Diagnosis Of Laryngopharyngeal Reflux Research Articles

Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score

The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001).When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.

Laryngopharyngeal Reflux Disease is More Severe in Obese Patients: A Prospective Multicenter Study.

To investigate whether there is an impact of obesity and overweight on the clinical findings and therapeutic responses of patients with laryngopharyngeal reflux (LPR). Prospective uncontrolled. Patients with LPR-related symptoms and positive LPR diagnosis at the hypopharyngeal-esophageal multichannel intraluminal impedance pH-monitoring (HEMII-pH) were recruited from December 2017 to December 2020. Patients were treated with a combination of diet, proton pump inhibitors, and alginate for 3 to 6 months. The following outcomes were studied according to the weight of patients: HEMII-pH, gastrointestinal endoscopy features, symptoms, findings, and therapeutic response. A total of 262 patients completed the study, accounting for 134, 85, and 43 patients with normal weight (body mass index [BMI] <25), overweight (BMI=25-29.99), and obesity (BMI >30). Obese patients reported significant higher prevalence of gastroesophageal reflux disease (GERD), acid LPR, and a more severe LPR disease regarding the number of pharyngeal reflux events, reflux symptom score (RSS), and reflux sign assessment (RSA). RSS and RSA scores significantly improved from baseline to 3-month posttreatment irrespective of the patient weight group. Symptoms and signs continued to improve from 3 to 6-month posttreatment only in patients with a normal weight. Obesity is associated with a more severe LPR disease and a higher proportion of GERD and acid LPR. Obese LPR patients may require more frequently PPI-therapy regarding the higher prevalence of GERD. 3 Laryngoscope, 131:E2742-E2748, 2021.

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

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

Proton pump inhibitor treatment improves pulmonary function in acute exacerbations of COPD patients with 24-hour Dx-pH monitoring-diagnosed laryngopharyngeal reflux.

Chronic obstructive pulmonary disease (COPD) patients have higher laryngopharyngeal reflux (LPR)-related symptom incidence. But LPR treatment is empirical. We aimed to determine the frequency of LPR, diagnosed by 24-hour Dx-pH monitoring, among acute exacerbations of COPD (AECOPD) patients with Reflux Symptom Index (RSI) ≥13 and investigate proton pump inhibitor (PPI) treatment effect on LPR, COPD symptoms, and pulmonary function. From January 2016 to September 2017, 102 AECOPD patients with RSI ≥13 were enrolled. COPD assessment test (CAT), mMRC dyspnea scale, pulmonary function tests, and 24-hour Dx-pH monitoring were performed. The Ryan score was evaluated by using the Dx-pH DataView Lite software, which identifies patients with abnormal pharyngeal pH environments. Associations among RSI, pulmonary function test results, and Ryan score parameters were evaluated. The abovementioned assessments were reperformed after treatment, and pre- and posttreatment data were compared. Of the 102 eligible patients, 49 (48.04%) were diagnosed with LPR based on Ryan score. Percentage of the forced expiratory volume at 1 second (FEV1%) was significantly worse in Ryan-positive than in Ryan-negative AECOPD patients. There were significant negative correlations between FEV1% and Ryan score (r=-0.394, P<0.001), FEV1% and % time below pH threshold (r=-0.371, P<0.001) in upright position but not in supine position. There was no significant correlation between RSI and Ryan score parameters. There were significant improvements in RSI, mMRC, CAT, and FEV1% in Ryan-positive AECOPD patients after PPI and basic treatments. Study results indicate unreliability of RSI threshold for LPR diagnosis. Combination of symptoms, endoscopic findings, and 24-hour Dx-pH monitoring is recommended for LPR diagnosis and PPI treatment decisions, especially in difficult-to-control or severe COPD patients.

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

To study the management of laryngopharyngeal reflux (LPR) among the subspecialties of practicing otolaryngology-head and neck surgeons and their trainees. A survey was sent to over 8000 otolaryngologists (OTOHNS) over 65 countries, utilizing membership lists of participating otolaryngological societies. The outcomes were answers to questions regarding LPR knowledge and practice patterns, and included queries about its definition, prevalence, clinical presentation, diagnosis, and treatment. Of the 824 respondents, 658 practiced in one specific otolaryngologic subspecialty. The symptoms and findings thought to be the most related to LPR varied significantly between subspecialists. Extra-laryngeal findings were considered less by laryngologists while more experienced OTOHNS did not often consider digestive complaints. Compared with colleagues, otologists, rhinologists and laryngologists were less aware of the involvement of LPR in otological, rhinological and laryngological disorders, respectively. Irrespective of subspecialty, OTOHNS consider symptoms and signs and a positive response to empirical therapeutic trial to establish a LPR diagnosis. Awareness regarding the usefulness of impedance pH-studies is low in all groups. The therapeutic approach significantly varies between groups, although all were in agreement for the treatment duration. The management of non-responder patients demonstrated significant differences among laryngologists who performed additional examinations. The majority of participants (37.1%) admitted to being less than knowledgeable about LPR management. LPR knowledge and management vary significantly across otolaryngology subspecialties. International guidelines on LPR management appear necessary to improve knowledge and management of LPR across all subspecialties of otolaryngology.

Current possibilities and challenges in the diagnosis of laryngopharyngeal reflux

Der laryngopharyngeale Reflux (LPR) ist definiert als ein Zurückfließen von gastralem bzw. gastroduodenalem Sekret in den Larynx- bzw. Pharynxbereich und ist durch ein sehr breites Spektrum an teils unspezifischen Symptomen wie beispielsweise chronischem Husten, zervikalem Globusgefühl oder Hypersekretion von Mukus im Larynx und Pharynx charakterisiert. Aufgrund des Fehlens eines Goldstandards und der heterogenen Studienlage gestaltet sich die Diagnosestellung des LPR jedoch weiterhin schwierig und wird in absehbarer Zeit weiterhin kontrovers diskutiert werden. Insgesamt kann man jedoch davon ausgehen, dass bei suggestiver Anamnese mit erhöhten Scores im Reflux Symptom Index (RSI), entsprechenden endoskopischen Befunden mit pathologischem Reflux Finding Score (RFS) und auffälliger ösophagealer oder oropharyngealer 24-h-pH-Metrie ohne Hinweise auf eine andere Grunderkrankung die Diagnose eines LRP wahrscheinlich ist. In der vorliegenden Übersichtsarbeit sollen die genannten Methoden ebenso wie neuere Werkzeuge bei der Diagnose des LPR kritisch diskutiert werden.

Peak nasal inspiratory airflow measurements for assessing laryngopharyngeal reflux treatment.

To evaluate the effect of laryngopharyngeal reflux (LPR) and antireflux treatment on peak nasal inspiratory airflow (PNIF). Prospective observational study was conducted. Tertiary otorhinolaryngology clinic. Adults with LPR and healthy controls. PNIF measurements were performed on 60 patients who applied with complaints suggestive of LPR having higher Reflux Symptom Index (RSI) (>13) and Reflux Finding Scores (RFS) scores (>7). Proton pump inhibitor (PPI) treatment was started and PNIF measurements were repeated two months later. A total of 100 patients without any history of LPR and sinonasal disease were included in the study. A statistically significant increase was observed in PNIF values after proton pump inhibitor treatment. The mean PNIF values of the LPR patients were 133.83±27.99 L/min and 149.92±23.23 L/min before and after treatment, respectively. The mean PNIF value in the control group was 145.0±25.92 L/min. PNIF values were significantly lower in the LPR relative to the control group (P<.05). Laryngopharyngeal reflux decreases PNIF. This negative effect on PNIF disappears after antireflux medication. The results of the study indicate that PNIF measurements may be an appropriate method for clinical diagnosis of LPR and evaluation of treatment results.

Application of High Speed Digital Imaging (HSDI) technique in the diagnosis of dysphonia in patients with laryngopharyngeal reflux disease (LPR).

Introduction Gastroesophageal reflux disease (GERD) may cause extra-esophageal complications, including laryngopharyngeal reflux disease (LPR). It is caused by morphological changes in the laryngeal mucosa due to the regurgitation of gastric contents. Laryngopharyngeal reflux has a wide symptomatology. There is no pathognomonic image of the larynx for LPR. In the diagnosis of LPR, the subjective RSI scale is commonly used, which assesses symptoms in conjunction with the laryngoscopic assessment of the larynx on the RFS scale. The aim of the study was to diagnose the clinical form of dysphonia in patients with laryngopharyngeal reflux (LPR) using the HS camera and HSDI technique. Material and methods The study included a group of 72 patients of both genders, age 20 to 65, who obtained more than 13 points in the RSI scale and more than 7 points in the RFS scale. Results Application of HSDI technique with camera in the high speed (HS) and high resolution (HR) mode allowed precise objective diagnosis of organic and functional disorders of a hyperfunctional dysphonia.

Effectivity of alkaline water on the clinical improvement in laryngopharyngeal reflux

Laryngopharyngeal reflux (LPR) is the reflux of gastric acid through the upper oesophageal sphincter causing mucosal damage of the larynx, the gastrointestinal tract, and the upper airway. Alkaline water has the ability to withstand acidic conditions in the body, the formation of carbonic anhydrase, and reepithelization. This study aimed to investigate the effect of alkaline water on the clinical improvement in LPR patients. A randomized control trial with pre-test and post-test control group design on LPR patients aged 18 to 60 y.o. was conducted at the ENT-HS outpatient clinic of Dr Kariadi Central Hospital, Semarang, Central Java, Indonesia. Thirty subjects were recruited and divided into two group with 15 subjects in each group. In the control group, the subjects were given standard therapy and mineral water. In the treatment group, the subjects were given standard therapy and alkaline water. The diagnosis of LPR was made if the reflux scoring index (RSI) was ≥13, and the reflux finding score (RFS) was &gt;7. ,After two weeks of intervention, the clinical improvements were evaluated by reassessing the RSI score. The data were analyzed using the Shapiro-Wilk test and independent t-test. The results showed that the most common main complaint was throat clearing [11 subjects (37%)]. Based on the RSI score, there were clinical improvements in both the control (p &lt;0.001) and the treatment groups (p &lt;0.001). However, there was no significant difference in the RSI score before and after the intervention in the control (p = 0.058) and the treatment groups (p = 0.322). In conclusion,tbe d there is an effect of alkaline water on the clinical improvement of LPR patients. However, there is no significant difference in the clinical improvement between the control and the treatment groups.

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

To study the profile and the therapeutic response of patients with laryngopharyngeal reflux (LPR) at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) according to the initial pepsin saliva concentration. From January 2018 to January 2020, patients with positive LPR diagnosis at the HEMII-pH were consecutively recruited from 3 European Hospitals. Saliva pepsin concentration (Peptest™) was measured during the HEMII-pH testing period and patients were classified into 2 groups: negative versus positive Peptest. The clinical outcomes, that is, gastrointestinal and HEMII-pH findings, reflux symptom score-12 (RSS-12), and 3-month therapeutic response, were compared between groups. A total of 124 patients completed the study. Among them, 30 patients had negative Peptest. Pharyngeal reflux events occurred outside 1-hour post-meal time in 74.0%, after the meals in 20.5% and nighttime in 5.5%. The pepsin saliva level was not significantly associated with the reflux events preceding the sample collection. Patients with positive Peptest had better improvement of RSS-12 digestive and respiratory subscores and oral, pharyngeal, and laryngeal findings compared with patients with negative Peptest. Patients with high saliva pepsin concentration had no stronger gastrointestinal, HEMII-pH, or clinical outcomes compared with those with low or undetectable saliva pepsin concentration.

Poor consistency between reflux symptom index and laryngopharyngeal pH monitoring in laryngopharyngeal reflux diagnosis in Chinese population.

BackgroundIt is unknown whether the reflux symptom index (RSI) can replace pH monitoring as a diagnostic tool for laryngopharyngeal reflux (LPR) in Chinese people. The relationships between reflux parameters and LPR symptoms also require further research.MethodsA total of 216 Chinese patients underwent laryngopharyngeal pH monitoring and filled out an RSI questionnaire. Laryngopharyngeal pH monitoring indicated a diagnosis of LPR for patients with 7 or more episodes of reflux or a reflex area index (RAI) of 6.3 or more. The RSI questionnaire indicated a diagnosis of LPR for patients with RSI scores of 14 or higher.ResultsOf the 216 patients, 85 were diagnosed with LPR as assessed by the RSI, and 72 were diagnosed with LPR through laryngopharyngeal pH monitoring. The Cohen’s kappa coefficient comparing LPR diagnosis consistency between RSI score and laryngopharyngeal pH monitoring was 0.133 (P=0.007). This indicated the two diagnostic methods were consistent to a low degree; the total consistency rate was only 59.7% (129/216). The sensitivity of the RSI was 48.6% (35/72), and its specificity was 82.5% (94/114). For convenience, we named the nine symptom groups in the RSI sequentially as P1–P9. P1, P2, P3, P5, P6, and P7 were all correlated with at least one reflux parameter (P<0.05), but P4, P8, and P9 were not correlated with any reflux parameters (P>0.05). A total of 72 patients were diagnosed using pH monitoring, the gold standard for LPR diagnosis. The most common symptoms of LPR were found to be P9, P3, P8, P7, and P2 in these patients. The symptoms that most seriously affected patients were P9, P8, P3, P7, and P2.ConclusionsThe consistency in diagnosis of LPR between the RSI and laryngopharyngeal pH monitoring was poor, meaning the RSI is not a suitable LPR initial screening tool and cannot replace pH monitoring. Additionally, reflux symptoms P4, P8, and P9 were not correlated with any reflux parameters. The most prevalent LPR symptom was P9, followed by P3, P8, P7, and P2. The most severe symptom was also P9, followed by P8, P3, P7, and P2.

Management of Laryngopharyngeal Reflux Around the World: An International Study.

To investigate worldwide practices of otolaryngologists in the management of laryngopharyngeal reflux (LPR). An online survey was sent on the management of LPR to members of many otolaryngological societies. The following aspects were evaluated: LPR definition, prevalence, clinical presentation, diagnosis, and treatment. A total of 824 otolaryngologists participated, spread over 65 countries. The symptoms most usually attributed to LPR are cough after lying down/meal, throat clearing and globus sensation while LPR-related findings are arytenoid erythema and posterior commissure hypertrophy. Irrespective to geography, otolaryngologists indicate lack of familiarity with impedance pH monitoring, which they attribute to lack of knowledge in result interpretation. The most common therapeutic regimens significantly vary between world regions, with a higher use of H2 blocker in North America and a lower use of alginate in South America. The duration of treatment also significantly varies between different regions, with West Asia/Africa and East Asia/Oceania otolaryngologists prescribing medication for a shorter period than the others. Only 21.1% of respondents are aware about the existence of nonacid LPR. Overall, only 43.2% of otolaryngologists believe themselves sufficiently knowledgeable about LPR. LPR knowledge and management significantly vary across the world. International guidelines on LPR definition, diagnosis, and treatment are needed to improve knowledge and management around the world. N.A. Laryngoscope, 131:E1589-E1597, 2021.

Diagnostic Utility of Salivary Pepsin as Compared With 24‐Hour Dual pH/Impedance Probe in Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) is defined as the retropulsion of gastric contents into the larynx, oropharynx, and/or nasopharynx. The 24-hour combined hypopharyngeal-esophageal multichannel intraluminal impedance with dual pH probe (24h-HEMII-pH) is currently the gold standard in LPR diagnosis; however, it is invasive, user dependent, and not always tolerated. This study assesses the diagnostic utility of salivary pepsin (Peptest) at different thresholds and during symptomatic periods as compared with the 24h-HEMII-pH probe in diagnosing LPR. Prospective cohort study. Private laryngology clinic in Melbourne, Australia. Thirty-five patients with a clinical history and endoscopic findings of LPR were recruited and simultaneously evaluated for LPR via 24h-HEMII-pH probe and salivary pepsin analysis at 5 key time points over the same 24-hour period. Salivary pepsin was 76.9% sensitive and had a positive predictive value (PPV) of 87.0% at a threshold of 16 ng/mL when compared with the 24h-HEMII-pH probe. If the pathologic pepsin threshold was raised to 75 ng/mL, salivary pepsin had a sensitivity of 57.7%, a specificity of 75.0%, and a PPV of 93.8%. Symptomatic testing conferred a superior specificity at 16 ng/mL (66.7%) and 75 ng/mL (100.0%) and a superior PPV at 16 ng/mL (92.3%) and 75 ng/mL (100.0%). Salivary pepsin detection is a simpler, more cost-effective, and less traumatic universal first-line alternative to 24h-HEMII-pH probe in diagnosing LPR. Superior specificities conferring greater diagnostic value may be achieved with higher thresholds and symptomatic testing. If clinical suspicion remains high following negative salivary pepsin analysis, a 24h-HEMII-pH study could provide further diagnostic information.

Inter-Rater Variability of Reflux Finding Score Amongst Otolaryngologists

Laryngopharyngeal reflux (LPR) is an extra-oesophageal variant of gastro-oesophgeal reflux disease. Patients often do not present with the classic reflux symptoms of heartburn or regurgitation. Accurate diagnosis of LPR can be challenging. The reflux finding score (RFS) is system based on the assessment of eight parameters seen on fibre optic laryngoscopy, used to determine the presence and the severity of laryngopharyngeal reflux (LPR). Scoring the RFS is subjective and highly dependent on the examiner's eye and experience. In this study, we investigated the inter-rater reliability between three otolaryngologists scoring a large library of video-recorded laryngoscopies for RFS. To evaluate the usefulness of RFS in daily clinical practice by assessing inter-rater reliability among otolaryngologists when interpreting a bank of identical fibre optic laryngoscopy examinations. Three board-certified otolaryngologists with different subspecialist interests examined video-recorded fibre optic laryngoscopies of 193 patients with or without LPR symptoms and rated each video for RFS. Statistical analysis was performed. Results were compared to determine the inter-rater reliability. Fair to poor correlation was found between the three expert raters for total RFS score, as well as for RFS component items with nonbinary outcomes. For the dichotomous items, the inter-rater reliability was slight to moderate. Inter-rater correlation for determining whether an examination is pathological or nonpathological was fair. The RFS alone was not reliable for confirming the diagnosis of LPR, due to low inter-rater reliability and the subjective nature of the scoring system.

Screening and diagnosis of laryngopharyngeal reflux in patients with laryngeal cancer stage I-II (T1-2N0M0)

Topicality: The variety of manifestations of laryngopharyngeal reflux (LPR) in otolaryngological practice has made this problem relevant for the past decades. The development of LPR is associated with impaired function of the upper esophageal sphincter, which allows reflux to enter the larynx, pharynx, nasal cavity and middle ear cavity. In a number of studies, pathological reflux has been identified as one of the factors in the development of cancer of the upper respiratory and digestive tract. Aim of the study: to improve methods fors creening and diagnosis of laryngopharyngeal reflux in patients with laryngeal cancer stage I-II (T1-2N0M0). Materials and methods: The study group included 93 patients with stage I-II laryngeal cancer (T1-2N0M0). The control group was represented by 36 patients with reflux-associated benign neoplasms of the larynx. For preliminary diagnosis and objectification of complaints used the RSI test. To increase the accuracy of interpretation and objectification of laryngoscopic manifestations of LPR, the RFS scale was used. The daily pH-monitoring was carried out using an AG-1pH-M acidogastrograph with an electrode system. The severity of reflux was determined according to DeMeester criteria. According to the results of pH monitoring, clinical groups were formed. Results: When analyzing the results of the examination, the RSI index exceeded “9” in 41 (44.1%) patients. When tested on the RFS scale, the indicator “13 and higher” was recorded in 48 (51.6%) patients. All patients (41) with a positive RSI test received 24-hour pH monitoring. According to 24-hour pH-monitoring, the presence of LPR was verified in 33 (80.1%) patients with a positive RSI test. The study group consisted of 33 (80.1%) patients with squamous cell carcinoma of the larynx T1-2N0M0. After 24-hour pH-monitoring, we obtained the data: mild LPR was observed in 6 (18.2%) patients, moderate severity of LPR in 18 (54.5%) and severe LPR in 9 (27.3%). In patients with laryngeal cancer T1-2N0M0, which is associated with LPR, the DeMeester criterion exceeded 14.72. Conclusions: Comparison of pH-monitoring data and visual-analogue scales reaches 80.1% of compliance in patients with laryngeal cancer T1-2N0M0, which is associated with LPR. According to 24-hour pH-monitoring, the presence of LPR was verified in 33 (35.5%) of the examined patients with squamous cell carcinoma of the larynx. Using the modified The Reflux Symptom Index and The Reflux Finding Score scales is a highly reliable method for screening the diagnosis of laryngopharyngeal reflux in patients with laryngeal cancer.

Laryngopharyngeal Reflux: Symptoms, Signs, and Presence of Pepsin in Saliva - A Reliable Diagnostic Triad.

Introduction Twenty-four-hour multichannel intraluminal impedance with double probe pH monitoring (MII-pH), though considered the most sensitive tool for the diagnosis of gastroesophageal reflux disease (GERD), is invasive, time consuming, not widely available, and unable to detect non-acid reflux. In contrast, the presence of pepsin in the saliva would act as a marker for reflux, considering that pepsin is only produced in the stomach. Objective To evaluate the predictive value of salivary pepsin in diagnosing laryngopharyngeal reflux (LPR) as suggested by the results of reflux symptom index (RSI > 13), reflux finding score (RFS > 7), and positive response to treatment with a 4-week course of proton-pump inhibitors. Methods This prospective study was done at a tertiary care hospital on 120 adult patients attending ENT OPD with clinical diagnosis of LPR. The presence of pepsin in their pharyngeal secretions and saliva using a lateral flow device, the Peptest, was compared with RSI, RFS, and with the response to medical treatment using the Chi-squared test. Results Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of them showing positive response to treatment. Chi-squared analysis showed a significant association between positive salivary pepsin and RFS > 7, RSI >13, a combination of RFS > 7 and RSI > 13 as well as with response to treatment ( p < 0.0001). Conclusion When considered along with the clinical indicators of RFS and RSI of more than 7 and 13, respectively, and/or with a response to treatment, a positive salivary pepsin test indicates statistically significant chance of presence of LPR.

Involvement of Laryngopharyngeal Reflux in Select Nonfunctional Laryngeal Diseases: A Systematic Review.

To investigate the existing published evidence supporting the role of laryngopharyngeal reflux (LPR) in the development of the select nonfunctional laryngeal diseases of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. PubMed, Cochrane Library, and Scopus. A systematic review was performed by 3 independent investigators for studies providing information about the prevalence and role of LPR in the development of laryngotracheal stenosis, granuloma, leukoplakia, and laryngeal infections. Diagnostic criteria and clinical outcome evaluation of included studies were analyzed with PRISMA criteria. Of the 64 relevant publications, 27 clinical and 4 basic science studies were included. Ten studies used objective reliable examinations for LPR diagnosis (eg, dual- or triple-probe or oropharyngeal pH monitoring, multichannel intraluminal impedance-pH monitoring, or pepsin detection). According to the bias analysis and the results of studies, the association between LPR and laryngotracheal stenosis, leukoplakia, laryngeal papillomatosis, or vocal fold granuloma remains poorly demonstrated. There is a notable heterogeneity among included studies regarding their inclusion criteria, diagnostic methods, and clinical outcome evaluation. Although some experimental findings support the involvement of bile salts and other gastroduodenal proteins active in alkaline pH, no included clinical studies assessed the role of nonacid and mixed reflux through multichannel intraluminal impedance-pH monitoring. The involvement of LPR in the development of leukoplakia, laryngotracheal stenosis, vocal fold granuloma, and laryngeal papillomatosis is currently not demonstrated. The potential relationship between LPR and these select nonfunctional laryngeal diseases must be confirmed through future clinical and experimental studies considering acid, nonacid, and mixed LPR.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques.

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

Software improvement for evaluation of laryngopharyngeal pH testing (Restech) - a comparison between DataView 3 and 4.

BACKGROUNDWhen gastroesophageal reflux contents reach above the upper esophageal sphincter, patients may, in addition to typical reflux symptoms, present with atypical, extraesophageal symptoms related to laryngopharyngeal reflux (LPR). Surgical treatment of LPR has shown to lead to 70% symptom improvement, however no gold standard for the diagnosis of LPR exists. In 2007, the Restech Dx-pH was released as a valid method to measure acid exposure above the upper esophageal sphincter. Recently, a new software update was introduced for analysis of measured pH data and calculation of composite scores. The effect of the changes applied to the new software version have not yet been analyzed.AIMTo compare results generated by DataView 3 to the most recently released DataView 4.METHODSAll patients with gastroesophageal reflux disease symptoms were seen in a specialized surgical outpatient clinic for gastrointestinal function testing. Retrospective chart review was performed of all patients presenting with suspected gastroesophageal reflux disease and extraesophageal reflux symptoms, who underwent laryngopharyngeal pH monitoring using the Restech Dx-pH system (Respiratory Technology Corp., Houston, TX, United States) and simultaneous esophageal pH monitoring. DataView 3 and DataView 4 were used to evaluate Restech studies obtained. Diary entries such as mealtimes, supine and upright periods, and symptoms were entered manually to ensure accuracy and precise conversion of data between both software versions. Paired t test was performed for statistical analysis of results.RESULTSA total of 174 patients (63.8% female) met inclusion criteria, all suffering from extraesophageal reflux symptoms as well as typical gastroesophageal reflux disease symptoms. Mean RYAN score upright was 48.77 in DataView 3 compared to 22.17 in DataView 4, showing a significant difference (aP = 0.0001). Similar results were shown for supine period (mean RYAN Score DataView 3 5.29 vs 1.42 in DataView 4, cP = 0.0001). For upright periods 80 patients showed a decrease of value of the RYAN score with a mean of -58.9 (mean 51.1% decrease). For supine position 25 patients showed a decrease of value of the RYAN score with a mean of -15.13 [range (-153.44)–(-0.01)], which equals a mean decrease of value of 44.5%. Ten patients showed no oropharyngeal acid exposure in DataView 3, but mild/moderate (n = 7) or severe (n = 3) acid exposure in DataView 4. Correlation with positive esophageal pH measurement was improved in all 10 patients.CONCLUSIONResults of both software versions cannot be compared to each other. However, our data suggests that DataView 4 may be an improvement of the Restech pH measurement in the evaluation of LPR.

Is the pepsin immunohistochemical staining of laryngeal lesions an available way for diagnosing laryngopharyngeal reflux

Backgound: Pepsin immunohistochemical (IHC) staining is a promising diagnostic approach of laryngopharyngeal reflux (LPR). The interarytenoid mucosa has been proved to be an effective biopsy area.Objectives: To investigate whether positive result of pepsin IHC staining in laryngeal lesions can predict LPR.Methods: The study included 136 patients with laryngeal cancer or vocal cord leukoplakia. 24 h multichannel intraluminal impedance-pH (MII-pH) was performed before operation, and pepsin IHC staining was performed on pathological sections after operation. The results of the two methods were compared.Results: Among the 136 patients, 101 with at least one LPR event were regarded as MII-pH positive group, and another 35 were negative. The positive rate of pepsin IHC staining was 93.1% in MII-pH positive group and 54.1% in MII-pH negative group (p < .05). If the MII-pH results were used as a reference, the sensitivity and specificity of pepsin IHC staining in the diagnosis of LPR were 93.1 and 45.7%, respectively. The consistency of pepsin IHC and MII-pH was moderate (Kappa value = 0.452).Conclusions: The sensitivity of pepsin IHC staining in laryngeal lesions for diagnosing LPR is satisfactory. The existence of false negative of MII-pH may be the main reason for the low specificity.