-up reflux symptom index score during treatment periods compared with pre treatment were defined as responders. Among various demographic and 24-hour MII-pH monitoring parameters, features showing the absolute correlation coefficients ≥0.1 with response were selected. Four machine learning models-logistic regression, random forest, support vector machine, and gradient boosting-were applied to the training cohort and assessed in the internal and external validation cohorts.

RESULTS

Patients from two otolaryngologic clinics were assigned to the internal dataset (n = 157) and external dataset (n = 53). All four models showed comparable predictive performances, illustrating their potential utility in clinical decision-making. Among them, the logistic regression model demonstrated the best performance with accuracy and F1 scores of 82.98% and 88.24% in the internal validation cohort and 84.91% and 86.21% in the external validation cohort predicting therapeutic responses in LPRD. Feature importance analysis revealed vital factors, such as proximal total reflux time and weak acid time, influencing therapeutic response, and offering insights into LPRD management.

CONCLUSIONS

This study provides valuable insights into the factors influencing the therapeutic response in LPRD, underscoring the utility of machine learning in refining treatment strategies. Our findings suggest that integrating machine learning models into clinical practice can significantly improve LPRD management.

Reflux Symptom Index: Translation to the Kazakh Language and Validation

BACKGROUND

This research focuses on the translation and validation of the Reflux Symptom Index (RSI) in Kazakh language and the comparison of its results among patients with symptoms of Laryngopharyngeal reflux (LPR) and without LPR symptoms.

OBJECTIVE

This study aims to translate and validate the RSI in Kazakh language (Kz-RSI).

METHODS

The RSI from the original American English version has been translated according to standard procedures into Kazakh language. The study included 248 patients, 124 LPR patients, and 124 asymptomatic controls. A final version of the Kz-RSI was tested twice: on Day 0 and Day 14 for participants without LPR symptoms and on Day 0 and posttreatment for those with LPR symptoms. Reliability, validity, and internal consistency of test-retest were calculated.

RESULTS

The Cronbach's alpha value for Kz-RSI was 0.94, indicating excellent internal consistency. The single measurement absolute agreement of the interclass correlation coefficient was 0.90 (95% confidence interval [0.86; 0.93]), which indicates good retest reliability. The total Kz-RSI scores and each item were significantly higher in the LPR group than in the control group (P < 0.001). In the posttreatment LPR patient group, the Kz-RSI scores for each item and overall were significantly lower than the pretreatment scores (P < 0.001).

CONCLUSIONS

Kz-RSI has been successfully translated and validated to identify LPR among the Kazakh-speaking population. Moreover, it is an inexpensive method with strong internal consistency, high retesting rates, reliability, and optimal clinical validity.

The Inhibitory Effect of Hedera helix and Coptidis Rhizome Mixture in the Pathogenesis of Laryngopharyngeal Reflux: Cleavage of E-Cadherin in Acid-Exposed Primary Human Pharyngeal Epithelial Cells

Laryngopharyngeal reflux disease (LPRD) is a prevalent upper airway disorder characterized by inflammation and epithelial damage due to the backflow of gastric contents. Current treatments, primarily proton pump inhibitors (PPIs), often show variable efficacy, necessitating the exploration of alternative or adjunctive therapies. This study investigates the therapeutic potential of a mixture of Hedera helix and Coptidis rhizome (HHCR) in mitigating the pathophysiological mechanisms of LPRD. Using an in vitro model of human pharyngeal epithelial cells exposed to acidic conditions, we observed that acid exposure significantly increased the expression of adenosine A3 receptor (adenosine A3) and matrix metalloproteinase-7 (MMP-7), leading to E-cadherin cleavage and compromised epithelial integrity. Treatment with the HHCR mixture effectively suppressed adenosine A3 expression and MMP-7 activity, thereby reducing E-cadherin cleavage and preserving cellular cohesion. These results highlight the HHCR mixture's ability to modulate the adenosine A3-MMP-7-E-cadherin pathway, suggesting its potential as a valuable adjunctive therapy for LPRD, particularly for patients unresponsive to conventional PPI treatment. This study provides new insights into the molecular interactions involved in LPRD and supports further clinical evaluation of HHCR as a complementary treatment option.

Efficacy and safety of fexuprazan in patients with symptoms and signs of laryngopharyngeal reflux disease: a randomized clinical trial

PURPOSE

Laryngopharyngeal reflux disease (LPRD) is mainly treated with proton pump inhibitors (PPI) such as esomeprazole, which have shortcomings like delayed absorption and increased osteoporosis. Fexuprazan is a novel potent potassium-competitive acid blocker that inhibits gastric acid secretion with rapid onset and long duration of action. To assess the efficacy and safety of fexuprazan compared to esomeprazole in patients with LPRD.

METHODS

This prospective, randomized, double-blinded, multicenter, active-controlled trial was conducted in nine otolaryngologic clinics. Patients with reflux symptom index (RSI) ≥ 13 and reflux finding score (RFS) ≥ 7 were randomly assigned to the fexuprazan or esomeprazole groups, and received fexuprazan 40-mg or esomeprazole 40-mg once daily for 8 weeks. The outcomes were (1) mean change, change rate, and valid rate in RSI, RFS, and LPR-related questionnaires; and (2) adverse events.

RESULTS

A total of 136 patients (fexuprazan n = 68, esomeprazole n = 68) were followed up for ≥ 1 month. Each parameter significantly improved after 4 and 8 weeks in each group, with no significant differences between the two groups. For those with severe symptoms (RSI ≥ 18), the fexuprazan group (n = 32) showed more improvement in the mean change and change rate in the RSI than esomeprazole group (n = 31) after 4 weeks (p = .036 and .045, respectively). This phenomenon was especially observed in hoarseness and troublesome cough.

CONCLUSION

Fexuprazan improved symptoms and signs without no serious adverse events in patients with LPRD. In patients with severe symptoms, fexuprazan resulted in a faster symptom improvement than PPI.

TRIAL REGISTRATION

KCT0007251, https://cris.nih.go.kr/cris/search/detailSearch.do?seq=22100 .

The Impact of Nutrition on the Onset, Course of Disease and Quality of Life of Patients with Laryngopharyngeal Reflux

Research background

The role of dietary habits of patients with laryngopharyngeal reflux (LPR) is comparatively underexplored. The aim of the study is to examine dietary habits, onset and course of the disease as well as the quality of life of patients with LPR.

Experimental approach

The results of the modified food frequency questionnaire (FFQ-m) and laryngopharyngeal reflux health-related quality of life (LPR-HRQL) questionnaires were compared between subjects with and without LPR. There were a total of 100 subjects with LPR and 65 subjects in the control group. The group of subjects with LPR was further randomly divided into two subgroups; the first subgroup was treated with esomeprazole at a dose of 20 mg twice daily combined with the instructions for dietary and general lifestyle changes, and the other with pantoprazole at a dose of 20 mg twice daily combined with the instructions for dietary and general lifestyle changes. Participants were instructed to fill out FFQ-m and LPR-HRQL questionnaires immediately after the initial examination and then after control examinations 30 and 60 days after the initial examination.

Results and conclusions

Patients with LPR consume more food with high reflux potential, drink more carbonated drinks and juices and have a worse quality of life than the control group (p<0.001). Taking proton pump inhibitors at a dose of 20 mg twice daily in combination with a change in dietary habits such as substituting acidic, spicy, fermented, sweet, fried foods and other foods with a high reflux potential as well as carbonated drinks and juices with the food with a low reflux potential and water significantly reduced the symptoms of LPR and increased the quality of life of the patients (p<0.001).

Novelty and scientific contribution

This is the first study showing the correlation between dietary habits and the quality of life of patients with LPR. The contribution of this research is an objective assessment of the follow-up of patients with LPR that could be used in their regular assessment.

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.

Amprenavir inhibits pepsin-mediated laryngeal epithelial disruption and E-cadherin cleavage in vitro

Background

Laryngopharyngeal reflux (LPR) causes chronic cough, throat clearing, hoarseness, and dysphagia and can promote laryngeal carcinogenesis. More than 20% of the US population suffers from LPR and there is no effective medical therapy. Pepsin is a predominant source of damage during LPR which disrupts laryngeal barrier function potentially via E-cadherin cleavage proteolysis and downstream matrix metalloproteinase (MMP) dysregulation. Fosamprenavir (FDA-approved HIV therapeutic and prodrug of amprenavir) is a pepsin-inhibiting LPR therapeutic candidate shown to rescue damage in an LPR mouse model. This study aimed to examine amprenavir protection against laryngeal monolayer disruption and related E-cadherin proteolysis and MMP dysregulation in vitro.

Methods

Laryngeal (TVC HPV) cells were exposed to buffered saline, pH 7.4 or pH 4 ± 1 mg/mL pepsin ± amprenavir (10-60 min). Analysis was performed by microscopy, Western blot, and real time polymerase chain reaction (qPCR).

Results

Amprenavir (1 μM) rescued pepsin acid-mediated cell dissociation (p < .05). Pepsin acid caused E-cadherin cleavage indicative of regulated intramembrane proteolysis (RIP) and increased MMP-1,3,7,9,14 24-h postexposure (p < .05). Acid alone did not cause cell dissociation or E-cadherin cleavage. Amprenavir (10 μM) protected against E-cadherin cleavage and MMP-1,9,14 induction (p < .05).

Conclusions

Amprenavir, at serum concentrations achievable provided the manufacturer's recommended dose of fosamprenavir for HIV, protects against pepsin-mediated cell dissociation, E-cadherin cleavage, and MMP dysregulation thought to contribute to barrier dysfunction and related symptoms during LPR. Fosamprenavir to amprenavir conversion by laryngeal epithelia, serum and saliva, and relative drug efficacies in an LPR mouse model are under investigation to inform development of inhaled formulations for LPR.

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.

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.

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.

Effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases: physiopathology and therapeutic targets

PURPOSE

Laryngopharyngeal reflux disease (LPRD) is a general term for the reflux of gastroduodenal contents into the laryngopharynx, oropharynx and even the nasopharynx, causing a series of symptoms and signs. Currently, little is known regarding the physiopathology of LPRD, and proton pump inhibitors (PPIs) are the drugs of choice for treatment. Although acid reflux plays a critical role in LPRD, PPIs fail to relieve symptoms in up to 40% of patients with LPRD. The influence of other reflux substances on LPRD, including pepsin, bile acid, and trypsin, has received increasing attention. Clarification of the substances involved in LPRD is the basis for LPRD treatment.

METHODS

A review of the effects of acids, pepsin, bile acids, and trypsin on laryngopharyngeal reflux diseases was conducted in PubMed.

RESULTS

Different reflux substances have different effects on LPRD, which will cause various symptoms, inflammatory diseases and neoplastic diseases of the laryngopharynx. For LPRD caused by different reflux substances, 24-h multichannel intraluminal impedance combined with pH-metry (MII-pH), salivary pepsin, bile acid and other tests should be established so that different drugs and treatment courses can be used to provide patients with more personalized treatment plans.

CONCLUSION

This article summarizes the research progress of different reflux substances on the pathogenesis, detection index and treatment of LPRD and lays a theoretical foundation to develop target drugs and clinical diagnosis and treatment.

How to Understand and Treat Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Effects of Antiacid Therapy on Granuloma after Transoral Type IV-VI Cordectomy in Patients with Early-Stage Glottic Cancer

Objective

To investigate whether preventive administration of a proton pump inhibitor (PPI) can reduce the occurrence and development of traumatic granuloma (TG) following type IV-VI cordectomy.

Methods

We retrospectively analyzed the status of postoperative granulomas in 37 patients who underwent type IV-VI cordectomy due to glottic cancer and determined whether postoperative administration of a PPI had any impact on granuloma formation and development.

Results

The percentage and number of patients with granuloma in the PPI treatment group (experimental group) at the 1st, 2nd, 3rd, and 6th month following surgery were 81.25% (13/16), 25.00% (4/16), 18.75% (3/16), and 0.00% (0/16), respectively. The percentage and number of patients with granuloma in the no-PPI group (control group) were 95.24% (20/21), 71.43% (15/21), 52.38% (11/21), and 14.29% (3/21), respectively. The granuloma percentage of the PPI treatment group was lower than that of the control group at all postoperative time points assessed. The differences were not statistically significant at the 1st month (p = 0.175) but were statistically significant at the 2nd and 3rd months after surgery (p = 0.005, p = 0.037).

Conclusion

Preventive use of a PPI in patients after type IV-VI cordectomy can shorten the TG recovery duration and may reduce the severity of TG, but it cannot prevent TG from occurring. Our results should be confirmed by prospective randomized controlled trials with large sample sizes.

Is empirical treatment a reasonable strategy for laryngopharyngeal reflux? A contemporary review

BACKGROUND

Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing.

OBJECTIVES

To review contemporary evidence that does and does not support empiric medication trials for presumed LPR.

METHODS

PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices.

RESULTS

The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-oesophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR.

CONCLUSIONS

Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with non-acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.