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Laryngopharyngeal Reflux Disease: Clinical Presentation, Diagnosis and Therapeutic Challenges

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Laryngopharyngeal Reflux Disease: Clinical Presentation, Diagnosis and Therapeutic Challenges See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/327798669 Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018 Article in Current opinion in otolaryngology & head and neck surgery · September 2018 DOI: 10.1097/MOO.0000000000000486 CITATIONS READS 0 25 3 authors, including: Jérôme Lechien Sven Saussez Université de Mons Université de Mons 69 PUBLICATIONS 247 CITATIONS 139 PUBLICATIONS 2,131 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Laryngopharyngeal reflux disease: how to improve the science. View project YO-IFOS (Young Otolaryngologists of IFOS) View project All content following this page was uploaded by Jérôme Lechien on 17 November 2018. The user has requested enhancement of the downloaded file. REVIEW CURRENT OPINION Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018 Jerome R. Lechiena,b,c,d, Sven Sausseza,b,d, and Petros D. Karkosa,e 11/05/2018 on veIGHXkdYRMunE7zk3mi1FXI/Ffj6FWvry18rJxU4Oh9r3ePRhHA4Ewyw/RmvpnICr/56wfuplflIsTleQ9a+IZWpDxCScd15JHVI1SpRG/9pbM31OTfuUnLyq5T9CSn5SOv7cugSYw= by http://journals.lww.com/co-otolaryngology from Downloaded Downloaded from Purpose of review http://journals.lww.com/co-otolaryngology To review the recent literature on presentation, diagnosis and treatment of laryngopharyngeal reflux. Recent findings Patients with laryngopharyngeal reflux have a higher risk for gastroesophageal reflux and respiratory- related diseases. Many symptoms and findings are underestimated, contributing to the inconclusive results of many therapeutic trials. Additionally, little significance is given to nonacid and mixed refluxates, although a significant prevalence. The association between symptoms, signs, impedance-pH studies and by pepsin detection could be the most accurate way for a clear diagnosis. ‘Reflux profiling’ is also important veIGHXkdYRMunE7zk3mi1FXI/Ffj6FWvry18rJxU4Oh9r3ePRhHA4Ewyw/RmvpnICr/56wfuplflIsTleQ9a+IZWpDxCScd15JHVI1SpRG/9pbM31OTfuUnLyq5T9CSn5SOv7cugSYw= for the administration of a personalized treatment based on diet, proton pump inhibitors, alginate, magaldrate and other second-line drugs. There are only a handful of studies focusing on the addition of alginate or magaldrate to the treatment of laryngopharyngeal reflux, although their contribution has extensively been demonstrated. Summary Diagnosis remains controversial despite improvement in impedance and availability of pepsin detection in daily practice. With recent studies exhibiting a significant prevalence of nonacid or mixed refluxes, the addition of alginate or magaldrate to proton pump inhibitors should be considered. Future studies are needed to assess these new therapeutic schemes in moderate and severe laryngopharyngeal reflux. Keywords diagnosis, laryngitis, laryngopharyngeal, reflux, treatment INTRODUCTION and treatment. The purpose of this article is to Laryngopharyngeal reflux (LPR) is an inflammatory review the recent literature on clinical presentation, condition of the upper aerodigestive tract tissues diagnosis and treatment and to propose a complete related to direct and indirect effect of gastroduode- management algorithm of LPR. nal content reflux, which induces morphological changes in the upper aerodigestive tract [1&&]. This aLaryngopharyngeal Reflux Study Group of Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO- definition differs from the past definition of the b 2002 position statement of American Academy of IFOS), Paris, France, Department of Anatomy and Experimental Oncol- ogy, Mons School of Medicine, UMONS Research Institute for Health Otolaryngology-Head and Neck Surgery [2] that did Sciences and Technology, cLaboratory of Phonetics, Faculty of Psychol- not take into consideration the irritation of some ogy, Research Institute for Language Sciences and Technology, Univer- duodenal molecules [3,4] into all upper aerodiges- sity of Mons (UMONS), Mons, dDepartment of Otorhinolaryngology and Head and Neck Surgery, CHU Saint-Pierre, Universite´ Libre de Bruxelles, on tive tract mucosa (and not only into the laryngo- e 11/05/2018 pharynx), and the possible multifactorial origin of Brussels, Belgium and Department of Otorhinolaryngology and Head and Neck Surgery, AHEPA University Hospital, Aristotle University of some symptoms that can be triggered by neurore- Thessaloniki, Thessaloniki, Greece flexive signaling and compensatory vagal responses Correspondence to Dr Jerome R. Lechien, MD, PhD, MS, Laboratory of (indirect effect) [5]. Over the last three decades, the Anatomy and Cell Biology, Faculty of Medicine, University of Mons number of LPR publications has progressively (UMONS), Avenue du Champ de mars, 6, B7000 Mons, Belgium. increased (Fig. 1), however, despite this enthusiasm, Tel: +32 65 37 35 84; e-mail: [email protected] it still remains a controversial topic particularly Curr Opin Otolaryngol Head Neck Surg 2018, 26:392–402 when dealing with clinical assessment, diagnosis DOI:10.1097/MOO.0000000000000486 www.co-otolaryngology.com Volume 26 Number 6 December 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Laryngopharyngeal reflux disease Lechien et al. EPIDEMIOLOGY KEY POINTS There is a consensus that recognizes LPR as one of LPR is a prevalent disease in otolaryngology but the the most frequently encountered chronic inflamma- exact incidence and prevalence remain unknown. tory conditions of upper aerodigestive tract, but real incidence and prevalence are inaccurate and diffi- A large number of patients may concomitantly have LPR, GERD, and respiratory-related disorders that need cult to estimate worldwide because of lack of diag- the use of multidimensional clinical tools for the nostic criteria. Since the initial work by Koufman [6] diagnosis and the therapeutic outcomes. that estimated the LPR incidence at 10% of the ear, nose, and throat (ENT) outpatients, only a few epi- Many symptoms and findings are not described in the demiological studies have been published. In China current patient-reported outcome measures and instruments evaluating the clinical findings of and Greece, the LPR prevalence was estimated to 5 laryngopharyngeal reflux. and 18.8%, respectively, but these evaluations were only based on patient-reported outcomes question- Future diagnosis may associate symptoms, upper naires that are insufficient to make the diagnosis aerodigestive tract findings, impedance-pH metry, [7,8]. In another report from a tertiary voice center, pepsin and trypsin detections. This approach will help to determine a patient profile with laryngopharyngeal an evaluation of the prevalence of patients with LPR reflux for personalized treatment. complaints was carried out during a 5-month period. With pH monitoring, the author showed Diet can be sufficient treatment for mild LPR whereas that 69% of patients had LPR symptoms and find- alginate or magaldrate are required for mixed and ings and 50% of total patients had positive pH nonacid reflux, respectively. Long-term control of reflux requires diet and lifestyle modifications. monitoring (defined as pH <4 in the esophageal probe, 8.1% upright and 2.9% supine) [9]. Since Therapeutic efficiency evaluation must include changes this initial report, there is no additional study eval- of signs and symptoms. Compliance with medication uating incidence or prevalence of LPR in voice cen- intake is often the cause for resistant patients. When ter with objective examination. To get precise LPR resistance is confirmed with good compliance to diet and medication recommendations, additional incidence and prevalence rates, future conducted examinations are required to propose second-line studies will need to include 24-h multichannel treatment. intraluminal impedance-pH metry (MII-pH metry) or a future best diagnostic tool in all patients with FIGURE 1. The evolution of publications about laryngopharyngeal reflux during the past six decades. To identify publications about LPR, we performed a systematic electronic research on PubMED with the following keywords. ‘laryngopharyngeal,’ ‘laryngitis,’ ‘reflux,’ ‘gastroeosophageal.’ This graph shows the total number of publications performed about laryngopharyngeal reflux according to the year. LPR, laryngopharyngeal reflux. 1068-9508 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-otolaryngology.com 393 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Laryngology and bronchoesophagology LPR signs and symptoms presenting at the ENT complaints usually concern 32.8% of GERD patients. consultation. The incidence and prevalence of In another study, Dore et al. [33] identified globus LPR is particularly important when considering sensation (39%), eructation (26%), cough (24%), and the increase in junk food [10–12], obesity, acidifica- hoarseness (23%) as the most prevalent ENT symp- tion of foods [10], and the increase in risk factors for toms in GERD patients. Classical GERD symptoms gastroesophageal reflux disease (GERD) and LPR in such as heartburn are usually less prevalent in LPR in western countries [8,13–15]. comparison with GERD [34]. However, recent find- ings support that GERD and complications seem to Clinical presentation coexist with LPR more often that it was previously assumed [34–37]. This controversial relationship between GERD and LPR led to the
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