James A. Koufman

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

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.

Validity and Reliability of the Reflux Symptom Index (RSI)

Laryngopharyngeal reflux (LPR) is present in up to 50% of patients with voice disorders. Currently, there is no validated instrument that documents symptom severity in LPR. We developed the reflux symptom index (RSI), a self-administered nine-item outcomes instrument for LPR. The purpose of this investigation was to evaluate the psychometric properties of the RSI. For validity assessment, 25 patients with LPR were evaluated prospectively before and six months after b.i.d. treatment with proton pump inhibitors (PPI). Each patient completed the RSI as well as the 30-item voice handicap index (VHI). For reliability assessment, the study patients were given the RSI on two separate occasions before the initiation of treatment. Normative RSI data were derived from 25 age-matched and gender-matched controls taken from an existing database of asymptomatic individuals without any evidence of LPR. The mean RSI (+/- standard deviation) of patients with LPR improved from 21.2 (+/- 10.7) to 12.8 (+/- 10.0), and the mean VHI improved from 52.2 (+/- 24.7) to 41.5 (+/- 25.0) after 6 months of therapy (p = 0.001 and 0.065, respectively). Of the three VHI subscales (emotional, physical, functional), only the functional subscale improved significantly (p = 0.037). Patients who experienced a five point or better improvement in RSI were 11 times more likely to experience a five-point improvement in VHI (95% confidence interval = 1.7, 76.8). For reliability assessment, the first and second pretreatment RSIs were 19.9 (+/- 11.1) and 20.9 (+/- 9.6), respectively (correlation coefficient = 0.81, p < 0.001). The single-item correlation coefficients ranged from 0.41 to 0.91 (p < 0.05 for all items). The mean pretreatment RSI in patients with LPR was significantly higher than controls (21.2 versus 11.6; p < 0.001). The mean RSI of patients with LPR after 6 months of PPI therapy approached that of asymptomatic controls (p > 0.05). The RSI is easily administered, highly reproducible, and exhibits excellent construct and criterion-based validity.

The validity and reliability of the reflux finding score (RFS)

Background The evaluation of medical and surgical outcomes relies on methods of accurately quantifying treatment results. Currently, there is no validated instrument whose purpose is to document the physical findings and severity of laryngopharyngeal reflux (LPR).

Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery

The termreflux (derived from the Latin wordsre [“back”] andfluere [“to flow”]) literally meansbackflow. The termgastroesophageal reflux (GER) refers to the backflow of stomach contents into the esophagus. GER may be physiologic, and indeed up to 50 GER episodes a day, occurring mostly after meals, is accepted as being within the normal range. 1-3 Gastroesophageal reflux disease (GERD) is a clinical term that refers to GER that is excessive and that causes tissue damage (eg, esophagitis) and/or clinical symptoms (eg, heartburn). 1

Prevalence of Reflux in 113 Consecutive Patients with Laryngeal and Voice Disorders

OBJECTIVES: The goal was to estimate the prevalence of laryngopharyngeal reflux (LPR) in patients with laryngeal and voice disorders. STUDY DESIGN AND SETTING: This was a prospective study of 113 unselected, new patients with laryngeal and voice disorders. Patients completed an extensive medical history form including a reflux symptom profile. A comprehensive otolaryngologic examination was performed with photographic transnasal fiberoptic laryngoscopy. Patients with both symptoms and findings of LPR (78/133, 69%) underwent ambulatory 24-hour double-probe pH monitoring. RESULTS: Seventy-three percent (57/78) of patients undergoing pH testing had abnormal studies. Thus 50% (57/113) of the entire the study population had pH-documented reflux. Of the diagnostic sub-groups studied, the highest incidence of reflux was found in patients with vocal cord neoplastic lesions (88%) and patients with muscle tension dysphonias (70%). LPR was infrequently found in patients with neuromuscular disorders. CONCLUSION: LPR occurs in at least 50% of all patients at our center with laryngeal and voice disorders at presentation. (Otolaryngol Head Neck Surg 2000;123:385-8.)

Laryngopharyngeal reflux: Consensus conference report

On September 16, 1995, a consensus conference was convened in New Orleans, Louisiana, to consider laryngopharyngeal reflux (LPR) and other extraesophageal manifestations of reflux disease. Participants included specialists in otolaryngology, gastroenterology, and pulmonary medicine,* and the conference was supported by Astra Merck. This document summarizes the opinions reached by consensus during the conference.

Vocal fold scarring: current concepts and management.

Scarring of the vocal folds can occur as the result of blunt laryngeal trauma or, more commonly, as the result of surgical, iatrogenic injury after excision or removal of vocal fold lesions. The scarring results in replacement of healthy tissue by fibrous tissue and can irrevocably alter vocal fold function and lead to a decreased or absent vocal fold mucosal wave. The assessment and treatment of persistent dysphonia in patients with vocal fold scarring presents both diagnostic and therapeutic challenges to the voice treatment team. The common causes of vocal fold scarring are described, and prevention of vocal fold injury during removal of vocal fold lesions is stressed. The anatomic and histologic basis for the subsequent alterations in voice production and contemporary modalities for clinical and objective assessment will be discussed. Treatment options will be reviewed, including nonsurgical treatment and voice therapy, collagen injection, fat augmentation, endoscopic laryngoplasty, and Silastic medialization.

Laryngoplasty for vocal cord medialization: an alternative to Teflon.

Laryngeal framework surgery, using a Silastic®implant placed between the thyroid cartilage and inner thyroid perichondrium for vocal cord medialization, offers an exciting new surgical option to intracordal Teflon®injection for the relief of symptomatic unilateral vocal cord paralysis. A series of 11 patients who have undergone medialization laryngoplasty is presented. The advantages, technical details, and results of surgery are discussed.

Laryngopharyngeal reflux symptoms improve before changes in physical findings

Background Patients with laryngopharyngeal reflux (LPR) undergoing treatment appear to have improvement in symptoms before the complete resolution of the laryngeal findings.

Cell biology of laryngeal epithelial defenses in health and disease: further studies.

This is the second annual report of an international collaborative research group that is examining the cellular impact of laryngopharyngeal reflux (LPR) on laryngeal epithelium. The results of clinical and experimental studies are presented. Carbonic anhydrase (CA), E-cadherin, and MUC gene expression were analyzed in patients with LPR, in controls, and in an in vitro model. In patients with LPR, we found decreased levels of CAIII in vocal fold epithelium and increased levels in posterior commissure epithelium. The experimental studies confirm that laryngeal CAIII is depleted in response to reflux. Also, cell damage does occur well above pH 4.0. In addition, E-cadherin (transmembrane cell surface molecules, which have a key function in epithelial cell adhesion) was not present in 37% of the LPR laryngeal specimens. In conclusion, the laryngeal epithelium lacks defenses comparable to those in esophageal epithelium, and these differences may contribute to the increased susceptibility of laryngeal epithelium to reflux-related injury.