Signs Of Laryngopharyngeal Reflux Research Articles

Effect of positive airway pressure compliance on laryngopharyngeal reflux in obstructive sleep apnea patients

ObjectivesTo determine the effect of continuous positive airway pressure (CPAP) compliance on symptoms and signs of laryngopharyngeal reflux (LPR) in patients with obstructive sleep apnea (OSA).ResultsThirty patients were included. The participants were divided into good compliance (n = 21) and poor compliance (n = 9) groups. After 6-month CPAP treatment, the reflux symptom index score significantly decreased in both the good compliance group (20 (17,24) vs. 14 (10,18), p < 0.001) and the poor compliance group (21 (18,25) vs. 10 (5,16), p < 0.05). Reflux finding score was significantly reduced in both the good compliance group (8 (6,9) vs. 4 (3,5), p < 0.001) and the poor compliance group (6 (4,8) vs. 3 (2,4), p < 0.05). However, there were no statistically significant differences between the groups. CPAP treatment reduces the symptoms and signs of LPR. However, CPAP compliance does not correlate with improvement in LPR in patients with OSA.

Translation and cultural adaptation of the Short Version of the Reflux Symptom Score: Reflux Symptom Score-12 into Brazilian Portuguese.

To describe the process of translation into Brazilian Portuguese and cross-cultural adaptation of the French Reflux Symptom Score-12 questionnaire used for the diagnosis of laryngopharyngeal reflux. This was a cross-cultural translation and adaptation study of a health instrument, with a cross-sectional design. It was carried out in eight stages: translation from French into Brazilian Portuguese, cultural adaptation by a panel of experts, application of the first version (pilot test 1), adaptation by a panel of experts, application of the second version (pilot test 2), back translation, reviewing by a committee in conjunction with the author of the original instrument and, application of the final version. The Brazilian Portuguese versions of the questionnaire were applied to individuals with symptoms and signs of laryngopharyngeal reflux who underwent pHmetry and esophageal manometry at the study site. In pilot test 1, the first version of the RSS-12 in Brazilian Portuguese was applied to 30 patients. The patients had no difficulty to understand any of the 12 symptom items, but 15 patients (50%) had difficulty interpreting the symptom frequency score. After adapting the format of the frequency score, a version 2 of the RSS-12 in Brazilian Portuguese was applied to another 23 patients, who completed the questionnaire in full without any difficulty. Along with the review committee, the author of the original RSS-12 considered the version 2 to be adequate and did not propose any changes, so it was approved as the final version of the Brazilian Portuguese RSS-12. The Brazilian Portuguese version of the instrument, called Reflux Symptom Score-12 PT-BR, shows good understanding and linguistic, conceptual and content equivalence, in relation to the original Reflux Symptom Score-12.

Clinical Evaluation of Laryngopharyngeal Reflux and its Response to Proton Pump Inhibitors.

To clinically evaluate the patients of laryngopharyngeal reflux(LPR) and their response to Proton Pump Inhibitors(PPIs) using laryngeal Reflux Symptom Index (RSI) and Reflux Finding Score (RFS). This prospective observational study was conducted on 128 patients attending the ENT-OPD of VSSIMSAR,Burla,India,who had persistent laryngeal symptoms for more than 2 months.Data was collected using standardized RSI and RFS after taking detailed history and laryngoscopic examination.Patients who were diagnosed of LPR on the basis of their RSI & RFS were subjected to treatment with PPI-Pantoprazole & were called back for follow up at 2nd, 4th and 6th months.Pre and post treatment RSI& RFS were compared using appropriate statistical tests and results with p-value< 0.01 were considered statistically significant. The overall effect of PPIs on all symptoms & signs of LPR,included in RSI and RFS respectively,is statistically significant except on swallowing (not statistically significant at p<0.01) showing a careful usage of RSI & RFS while diagnosing LPR clinically.Study also elucidated that PPI are effective in relieving symptoms of LPR patients.Evaluating Pearson correlation coefficient,the value of R=0.3717;R2=0.1382 shows low positive correlation between the RSI & RFS.RSI & RFS are related to each other and any change in the RSI will affect the value of RFI and vice versa. From this study we conclude that LPR is prevalent in age of 28-37 years & has female preponderance.PPIs are effective in treating LPR.Though RSI and RFS are effective and valid parameters for managing LPR cases but have to be used cautiously while interpreting the results.

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

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

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

To investigate the sensitivity (SE), specificity (SP), and positive and negative predictive value (PPV and NPV) of symptoms and signs of laryngopharyngeal reflux (LPR). Prospective controlled. University medical center. Patients presenting with LPR symptoms and signs were consecutively included after diagnosis confirmation through 24-hour hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring. Healthy individuals were recruited to compose a control group. Symptoms and signs were evaluated with the reflux symptom score and reflux sign assessment. The SE, SP, PPV, and NPV of symptoms and signs were assessed. The study included 403 patients with LPR and 144 healthy individuals. Throat clearing, globus sensation, heartburn, and excess throat mucus were symptoms with the highest SE (67.5%-69.7%), SP (12.5%-20.8%), and NPV (48.3%-49.2%). The combination of throat clearing, heartburn, globus sensation, and excess throat mucus led to a high SE (96.0%) and NPV (85.2%). Anterior pillar erythema, tongue tonsil hypertrophy, and posterior commissure hypertrophy resulted in the highest SE (75.5%-83.5%). The highest SP was found for uvula erythema/edema, epiglottis erythema, and interarytenoid granulatory tissue (97.1%-97.2%). The association of nonendoscopic signs (anterior pillar erythema, uvula erythema/edema, and coated tongue) had an SE and SP of 80.1% and 47.2%, respectively. The association of throat clearing, heartburn, globus, anterior pillar erythema, and uvula erythema/edema had the highest SE (98.8%), SP (33.3%), PPV (94.3%), and NPV (70.6%). LPR symptoms and signs reported low SP and NPV. The SE, SP, PPV, and NPV may be maximized with the association of throat clearing, heartburn, globus sensation, anterior pillar erythema, and uvula erythema/edema.

Analysis of symptoms and clinical signs of laryngopharyngeal reflux depending on pepsia in saliva

In the last fifty years, an epidemic of reflux disease has occurred as a result of poor eating habits, stress, and activities of the food industry. Part of this disease is laryngopharyngeal reflux, a disease characterized by the return of gastric contents to the throat and surrounding organs, leading to hoarseness, coughing, difficulty in swallowing and breathing, and ultimately the development of benign and malignant changes in the larynx. This study is aimed to examine the symptoms and signs of laryngopharyngeal reflux in the study group before and after therapy and to compare the concentration of pepsin in saliva with the above. The prospective longitudinal cohort study included 50 subjects, divided into two groups. The first group consisted of 25 subjects with laryngopharyngeal reflux. The second group consisted of 25 healthy subjects without symptoms and signs of laryngopharyngeal reflux. Symptoms and signs before and after therapy were collected using RSI and RFS questionnaires. Pepsin in saliva was measured with Peptest before and after therapy. The most pronounced symptoms are hoarseness, postnasal drip, and a feeling of "a lump in the throat". The median RSI score after three months of therapy was reduced from 20 to 8. From the first group, 7 subjects had measurable levels of pepsin in saliva, and none after therapy. In the control group, no subjects were found to have pepsin in their saliva. Significant improvement was observed in clinical findings (subglottic edema, posterior commissure hypertrophy, vocal cord edema, dense endolaryngeal secretion) after three months of therapy in subjects with LPR. No association of pepsin with LPR symptoms was observed but there is a significant positive association between pepsin and the clinical finding of erythema/hyperemia. In most cases, we start therapy with medication. It is, therefore, important to emphasize that laryngopharyngeal reflux treatment must always begin with a change in diet, lifestyle, and stress regulation. Treatment must be individual and should include a multidisciplinary team with a nutritionist, psychologist, and psychiatrist.

Clinical assessment of laryngo-pharyngeal reflux disease by reflux symptom index and reflux finding score in a tertiary care hospital, Madhya Pradesh

Background: Laryngopharyngeal reflux (LPR) or LPR disease (LPRD) is a commonly diagnosed clinical entity caused by the back-flow of gastric contents into the laryngo-pharynx. Diagnosis was made by a set of non-specific clinical symptoms, endoscopic laryngeal examination signs, reflux symptom index (RSI), and reflux finding score (RFS). Aims and Objectives: The aims and objectives of the present study were to establish the diagnosis and treatment of LPR by assessment of the RSI and RFS and also evaluate the impact of proton pump inhibitor (PPI) therapy on LPR. Materials and Methods: A total of 60 clinically suspected patients attending the ENT outpatient department presenting LPRD signs and symptoms were enrolled in the present study. LPR symptoms were assessed using the RSI, and LPR signs were assessed by laryngoscopic examination of the larynx using the RFS. Patient having an RSI score of ≥13 and an RFS of &gt;7 was included in the present study and it was also considered for starting LPR treatment. We have again calculated the both the score (RSI and RFS) after 3 months of successful PPI therapy and compared them with the initial scores. Results: Out of total 60 patients, 50 (83.4%) had RSI score &gt;13 and RFS &gt;7 indicating severe LPRD. Most common symptoms were troublesome/annoying cough (95%), sensation of something sticking in throat (95%), heartburn(95%), frequent throat clearing (91%), and excess throat mucous (87.9%), whereas the most common sign noted on laryngoscopic examination were arytenoids erythema (86.66%), partial ventricular obliteration (83.33%), vocal cord edema (56.7%), posterior commissure hypertrophy (51.7%), and diffuse laryngeal edema (50%). Majority of the patients significantly responded on 3 months PPI therapy. Reduction of clinical signs, symptoms of LPR and also observed significant reduction of RSI and RFS score after successful PPI therapy. Conclusions: In the present study, most of the patients suffering from severe LPRD who presented in our hospital RSI and RFS scored that were clinically significant in current study. After 3 months of proton-pump inhibitor therapy, there was a significant reduction in clinical signs and symptoms of LPR as well as RSI/RFS scores, indicating that PPI therapy was the mainstay of LPRD treatment in the current era.

Preliminary Correlation of the Immunoexpression of Cathepsin B and E-Cadherin Proteins in Vocal Fold Leukoplakia

Early identification of vocal fold leukoplakia (VFL), which has a risk of progressing to malignant transformation, remains a controversial topic. The identification of biological markers for diagnosing these lesions would lead to a more effective treatment. We aimed to analyze the immunoexpression of cathepsin B and E-cadherin in VFL and correlate it with clinical and epidemiological data and disease prognosis. Thirty-two patients with VFL treated with microsurgery were retrospectively evaluated. The patients were distributed according to the histological results into Group A (low grade) and Group B (high grade). The expression of markers was quantitatively determined as per their staining intensity and tissue distribution using ImageLab. The index of expression (IE) of each marker was correlated with tobacco and alcohol consumption, signs of laryngopharyngeal reflux, and local recurrence of the lesion. The correlation between the IE of markers and variables within the two groups (A and B) demonstrated that patients in Group B with local recurrence had a higher IE of cathepsin B. When all patients (A + B) were included, the same analysis demonstrated that the IE of cathepsin B was higher among smokers and patients who did not show signs of reflux and that the IE of E-cadherin was higher only in patients with recurrence. Patients with moderate to severe dysplasia and carcinoma in situ who smoked as well as had a high IE of cathepsin B were more prone to local recurrence. Regardless of the type of histological lesion, patients with signs of laryngopharyngeal reflux had a lower IE of cathepsin B. The IE of E-cadherin was higher among patients with VFL who relapsed after initial treatment.

Enlarging the spectrum of cluster headache: Extracranial autonomic involvement revealed by voice analysis.

BackgroundPeople with cluster headache (CH) are frequently burdened by misdiagnosis or diagnostic delay. The peculiar somatic and behavioral changes characterizing patients with CH are not useful to improve diagnostic accuracy. In our clinical experience, we noticed a typical voice quality with low and croaking tone in patients with CH.In this cross‐sectional study, we evaluated, by digital voice analysis, whether it is possible to identify typical voice quality characterizing patients with CH compared with healthy controls (HCs). Furthermore, to investigate whether putative differences in voice characteristics could be underpinned by constitutional aspects or pathological processes of vocal cords, subjects underwent a videolaryngostroboscopy. Smoking habits and alcohol consumption were specifically investigated.MethodsAfter conducting digital recording of the voices from both patients with CH and HCs in a soundproof insulated cabin in the laboratory of the Audiology Department, a set of voice parameters was analyzed. We included the measures of fundamental frequency, calculations of jitter and shimmer, and noise‐to‐harmonics ratios as well as quantities related to the spectral tilt (i.e., H1–H2, H1–A1, H1–A2, and H1–A3) in 20 patients with CH and in 13 HCs. A videolaryngostroboscopy was performed in all subjects.ResultsPatients with CH, explored during the cluster bout period, showed significantly lower second harmonic (H1–H2) values compared with HCs (−6.9 ± 7.6 vs. 2.1 ± 6.7, p = 0.002), usually characterizing the so‐called creaky voice. By using a laryngoscopy investigation, a significantly higher prevalence of mild to moderate vocal cord edema and laryngopharyngeal reflux signs were found in patients with CH (100% of patients with CH vs. 15% of HC, p < 0.001).ConclusionCreaky phonation is a “physiological mode of laryngeal operation” usually underpinned by shortened and thickened vocal folds. Creaky voice phonation can be due to a vocal fold's reduced capability to become slack or flaccid secondary to vocal cord edema underpinned by laryngopharyngeal reflux affecting the phonatory mechanisms in patients with CH. The laryngopharyngeal reflux may represent a dysautonomic sign related to the increased parasympathetic tone during in‐bout period, reinforcing the hypothesis of an extracranial autonomic dysfunction as part of CH clinical picture.

Videolaryngoscopy Findings of the Vocal Health Program in Dysphonic Teachers in the Federal District, Brazil.

Introduction The high phonatory demand required of teachers is a direct cause of the onset of vocal symptoms and of the development of laryngeal disorders. Objective To describe the findings of the laryngeal screening performed as part of the Vocal Health Program held in the Federal Distrcit of Brazil in 2014 and 2015. Methods The study was performed with 361 dysphonic teachers from public schools who attended the laryngeal screening (videolaryngoscopy) part of the program. Data on anamnesis, the degree of dysphonia, the findings of the laryngeal screening, the referrals made after the laryngeal screening, and the result of the assessment of vocal aptitude for work were analyzed from the forms of each participating teacher. Results The sample of the present study ( N = 361) represents 18.23% of the 1,980 teachers that went through the vocal screening of the program in 2014 and 2015. In total, 98 (27.15%) teachers presented mild dysphonia, 221 (61.22%), moderate dysphonia, and 42, (11.63%) severe dysphonia. Regarding the laryngeal screening (videolaryngoscopy exam), 269 teachers (74.52%) presented laryngeal disorders, and the main ones found were vocal nodules (43.87%), signs of laryngopharyngeal reflux (37.17%), hourglass chink (18.22%), vascular dysgenesis (18.22%), midposterior triangular chink (9.67%), and double chink (8.55%). Conclusion Laryngeal screening through videolaryngoscopy and auditory-perceptual screening of the voice as part of vocal health programs are essential to define the diagnosis and therapeutic conduct for teachers with dysphonia. Together with intervention activities, continuing education and adequate and accessible treatment, the periodic evaluation of vocal health can contribute to reduce absenteeism and improve the quality of life and of the voice of teachers.

Dysphonia in Performers: Prevalence of Vocal Lesions and Voice Emergencies in a Private Otorhinolaryngology Practice

To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency. Retrospective study of professional singers and actors who presented for a vocal evaluation. A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR). A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n=33), followed by cyst 27% (n=25) and acute laryngitis, 14% (n=13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P<0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n=47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P=0.008). Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Tracheobronchomalacia and excessive dynamic airway collapse are conditions affecting the trachea and mainstem bronchi leading to respiratory symptoms through excessive central airway collapse (ECAC) during expiration. Patients with this condition often present with laryngeal pathology resulting in hoarseness, shortness of breath, dysphagia, or cough. Despite previous descriptions of the incidence of paradoxical vocal fold motion in this population, the various possible laryngeal abnormalities have not been characterized. METHODS: We performed a retrospective review of our prospectively collected institutional tracheobronchomalacia database. The most recent patients seen at the chest disease center during the previous and current year (2019-2020) were evaluated. Demographics, comorbidities, previous airway surgeries, and laryngoscopy results were included. Continuous outcomes are presented as means or medians based on the assessment of normality (Shapiro-Wilk test). Dichotomic outcomes are presented as proportions. RESULTS: A total of seventy patients were included in the study. The median age was 57 (49 – 64) and 55 patients were female (78.6%). The most common comorbidities were asthma in 46 (66.7%), gastroesophageal reflux in 41 (59.4%), and obstructive sleep apnea in 32 (46.4%) patients. Only 4 (5.8%) patients had a previous tracheostomy, while 7 (10.1%) had had a previous airway surgery. Out of 70 patients, 64 (91.4%) were evaluated by the laryngology service. Of the patients that were evaluated, 53 (82.8%) had at least one abnormality in their larynx. The most common findings were laryngeal hyperfunction/muscle tension dysphonia in 34 (53.1%), signs of laryngopharyngeal reflux in 27 (42.2%), and vocal fold hypomobility/paresis in 25 (39.1%) patients. More severe conditions like paradoxical vocal fold motion, laryngospasm, and vocal fold paralysis were present in 13 (20.3%), 2 (3.1%), and 2 (3.1%) patients respectively. CONCLUSIONS: ECAC patients have a high incidence of laryngeal disorders that may contribute to their respiratory symptomatology and deteriorate their health-related quality of life. For this reason, it is important to have a baseline laryngeal evaluation before any airway intervention, especially when respiratory symptoms are out of proportion to the degree of dynamic central airway collapse. CLINICAL IMPLICATIONS: Laryngeal pathology may be an additional cause of symptoms in patients with ECAC that can be overlooked if a detailed laryngoscopy evaluation is not conducted. Early identification and opportune intervention could lead to improved patient-centered outcomes. DISCLOSURES: No relevant relationships by Alex Chee, source=Web Response No relevant relationships by Sidhu Gangadharan, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Pavan Mallur, source=Web Response No relevant relationships by Daniel Ospina-Delgado, source=Web Response No relevant relationships by Mihir Parikh, source=Web Response No relevant relationships by Jennifer Wilson, source=Web Response

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

Diagnosis and treatment of presumed laryngopharyngeal reflux (LPR) remain controversial. Empiric medication trials remain widespread for suspected LPR despite emerging evidence against proton pump inhibitor (PPI) safety and for pepsin as a mediator of LPR symptoms. Ongoing concerns exist related to inaccurate diagnosis, the cost and morbidity of potentially unnecessary PPI prescriptions, and availability and interpretation of objective reflux testing. To review contemporary evidence that does and does not support empiric medication trials for presumed LPR. PubMed, Scopus and Cochrane Library were searched for literature about benefits, limitations and alternatives to empiric medication trial for LPR, in order to present both sides of this debate and identify best practices. The majority of physicians perform prolonged empiric medication trial with PPIs for patients with suspected LPR. Because symptoms and signs of LPR are non-specific, empiric medication trials require exclusion of other conditions that can mimic LPR. Following a PPI empiric medication trial, over one-third of patients remain non-responders. The use of hypopharyngeal-oesophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) has benefits and limitations in objective diagnosis of LPR. Use of PPIs for single-agent empiric medication trial does not account for possible non-responders with non-acid or mixed LPR. If LPR diagnosis remains uncertain, alginates can be added to PPI trials. HEMII-pH testing upfront is ideal for patients with suspected LPR, but not always practical; it is indicated when PPI and alginate empiric medication trials have failed or when comorbidities confuse the diagnosis. A more comprehensive, combination therapy empiric medication trial regimen may be needed.

Does Pepsin Play a Role in Etiology of Laryngeal Nodules?

Vocal fold nodules (VFNs) are benign disorders affecting the superficial lamina propria of the true vocal folds. The etiology of VFNs still remains unclear but laryngeal trauma caused by vocal abuse, tobacco, alcohol, and laryngopharyngeal reflux (LPR) plays a crucial role on the pathogenesis. The aim of this study was to assess the presence of pepsin in formalin-fixed, paraffin-embedded (FEPE) specimens of VFNs to evaluate the role of LPR as a risk factor for VFNs. A total of 28 pathology specimens of patients suffering from VFNs who had undergone laser microsurgery under general anesthesia were evaluated. The specimens were maintained in paraffin blocks in the pathology department. Western blot (WB) and enzyme-linked immunosorbent assay (ELISA) analyses were used to measure pepsin enzyme levels in the VFNs tissue specimens. Signs of LPR were assessed according to the reflux finding score. The mean reflux finding score of the patients was 13.6 ± 2.89 (8-21). According to WB and ELISA analyses, pepsin was detected with both the WB the ELISA tests in positive controls, but there was no pepsin enzyme in any of the 28 laryngeal FEPE VFNs specimens. The pepsin enzyme was not detected in any of the FEPE VFNs specimens, and it is concluded that further studies are needed to reveal the role of pepsin in the etiology of VFNs.

The Role of Reflux in Childhood Otorhinolaryngological Disorders

This article seeks to review the current literature on the role of laryngopharyngeal reflux in the development of various disorders of the ear, nose and throat in infants and children including otitis media, chronic rhinosinusitis and airway disorders. The aim is to guide the otolaryngology clinician in investigation and management of reflux and to identify priorities for future research in this area. Many otolaryngological disorders coexist with reflux more often than might be expected by chance, but evidence of causality is weak. Although many otolaryngologists are convinced that treatment of reflux can make a significant difference to the clinical course of many upper airway disorders, the evidence to support this is lacking. In part, this is due to inadequate tools for describing the symptoms and endoscopic signs of laryngopharyngeal reflux and the lack of a sensitive, specific and reliable objective test. Further research demonstrating simple associations between otolaryngological diseases and reflux is unlikely to be of much value. Instead, researchers should concentrate their efforts on studies to develop and validate better means of recording symptoms and signs of laryngopharyngeal reflux and investigating the clinical utility of salivary pepsin, oropharyngeal pH monitoring and multichannel intraluminal impedance.

Substernal goiter and laryngopharyngeal reflux.

This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Acoustic Analysis of Voice and Electroglottography in Patients With Laryngopharyngeal Reflux

Laryngopharyngeal reflux (LPR) refers to the flow of gastric acid content into the laryngopharynx. It has been reported that 10% of the patients consulting an otolaryngologist present with this condition. Signs of LPR can be identified during flexible or rigid laryngoscopy. The Voice Handicap Index (VHI) is a reliable tool for detecting the impact of voice disorders, and acoustic assessment of voice including acoustic analysis of voice (AAV) and electroglottography (EGG) provide objective data of voice production and voice disorders. This study aimed to describe changes in AAV, EGG, and VHI in patients who present with LPR compared with a matched control group of healthy subjects. Seventeen patients with LPR were studied. A group of healthy subjects matched by age and gender without any history of voice disorder, LPR, or gastroesophageal reflux disease was assembled. Both groups of patients were studied by VHI, flexible laryngoscopy, AAV, and EGG. All patients with LPR demonstrated abnormal VHI values. Shimmer, jitter, open quotient, and irregularity were significantly increased in the patients with LPR. Nonsignificant correlations were found between VHI scores and abnormal acoustic parameters in patients with LPR. Although abnormal acoustic parameters of patients with LPR were not predictive of the overall VHI score, the abnormal acoustic parameters of patients with LPR suggest a decrease in adequate laryngeal control during phonation.

Optimal timing of saliva collection to detect pepsin in patients with laryngopharyngeal reflux.

To determine salivary pepsin levels as a function of collection time. A prospective, case-control study. We selected 57 patients with clinical symptoms and signs of laryngopharyngeal reflux who underwent 24-hour multichannel intraluminal impedance-pH (24h MII-pH) monitoring tests, and 12 control subjects without clinical symptoms and signs of laryngopharyngeal reflux. All subjects were instructed to collect saliva samples upon waking, 1 hour after each meal (3 times per day), and upon any occurrence of laryngopharyngeal reflux (LPR) symptoms. The pepsin levels in saliva were measured by using enzyme-linked immunosorbent assay. The Reflux Symptom Index survey was also administered. A total of 50 patients in whom LPR was diagnosed based on results of 24h MII-pH monitoring test were enrolled in the study. The average pepsin level upon waking was 17.2 ng/mL, which was significantly higher than that measured in samples collected at any other time (P < .005). Pepsin levels were higher in patients with LPR than those in controls. The Reflux Symptom Index scores were statistically different between these groups of subjects. The levels of total pepsin in saliva collected upon waking were significantly higher in the group of patients presenting with LPR symptoms and who demonstrated at least one episode of proximal esophageal reflux during 24h MII-pH monitoring. Furthermore, the average pepsin level upon waking was higher than that measured at any other time. Measuring pepsin levels in the saliva upon waking may be a useful method in the diagnosis of LPR. 3b Laryngoscope, 126:2770-2773, 2016.

Definition of nocturnal gastroesophageal reflux for studies on respiratory diseases

ABSTRACTObjective Nocturnal gastroesophageal reflux (nGER) has been associated with respiratory diseases. Our aim was to study a questionnaire method to identify nGER subjects with respiratory involvement in a general population. Material and methods A subgroup of Icelandic participants in the European Community Respiratory Health Survey III (ECRHS III) reporting symptoms of nGER (n = 48) as well as age and gender paired controls (n = 42) were studied further by a structured interview, questionnaires, laryngeal fibrescopy, and exhaled breath condensate. A subgroup underwent 24-h oesophageal pH impedance (24-h MII-pH) measurements. Symptoms of nGER were assessed with a modified version of the reflux disease questionnaire (RDQ), where symptoms were divided into daytime and nocturnal. A report of nGER both at baseline and at follow-up was defined as persistent nGER. Results Participants reporting persistent nGER had significantly more signs of laryngopharyngeal reflux according to the reflux finding score than those without nGER (Mean ± SD: 5.1 ± 2.3 vs. 3.9 ± 2.2, p = 0.02). Of the 16 persistent nGER subjects that underwent 24-h MII-pH, 11 had abnormal gastroesophageal reflux, but none of three control subjects (69% vs. 0%). Pepsin was more commonly found in exhaled breath condensate in the nGER group (67% vs. 45%, p = 0.04). Conclusions Participants with nGER symptoms at least once a month, reported on two occasions, had a high level of positive 24-h MII-pH measurements, laryngeal inflammation and pepsin in exhaled breath condensate. This nGER definition identified a representable group for studies on nGER and respiratory diseases in a general population.

OP‐5 INTEROBSERVER VALIDITY OF THE REFLUX FINDING SCORE FOR INFANTS (RFS‐I) IN FLEXIBLE VERSUS RIGID LARYNGOSCOPY.

Background:The Reflux Finding Score for Infants (RFS‐I) was developed to objectively assess signs of laryngopharyngeal reflux (LPR). Based on review of flexible laryngoscopic videos, only moderate inter‐ and highly variable intraobserver reliability was found. We hypothesized that examination of the infant larynx with rigid laryngoscopy would provide better agreement. AIM: to assess the validity of the RFS‐I in the detection of LPR‐related findings using flexible versus rigid laryngoscopy.Methods:Thirty consecutive infants underwent flexible and rigid laryngoscopy. Based on the recorded videos, RFS‐I was scored by 4 otorhinolaryngologists, 2 otorhinolaryngology fellows, and 2 inexperienced observers. Videos were presented in a randomized order, blinded for clinical profile and findings during initial examination. Observers were provided an instruction sheet prior to evaluation. For categorical data, agreement was calculated using Cohen's kappa (2 observers) and Fleiss’ kappa (&gt;2 observers). For ordinal data the intraclass correlation coefficient (ICC) was used.Results:Of 30 included patients (17 M; median age 7.5 (0–19.8) months), main reasons for referral were: stridor (n = 15,50%), ALTE/apneas (n = 7,23.3%), follow‐up of laryngeal abnormalities (n = 6,20%), aspiration (n = 5,16.7%), and other indications (n = 7,23.3%). Overall interobserver agreement of the RFS‐I was moderate for both flexible (ICC = 0.60, [95%CI 0.44–0.76]) and rigid (ICC = 0.42, [95%CI 0.26–0.62] laryngoscopy. There were no significant differences in agreement on overall RFS‐I scores and individual RFS‐I items for flexible versus rigid laryngoscopy. We did observe higher overall agreement amongst the 2 inexperienced observers for rigid (ICC = 0.40, [95%CI 0.03–0.67]), compared to flexible (ICC = 0.11, [95%CI 0.17–0.41]) laryngoscopy, albeit not significant. Comparing RFS‐I results for flexible versus rigid laryngoscopy per observer, agreement ranged from no to substantial agreement (k = ‐0.16–0.63, mean k = 0.22) and the observed agreement (not adjusted for chance) was 0.08–0.35%.Conclusions:Interobserver agreement of the RFS‐I was only moderate and did not differ between flexible and rigid laryngoscopy. This indicates that the RFS‐I should not be used with flexible, nor rigid laryngoscopy to detect signs of LPR.