Detecting the &lt;i&gt;other&lt;/i&gt; reflux disease

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Applied Evidence

Detecting the other reflux disease

J Fam Pract. 2010 February;59(2):102-107

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References

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2. Karkos PD, Thomas L, Temple RH, et al. Awareness of general practitioners towards treatment of laryngopharyngeal reflux: a British survey. Otolaryngol Head Neck Surg. 2005;133:505-508.

3. Morrison MD. Is chronic gastroesophageal reflux a causative factor in glottic carcinoma? Otolaryngol Head Neck Surg. 1988;99:370-373.

4. Ward PH, Hanson DG. Reflux as an etiologic factor of carcinoma of the laryngopharynx. Laryngoscope. 1988;98:1195-1199.

5. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991;101(4 pt 2 suppl 53):S1-S78.

6. Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg. 2000;123:385-388.

7. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. 2005;294:1534-1540.

8. Aviv JE, Liu H, Parides M, et al. Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia. Ann Otol Rhinol Laryngol. 2000;109:1000-1006.

9. Johnston N, Bulmer D, Gill GA, et al. Cell biology of laryngeal epithelial defenses in health and disease: further studies. Ann Otol Rhinol Laryngol. 2003;112:481.-

10. Gill GA, Johnston N, Buda A, et al. Laryngeal epithelial defenses against laryngopharyngeal reflux: investigations of E-cadherin, carbonic anhydrase isoenzyme III, and pepsin. Ann Otol Rhinol Laryngol. 2005;114:913-921.

11. Okamura H, Sugai N, Kanno T, et al. Histochemical localization of carbonic anhydrase in the trachea of the guinea pig. Histochem Cell Biol. 1996;106:257-260.

12. Johnston N, Knight J, Dettmar PW, et al. Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope. 2004;114:2129-2134.

13. Johnston N, Dettmar PW, Bishwokarma B, et al. Activity/stability of human pepsin: implications for reflux attributed laryngeal disease. Laryngoscope. 2007;117:1036-1039.

14. Axford SE, Sharp N, Ross PE, et al. Cell biology of laryngeal epithelial defenses in health and disease: preliminary studies. Ann Otol Rhinol Laryngol. 2001;110:1099-1108.

15. Toros SZ, Toros AB, Yüksel OD, et al. Association of laryngopharyngeal manifestations and gastroesophageal reflux. Eur Arch Otorhinolaryngol. 2009;266:403-409.

16. Koufman JA. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease Ear Nose Throat J. 2002;81(9 suppl 2):S7-S9.

17. Book DT, Rhee JS, Toohill RJ, et al. Perspectives in laryngopharyngeal reflux: an international survey. Laryngoscope. 2002;112(8 Pt 1):1399-1406.

18. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the Reflux Symptom Index (RSI). J Voice. 2002;16:274-277.

19. Ulualp SO, Roland PS, Toohill RJ, et al. Prevalence of gastroesophagopharyngeal acid reflux events: an evidence-based systematic review. Am J Otolaryngol. 2005;26:239-244.

20. Merati AL, Lim HJ, Ulualp SO, et al. Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux. Ann Otol Rhinol Laryngol. 2005;114(3):177-82.

21. Vaezi MF, Schroeder PL, Richter JE. Reproducibility of proximal probe pH parameters in 24-hour ambulatory esophageal pH monitoring. Am J Gastroenterol. 1997;92:825-829.

22. Vincent DA, Jr., Garrett JD, Radionoff SL, et al. The proximal probe in esophageal pH monitoring: development of a normative database. J Voice. 2000;142:247-254.

23. Reavis KM, Morris CD, Gopal DV, et al. Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Ann Surg. 2004;239:849-858.

24. Gupta R, Sataloff RT. Laryngopharyngeal reflux: current concepts and questions. Curr Opin Otolaryngol Head Neck Surg. 2009;17:143-148.

25. Tsunoda K, Ishimoto S, Suzuki M, et al. An effective management regimen for laryngeal granuloma caused by gastro-esophageal reflux: combination therapy with suggestions for lifestyle modifications. Acta Otolaryngol. 2007;127:88-92.

26. Hopkins C, Yousaf U, Pedersen M. Acid reflux treatment for hoarseness [protocol]. Cochrane Database Syst Rev. 2006;(1):CD005054.-

27. Kahrilas PJ, Falk GW, Johnson DA, et al. The Esomeprazole Study Investigators Esomeprazole improves healing and symptom resolution as compared with omeprazole in reflux oesophagitis patients: a randomized controlled trial. Aliment Pharmacol Ther. 2000;14:1249-1458.

28. Park W, Hicks DM, Khandwala F, et al. Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response. Laryngoscope. 2005;115:1230-1238.

29. Qadeer MA, Phillips CO, Lopez AR, et al. Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials. Am J Gastroenterol. 2006;101:2646-2654.

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Common signs and symptoms that signal LPR
LPR is primarily a clinical diagnosis based on signs and symptoms—which are also used to rule out GERD. Notably, less than 50% of patients with LPR suffer from heartburn and regurgitation.¹⁶ Those who do have heartburn and regurgitation typically suffer with reflux during the day, when they’re in an upright position, whereas reflux associated with GERD develops primarily at night.¹⁶ The results of a recent survey of members of the American Bronchoesophagological Association highlight the most common signs and symptoms of LPR, listed below from the most to the least frequent:¹⁷

throat clearing
persistent cough
globus sensation
hoarseness
choking episodes.

Additional signs and symptoms include excessive and chronic throat clearing, sore throat, postnasal drip, and dysphagia.

Use a validated symptom index. To further assess the probability and severity of LPR, use the Reflux Symptom Index¹⁸ (TABLE 1). A recent cohort study validated the index, with an average score of 21.2 for those with LPR, vs an average of 11.6 for controls (P<.001). A score >13 is suggestive of LPR (odds ratio=9.19), the researchers found.¹⁸

If the diagnosis remains uncertain and the patient continues to be troubled by signs and symptoms suggestive of LPR, refer him or her to an otolaryngologist for further investigation. A referral is needed, too, to rule out malignancy in any patient with 3 or more of the following red flags: older than 50 years, otalgia, weight loss, progressive hoarseness, neck mass, a significant history of alcohol use, and a history of smoking.⁷

TABLE 1
The Reflux Symptom Index for laryngopharyngeal reflux

Within the last month, how did the following problems affect you?	0 = NO PROBLEM 5 = SEVERE PROBLEM (CIRCLE THE APPROPRIATE RESPONSE)
1. Hoarseness or a problem with your voice	0	1	2	3	4	5
2. Clearing your throat	0	1	2	3	4	5
3. Excess throat mucus or postnasal drip	0	1	2	3	4	5
4. Difficulty swallowing food, liquids, or pills	0	1	2	3	4	5
5. Coughing after you ate or after lying down	0	1	2	3	4	5
6. Breathing difficulties or choking episodes	0	1	2	3	4	5
7. Troublesome or annoying cough	0	1	2	3	4	5
8. Sensations of something sticking in your throat or a lump in your throat	0	1	2	3	4	5
9. Heartburn, chest pain, indigestion, or stomach acid coming up	0	1	2	3	4	5
	TOTAL SCORE=
*A score >13 is considered suggestive of laryngopharyngeal reflux.
Source: Belafsky PC et al. J Voice. 2002.¹⁸ Reprinted with permission.

Diagnostic tools the specialists will use

Fiberoptic laryngoscopy is the most common test used by otolaryngologists to confirm LPR and rule out other pathology. The test reveals inflammatory findings (FIGURE), such as erythema, edema, granulomas, and contact ulcers, in several anatomical locations of the larynx—especially the posterior aspect and the true vocal folds. It is important to note, however, that as many as 70% of the general population will have some laryngeal inflammation, so these findings alone are not definitive evidence of LPR.⁷

FIGURE
Fiberoptic laryngoscopy: Before and after treatment

Ambulatory 24-hour dual sensor pH probe monitoring is sometimes used as an adjunctive test to confirm LPR. In 2005, 2 meta-analyses found that the pH probe is reliable and sensitive and specific enough to identify significantly more acid reflux in patients with LPR than in controls.^19,20 However, not everyone agrees: Some clinicians question its use as a diagnostic tool for LPR, citing problems with observer reliability, among other things. Because it increases costs to the patient and is impractical, pH monitoring is not widely used by specialists, but primarily as a research tool.^21,22

Barium swallow and esophagogastroduodenoscopy (EGD) are relatively common diagnostic tools used to identify anatomical abnormalities in the gastrointestinal tract, such as a Schatzki’s ring or hiatal hernia, that can lead to symptoms of GERD and/or LPR. Some studies suggest that all patients with symptoms of LPR should undergo EGD to screen for esophageal adenocarcinoma.^23,24 Because LPR symptoms are relatively common, however, many clinicians believe that EGD should be considered only when heartburn is a primary complaint in a patient with signs and symptoms of LPR—or when a patient believed to have LPR fails to respond to medical management.²⁴

Treating LPR: Lifestyle changes, drug therapy

FAST TRACK

Advise patients to avoid eating too rapidly or drinking large quantities of fluid.

For all patients with LPR, dietary and lifestyle modifications have been shown to be both clinically effective and cost effective.²⁵ In addition to dietary restrictions (TABLE 2), advise patients to avoid eating too rapidly or drinking large quantities of fluid. Late night meals—indeed, eating within 3 hours of bedtime—should also be avoided, as should heavy lunches and dinners. Tell patients to eat small, frequent meals instead.^7,25,26

Recommend other behavioral changes, as well. Tell patients to avoid tight clothing, lying down immediately after a meal, and applying pressure to the abdomen, whether through exercise, heavy lifting, singing, or bending over. Smoking and overuse (or misuse) of the voice—screaming at a concert or singing for hours, for instance—are contraindicated, as well.^7,25,26