Tag Archives: laryngopharyngeal reflux

Improving Laryngopharyngeal Symptoms with Laryngeal Recalibration

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E Walsh et al. Am J Gastroenterol 2024; 119: 2198-2205. Laryngeal Recalibration Therapy Improves Laryngopharyngeal Symptoms in Patients With Suspected Laryngopharyngeal Reflux Disease (Thanks to Ben Gold for this reference)

For a lot of patients with rheumatologic complaints like joint pain, treatment often consists of sending patients to physical therapy rather than using pharmaceuticals. This type of approach is under-utilized in gastroenterology. A recent study, however, suggests that an analogous approach is likely beneficial in patients with chronic laryngopharyngeal symptoms.

Background: Laryngopharyngeal symptoms such as cough, throat clearing, voice change, paradoxic vocal fold movement, or laryngospasm are hyper-responsive behaviors resulting from local irritation (e.g., refluxate) and heightened sympathetic tone. Laryngeal recalibration therapy (LRT) guided by a speech-language pathologist (SLP) provides mechanical desensitization and cognitive recalibration to suppress hyper-responsive laryngeal patterns.

Methods: Adults (n=65, mean age 55 years) with chronic laryngopharyngeal symptoms referred for evaluation of GERD to a single center were prospectively followed. Inclusion criteria included ≥2 SLP-directed LRT sessions (60 minutes sessions). “Mechanical desensitization focuses on well-known laryngeal suppression techniques (i.e. pursed lip breathing to suppress throat clearing or cough) or changing voice production by means of acoustic and aerodynamic techniques…Cognitive recalibration uses relaxation and conceptualization of symptoms to rework thought patterns around chronic laryngeal behaviors.”

Key findings:

  • Overall, 55 participants (85%) met criteria for symptom response. 17 (26%) had complete resolution, 19 (29%) had near-complete resolution, and 19 (29%) had a moderate response
  • Specifically, symptom response was similar between those with isolated laryngopharyngeal symptoms (13/15, 87%) and concomitant laryngopharyngeal/esophageal symptoms (42/50, 84%)

My take: Historically, patients with laryngopharyngeal symptoms have been difficult to treat. Many do not respond to reflux therapies. This study highlights a different approach and shows that the benefit of working with highly-skilled SLPs.

Snow day in Atlanta (Jan 10, 2025)

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How to Sort Out Chronic Laryngeal Symptoms and Reflux

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Two recent articles provide some insight into the muddy waters of laryngeal symptoms and reflux which is a much bigger challenge in the adult population than in the pediatric age group.

AJ Krause et al. Clin Gastroenterol Hepatol 2024; 22: 1200-1209. Open Access! Validated Clinical Score to Predict Gastroesophageal Reflux in Patients With Chronic Laryngeal Symptoms: COuGH RefluX

AJ Krause et al. Am J Gastroenterol 2024; 119: 627-634. Diagnostic Yield of Ambulatory Reflux Monitoring Systems for Evaluation of Chronic Laryngeal Symptoms. Thanks to Dr. Benjamin Gold for this reference.

In the first study, there were a total of 856 adults, 304 in the training cohort and 552 in the validation cohort. Key finding: In the validation phase, the COuGH RefluX score had an area under the curve of 0.67 (95% CI, 0.62–0.71), with 79% sensitivity and 81% specificity for proven GERD. Graphical abstract from the first study:

In the second study, the authors retrospectively examined 813 adults with chronic laryngeal symptoms over a 5 year period comparing . The diagnostic yield for prolonged wireless pH testing (n=296) was compared to 24-hour pH-impedance monitoring (n=532) off anti-secretory agents. Key finding: the prolonged wireless pH testing had a yield of 50% compared to 27% for the 24-hr pH-impedance testing.

My take: In the 1st study, the scoring system of cough, obesity, globus sensation, hiatal hernia, regurgitation, and male sex provides a good idea about the likelihood of reflux. In the 2nd study, the authors conclude that prolonged wireless pH testing may be preferrable due to higher diagnostic yield. However, the more proper conclusion is that we still don’t know the best way to determine when reflux causes chronic laryngeal symptoms or even the best way to measure reflux.

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Current Thinking with Laryngopharyngeal Reflux Symptoms

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A recent study (H-C Lien et al. Clin Gastroenterol Hepatol 2020; 18: 14-66-74) adds a bit more insight into the topic of larygnpharyngeal symptoms (related blog post:  Gastroestophageal Reflux Phenotypes and Where ‘Rome, Lyon, and Montreal Meet’ provides more information on treatment outcomes).

Methods: In this prospective multi-center observational study with adults aged 20-70 years, n=142 completed study), enrollment required chronic laryngitis symptoms >3 months and “laryngoscopic” signs suggestive of reflux.  Subsequently, patients were examined with multiple modalities, including 24-pH testing, manometry, and Bernstein test followed by treatment with omeprazole 40 mg twice a day.

Key Findings:

  • Pathologic reflux was identified in 146/252 (58%) of those meeting inclusion criteria.  Thus, approximately 40% did NOT have objective findings of reflux despite suspicion of laryngopharyngeal reflux (LPR); this is similar to other studies.
  • In those with documented reflux, those with and without typical reflux symptoms had improvement in LPR with omeprazole therapy: 57% and 63% respectively; whereas, omeprazole therapy was effective in 32% in those without objective (pH probe) findings of reflux. In previous studies, reflux laryngitis response to PPIs has been similar to placebo.

My take: Typical reflux symptoms are not needed for patients with LPR to respond to PPIs.  However, more than 40% of individuals with LPR do NOT have objective evidence of reflux; in this subset, response to PPI therapy is low.

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Gastroesophageal Reflux Phenotypes and “Where Rome, Lyon, and Montreal Meet”

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A useful review (DA Katzka et al. Clin Gastroenterol Hepatol 2020; 18: 767-76) discusses the phenotypes of gastroesophageal reflux and related disorders.   The authors note that consensus initiatives (Montreal, Rome, and Lyon) have looked at these disorders from different perspectives and their goal was to merge their perspectives.

Table 1 lists the major phenotypes:

  • Nonerosive reflux disease
  • Reflux hypersensitivity
  • Functional heartburn
  • Erosive esophagitis (low grade and high grade).  LA grade A esophagitis “can be found in approximately 6% of asymptomatic controls”
  • Barrett’s esophagus
  • Reflux chest pain syndrome
  • Regurgitation-dominant reflux disease: “need to differentiate from rumination and achalasia”
  • Laryngopharyngeal reflux
  • Chronic cough  “although reflux may contribute, it is rarely the dominant pathophysiology… more amenable to GERD therapy when accompanied by typical reflux symptoms”

Figure 1 provides a model for the pathogenesis of GERD. Figure 2 describes the relationship between reflux phenotypes and PPI responsiveness:

In those with typical reflux symptoms: 

  • esophagitis healing 84% with PPI Rx compared to 28% with placebo (NNT =1.8)
  • heartburn relief (with and without esophagitis) 56% with PPI Rx compared to 16% with placebo (NNT =4.4)
  • heartburn relief without esophagitis 40% with PPI Rx compared to 13% with placebo (NNT =3.7)
  • regurgitation relief (with and without esophagitis) 47% with PPI Rx compared to 30% with placebo (NNT =5.9)

In those with atypical reflux symptoms:

  • chest pain relief with objective GERD 74% with PPI Rx compared to 20% with placebo (NNT =1.6) (Studies used a 50% reduction in pain as opposed to complete elimination…opens the door for a greater placebo response)
  • chest pain relief without objective GERD 29% with PPI Rx compared to 23% with placebo (NNT =16.7) (Studies used a 50% reduction in pain as opposed to complete elimination…opens the door for a greater placebo response)
  • chronic cough with objective GERD 33% with PPI Rx compared to 9% with placebo (NNT =4.2)
  • chronic cough without objective GERD 31% with PPI Rx compared to 27% with placebo (NNT =25)
  • reflux laryngitis (without heartburn, complete resolution) 15% with PPI Rx compared to 16% with placebo
  • poorly-controlled asthma (without heartburn)-exacerbations per year: 2.5 with PPI Rx compared to 2.3 with placebo 
  • *references for this figure provided

Other useful points:

  • “An exception to the de-emphasizing the relationship of GERD to an extraesophageal syndrome is with lung transplantation, which …has unique considerations…the sequelae of untreated GERD …may lead to accelerated mortality from allograft injury…data have suggested that PPIs may be effective at prolonging allograft survival.”
  • The authors state that escalating PPI/antisecretory treatments for esophagitis is often effective but this approach has limited applicability for other indications and can result in overuse. “Similarly, failing to recognize the modulating effects of anxiety, hypervigilance, and visceral and central hypersensitivity on symptom severity has greatly oversimplified the problem.”

My take (borrowed in part from authors): PPIs work well for esophagitis and documented reflux; “the broad spectrum of syndromes [are] much less amenable to PPI therapy in any dose.”

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Curbside Humor

 

Accuracy of ENT diagnosis of Reflux Changes

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Many gastroenterologists suspiciously view a diagnosis of laryngopharyngeal reflux (LPR) as assessed by an Ear, Nose, and Throat (ENT or otorhinolaryngologist) physician.  This is due to a high degree of variability of these visible findings in a number of studies.  A recent pediatric study reaches the same conclusion (J Pediatr 2014; 165: 479-84).

In this study, the authors recruited 52 infants in an effort to establish a reflux finding score for infants (RFS-I).  This infant scale was modified based on a previous RFS developed in adults (Laryngoscope 2001; 111: 1313-7).  In these infants, scored videos were evaluated by 3 pediatric ENTs, 2 adult ENTs, and 2 gastroenterology fellows.

Specific finding:

  • “laryngeal erythema/edema showed the lowest observer agreement…it is often speculated that laryngeal edema is caused by LPR, but no convincing evidence is available to support this theory.”

Bottomline: “Only moderate interobserver agreement [of the RFS-I] was reached with a highly variable intraobserver agreement…the RFS-I and flexible laryngoscopy should not be used solely to clinically assess LPR related findings of the larynx, nor to guide treatment.”

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