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Laryngopharyngeal Reflux: Position Statement of the Committee on Speech, Voice, and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery
... Laryngopharyngeal reflux (LPR) refers to symptoms (dysphonia, globus, etc.) and morphological changes in the larynx due to direct or indirect damage caused by reflux of gastroduodenal contents such as acid and pepsin. 88,199,200 The true prevalence of LPR is unclear but estimated at 10%-30% in the Western population, accounting for 10% of otolaryngology consultations. 201 The lack of tools to accurately diagnose LPR, and the possible multifactorial etiologies for its symptoms pose a challenge in clinical practice. ...
... [199][200][201]216,217 The pharyngeal pH measurement system (RESTECH) was developed as a less invasive and more tolerable test to detect acid in liquid or aerosol form in the hypopharynx during 24 h. 88 However, a study that evaluated 24-h RESTECH monitoring in 10 patients with total gastrectomy and no reflux symptoms, found that the test revealed pathologic reflux in 60% of the subjects, 218 casting doubt on the usefulness of this test in LPR. ...
... Level of agreement: 93%. Barrett's esophagus and peptic stenosis were not addressed as they are strongly associated with GERD and endorsed by the Lyon and Porto consensus as diagnostic of GERD.Quality of evidence: LOW ⨁ ⨁ ◯ ◯GRADE Recommendation: STRONGLY AGAINSTClinical relevance: Laryngoscopy is not recommended to diagnose GERD, though it is important to rule out non-GERD pathologies like cancer.20%-60% of the North American population presents symptoms suggestive of laryngopharyngeal reflux (LPR), but there is no gold standard for its diagnosis.[86][87][88] A presumptive LPR diagnosis, often made based on symptoms and laryngoscopic findings, has a strong impact on health economics, 60 with a 14-fold increase in PPI prescriptions for this from 1990 to 2001.89,90 ...
Background
Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH‐metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts.
Methods
This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard.
Key Results
A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI‐refractory symptoms and normal endoscopy require reflux monitoring by pH or pH‐impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH‐impedance can identify supragrastric belching, impedance‐manometry can diagnose rumination.
Conclusions
Erosive esophagitis on endoscopy and abnormal pH or pH‐impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.
... 1,2 This condition is characterized by non-specific symptoms such as hoarseness, coughing, and dysphagia, which can make LPR difficult to diagnose and treat because they can be caused by various underlying conditions. 3,4 It is estimated that 40% of people in Western populations experience LPR symptoms, and the prevalence of this condition is likely to increase as a result of population aging and lifestyle factors, such as diet and stress. 5 The precise pathogenesis of LPR remains incompletely understood; however, it is thought to result from exposure of the laryngopharynx to both acidic and non-acidic gastric contents. ...
... Numerous studies have investigated the efficacy of PPIs in reducing LPR symptoms, but few have directly compared different dosing regimens. At present, twicedaily dosing is the recommended approach, 3,7 and some studies support the use of a twice-daily regimen over a once-daily regimen. [10][11][12] However, the evidence for the optimal dosing regimen of PPIs in LPR is limited, leading to uncertainty regarding the superiority of 1 regimen over another. ...
Background/aims:
Proton pump inhibitors (PPIs) play a crucial role in managing laryngopharyngeal reflux (LPR), but the optimal dosing regimen remains unclear. We aim to compare the effectiveness of the same total PPI dose administered twice daily versus once daily in LPR patients.
Methods:
We conducted a prospective randomized controlled trial at a tertiary referral hospital, enrolling a total of 132 patients aged 19 to 79 with LPR. These patients were randomly assigned to receive either a 10 mg twice daily (BID) or a 20 mg once daily (QD) dose of ilaprazole for 12 weeks. The Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) were assessed at 8 weeks and 16 weeks. The primary endpoint was the RSI response, defined as a reduction of 50% or more in the total RSI score from baseline. We also analyzed the efficacy of the dosing regimens and the impact of dosing and duration on treatment outcomes.
Results:
The BID group did not display a higher response rate for RSI than the QD group. The changes in total RSI scores at the 8-week and 16- week visits showed no significant differences between the 2 groups. Total RFS alterations were also comparable between both groups. Each dosing regimen demonstrated significant decreases in RSI and RFS.
Conclusions:
Both BID and QD PPI dosing regimens improved subjective symptom scores and objective laryngoscopic findings. There was no significant difference in RSI improvement between the 2 dosing regimens, indicating that either dosing regimen could be considered a viable treatment option.
... Laryngopharyngeal reflux (LPR) is a disease caused by the backflow of stomach contents into the laryngopharynx. 1 Based on survey data from Otolaryngologists in the West and East Asia, it was discovered that up to 70% of patients were diagnosed with LPR in numerous Asian nations. 2 Furthermore, LPR diagnoses ranged from 10% to 30% in Western countries. 3 In 2018, 20-30% of patients with laryngeal complaints were diagnosed with LPR in Indonesia. ...
... The combination of these causes edema of the vocal folds, ulcers, and granulomas resulting in symptoms of hoarseness and a lumpy feeling in the throat. 1,8 ...
... Laryngopharyngeal reflux (LPR) is retrograde flow of gastric contents to the larynx and pharynx through the esophagus. The term was coined and preferred by otolaryngologists who defined LPR as "backflow of the stomach contents in to the throat, that is, into the laryngopharynx" [11]. It was stated that LPR differed from classic GERD in pathophysiologic mechanics as well as treatment response [11] which initiated a persistent controversy. ...
... The term was coined and preferred by otolaryngologists who defined LPR as "backflow of the stomach contents in to the throat, that is, into the laryngopharynx" [11]. It was stated that LPR differed from classic GERD in pathophysiologic mechanics as well as treatment response [11] which initiated a persistent controversy. LPR may be described as a phenotype of GERD by some gastroenterologists [12] whereas e.g. the American Gastroenterology Association (AGA) expert review on EE GERD published in 2023 does not use the term LPR at all [13]. ...
Background
The prevalence of gastroesophageal reflux disease (GERD) has had a marked increase in Western countries with a paralleling interest in extraesophageal (EE) manifestations of GERD, including laryngopharyngeal reflux (LPR). There are considerable differences in clinical practice between gastroenterologists, otolaryngologists and pulmonologists.
Methods
In this narrative review we address some of these controversies concerning EE manifestations of GERD and LPR.
Results
It is disputed whether there is causal relationship between reflux and the numerous symptoms and conditions suggested to be EE manifestations of GERD. Similarly, the pathophysiology is uncertain and there are disagreements concerning diagnostic criteria. Consequently, it is challenging to provide evidence-based treatment recommendations. A significant number of patients are given a trial course with a proton pump inhibitor (PPI) for several months before symptoms are evaluated. In randomized controlled trials (RCTs) and meta-analyses of RCTs PPI treatment does not seem to be advantageous over placebo, and the evidence supporting that patients without verified GERD have any benefit of PPI treatment is negligible. There is a large increase in both over the counter and prescribed PPI use in several countries and a significant proportion of this use is without any symptomatic benefit for the patients. Whereas short-term treatment has few side effects, there is concern about side-effects after long-term use. Although empiric PPI treatment for suspected EE manifestations of GERD instead of prior esophageal 24-hour pH and impedance monitoring is included in several guidelines by various societies, this practice contributes to overtreatment with PPI.
Conclusion
We argue that the current knowledge suggests that diagnostic testing with pH and impedance monitoring rather than empiric PPI treatment should be chosen in a higher proportion of patients presenting with symptoms possibly attributable to EE reflux.
... Many otorhinolaryngologists believe that globus symptoms are linked to esophageal conditions, especially laryngopharyngeal reflux (LPR). LPR is defined as the retrograde flow of gastric contents into the larynx and pharynx via the esophagus [2]. Unlike the esophageal mucosa, which is more resistant to gastric acid, the larynx and pharynx are highly sensitive, making patients with LPR more prone to experiencing laryngeal symptoms. ...
Background/Objectives: This study investigated the potential chemopreventive role of proton pump inhibitor (PPI) use in relation to the occurrence of head and neck cancer (HNC) within a national cohort amid concerns of PPI overprescription. Methods: From a cohort of 1,137,861 individuals and 219,673,817 medical claim records collected between 2005 and 2019, 1677 HNC patients were identified and matched 1:4 with 6708 controls after adjusting for covariates. Odds ratios (ORs) for PPI use and its duration in relation to HNC and its subsites were estimated using propensity score overlap-weighted multivariable logistic regression. Additional subgroup analyses were performed based on age, sex, income level, and geographic region. Results: In the crude model, both current (OR 7.85 [95% CI 6.52–9.44]) and past PPI (OR 1.44 [95% CI 1.23–1.70]) use were associated with increased odds for HNC. However, after overlap weighting, this association reversed for both current (aOR 0.14 [95% CI 0.11–0.17]) and past PPI (aOR 0.69 [95% CI 0.60–0.79]). Subsite analysis showed reduced odds for hypopharyngeal (aOR 0.33, [95% CI 0.25–0.43]) and laryngeal cancer (aOR 0.19 [95% CI 0.16–0.22]) in current PPI users and similar results for past users. Conclusions: This study suggests a potential chemopreventive effect of PPIs, particularly in hypopharyngeal and laryngeal cancers. Additional studies are required to investigate the mechanisms underlying the association of the development of HNC with PPI use.
... It could be defined as the reflux of gastric contents into the upper aerodigestive tract, with the absence of classical symptoms of GERD (heartburn and regurgitation). (Yazici et al, 2010 andKoufman et al, 2002). ...
Gastroesophageal reflux disease is a chronic, complex condition that may present with atypical symptoms, including laryngitis. The aim of study to demonstrates the relationship of sings of reflux laryngitis in patients with typical manifestations of Gastroesophageal reflux disease (GERD). The present study included a total of 60 patients suffering chronic laryngitis with a range of age of 23 to 88 years in descriptive study in Benghazi Medical Center in the year 2018. History was collected and indirect laryngoscopy done for cases and data were analyzed using SPSS 23.0. Results The most common symptoms were hoarseness of voice, throat clearing, dysphagia, throat discomfort and globus sensation. No significant association of symptoms with gender of the patients. Most common laryngeal findings were hyperemia, vocal cord changes and posterior commisure hypertrophy. Significant association included only posterior commissure hypertrophy and infra-glottal edema. Conclusions and recommendations, Many didn't seek medical advice and most had no diagnostic procedure. Stronger study designs using proper diagnostic technique and patient education with staff training are recommended.
... Регулярный желудочный рефлюкс оказывает непосредственное цитотоксическое воздействие на слизистую верхних дыхательных путей, а отсутствие в данной анатомической области перистальтики, характерной для стенок пищевода, позволяет кислотам и энзимам оставаться на слизистой дольше, взаимодействовать друг с другом, потенцируя негативный эффект [10][11][12]. Исходя из этого, формируются многочисленные клинические проявления НФР и ЛФР от рецидивирующих фарингитов до формирования неопластических процессов [13][14][15][16][17]. Регулярные нарушения гомеостаза эпителиальной выстилки верхних дыхательных путей ослабляют ее барьерную функцию, способствуя колонизации микроорганизмов и увеличивая вероятность хронического воспаления [18,19]. ...
The extraesophageal reflux effect investigation on the middle ear structures in adults is of considerable interest. The gastroesophageal reflux disease associated otitis media formation mechanism is closely related to such concepts as nasopharyngeal reflux and laryngopharyngeal reflux. It has been established that the pathophysiological mechanism originates in the nasopharynx and further spread to the middle ear structures. The tympanic cavity mucous membrane under the gastric enzymes influence is prone to remodeling, which results in the various chronic inflammation types gradual formation. The study purpose was to analyze medical literature from 1990 to 2024, aimed at studying the middle ear cavity inflammation causes and mechanisms formed by the gastric contents influence. As materials and methods, this article uses publications in such scientific databases as PubMed, eLIBRARY, Science Direct, Research Gate. The analyzed scientific materials provide insight into the relationship between the tympanic cavity inflammation formation and extraesophageal manifestations of GERD, as well as the potential negative H. Pylori impact on the middle ear structures. Conclusions. A detailed understanding of the middle ear cavity inflammation formation by pathophysiological mechanisms of the extraesophageal reflux influence, consisted of various gastrointestinal tract components had been obtained. The potential H. Pylori role in the tympanic cavity mucous membrane alteration remains controversial. This is due to the large number of scientific publications conflicting results in this research field. Major scientific studies confirm that gastroesophageal reflux disease acts as a risk factor for the different types middle ear cavity inflammation formation
... 5 Despite its implications, LPRD has historically been underdiagnosed and undertreated. 6,7 Research has linked LPRD with various laryngeal conditions, ranging from functional issues such as muscle tension and dysphonia, to structural abnormalities like spasm and stenosis, and even malignant transformation. [8][9][10][11][12] Factors such as increased tobacco and table salt consumption are associated not only with hypertension and renal disease but also with elevated LPRD risk, whereas physical exercise and dietary fiber intake have been shown to reduce this risk. ...
Background: Laryngopharyngeal reflux disease (LPRD) is characterized by vague symptoms, often leading to delayed presentation and advanced disease, potentially increasing the risk of malignancy. The extent and clinical features of this condition remain poorly understood among patients seeking Otorhinolaryngology services in Bihar. Methods: This descriptive cross-sectional study was conducted at Narayan Medical College and Hospital within the Department of Otorhinolaryngology. It included patients exhibiting symptoms of Laryngopharyngeal reflux disease. Data collection utilized questionnaires and clinical examination forms, with analysis performed using Microsoft Excel. Results were presented through frequency tables, cross-tabulations, and figures. Results: In this study, 210 participants were enrolled, of whom 137 (65.24%) were females. The median age was 35.5 years with an interquartile range of 21-50 years. The prevalence of Laryngopharyngeal reflux disease was found to be 18.57%, with no gender preference observed. The most common symptoms reported were globus sensation and hoarseness of voice, affecting 97.44% and 94.87% of participants, respectively. The most frequently observed signs included thick endo laryngeal mucus (94.87%) and erythema/hyperemia (84.62%). Risk factors identified included lying down within two hours after meals and consumption of spicy foods. The most prevalent comorbid conditions associated with Laryngopharyngeal reflux disease were hypertension and Type 2 diabetes Mellitus. Conclusion: The prevalence of laryngopharyngeal reflux disease is high among patients attending Otorhinolaryngology services at Narayan medical College and hospital. All patients with laryngopharyngeal reflux disease related symptoms should get thorough evaluation for early diagnosis and treatment.
... The clinical diagnosis is still challenging according to the non-specific laryngeal and extra-laryngeal symptoms and findings that can be found in many other otolaryngological conditions [2,3]. In the United States, the number of publications dedicated to LPR progressively increased since the end of the nineties [4][5][6], which improved the awareness of American practitioners towards the differences between LPR and gastroesophageal reflux disease (GERD), and the related LPR management [7]. The findings of a recent international survey supported awareness differences towards LPR across world regions [8]. ...
Objective
To investigate the impact of physician unawareness towards laryngopharyngeal reflux (LPR) on healthcare costs.
Methods
Patients with a confirmed LPR diagnosis were consecutively recruited from Belgian Hospitals. Demographics and clinical outcomes (impedance-pH testing features, reflux symptom score, and reflux sign assessment) were extracted. The past consultations and additional examinations dedicated to the investigation of laryngopharyngeal symptoms and findings without suspicion of LPR were collected. The estimated costs of consultations and procedures were those indicated in the National Health Insurance Institute's Charges for 2022. Part was reimbursed by the social security system, and the rest was paid by patients.
Results
Seventy-six patients were recruited. Seventeen patients (22.4%) had no previous consultation or additional examination for their LPR-symptoms. The estimated mean (standard deviation) costs related to the unawareness of LPR for the healthcare system and patient, were 310.06 ± 370.49 €, and 54.05 ± 46.28 €, respectively. The highest estimated costs were related to gastroenterology consultations and procedures, which did not lead to a confirmation of LPR diagnosis. The total estimated cost for the Belgian healthcare system and patients (11,590,000 million), could range from 359 359 540 € to 1 078 078 620 €; and 62 643 950 € to 187 931 850 €, respectively. The estimated costs related to gastroenterology practice of patients with severe disease were significantly higher than patients with mild disease.
Conclusion
The unawareness of practitioners toward LPR leads to significant costs for healthcare system and patients. The teaching and awareness towards LPR need to be improved in medical schools and clinical practice.
... Der laryngopharyngeale Reflux (LPR) ist ein sekundär entzündlicher Zustand, der durch Rückstrom von saurem Mageninhalt in den Laryngopharynx verursacht wird und zur Reizung der Schleimhaut im oberen Aerodigestivtrakts führt (Koufman et al. 2002). Der LPR kann zu Irritationen der Interarytänoidregion des Larynx mit weißlicher Schleimhautverfärbung und quer stehenden Falten in diesem Bereich (Laryngitis posterior) führen. ...
... По данным Техасского университета, явления ЛФР встречаются у 50 млн американцев [30]. Роль ЛФР в развитии ХФ неоднократно была продемонстрирована в ряде исследований [31][32][33][34]. Последнее определяет необходимость проведения комплексного гастроэнтерологического обследования у пациентов с ХФ, особенно резистентным к стандартным схемам терапии. ...
Chronic nonspecific pharyngitis (CNP) is an extremely common pathology, but there are no consensus documents regulating the diagnosis and treatment of CNP. We compiled a questionnaire with a list of questions on the problem of CNF, distributed a google form among practitioners and conducted a survey with subsequent analysis of the answers. Then, a search and analysis of scientific works on this topic was carried out on the platforms PubMed, eLibrary.Ru , CyberLeninka, as well as in other open Internet sources. The data of the survey of specialists are compared with the results of the literature review. Therapeutic and diagnostic approaches in CNF are largely determined by the traditional ways of life of a medical institution. This fact, as well as the lack of regulatory documents on the problem of CNF, makes it difficult to competently diagnose and choose an adequate treatment tactics for this disease. The results of the study suggest that CF should be considered as a multifactorial disease, paying attention to the comorbid profile of the patient. The vast majority of respondents consider gastroesophageal reflux and other gastroenterological diseases to be the main predisposing factors. This is confirmed by the literature, and the specialists interviewed by us suggest that the main bias should be made to the assessment of complaints, anamnesis, and pharyngoscopy. Therapy of CNF with the use of only topical drugs is prescribed everywhere, but does not give the desired result. It is necessary to have a multi-stage treatment aimed at eliminating predisposing factors and correcting local changes with the involvement of not only otorhinolaryngologists, but also doctors of other specialties (gastroenterologists, endocrinologists, psychiatrists and neurologists).
... The presence of LPR in OSA is very frequent: 20%-67% OSA patients coexist with LPR. 7 In recent years, many studies have explored the association between OSA and LPR, but the correlation between them is still controversial. Some studies demonstrated that CPAP treatment significantly improved reflux symptoms in OSA patients. ...
Objectives. The study used re¬flux symptom index (RSI) and Reflux Finding Score (RFS) questionnaire to estimate laryngopharyngeal reflux (LPR) change after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA). Design. An observational, retrospective study. Setting. University, tertiary level hospital. Participants. 91 subjects were recruited and divided into three groups: control group (n=27), OSA mild to moderate group (n=29) and OSA severe group (n=35) according to polysomnography. All subjects completed preoperative RSI and RFS under electronic laryngoscope. 34 OSA patients with UPPP surgery completed postoperative polysomnography, again after 6-month follow-up. Main outcome measures. Polysomnography, RSI and RFS questionnaire. Results. RSI and RFS in OSA patients were higher than non-OSA patients. Severe OSA patients also had higher RSI and RFS than mild to moderate OSA. LPR symptoms had positive and L-SpO2 had negative correlation with AHI and CT90. The mean RSI and RFS before UPPP surgery were 15.88±4.85 and 13.18±4.80; these number decreased to 9.53±4.16 and 8.65±4.87 after surgery (P<0.05). In 25 successful-surgery patients, RSI and RFS scores and individual variables of RSI were downward after surgery. Conclusion. LPR symptoms are common among OSA patients, the coexistence of OSA and LPR cannot be ignored. Successful UPPP surgery as a treatment for OSA patients, poten¬tially reduces laryngeal reflux symptoms and improves laryngoscope signs by alleviating sleep respiratory disorder.
... LPR was diagnosed based on several symptoms, such as frequent throat clearing, hoarseness, throat irritation, and chronic cough, lasting for more than 3 months, as well as the Reflux Symptom Index (RSI) score and the Reflux Finding Score (RFS) obtained during laryngoscopy [5][6][7]. The RSI [7] considers 9 symptoms rated on a scale from 0 to 5, according to their impact on daily life (0=no problem, 5=severe problem), and was used to quantify the severity of the reflux symptoms. ...
Background and Objectives: Laryngopharyngeal reflux (LPR) is an increasingly common disease, characterized by stomach acid reflux reaching the upper airways. Postnasal drip (PND) is a known consequence of LPR, defined as mucus accumulation perceived in the posterior areas of the nose and throat. PND is among the most common causes of persistent cough, hoarseness, sore throat, and other symptoms, affecting the quality of life. This study aimed to evaluate the effects of a proton-pump inhibitor (PPI) on PND symptoms in patients with LPR.Methods: We prospectively enrolled patients diagnosed with LPR at our institution between September 2019 and June 2020. The patients were randomly assigned to either the treatment group (20 mg of ilaprazole daily for 8 weeks) or the control group. The scores for the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), and Sino-Nasal Outcome Test (SNOT)-20 were evaluated at baseline and at the end of treatment, focusing on PND symptoms.Results: Eighty patients (28 men and 52 women; mean age, 48.8 years, range, 22–78 years) were enrolled, with 43 in the treatment group and 37 in the control group. The initial RSI, RFS, and SNOT-20 scores were similar between the two groups, and they decreased significantly only in the treatment group (p=0.002, p<0.001, and p=0.015, respectively). However, the PND symptom scores showed a significant decrease in the treatment group only in the RSI (p=0.012).Conclusion: PPI treatment for 8 weeks may be effective in improving PND symptoms in patients with LPR.
... Laryngopharyngeal re ux (LPR) is often misdiagnosed as gastroesophageal re ux disease (GERD) thus often result in treatment failure [1]. However, in 2002, American Academy of Otolaryngology-Head and Neck Surgery has recognized LPR as an independent entity [2]. Currently, Hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) is used to identify and characterize hypopharyngeal re ux events (HRE) and features of LPR by providing valuable information about the type and composition of re ux events occurring in the hypopharynx and helps in understanding the characteristics of LPR [3]. ...
Purpose: Laryngopharyngeal reflux (LPR) is commonly diagnosed based on symptoms, nonspecific clinical findings, or positive response to empirical treatment. This single centre data highlights the role of Oropharyngeal pH-metry (Restech®) in diagnosing LPR and its practicality as an alternative to Hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH).
Methods: A retrospective data of patients who underwent Oropharyngeal pH-metry (Restech®) at Department of Otorhinolaryngology Head and Neck Surgery, Center Hospitalier de Luxembourg Eich, Luxembourg from January 2022 until November 2022. 66 patients with probable LPR symptoms with suggestive flexible scope findings were included in the study.
Results: 66 patients consist of 29 male and 37 female patients (43.94%, 56.06% respectively). The median age is 51.5 ranges from 16 to 87 years old. A positive RYAN score demonstrated in 38 (57.57%) patients while negative RYAN score demonstrated in 28 (42.42%) patients. Furthermore, 24(36.36%) patients showed severe LPR, 28(42.42%) moderate and 12(18.18%) mild, 1(1.52%) no LPR and 1(1.52%) neutral LPR. Throat discomfort and irritative cough were the main symptoms reported by the patients. Proton pump inhibitor such as Pantoprazole and Esomeprazole were the common medications given to treat LPR. The dose given is either 20mg twice daily or 40mg twice daily depending on the severity of the LPR.
Conclusion: Oropharyngeal pH-metry (Restech®) is a feasible tool as an alternative to HEMII-pH in evaluating LPR.
... Laryngopharyngeal reflux disease (LPRD) refers to the reflux of gastric contents to the part above the upper esophageal sphincter, causing a series of unspecific symptoms such as dry throat, a sensation of something being stuck in the throat, persistent throat clearing and hoarseness, and signs such as subglottic edema, vocal fold edema, and posterior commissure hypertrophy [1]. LPRD is a common disease in the otorhinolaryngology department. ...
The aim of this study was to explore the changes in pH and pepsin concentrations in oral lavage fluid of rabbit reflux model. A total of 18 New Zealand rabbits were randomly divided into two groups. The lower esophageal sphincters (LESs) of the rabbits in the experimental group (EG) were dilated by balloon after the LESs were localized by manometry. The pH levels of the throat and the lower esophagus were monitored 1 week before and 2 weeks after inflation. Oral lavage fluid was collected 1 week before, and 2 and 8 weeks after inflation. The pH monitoring showed that the percentage of reflux time, the number of reflux events, and the longest time of reflux after the dilation (AE) in the EG were significantly higher than before the dilation (P < 0.01). The pepsin concentrations at 2 and 8 weeks AE in the EG were significantly higher than that before and that in the control group (P < 0.05). Based on receiver operating characteristic curve analysis, the best diagnostic threshold value was 30.3 ng/ml. The reflux model constructed by balloon inflation of the LES in rabbits is characterized by a decrease in throat pH and an increase in salivary pepsin concentration.
... Laryngopharyngeal/hypopharyngeal reflux (LPR) 5 is the primary manifestation of EGERD and refers to the involvement of the upper airways and intestinal districts in refluxate-induced inflammation. However, several signs and symptoms are not linked to this primary pathogenetic hypothesis, such as cardiac pseudosulcus, ventricular obliteration, or interarytenoid bar; therefore, extraesophageal GERD pathogenesis and manifestations are still strongly controversial 6,7 and are considered intriguing dilemmas. ...
Purpose:
Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are common gastrointestinal disorders with extraesophageal manifestations (EGERD). Studies showed a correlation between GERD/LPR and ocular discomfort. Our aim was to report the prevalence of ocular involvement in patients with GERD/LPR, describe clinical and biomolecular manifestations, and provide a treatment strategy for this novel EGERD comorbidity.
Methods:
Fifty-three patients with LPR and 25 healthy controls were enrolled in this masked randomized controlled study. Fifteen naive patients with LPR were treated with magnesium alginate eye drops and oral therapy (magnesium alginate and simethicone tablets) with a 1-month follow-up. Clinical ocular surface evaluation, Ocular Surface Disease Index questionnaire, tear sampling, and conjunctival imprints were performed. Tear pepsin levels were quantified by ELISA. Imprints were processed for human leukocyte antigen-DR isotype (HLA-DR) immunodetection and for HLA-DR, IL8, mucin 5AC (MUC5AC), nicotine adenine dinucleotide phosphate (NADPH), vasoactive intestinal peptide (VIP), and neuropeptide Y (NPY) transcript expression (PCR).
Results:
Patients with LPR had significantly increased Ocular Surface Disease Index (P < 0.05), reduced T-BUT (P < 0.05), and higher meibomian gland dysfunction (P < 0.001) compared with controls. After treatment, tear break-up time (T-BUT) and meibomian gland dysfunction scores improved to normal values. Pepsin concentration increased in patients with EGERD (P = 0.01) and decreased with topical treatment (P = 0.0025), significantly. HLA-DR, IL8, and NADPH transcripts were significantly increased in the untreated versus controls and comparable significant values were obtained after treatment (P < 0.05). MUC5AC expression significantly increased with treatment (P = 0.005). VIP transcripts were significantly higher in EGERD than in controls and decreased with the topical treatment (P < 0.05). No significant changes were observed in NPY.
Conclusions:
We report an increase in prevalence of ocular discomfort in patients with GERD/LPR. The observations of VIP and NPY transcripts demonstrate the potential neurogenic nature of the inflammatory state. Restoration of the ocular surface parameters suggests the potential usefulness of topical alginate therapy.
... Комментарий. Наличие внепищеводных симптомов у пациентов с ГЭРБ часто связано с наличием экстраэзофагеального (гастроэзофаголарингофарингеального) рефлюкса, который в специализированной литературе последнего десятилетия обозначается как ларингофарингеальный рефлюкс (ЛФР) и рассматривается в качестве возможного патологического состояния организма, обуславливаю щего воздействие агрессивного желудоч -ного/кишечного рефлюктанта на внепищеводные структуры [37][38][39]. ...
Currently, proton pump inhibitors (PPIs), H2-histamine receptor blockers (H2-blockers), antacids, and anticholinergics are used to treat acid-dependent diseases of the gastrointestinal tract. PPIs are considered the most effective drugs for the treatment of acid-dependent diseases of the gastrointestinal tract. However, in real clinical practice, interest remains in the use of antacids in acid-dependent diseases. This is due to the fact that antacids not only adsorb hydrochloric acid in the gastric lumen (by buffering the HCl present in the stomach, without a significant effect on its production) and reduce the proteolytic activity of gastric juice (reducing/ neutralizing the activity of pepsin), but also have a number of other pharmacotherapeutic properties demanded by the gastroenterological patient. Antacids in addition to antisecretory action have: 1) cytoprotective, primarily gastroprotective, action, which is mediated by: a) stimulation of the synthesis of bicarbonates and prostaglandins; b) mucoprotection – an increase in the production of protective mucus by epithelial cells; c) switching of the epithelial growth factor and its concentration in the area of erosive and ulcerative defects, which in turn activates angiogenesis, cell proliferation and local reparative and regenerative processes; 2) enveloping and adsorbing action, through chelation of lysolecithin and bile acids, which have an aggressive damaging effect on the upper gastrointestinal tract; 3) regulate gastroduodenal motility due to: a) antispasmodic action and streamlining gastroduodenal evacuation; b) decrease in intracavitary pressure in the stomach and duodenum; b) obstacles to the formation of duodenogastric reflux. To date, combined preparations, the basic composition of which includes magnesium hydroxide and aluminum hydroxide, meet the basic requirements for non-absorbable antacids. In conclusion, the authors present a number of clinical situations, indicating that today rationally prescribed antacid drugs successfully and significantly solve the main tasks of symptomatic therapy of acid-dependent and other diseases of the gastrointestinal tract, significantly improving the quality of life of patients.
BACKGROUND
Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.
AIM
To investigate whether PAR episodes alone predict a positive response to PPI therapy.
METHODS
Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.
RESULTS
A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, n = 11), followed by EAR alone (59%, n = 68), both pH (+) (56%, n = 18), and both pH (-) (33%, n = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold (P = 0.008), 4.2-fold (P = 0.0002), and 3.4-fold (P = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.
CONCLUSION
In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.
Background and Objectives: Laryngopharyngeal reflux disease (LPRD) has been implicated in the etiology of many laryngeal disorders and is also closely related to the occurrence and progression of a variety of throat diseases, including chronic cough, leukoplakia of the larynx, dysphonia, and even laryngeal tumors. LPRD can significantly reduce the quality of life of patients and cause substantial medical and economic burdens to the society. Reflux Symptom Index (RSI), a self-administered 9-item outcomes instrument for laryngopharyngeal reflux (LPR), has been widely used to screen for LPRD, but there is a lack of feasibility studies on the use of RSI for LPRD screening and alternative diagnostic tools in otolaryngology-head and neck surgery (OHNS) clinics. To study the incidence, clinical characteristics, diagnostic status, and influencing factors of LPRD at OHNS clinics, RSI as an alternative diagnostic tool has also been studied. LPRD was defined as RSI > 13. Methods: Systematic collection of data by the RSI questionnaire was used to identify patients in the outpatient clinic suffering from LPRD; in addition, the personal history of participants was collected. Follow-up observation was carried out for 6 months for patients with suspected LPRD (RSI > 13), including whether they were treated with standardized anti-reflux therapy, and the questionnaire based on RSI was completed again after treatment. Results: The LPRD rate was 7.92% (94/1187) in this survey. The proportions of LPRD patients with smoking history (vs no smoking) and alcohol consumption history (vs. no alcohol consumption) were significantly higher (χ2 values: 7.025 and 4.562, and P values: .008 and .033; respectively). Smoking significantly increased the risk of LPRD (OR: 2.140, 95% CI: 1.058-4.331, P = .034). Among patients with LPRD positive, the incidence of "foreign body sensation in the throat" (symptom 8) score equal to 5 was the highest (19.15%). The severity of "excess mucus in the throat or postnasal drip" (symptom 3) contributed mostly to the total RSI score in patients with LPRD (r = .409, P < .001). ROC curve analysis showed that RSI ≥ 14 had a sensitivity of 72.9% and a specificity of 71.4% for the diagnosis of LPRD, with AUC = 0.797 (95% CI: 0.577-0.884, P < .001). Conclusions: The incidence of LPRD was high in patients we examined in OHNS clinics. We recommend that RSI can be used by otolaryngologists as a reliable tool for screening and diagnosing LPRD in OHNS clinics, which is beneficial for clinical practice.
To determine salivary pH in patients with Laryngopharyngeal Reflux (LPR) and compare it with that of normal individuals. A cross sectional analytical study was done. Adults with LPR as determined by Reflux Symptom Index (RSI) > 13 and Reflux Finding Score (RFS) > 7 were included in LPR group. Normal healthy adult participants with Reflux Symptom Index ≤ 3 and Reflux Finding Score ≤ 2 were included in non LPR group.32 participants were included in each groups. Salivary pH was determined in all participants using a standardized pH meter. Difference in salivary pH between two groups was statistically analyzed. The mean salivary pH in LPR group was 7.43 ± 0.77 and in non LPR group 7.0 ± 0.77. There was a statistically significant difference between the mean salivary pH between the two groups as determined by p value 0.004. The results of our exploratory study showed statistically significant difference in salivary pH between LPR and non LPR group. The salivary pH in 10(31.2%) out of 32 participants in LPR group was beyond the normal range and surprisingly the value was > 7.6, which was in contrast to acidic pH that was expected as per hypothesis. The rest 68.8% in LPR group had pH in the normal range. However salivary pH as a modality for diagnosing LPR cannot be concluded from such preliminary study with a small study population. This study forms a basis for future research for the role of salivary pH in LPR with better study designs and finer modalities of pH testing.
Objectives
There is currently no reference standard test for the detection of the extra‐esophageal manifestations of gastroesophageal reflux disease (GERD). The current suite of diagnostic tests principally assesses reflux events in the esophagus. A new scintigraphic technique has been developed and validated against reference standards. It allows direct visualization of refluxate in the laryngopharynx and lungs.
Methods
Fifty patients were assessed by scintigraphy before and after fundoplication at a single nuclear medicine facility. Standardized reflux symptom indices (RSIs) were obtained from each patient before and after surgery. Patients were scanned after oral 99 m technetium Fyton administration with early dynamic images and delayed SPECT/CT images of the head, neck, and lungs. ANOVA, Spearman correlation, and the Student's t ‐test were utilized for analysis.
Results
The study population (35F, 15 M) had a mean age of 63.9 years. Mean BMI was 26.8 with 67% being overweight or obese. All patients had significant reflux. SPECT/CT showed LPR events in 45/50 and pulmonary micro‐aspiration (PMA) in 45/50 preoperatively and in 36/50 and 20/50 postoperatively, respectively. The RSI, cough, and throat clearing indices showed a significant fall postoperatively ( p < 0.001). Frequency of scintigraphic reflux events was reduced from a mean of 4.5 in 30 min to 2.9 ( t = 9.1, p = 0.004).
Conclusion
The novel scintigraphic test detects esophageal and extra‐esophageal reflux events and permits direct visualization of refluxate in the head and neck structures and lungs. It correlates well with symptoms of reflux in the esophagus and extra‐esophageal structures and the response to therapy.
Level of Evidence
Although prospective, the study did not randomize patients and in effect each patient became their own control following an intervention (fundoplication). Thus, the study is Level 3 evidence Laryngoscope , 2024
Background: Recent guidelines have advocated for upfront pH testing in patients with isolated symptoms of extra-esophageal gastrointestinal reflux disease (EE-GERD) under the assumption that a negative pH study will prevent further gastrointestinal (GI) investigations, proton pump inhibitor (PPI) use, and reduce cost. We sought to evaluate if this actually occurs. Methods: A retrospective study was performed on patients who underwent 24-hour combined pH-impedance testing off PPI for suspected EE-GERD. A negative study was defined as DeMeester score <14.7. Results: 59 patients were included (mean age 53.2; 50.8% women). Most (38, 64.4%) had a negative study. Findings of laryngopharyngoreflux on laryngoscopy did not predict pH results. Those with a negative study had the same number of follow-up GI appointments, repeat endoscopies, and repeat pH studies compared to those with a positive study (p=NS). While PPIs were more frequently stopped in those with a negative pH study, still 14 (36.8%) were continued on a PPI. At the end of the follow-up period (mean 43.6 months), 18 (47.4%) subjects with a negative pH study were still prescribed PPIs. Patients who were diagnosed with post-nasal drip or rhinits were significantly less likely to still be receiving a PPI (5.6% vs 35.0%, p=0.045). Conclusions: Despite a negative pH study, a substantial number of patients with isolated EE-GERD symptoms are continued on a PPI and they undergo GI follow-up at the same rate as those with a positive study. These findings bring into question the recent recommendations for upfront pH testing in suspected EE-GERD and its reported cost savings. (Acta gastroenterol. belg., 2024, 87, 255-261).
Laryngopharyngeal reflux disease (LPRD) is an inflammatory condition in the laryngopharynx and upper aerodigestive tract mucosa caused by reflux of stomach contents beyond the esophagus. LPRD commonly presents with sym-ptoms such as hoarseness, cough, sore throat, a feeling of throat obstruction, excessive throat mucus. This complex condition is thought to involve both reflux and reflex mechanisms, but a clear understanding of its molecular mechanisms is still lacking. Currently, there is no standardized diagnosis or treatment protocol. Therapeutic strategies for LPRD mainly include lifestyle modifications, proton pump inhibitors and endoscopic surgery. This paper seeks to provide a comprehensive overview of the existing literature regarding the mechanisms, patho-physiology and treatment of LPRD. We also provide an in-depth exploration of the association between LPRD and gastroesophageal reflux disease.
Gelişimsel Anatomi Burak ERKMEN Melike Pınar ÜNSAL Pediatrik Otolaringoloji Cerrahisinde Anestezi Uygulamaları Pınar YILDIRIM ÖZKAN Ahu BAYSAL ÇİTİL Dış Kulak Malformasyonları, Konjenital Aural Atrezi ve İç Kulak Malformasyonları Hüseyin ÇUBUK Konjenital İşitme Kayıpları Mahmut Ozan FINDIK Akut Otitis Media Caner AKUFUK Muhammed Semih GEDİK Effüzyonlu Seröz Otit Ahmet Adnan CIRIK Yeşim ESEN YİĞİT Kronik Otitis Media Şeyma AKGÜN BOSTANCI Burun, Paranazal Sinus ve Nazofarenksin Konjenital Anomalileri Semih YAZLA BÖLÜM 9 Pediatrik Alerjik Rinit Fuad SOFUOĞLU Pediatrik Rinosinüzit Birsen ERZİNCAN Pediatrik Farenjit & Tonsillit Döne SAVURAN ORAKCI Pediatrik Obstruktif Uyku Apnesi Sendromu Hasan ÇANAKCI Çocukluk Çağı Boyun Kitlelerine Yaklaşım Ferhat KÜÇÜK Baş ve Boyun Vasküler Anomalileri Yaşar Kemal DUYMAZ Baş ve Boyun Tümörleri Yaşar Kemal DUYMAZ Pediatrik Fasiyal Travmalar Alp YÜCE Pediatrik Tükürük Bezi Hastalıkları Büşra BALCIOĞLU Melike Pınar ÜNSAL Pediatrik Hava Yoluna Yaklaşım Betül AKTAŞ KİPOĞLU Konjenital Larenks ve Trakea Anomalileri Fatih SAVRAN Edinilmiş Laringeal Anomaliler Müslüm AYRAL Yabancı Cisim Aspirasyonu ve Kostik Madde Yaralanmaları Burak ERKMEN Yutma Fizyolojisi ve Aspirasyon Problemleri Ahmet DEVECİ Pediatrik Özofagus Hastalıkları Büşra BALCIOĞLU Melike Pınar ÜNSAL Pediyatrik Baş ve Boyun Hastalıklarında Görüntüleme Elif Dilara TOPCUOĞLU Adenoid Hastalıkları Ahmet Adnan CIRIK Furkan BAYRAM
PSG needs to be distinguished from bilateral true vocal fold paralysis. Ninety-five percent of the time a history of previous prolonged intubation, followed by a 4- to 8-week time course of progressive airway obstruction, is associated with PGS. Careful physical examination will document abnormalities of the cartilaginous glottis in over 80% of these patients.
Laryngeal electromyography may be undertaken if the airway is safe or tracheotomy has been performed. EMG will usually show normal activity in PGS patients.
Direct laryngoscopy with palpation can be used to confirm the suspected diagnosis. (This can also be done as an awake CA joint palpation procedure.)
At the time of direct laryngoscopy, attempts to release the posterior scar band through simple excision or mucosal flaps can be undertaken.
Surgical success is usually associated with an immediate noticeable improvement in passive mobility of one or both vocal folds. Patients will also notice improvement in respiratory status immediately after the operation.
Endoscopic attempts to restore CA joint mobility will fail if the causative injury has resulted in cartilaginous disruption with loss of the normal arytenoid structure or fusion of the arytenoids to the cricoid ring.
Destructive procedures such as posterior transverse cordotomy, partial arytenoidectomy, or total arytenoidectomy (Chapter 32—“Bilateral Vocal Fold Paralysis”) may be used but are usually less successful in patients with PGS than patients with bilateral vocal fold paralysis. This is due to erosion of the posterior cartilaginous glottis with loss of the normal dimension and preexisting scar tissue, which predisposes to recurrent scar formation.
Severe PGS (Types 3 and 4) frequently require more aggressive techniques to achieve an adequate airway. These techniques include endoscopic mobilization of cricoarytenoid joint with arytenoid abduction lateropexy, subtotal arytenoidectomy with permanent suture lateralization, and endoscopic posterior cricoid split with costochondral cartilage grafting.
LPRD can be caused by acidic or nonacidic reflux. Treatment failure with empiric PPIs does not rule out nonacidic reflux.
Stroboscopic evaluation of the larynx is recommended in dysphonic patients that are unresponsive to LPRD treatment.
Because LPR symptoms are often vague and can overlap with other etiologies, objective testing using HEMII-pH and HREM can help rule in or rule out LPRD.
Up-front testing using HEMII-pH and HREM appears to be more cost-effective in the diagnosis and treatment of LPR compared to empiric medication trials. Currently, the decision between empiric therapy and objective testing depends on physician and patient preferences.
For nonacidic or refractory LPRD, alginate therapy is often recommended as an adjunct to acid suppression for empiric medication trials or alternative therapy before anti-reflux surgery.
Objective
The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR.
Methods
Forty‐eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician.
Results
After the third round, 79.2% of statements ( N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non‐specific laryngeal and extra‐laryngeal symptoms and signs that can be evaluated with validated patient‐reported outcome questionnaires and clinical instruments. The hypopharyngeal–esophageal multichannel intraluminal impedance–pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h.
Conclusion
A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR.
Level of Evidence
5 Laryngoscope , 2023
Objective: To summarize the characteristics of laryngopharyngeal reflux in patients with chronic cough induced by gastroesophageal reflux disease (GERD). Materials and Methods: The clinical data of patients with chronic cough induced by GERD treated at our hospital were retrospectively analyzed, including their reflux symptom index (RSI), reflux finding scores (RFS), and results of oropharyngeal pH monitoring. Results: There were 44 patients in total, including 21 males and 23 females. The average history of chronic cough was 29.60 (29.60 ± 37.60) months. In addition to coughing, all patients had at least 2 symptoms of laryngopharyngeal reflux disease (LPRD), and their RSI averaged 15.66 (15.66 ± 6.33). The most frequent symptoms were cough, throat clearing, excessive phlegm, or postnasal drip. All patients had LPRD signs, with an average RFS of 10.89 (10.89 ± 2.81). The most frequent signs were erythema or hyperemia/vocal cord edema, posterior commissure hypertrophy, and diffuse laryngeal edema. There were 42 patients (42/44, 95.45%) whose RSI and/or RFS were abnormal. Oropharyngeal pH monitoring identified 10 patients (10/44, 22.72%) with abnormal Ryan scores. Conclusions: All patients with chronic cough induced by GERD had symptoms and signs of LPRD, and most of them had an abnormal RSI and/or RFS and could be diagnosed with suspect LPRD. A part of the patients had LPR episodes according to Dx-pH monitoring, most of which occurred in the upright position. These results indicated that most patients with chronic cough induced by GERD may have suspected LPRD simultaneously and that cough was one of their LPRD symptoms.
Laryngopharyngeal reflux (LPR) is an inflammatory condition of the pharynx and larynx resulting from reflux of gastroduodenal contents. LPR presents with multiple symptoms and signs that are not pathognomonic of the disease and overlap with other laryngeal disorders. The objective tests to diagnose LPR include the following: (1) oropharyngeal pH monitoring, (2) pepsin detection in the oropharynx, and (3) multichannel intraluminal impedance (MII)—pH monitoring. Despite the availability of these tests, there is no consensus on standard diagnostic criteria. The diagnosis of LPR is made after reviewing the medical history, analyzing symptoms and signs, and interpreting diagnostic tests. Attention needs to be paid to exclude any potential overlapping laryngeal disorders.
Laryngopharyngeal reflux (LPR) is an inflammatory condition of the upper respiratory tract tissues resulting from the direct or indirect effects of gastroduodenal content reflux. Although LPR shares similarities with gastroesophageal reflux disease (GERD) in pathophysiology, its symptoms and signs differ considerably. There remains a lack of consensus regarding diagnostic criteria, and no gold standard diagnostic method has been established, leading to ongoing research on standardizing diagnosis and treatment. Epidemiological data on LPR prevalence are scarce due to the absence of a definitive diagnostic technique, and the non-specific nature of its symptoms. Pathophysiologically, LPR can cause damage and irritation to the upper respiratory tract mucosa through direct and indirect mechanisms involving pepsin, bile acids, and vagal reflexes. Diagnosis remains challenging and relies on clinical evaluation, laryngopharyngoscopy, and pH-monitoring. Various clinical tools, such as the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), and Reflux Sign Assessment (RSA), have been developed to aid diagnosis. Treatment approaches for LPR include lifestyle modifications, medical therapy, and surgical interventions. This book chapter provides an extensive and analytical overview of LPR, focusing on its epidemiology, pathophysiology, symptoms, signs, differential diagnosis, diagnostic methods, and treatment options.
Introducción: el reflujo laringofaríngeo (RLF) se origina por el flujo retrógrado de contenido gástrico hacia la faringe, pero es una entidad diferente de la enfermedad por reflujo gastroesofágico (ERGE). El objetivo del estudio fue determinar la correlación entre los signos endoscópicos de la fibrolaringoscopia y la videoendoscopia digestiva alta (VEDA). Material y métodos: estudio observacional, retrospectivo y analítico. Se incluyeron pacientes que consultaron por sintomatología de RLF y ERGE. Los hallazgos visualizados por fibrolaringoscopia flexible, VEDA y biopsia de mucosa gástrica de cada paciente se compararon con la prueba de chi-cuadrado
Background:
The Reflux Symptom Score (RSS) is a patient-related outcomes measure (PROM) that was developed to diagnose Laryngopharyngeal reflux (LPR), by assessing the severity and frequency of specific symptoms and their respective impact on quality of life (QoL).
Objective:
To develop the Arabic version of RSS-12 (Ar-RSS-12), and to assess its validity and reliability.
Method:
The RSS-12 was translated from French into Arabic using the forward-backward translation method, and the translated version underwent transcultural validation. A case-control study was conducted at the otolaryngology clinics of a referral hospital, during the period November to December 2022. It included 61 patients with LPR-related symptoms and a Reflux Symptom Index (RSI) score >13, and 61 control without LPR-related symptoms and negative RSI scores ≤13. The internal consistency, internal and external validity, and Test-Retest reliability of Ar-RSS-12 were analyzed.
Result:
Patients had significantly higher scores than controls in all 12 items and total Ar-RSS and QoL impact scores, with high Z score values. Item scores showed variable correlation levels with total Ar-RSS score, with ear-nose-throat items showing the strongest correlation (Spearman's rho 0.592-0.866). The QoL scores were more strongly correlated to the symptoms' severity than frequency. The internal consistency was high, with Cronbach's alpha = 0.878. Regarding external validity, correlations with RSI score showed high Spearman's rho values for total Ar-RSS (0.905) and QoL total score (0.903). No statistically significant difference was observed between Test and Retest results in any of the 12 items' score or the total score and QoL, indicating the reproducibility of the test.
Conclusion:
The Ar-RSS is a valid and reproducible tool for the screening, assessment, and monitoring of LPR in Arabic speaking patients. The inclusion of symptoms severity and frequency, as well as their individual effects on patient's QoL, support the superior clinical applications of RSS compared to other existing PROMs.
Gastroesophageal reflux (GER) has been implicated in otolaryngologic problems, particularly chronic hoarseness that cannot be attributed to other causes. To study this relationship, we used 24-h ambulatory intraesophageal or dual pharyngoesophageal pH monitoring in 33 patients with chronic hoarseness and laryngeal lesions suggestive of acid irritation. Twenty-six of the patients (78.8%) had pH evidence of severe GER, being at least three times greater than the upper limit of normal. In contrast to 19 patients with proven esophagitis, this GER was worse in the upright position. Of 15 patients with both pharyngeal and esophageal probes, three had esophagopharyngeal reflux, and two had atypical unexplained pharyngeal decreases in pH to below 4.0. Less than half of the 33 patients had the typical symptoms of GER, and standard esophageal tests usually yielded normal findings. Occult GER, predominantly in the upright position, appears to be common and severe in patients with chronic hoarseness, who have laryngeal lesions suggestive of GER. The causative mechanisms are not clear. The 24-h esophageal pH monitor is useful in screening this potentially treatable problem.
Patients with reflux esophagitis have a high rate of relapse within one year after therapy is discontinued.
We enrolled 175 adults with endoscopy-confirmed reflux esophagitis in a prospective study comparing five maintenance therapies. All the patients were initially treated with omeprazole (40 mg orally once a day) for four to eight weeks, and healing was confirmed by endoscopy. Participants were then stratified according to their initial grade of esophagitis and randomly assigned to 12 months of treatment with one of the following: cisapride (10 mg three times a day), ranitidine (150 mg three times a day), omeprazole (20 mg per day), ranitidine plus cisapride (10 mg three times a day), or omeprazole plus cisapride. Endoscopy was repeated after 6 and 12 months of treatment; the endoscopists were blinded to the treatment assignments. Remission was defined as the absence of esophageal lesions on scheduled or unscheduled follow-up endoscopy.
In an intention-to-treat analysis, the numbers of patients in continued remission at 12 months were 19 of 35 (54 percent) in the cisapride group, 17 of 35 (49 percent) in the ranitidine group, 28 of 35 (80 percent) in the omeprazole group, 23 of 35 (66 percent) in the ranitidine-plus-cisapride group, and 31 of 35 (89 percent) in the omeprazole-plus-cisapride group. Omeprazole was significantly more effective than cisapride (P = 0.02) or ranitidine (P = 0.003), and combination therapy with omeprazole plus cisapride was significantly more effective than cisapride alone (P = 0.003), ranitidine alone (P < 0.001), or ranitidine plus cisapride (P = 0.03). Ranitidine plus cisapride was significantly better than ranitidine alone (P = 0.05).
For maintenance treatment of reflux esophagitis, omeprazole alone or in combination with cisapride is more effective than ranitidine alone or cisapride alone, and the combination of omeprazole and cisapride is more effective than ranitidine plus cisapride.
To critique the English-language reports describing the effects of medical and surgical antireflux therapy on respiratory symptoms and function in patients with asthma.
The Medline computerized database (1959-1999) was searched, and all publications relating to both asthma and gastroesophageal reflux disease were retrieved.
Seven of nine trials of histamine-receptor antagonists showed a treatment-related improvement in asthma symptoms, with half of the patients benefiting. Only one study identified a beneficial effect on objective measures of pulmonary function. Three of six trials of proton pump inhibitors documented improvement in asthma symptoms with treatment; benefit was seen in 25% of patients. Half of the studies reported improvement in pulmonary function, but the effect occurred in fewer than 15% of patients. In the one study that used optimal antisecretory therapy, asthma symptoms were improved in 67% of patients and pulmonary function was improved in 20%. Combined data from 5 pediatric and 14 adult studies of anti-reflux surgery indicated that almost 90% of children and 70% of adults had improvement in respiratory symptoms, with approximately one third experiencing improvements in objective measures of pulmonary function.
Fundoplication has been consistently shown to ameliorate reflux-induced asthma; results are superior to the published results of antisecretory therapy. Optimal medical therapy may offer similar results, but large studies providing support for this assertion are lacking.
Chronic laryngitis symptoms are commonly seen in otherwise healthy people. This article reviews recent progress in our understanding and effective treatment of chronic laryngitis. Clinical experience and prospective treatment and outcome studies have demonstrated objective evidence of the efficacy of treating patients with chronic laryngitis symptoms with nocturnal antireflux precautions and acid-suppressing medications. The role of pH testing and most common errors in treatment are reviewed.
Objective: To critique the English-language reports describing the effects of medical and surgical antireflux therapy on respiratory symptoms and function in patients with asthma. Methods: The Medline computerized database (1959–1999) was searched, and all publications relating to both asthma and gastroesophageal reflux disease were retrieved. Results: Seven of nine trials of histamine-receptor antagonists showed a treatment-related improvement in asthma symptoms, with half of the patients benefiting. Only one study identified a beneficial effect on objective measures of pulmonary function. Three of six trials of proton pump inhibitors documented improvement in asthma symptoms with treatment; benefit was seen in 25% of patients. Half of the studies reported improvement in pulmonary function, but the effect occurred in fewer than 15% of patients. In the one study that used optimal antisecretory therapy, asthma symptoms were improved in 67% of patients and pulmonary function was improved in 20%. Combined data from 5 pediatric and 14 adult studies of antireflux surgery indicated that almost 90% of children and 70% of adults had improvement in respiratory symptoms, with approximately one third experiencing improvements in objective measures of pulmonary function. Conclusions: Fundoplication has been consistently shown to ameliorate reflux-induced asthma; results are superior to the published results of antisecretory therapy. Optimal medical therapy may offer similar results, but large studies providing support for this assertion are lacking. Population-based studies have reported that one third of Western populations have symptoms of gastroesophageal reflux disease (GERD) at least once a month, with 4% to 7% of the population having daily symptoms. 1,2 Analogous studies have reported a 10% to 15% prevalence of asthma in the community. 3–12 Given these observations, it would not be surprising if the two conditions coexisted in some patients. Several reports have indicated that up to 50% of patients with asthma have either endoscopic evidence of esophagitis or increased esophageal acid exposure on 24-hour ambulatory pH monitoring. 13–19 This suggests that the frequency of dual pathology is higher than would be expected by serendipity alone. In addition, antireflux therapy may reduce the severity of respiratory symptoms in patients with both asthma and GERD. Despite the ubiquitous nature of both diseases and the documented association between asthma and GERD, controversy remains regarding the value of antireflux therapy in asthma. This reflects the small number of reports, the paucity of controlled studies, and the conflicting findings of many studies. With this in mind, the current study aimed to answer the following questions: • Does medical therapy improve asthma control? • If yes, what is the optimal medication and dosage? • Does antireflux surgery improve asthma control? • Is surgery superior to medical therapy? To address these questions, a literature search of the Ovid Medline database was performed to identify all English-language publications (1959–1998) relating to both asthma and GERD.
Objective: To determine rates and mechanisms of failure in 857 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia (1991–1998), and compare this population with 100 consecutive patients undergoing fundoplication revision (laparoscopic and open) at the authors’ institution during the same period. Summary Background Data: Gastroesophageal fundoplication performed through a laparotomy or thoracotomy has a failure rate of 9% to 30% and requires revision in most of the patients who have recurrent or new foregut symptoms. The frequency and patterns of failure of laparoscopic fundoplication have not been well studied. Methods: All patients undergoing fundoplication revision were included in this study. Symptom severity was scored before and after surgery by patients on a 4-point scale. Evaluation of patients included esophagogastroscopy, barium swallow, esophageal motility, 24-hour ambulatory pH, and gastric emptying studies. Statistical analysis was performed with multiple chi-square analyses, Fisher exact test, and analysis of variance. Results: Laparoscopic fundoplication was performed in 758 patients for gastroesophageal reflux disease and in 99 for paraesophageal hernia. Median follow-up was 2.5 years. Thirty-one patients (3.5%) have undergone revision for fundoplication failure. The mechanism of failure was transdiaphragmatic herniation of the fundoplication in 26 patients (84%). In 40 patients referred from other institutions, after laparoscopic fundoplication, only 10 (25%) had transdiaphragmatic migration (p < 0.01); a slipped or misplaced fundoplication occurred in 13 patients (32%), and a twisted fundoplication in 12 patients (30%). The failure mechanisms of open fundoplication (29 patients) followed patterns previously described. Fundoplication revision procedures were initiated laparoscopically in 65 patients, with six conversions (8%). The morbidity rate was 4% in laparoscopic procedures and 9% in open ones. There was one death, from aspiration and adult respiratory distress syndrome after open fundoplication. A year or more after revision operation, heartburn, chest pain, and dysphagia were rare or absent in 88%, 78%, and 91%, respectively, after laparoscopic revision, and were rare or absent in 91%, 83%, and 70%, respectively, after open revision, but 11 patients ultimately required additional operations for continued or recurrent symptoms, 3 after open revision (17%), and 8 after laparoscopic fundoplication (11%). Conclusions: Laparoscopic fundoplication failure is infrequent in experienced hands; the rate may be further reduced by extensive esophageal mobilization, secure diaphragmatic closure, esophageal lengthening (applied selectively), and avoidance of events leading to increased intraabdominal pressure. When revision is required, laparoscopic access may be used successfully by the laparoscopically experienced esophageal surgeon.
The purpose of this study is to examine the relation between gastroesophageal reflux and allergy as possible causes of chronic tubotympanal pathology. The 30 examined children (ages 2–13) were divided into two groups based on the otological criteria. The 16 examined children suffered from a secretory otitis, which lasted more than four months. Upon further examination with a microscope, seven of these children exhibited symptoms of the adhesive process of the middle ear. Furthermore, 14 patients suffered from a recurrent otitis, i.e. more than five cases of otitis per year, while five patients from this group suffered from a chronic otitis with a central defect of the tympanum. The method used for the examination of the gastroesophageal reflux consisted of a continual 24 h esophageal pH monitoring. The particular apparatus used for this included antimony electrode (Synetics Medical, Sweden), while the analysis we performed was processed through the PC software program Gastrosoft Inc. The reflux index higher than five was considered pathological. At the time of the gastroesophageal reflux examination, we also performed the allergological analysis. The presence of allergy was confirmed by three methods: the positive allergological anamnesis, the positive skin pick test and by the elevated quantities of specific IgEs (Pharmacia CAP system). The examination resulted in the following: 18 of the examined children suffered from the pathological gastroesophageal reflux (60%); further seven of our patients tested positive on the allergological test (23%); and the four who tested positive for allergy also suffered from the pathological gastroesophageal reflux (13%). In comparison with allergies, the pathological GER was substantially more frequent in the patients who suffered from chronic tubotympanal disorders.
Ambulatory 24-h intraesophageal pH monitoring was performed in 32 patients with hoarseness, documented laryngeal pathologic findings or lesions, globus, and/or chronic cough. The laryngeal lesions included granulomas, stenoses, and carcinomas. Twenty-two (68.8%) of the patients had no symptoms specific for reflux. One-half of the patients underwent pH monitoring with a double probe, one probe being placed in the distal esophagus and the second being placed in the hypopharynx just behind the laryngeal inlet. Twenty-four (75%) of the patients had abnormal studies, i.e., significant reflux. Of those, 17 (70.8%) had upright reflux, 13 (54.2%) had supine nocturnal reflux, and 10 (41.7%) had both types. Seven of the 16 patients undergoing double-probe-type monitoring had reflux into the pharynx (43.8%). These data suggest that occult gastroesophageal reflux may be involved in the pathogenesis of many conditions commonly encountered in otolaryngologic practice.
Gastroesophageal reflux (GER) is a common condition with many manifestations which are of interest to the otolaryngologist. Factors predisposing to GER include anatomic abnormalities of the esophagus and pharynx, neurogenic disease and diet induced decreased lower esophageal sphincter pressure. Three interesting cases are reported, including subglottic stenosis which has not previously been thought to be a complication of GER. A literature review of otolaryngologic symptoms, the problems of diagnosis, and a suggested treatment plan are presented.
In the treatment of reflux oesophagitis, H2-receptor antagonists are still widely used in spite of the apparent higher efficacy of proton pump inhibitors. In an attempt to compensate for the lower efficacy, H2-receptor antagonists are now increasingly being used at a higher dose.
To assess whether or not standard-dose lansoprazole (30 mg o.d.) is more effective than high-dose ranitidine (300 mg b.d.) in moderately severe reflux oesophagitis (grades II–III).
Lansoprazole or ranitidine was given to 133 patients for 4–8 weeks in a double-blind, randomized, parallel group, multicentre trial.
The percentage of patients with endoscopically-verified healing was significantly higher on lansoprazole than on ranitidine both after 4 weeks (79% vs. 42%) and 8 weeks (91% vs. 66%), though smoking had a negative impact on oesophagitis healing with lansoprazole. Heartburn, retrosternal pain and belching improved significantly better with lansoprazole than with ranitidine, as did the patient-rated overall symptom severity. Relief of heartburn appeared somewhat faster with ranitidine, but was more pronounced with lansoprazole. The number of patients with adverse events was similar in both treatment groups.
Standard-dose lansoprazole is better than high-dose ranitidine in moderately severe reflux oesophagitis.
Objective:
Historically, manometry has been used for sphincter localization before ambulatory 24-hour double-probe pH monitoring to ensure accurate placement of the probes. Recently, direct-vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard.
Methods:
Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry.
Results:
Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects.
Conclusion:
For double-probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid-exposure times. Thus, manometry is needed to ensure valid double-probe pH monitoring data.
The pharmacologic profile of the new proton pump inhibitor esomeprazole has demonstrated advantages over omeprazole that suggest clinical benefits for patients with acid-related disease.
1960 patients with endoscopy-confirmed reflux oesophagitis (RO) were randomized to once daily esomeprazole 40 mg (n=654) or 20 mg (n=656), or omeprazole 20 mg (n=650), the standard recommended dose for RO, for up to 8 weeks in a US, multicentre, double-blind trial. The primary efficacy variable was the proportion of patients healed at week 8. Secondary variables included healing and heartburn resolution at week 4, time to first resolution and sustained resolution of heartburn, and per cent of heartburn-free days and nights. Safety and tolerability were also evaluated.
Significantly more patients were healed at week 8 with esomeprazole 40 mg (94.1%) and 20 mg (89.9%) vs. omeprazole 20 mg (86.9%), using cumulative life table estimates, ITT analysis (each P < 0.05). Esomeprazole 40 mg was also significantly more effective than omeprazole for healing at week 4 and for all secondary variables evaluating heartburn resolution. The most common adverse events in all treatment groups were headache, abdominal pain and diarrhoea.
Esomeprazole was more effective than omeprazole in healing and symptom resolution in GERD patients with reflux oesophagitis, and had a tolerability profile comparable to that of omeprazole.
Background:
Patients with laryngopharyngeal reflux (LPR) undergoing treatment appear to have improvement in symptoms before the complete resolution of the laryngeal findings.
Objective:
To determine whether patients with LPR experience an improvement in symptoms before the complete resolution of the laryngeal findings.
Methodology:
Forty consecutive patients with LPR documented by double-probe pH monitoring were evaluated prospectively. Symptom response to therapy with proton pump inhibitors was assessed at 2, 4, and 6 months of treatment with a self-administered reflux symptom index (RSI). In addition, transnasal fiberoptic laryngoscopy (TFL) was performed and a reflux finding score (RFS) was determined for each patient at each visit.
Results:
The mean RSI at entry was 19.3 (+/- 8.9 standard deviation) and it improved to 13.9 (+/- 8.8) at 2 months of treatment (P <.05). No further significant improvement was noted at 4 months (13.1 +/- 9.8) or 6 months (12.2 +/- 8.1) of treatment. The RFS at entry was 11.5 (+/- 5.2), and it improved to 9.4 (+/- 4.7) at 2 months, 7.3 (+/- 5.5) at 4 months, and 6.1 (+/- 5.2) after 6 months of treatment (P <.05 with trend).
Conclusions:
Symptoms of LPR improve over 2 months of therapy. No significant improvement in symptoms occurs after 2 months. This preliminary report demonstrates that the physical findings of LPR resolve more slowly than the symptoms and this continues throughout at least 6 months of treatment. These data imply that the physical findings of LPR are not always associated with patient symptoms, and that treatment should continue for a minimum of 6 months or until complete resolution of the physical findings.
A canine model was used to investigate the efferent laryngeal responses to stimulation by topically applied acid and pepsin. Five adult mongrel dogs were studied. Electromyographic recordings from the thyroarytenoid muscle were measured with hooked-wire electrodes as an acid solution (normal saline/hydrochloric acid at pH 6.0, 5.0, 4.0, 3.0, 2.5, 2.0, 1.5, and 1.0) was sequentially instilled into the larynx. Laryngospasm (tonic, sustained contraction of the thyroarytenoid muscle) occurred in all animals at pH 2.5 to 2.0 or less. Control substances such as neutral pH isotonic saline, hypotonic saline, hypertonic saline, water, and pepsin alone failed to produce laryngospasm. Next, solutions containing both acid (in the same pH range) and pepsin were tested. The laryngeal responses were similar to those of acid alone. The superior laryngeal nerves were sectioned bilaterally and the above experiments repeated. None of the test solutions produced laryngospasm; however, when capsaicin (1%) was instilled into the subglottis, laryngospasm occurred. Thus, chemoreceptors in the subglottis (supplied by the recurrent laryngeal nerves) appear to be responsive to capsaicin stimulation but not to acid stimulation. The data suggest that pH-sensitive chemoreceptors in the canine larynx cause laryngospasm (when the pH of the test solution is 2.5 or less) and that these acid receptors are supplied by the superior laryngeal nerves.
Although omeprazole has a long duration of action and has usually been given in the morning, there are theoretical advantages in administering antisecretory drugs in the evening as has been shown for the H2-receptor antagonists. The aim of this study was to compare the effects of placebo and 20 mg omeprazole given either in the morning or evening, on gastric acidity, plasma gastrin levels and plasma omeprazole in 6 duodenal ulcer patients. The 24-hour mean pH (+/- S.E.M.) was: placebo 1.7 +/- 0.1; morning doing, 3.9 +/- 1.8 (P less than 0.01); evening dosing, 2.9 +/- 1.1 (N.S.). There was a large inter-individual variability of intragastric acidity in response to omeprazole, which was reflected both in the plasma gastrin and in the area under the plasma omeprazole concentration-time curve. Morning administration of omeprazole is optimal, but variability in the patient response to 20 mg omeprazole is still seen.
Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order to test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double‐probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx.
Two hundred twenty‐five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24‐hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double‐probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy.
The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18).
The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population.
Twenty‐eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentag with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively).
By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%).
All of the study patients were treated with antireflux therapy. Follow‐up was available on 68% of the patients and the mean follow‐up period was 11.6 ± 12.7 months. After 6 months of treatment, symptoms had resolved in 85% and medical therapy had failed in 15%. Subsequently, an additional 20% experienced medical treatment failure. Fifteen percent of patients underwent Nissen fundoplication, and all subsequently had resolution of symptoms.
To further investigate the role of gastroesophageal reflux in the development of laryngeal damage, experiments mimicking the effects of intermittent reflux (of acid and pepsin) on the canine larynx were performed. The results of these experiments revealed: 1 . Intermittent reflux (three episodes per week) can result in severe laryngeal damage if there is prior mucosal injury; 2 . pepsin, and not hydrochloric acid, is the principal injurious agent of the refluxate; and, 3 . severe laryngeal damage can occur even when the pH of the refluxate is 4.0.
The manuscript describes the limitations and advantages of standard diagnostic procedures and of 24‐hour pH monitoring. The differences between gastroenterology and otolaryngology patients with GERD are emphasized and specific new diagnostic and therapeutic recommendations are made.
Simultaneous 24-h intragastric and plasma gastrin concentrations were measured in 36 healthy subjects, when receiving placebo (day 0) and on days 1 and 8 of dosing with either placebo (n = 8), or high-dose H2-blockade with either ranitidine 300 mg q.d.s. (n = 8), ranitidine 1200 mg o.m. (n = 8), or sufotidine 600 mg b.d. (n = 12). Triplicate placebo studies demonstrated good reproducibility for this technique, with no significant differences of acidity or plasma gastrin concentration between the studies. There was a decrease in the anti-secretory activity of all three high-dose H2-antagonist regimens on day 8, when compared with that observed on day 1. This occurred in the presence of sustained or increasing hypergastrinaemia. It is concluded that a degree of tolerance develops during continued H2-blockade, and that this could be due to increasing gastrin drive to the parietal cells.
Results of medical therapy of reflux oesophagitis are disappointing, especially compared to the success obtained in peptic ulcer disease. H2-receptor antagonists, with or without the addition of mucosaprotectiva or prokinetica, produce healing only in 50% of the patients. Nowadays, even severe, resistant reflux oesophagitis can be treated successfully with the H+/K+-adenosine triphosphatase antagonist omeprazole. Experience of more than 3 years of continuous treatment with omeprazole, in doses which have been adjusted to prevent recurrences, has also demonstrated its high efficacy in the long-term management of the patients. The use of this drug emphasizes the importance of long-standing, strong acid inhibition for this condition, although careful surveillance of the safety profile of this drug remains obligatory.
This study examined charts and 16-mm pictures or videotapes of 138 patients with carcinoma of the larynx treated during the last 10 years. Among these patients, 19 were nonsmokers and nondrinkers or only light social drinkers with moderate to severe gastroesophageal reflux (GER). Serial cinephotographs are presented with follow-up of up to 10 years. The common presence of GER in these nonsmoking, nondrinking patients and the probable role of this chronic irritative disorder as a causative agent in carcinoma of the laryngopharynx are discussed.
To examine a possible esophageal basis for cervical symptoms, we studied 63 patients with persistent cervical complaints, 36 patients with gastroesophageal reflux but no cervical symptoms, and ten normal subjects. Patients were evaluated for a history of pyrosis and regurgitation and underwent otolaryngologic examination, barium esophagram, upper endoscopy, esophageal biopsy, standard esophageal manometrics, acid reflux testing, and Bernstein examination, as well as tests of esophageal dysmotility and acid clearance time before and after bethanechol (50 micrograms/kg, two doses). Standard diagnostic examinations usually were normal in patients with cervical symptoms. Pyrosis, regurgitation, and a positive Bernstein examination were uncommon in patients with cervical symptoms. This occurred despite frequent acid reflux (68%) and poor acid clearance (79%). Esophageal dysmotility also was common (63%). Patients with reflux but no cervical symptoms and normal subjects had a normal acid clearance time, and dysmotility was unusual (8%). We conclude that patients with cervical symptoms have diminished esophageal sensitivity despite frequent and long acid exposure. The pathophysiologic significance of this observation is discussed.
A case of subglottic stenosis, recalcitrant to conventional therapy, was associated with asymptomatic aspiration of gastric acid into the larynx. Once the reflux was controlled by use of an antacid regimen and an H2 blocker, the subglottic stenosis resolved and the patient could be decannulated. This case led to the use of an experimental canine model of subglottic stenosis to examine gastric acid as a pathogenic factor in the development of subglottic stenosis. In control animals, mucosal lesions healed without development of stenosis. In experimental animals with mucosal lesions painted with gastric acid, subglottic stenosis developed. When perichondrium and cartilage were violated and gastric acid applied, stenosis was even more severe and developed more rapidly.
Gastroesophageal reflux disease (GERD) is known to cause a variety of symptoms that lead a patient to seek otolaryngologic care. New advances in the treatment of GERD have enabled otolaryngologists to eliminate most of the signs and symptoms caused by acid reflux. Omeprazole, the most recent pharmacologic advancement, has been reported to be universally successful in controlling acid release from the stomach of patients with GERD. This report describes a series of patients with GERD for whom high-dose omeprazole therapy was not successful in completely reducing gastric acid levels of GERD symptomatology.
The role of radiologic imaging in evaluating patients with suspected GERD has been clarified in recent years. The barium esophagram is used primarily for detecting the gross morphologic changes of reflux esophagitis and is a reliable screening method for diagnosing the more severe grades of disease. Evaluation of gastroesophageal reflux by barium examination is less certain; the technique is poor if only spontaneous reflux is detected but may improve with the use of provocative tests. The radiographic method is also useful for qualitative assessment of esophageal function and clearance. Radionuclide imaging is most useful for evaluating esophageal function and clearance but may not be as sensitive as initially reported for demonstrating gastroesophageal reflux.
Sudden infant death syndrome (SIDS) has been shown to result from a variety of causes. One group of neonates at high risk for SIDS includes those who develop apnea secondary to gastroesophageal reflux (GER). Reflux has been shown to produce apnea in infants, and aggressive treatment results in significant improvement in symptoms.
Because it is a site of resistance in the airway, the larynx plays an important role in the development of apnea. Through its sensory innervation, the larynx also serves as the afferent limb for reflexes that regulate respiration. In order to investigate the relationship between obstructive apnea and central apnea induced by the instillation of acid on the larynx, simulating GER, a rabbit model was developed. Maturing rabbits at 15-day intervals up to 60 days of age were studied using saline and acid solutions. Acid solutions produced obstructive apnea in all age groups. With acid solutions, central apnea occurred in all age groups but had a peak incidence at 45 days. Gasping respirations were seen in all groups but were most common at 30 days of age. Although obstructive and central apnea occurred together as mixed apnea, both types of apnea were seen independently of each other.
Acid instilled on the larynx of maturing rabbits resulted in significant obstructive, central, and mixed apnea. Gasping respirations and frequent swallowing were frequent associated symptoms. Acid-induced obstructive apnea in rabbits mirrors symptoms seen in human infants with GER. Central apnea in infants with GER is seen less commonly; however, central apnea as the result of laryngeal stimulation has been demonstrated repeatedly in several animal models. Central apnea, culminating in fatal asphyxia, has been described in several animal models. The larynx appears to play a pivotal role in the development of apnea in susceptible infants with GER.
To determine (1) the appropriate omeprazole (Prilosec) dose required for adequate acid suppression in asthmatics with gastroesophageal reflux, (2) whether aggressive acid suppressive therapy of gastroesophageal reflux improves asthma outcome in asthmatics with gastroesophageal reflux, (3) the time course of asthma improvement, and (4) demographic, esophageal, or pulmonary predictors of a positive asthma response to antireflux therapy.
Thirty nonsmoking adult asthmatics with gastroesophageal reflux (asthma defined by American Thoracic Society criteria and reflux defined by symptoms and abnormal 24-hour esophageal pH testing) were recruited from the outpatient clinics of a 900-bed university hospital. Patients underwent baseline studies including a demographic questionnaire, esophageal manometry, dual-probe 24-hour esophageal pH test, barium esophogram, and pulmonary spirometry. During the 4-week pretherapy phase, patients recorded reflux and asthma symptom scores and peak expiratory flow rates (PEFs) upon awakening, 1 hour after dinner, and at bedtime. Patients began 20 mg/d omeprazole, and the dose was titrated until acid suppression was documented by 24-hour pH test. Patients remained on this acid suppressive dose for 3 months. Responders were identified by a priori definitions: asthma symptom reduction by >20% and/or PEF increase by >20%. Asthma symptom scores, PEF's baseline and posttherapy pulmonary spirometry were analyzed.
Twenty-two (73%) patients were asthma symptom and /or PEF responders: 20 (67%) were asthma symptom responders, and 6 (20%) were PEF responders. Responders reduced their asthma symptoms by 57% (P<0.001), improved their morning and night PEFs by 8% and 9% (both P <0.005), and had improvement in forced expiratory volume at 1 second (P <0.02), mean forced expiratory flow during the middle half (25% to 75%) of the forced vital capacity (P <0.04), and peak expiratory flow (P <0.01) with acid suppressive therapy. Mean acid suppressive dose of omeprazole was 27 mg/d (+/-2.2) with 27% (8) patients requiring more than 20 mg/d. The presence of regurgitation or excessive proximal esophageal reflux predicted asthma response with 100% sensitivity, 100% negative predictive value, specificity of 44% and a positive predictive value of 79%.
Acid suppressive therapy with omeprazole improves asthma symptoms and/or PEFs by >20% and improves pulmonary function in 73% of asthmatics with gastroesophageal reflux after 3 months of acid suppressive therapy. Many asthmatics (27%) required >20 mg/d of omeprazole to suppress acid. The presence of regurgitation and/or excessive proximal esophageal reflux predicts a positive asthma outcome.
The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study.
Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery.
Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation.
The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%.
Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.
To review gastroesophageal reflux disease (GERD) and its treatment, with emphasis on the use and place of omeprazole, a proton pump inhibitor.
A compilation prepared by the National Library of Medicine's Interactive Retrieval Services (Medlars II) for the period 1987 to 1994 was used as the data source.
Focus was placed on human comparative clinical studies with well-accepted measures of esophageal healing (endoscopy) and symptom resolution. Safety data were compiled from the clinical trials literature and large postmarketing data studies. Pharmacoeconomic studies selected were judged to meet the criteria of good design, presence of sensitivity testing, and statement of perspective.
Data were obtained from double-blind, controlled clinical studies. Other data were extracted from pertinent literature of good design and significant results.
Overall, the clinical trials of omeprazole for the treatment of patients with erosive GERD demonstrate that omeprazole provides superior therapy in terms of esophageal healing symptom resolution and patient compliance when compared with histamine2-receptor antagonists (H2RAs) and antacids. In addition, studies also indicate that omeprazole is the most effective agent for the treatment of patients with GERD refractory to other treatments. Dosage adjustment is not necessary in patients with impaired renal or hepatic function or in the elderly. Finally, although the acquisition drug cost for daily treatment of patients with GERD is highest with the use of omeprazole, pharmacoeconomic studies indicate that treatment is more cost-effective with the use of omeprazole than with H2RA or antacid treatment alone or combined with nonpharmacologic approaches.
Based on efficacy, safety, and cost-effectiveness, omeprazole is the drug of choice for the treatment of patients with endoscopically confirmed erosive GERD.
To identify patients with gastroesophageal reflux disease (GERD) who, despite omeprazole 20 mg b.i.d., demonstrate continued abnormal gastric acid secretion.
Eighty-eight patients with GERD completed ambulatory gastric and esophageal pH monitoring for persistent symptoms on omeprazole 20 mg b.i.d.. Seventeen (19%) demonstrated abnormal gastric acid secretion (percentage time gastric pH < 4 > 50%). The 17 omeprazole failures (OF) were compared with: 1) 19 randomly selected patients with GERD (also studied on omeprazole 20 mg b.i.d. and 2) 19 normal volunteers studied on both placebo and omeprazole 20 mg b.i.d.. Total time intragastric pH < 4, 24-hr gastric pH frequency distribution, and 15-min median pH values for the 6-h period after the evening omeprazole dose were compared.
Both the 24-hr frequency distribution for gastric pH and the 15-min median gastric pH profile for patients with GERD and volunteers on omeprazole 20 mg b.i.d. were almost identical. By contrast, gastric pH studies from the OF group receiving omeprazole 20 mg b.i.d. most closely resembled those of the normal subjects receiving placebo, with respect to these variables. Gastric pH monitoring in seven of the 17 OF patients while on omeprazole 80 mg/day demonstrated a significant decrease in the median percentage time gastric pH remained below 4 (32.8% on 80 mg/day vs 74.3% on 40 mg/day; p < 0.02).
There are individuals whose intragastric acidity persists despite conventional doses of omeprazole. Although the underlying mechanism remains unclear, the majority (six of seven) (87%) demonstrated improved gastric acid control when placed on high dose omeprazole, indicating that this is often a dose-dependent phenomenon.
Over a 2‐year period (1992 to 1994), 12 consecutive adult patients with paroxysmal laryngospasm were prospectively studied. All had had other symptoms of gastroesophageal reflux (GER); however, only 4 (33%) experienced symptoms of heartburn. Each patient underwent fiberoptic laryngeal examination, barium swallow/esophagography, and ambulatory, 24‐hour, double‐probe pH monitoring(pH‐metry).
Eleven (92%) of the 12 patients had evidence of GER on examination, and 10(83%) had abnormal pH‐metry, including 3 who demonstrated pharyngeal reflux while having normal total acid exposure times in the esophageal probe. All the patients responded to antireflux treatment, using dietary and lifestyle modifications and omeprazole, with complete cessation of the laryngospastic episodes.
This study documents the role of GER in the etiology of paroxysmal laryngospasm, it highlights the advantages of double‐probe pH‐metry in diagnosing this extraesophageal manifestation of GER, and it demonstrates that antireflux therapy with omeprazole is effective in controlling GER‐induced laryngospasm.
Epidemiologic data suggest that the etiology and pathogenesis of laryngeal carcinoma are influenced by environmental and lifestyle-related factors, such as tobacco use, ethanol consumption, and exposure to toxic substances. In addition, dietary factors, irradiation, papilloma virus infection, and laryngopharyngeal reflux seem to be significant carcinogenic cofactors. This article presents a multi-factorial model of laryngeal mucosal carcinogenesis.
Although extraesophageal gastric reflux has been implicated as a cause of many pediatric airway and respiratory diseases, its prevalence in these conditions remains unknown due to the relative lack of sensitivity and/or specificity of traditional reflux testing methods. A prospective study of 222 children (ages 1 day to 16 years) was performed with 24-hour double-probe (simultaneous esophageal and pharyngeal) pH monitoring. Seventy-six percent (168/222) of the study population had abnormal findings in either one or both of the pH probes. Of those, 46% (78/168) had pharyngeal reflux (extraesophageal gastric acid documented by the pharyngeal probe), despite having normal esophageal acid exposure times according to the esophageal probe. Thus, had the pharyngeal probe not been used, 46% of the children with documented extraesophageal (pharyngeal) reflux would have been falsely presumed to have normal reflux parameters. Patients with laryngeal abnormalities, pulmonary abnormalities, and emesis had significantly more pharyngeal acid reflux (p < .001) than patients with nonrespiratory symptoms. These data suggest that extraesophageal reflux may be underestimated by single-probe intraesophageal monitoring alone, and that laryngopharyngeal reflux may play a role in the pathogenesis of the conditions studied.
Laryngeal manifestations of gastroesophageal reflux disease are thought to be prevalent in our society. In general, diagnosis has been primarily based on symptoms. Historically, additional testing has included laryngoscopy, barium swallow, manometry, and single and double probe pH monitoring.
We assessed 96 patients who had symptoms suggestive of reflux laryngitis. We administered surveys grading their symptoms. All patients had standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then received a uniform regimen of dietary restrictions and omeprazole (a proton pump inhibitor) for 12 weeks, after which they were retested.
Using the new laryngoscopic grading system, we found that this regimen produced statistically significant improvement in all symptoms except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measurements of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement.
We conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if the patient is hoarse, acoustic analysis are useful techniques to aid diagnosis and monitor therapy. Antireflux therapy with omeprazole is effective, and improvement can be objectively shown with the techniques described.
The neuroanatomic proximity of the larynx to the hypopharynx and proximal esophagus make it particularly vulnerable to diseases that occur in those 2 areas. This is particularly true of gastroesophageal reflux disease (GERD). There is increasing awareness of this relationship, and dysphonias from gastroesophageal reflux (GER) are far more common than previously realized. The symptoms and findings of reflux laryngitis, vocal nodules, Reinke's edema, contact ulcer and granuloma, laryngeal stenosis, and paroxysmal laryngospasm are presented, and diagnostic protocols for each disorder are suggested. The treatment varies with the severity of each problem. Conservative lifestyles and dietary control are helpful, but long-term medical therapy with H2, H1, and prokinetic drugs are usually needed. Surgical therapy may be indicated for such life-threatening problems as laryngeal stenosis and paroxysmal laryngospasm. The need for physician and patient awareness, research, and improved and less expensive therapy are discussed.
Many symptoms have been recognized in association with laryngo-pharyngeal reflux disease (LPRD), but reports of perceptual voice disorders in this condition have been lacking to date. Forty-nine patients with suspected LPRD were studied for five specific perceptual voice characteristics, and these characteristics were compared to the same characteristics in individuals who had never seen an Otolaryngologist for a voice disorder or throat problem (controls). Sixteen of the suspected LPRD patients also underwent 24-hour pH probe studies. All patients with suspected LPRD had significantly increased abnormal perceptual voice characteristics (musculoskeletal tension, hard glottal attack, glottal fry, restricted tone placement, and hoarseness) compared to the controls. Statistical objective differences between the two groups was demonstrated by the presence of increased shimmer in patients with suspected LPRD compared to controls. The differential diagnosis between functional voice disorders and LPRD may be complex, and perceptual parameters may overlap. Interdisciplinary evaluation is advocated.
It is our experience that many patients treated with proton pump inhibitors (PPI) b.i.d. recover acid secretion during the night. Our aim was to assess the efficacy of omeprazole and lansoprazole b.i.d. on nocturnal gastric acidity.
Three groups were studied with intragastric pH monitoring. Group 1 consisted of 17 patients with gastroesophageal reflux disease (GERD) taking omeprazole 20 mg b.i.d. Group 2 was 16 male volunteers taking omeprazole 20 mg b.i.d. and Group 3 comprised 12 volunteers taking lansoprazole 30 mg b.i.d.
The percentages of time that subjects had pH < 4 were lower during supine than upright periods in Groups 1 and 3 (P < 0.01). Recovery of nocturnal acid secretion lasting > 1 h, termed acid breakthrough, occurred in three-fourths of all individuals within 12 h from intake of the evening dose of PPI. Median time to acid breakthrough for the whole group was 7.5 h.
Nocturnal acid breakthrough occurs in a majority of patients and normal volunteers taking PPI b.i.d.
Gastroesophageal reflux has been implicated in the pathogenesis of vocal cord nodules. However, a cause-and-effect relationship has not been established. Because documentation of pharyngeal acid reflux events makes this correlation more plausible, the aim of the present study was to determine the frequency of pharyngeal acid reflux events in patients with vocal cord nodules.
Eleven patients with vocal cord nodules (mean age, 42 +/- 6 years) and eleven healthy volunteers (mean age, 45 +/- 6 years) were studied. Patients underwent barium esophagram and ambulatory 24-hour simultaneous three-site pharyngoesophageal pH monitoring. Controls only had ambulatory 24-hour simultaneous three-site pH monitoring. In the ambulatory pH monitoring studies, pH was recorded from the manometrically determined sites of pharynx (2 cm above upper esophageal sphincter), proximal esophagus (10 cm distal to pharyngeal site), and distal esophagus (5 cm above the lower esophageal sphincter). Pharyngeal acid reflux event was deemed acceptable if all three sites recorded a decrease in pH below 4 which was not related to meal or drinking.
Pharyngeal acid reflux events occurred in seven of 11 patients with vocal cord nodules (1-4 episodes) and two of 11 controls (1-2 episodes) (P < .05). In both groups all pharyngeal acid reflux events occurred in upright position and were not associated with belching or coughing. Barium studies documented hiatal hernia in two patients and gastroesophageal reflux in five of 11 patients. However, none of the esophageal reflux events reached the pharynx on barium esophagram.
Prevalence of pharyngeal acid reflux events is significantly higher in patients with vocal cord nodules compared with normal controls and suggests a contributory role for gastroesophagopharyngeal acid reflux in the pathogenesis of some vocal cord nodules.
Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations.
Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation.
Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%).
The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.
Gastroesophageal reflux (GER) into the laryngopharynx causes or contributes significantly to a variety of upper respiratory problems in children. The pH probe, laryngeal examinations, and broncholveolar lavage results for children with subglottic stenosis, recurrent croup, apnea, chronic cough, laryngomalacia, recurrent choanal stenosis, vocal fold nodules, and chronic sinusitis/otitis/bronchitis were reviewed in an effort to quantify the role of GER in each of these disorders. This review suggests that GER plays a causative role in subglottic stenosis, recurrent croup, apnea, and chronic cough. It is an important inflammatory cofactor in laryngomalacia and possibly in true vocal cord nodules and problematic recurrent choanal stenosis. GER is also an important inflammatory cofactor in chronic sinusitis/otitis/bronchitis but may be the result of chronic illness in the older patients.
Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition with associated morbidity and an adverse impact on quality of life. The disease is common, with an estimated lifetime prevalence of 25 to 35 percent in the U.S. population. GERD can usually be diagnosed based on the clinical presentation alone. In some patients, however, the diagnosis may require endoscopy and, rarely, ambulatory pH monitoring. Management includes lifestyle modifications and pharmacologic therapy; refractory disease requires surgery. The therapeutic goals are to control symptoms, heal esophagitis and maintain remission so that morbidity is decreased and quality of life is improved.
H2-receptor antagonists are widely used in patients with gastro-oesophageal reflux disease (GERD) and are frequently continued when symptoms persist. Aim: To compare the efficacy of omeprazole 20 mg once daily with that of ranitidine 150 mg twice daily in relieving GERD symptoms, in patients who remained symptomatic following a 6-week course of ranitidine therapy.
Patients with heartburn on at least 4 days/week but who did not have endoscopy to assess oesophageal mucosa could participate. This two-phase, prospective trial included a 6-week open-label phase (phase I), followed by an 8-week double-blind phase (phase II). Patients still symptomatic following treatment with ranitidine 150 mg twice daily (phase I) were randomized to double-blind treatment (phase II) with either omeprazole 20 mg once daily or ranitidine 150 mg twice daily. The primary efficacy variable was the proportion of patients with heartburn resolution during weeks 4 and 8 of phase II.
Of the 533 patients with GERD who received ranitidine in phase I, 348 patients (65%) were still symptomatic. A total of 317 patients (59%) were randomized to double-blind treatment (phase II). At week 8, a significantly (P < 0.0004) greater proportion of omeprazole-treated patients (70%) experienced no more than mild heartburn compared with ranitidine-treated patients (49%). Complete resolution of heartburn also occurred in a significantly (P < 0. 00001) greater proportion of omeprazole-treated patients (46% vs. 16% of the ranitidine group at week 8).
After 6 weeks of ranitidine treatment, the majority of patients with GERD were still experiencing moderate to severe heartburn. Omeprazole was significantly more effective than ranitidine in resolving heartburn in this group of patients.
An increasing amount of evidence indicates that gastroesophageal reflux disease (GERD) is a contributing factor to hoarseness, throat clearing, throat discomfort, chronic cough, and shortness of breath. The association between GERD and these supraesophageal symptoms may be elusive. Heartburn and regurgitation are absent in more than 50% of patients. Acid reflux should be considered if signs of GERD are present, symptoms are unexplained, or symptoms are refractory to therapy. The diagnosis of GERD may be unclear, despite a careful history and initial evaluation. A high index of suspicion is required to make the diagnosis. An empiric trial of antireflux therapy is appropriate when GERD is suspected. Multiprobe ambulatory pH monitoring is currently the diagnostic test of choice, but the level of sensitivity and specificity for supraesophageal manifestations of GERD is uncertain. Response to antireflux therapy is less predictable than typical GERD. More intensive acid suppression and longer treatment duration are usually required.
The cause of pediatric chronic sinusitis is multifactorial, but nasal edema appears to be the initial pathologic step. The objective of this study is to evaluate gastronasal reflux as a possible cause of pediatric sinusitis.
Thirty children with chronic sinusitis were believed to be appropriate candidates for functional endoscopic sinus surgery. Children were evaluated retrospectively for their response to reflux therapy with regard to their sinus symptoms and avoidance of sinus surgery.
Two of the 30 children were eventually excluded because they were taken to surgery for the specific purpose of contact point release. Chart review at 24-month follow-up indicated that 25 of the 28 children (89%) avoided sinus surgery.
After reflux treatment, the number of children requiring sinus surgery was dramatically reduced. The results of this preliminary pediatric study indicate that gastronasal reflux should be evaluated and treated before sinus surgical intervention.
Review the roles of aggressive gastroesophageal reflux management and speech therapy in the treatment of patients with vocal process granulomas. Describe and assess our investigation and management protocol.
Retrospective review of 55 patients with 61 vocal granulomas treated according to a standard protocol at the Sydney Voice Clinic. Comparison with previous published series and review of the relevant literature pertaining to granulomas and to reflux. Description of laryngopharyngeal reflux grading, investigative modalities, and treatment regimen.
Case notes were reviewed and tabulated for age, sex, diagnosis, predisposing factors for granuloma formation, grade of laryngopharyngeal reflux, investigations, treatment, resolution, and recurrence. All patients were followed up for at least 12 months after resolution.
Fourteen of the 61 granulomas occurred after intubation. Ten patients were professional voice users. Our assessment of the 55 granuloma patients revealed an incidence of 76% of gastroesophageal reflux disease in patients with and without known vocal fold trauma. There was a 50% recurrence rate following surgical excision. However, aggressive antireflux therapy, lifestyle modifications, and adjuvant speech therapy were successful in achieving resolution of most of the granulomas and preventing recurrence. In four patients, antireflux surgery was required and total resolution of the granulomas followed.
Vocal process granulomas have perplexed laryngologists with their indeterminate pathogenesis and tendency to recur. Multiple surgical excisions and a variety of combined medical regimens have been used to treat granulomas with variable success. Recurrence after excision commonly occurs as the underlying causative factors have not been appropriately managed and may re-establish the chronic inflammatory process. We found acid reflux to be a common factor in the majority of our patients with granulomas. Therefore treatment should focus on managing both reflux and any functional voice disease or disorder. The only indications for laryngeal surgery are to resolve diagnostic doubt or to treat acute airway compromise. Based on results, we suggest an algorithm for the investigation and management of vocal process granulomas founded on appropriate antireflux and speech therapy.
The aim of this study was to compare oesophageal pH-metry with laryngeal signs and symptoms in patients suspected of laryngeal reflux disease. A total of 60 patients with voice disorders, who were suspected of laryngeal reflux, were tested by single probe oesophageal pH monitoring. Thirty-two suffered from reflux laryngitis. A comparison of symptoms in patients with proven reflux to patients with no reflux was made. The symptoms were more frequent in the patients in the reflux group than in the non-reflux group. There was a significant difference between the groups with regard to dysphonia, sore throat, thick mucus and heartburn. Clinical signs appeared more frequently in the reflux group than in the non-reflux group. A significant difference was found between the groups regarding oedema of the vocal cords and hyperaemia and oedema of the posterior commisure, contact granuloma, posterior wall granulation and increased muscle tension. The patients in the reflux group were given medical treatment using omeprazole, and 76% logopedic voice training program. More than 50% of the laryngeal reflux patients were treated for more than 4 months before their voice problems had resolved. It is important to realize that signs of reflux laryngitis are not confined to the posterior commisure.
Gastroesophageal reflux has been implicated in the pathogenesis of a wide variety of otolaryngologic disorders. Patients with otolaryngologic disorders associated with gastroesophageal reflux infrequently have the classic symptoms of gastroesophageal reflux, such as heartburn. Clinical presentation of laryngopharyngeal reflux is commonly characterized by chronic intermittent symptoms. A meticulous synthesis of the information obtained from a