A novel scoring system for evaluating laryngopharyngeal reflux

Abstract

Risk factors for the development of reflux disease include increased gastric acid production, prolonged gastric emptying, restricted oesophageal clearance, reduced saliva secretion, increased intraabdominal pressure and sphincter insufficiency. Above all, acid, pepsin, bile salts and other gastroduodenal proteins cause mucosal irritation. Particularly, the combination of acid and pepsin tends to lead to mucosal damage, whereas the laryngopharyngeal mucosa is much more sensitive than the oesophageal mucosa due to a lack of defence mechanisms. 1,2 Gastro-oesophageal reflux (GER) and laryngopharyngeal reflux (LPR) are two different clinical entities, and a fundamental distinction needs to be made. GER often occurs at night and has classic reflux symptoms such as heartburn, acid regurgitation and retrosternal pain.In contrast, LPR occurs mostly during daytime and causes non-specific symptoms such as hoarseness, globus sensation, chronic throat clearing and increased mucus. 3 Nevertheless, GER and LPR can occur simultaneously and cause similar symptoms. 4 A correlation between various clinical pictures and GER has already been established. 5 These include reflux oesophagitis, oesophageal strictures, Barrett oesophagus and Barrett carcinoma. However, data for LPR are less clear.Various medical conditions seen on a daily basis such as chronic laryngopharyngitis, chronic sinusitis, bronchial asthma, pulmonary fibrosis and recurrent otitis media are associated with LPR. 6 Today, oesophago-gastro-duodenoscopy and impedance pH monitoring are the gold standard to assess GER. 5 In contrast, LPR is often diagnosed by clinical signs and symptoms and/or a trial of proton pump inhibitor (PPI) therapy. A few validated methods already exist to detect and quantify LPR, namely the reflux symptom index (RSI), the reflux finding score (RFS) and oropharyngeal pH monitoring (PHM). The latter was first described in 2009 and has been validated by various research groups. [7][8][9] Meanwhile, its reliability and reproducibility was proven to be high for extraoesophageal reflux assessment. [10][11][12]

Value of Transnasal Esophagoscopy in the Workup of Laryngo-Pharyngeal Reflux

“…On the other hand, the diagnosis of LPR is frequently based on the reflux symptom index (RSI), reflux finding score (RFS) and/or a trial of proton pump inhibitor (PPI) therapy [ 6 , 7 ]. Recently, we described a completely new approach suggesting four different methods to establish the diagnosis of LPR, because no single test alone is able to reliably confirm or exclude LPR nor to visualize the underlying pathology leading to LPR [ 8 ]. Thus, upper endoscopy seems to be a reasonable supplement in the investigation of LPR.…”

Evaluation of Oropharyngeal pH-Monitoring in the Assessment of Laryngopharyngeal Reflux

“…A total of 180 consecutive patients with possible LPR were included in the present study using the same inclusion criteria as published before [13]. Subsequently, RSI and RFS were gathered [14,15].…”

“…Subsequently, RSI and RFS were gathered [14,15]. Oropharyngeal pH-metry and transnasal esophagoscopy were then carried out for further investigation and classified according to the Horvath Score as previously described [13]. The latter was used as the gold standard for LPR diagnosis.…”

“…The Horvath Score classifies LPR into 5 degrees of severity (severe, moderate, mild, neutral, alkaline) or excludes extraesophageal reflux. This scoring system comprises 4 validated diagnostic methods (RSI, RFS, PHM, TNE) consisting of subjective and objective criteria for LPR, providing 1 point each when pathological findings were noted, or 0 points when normal findings were present, as previously depicted [13].…”

“…Meanwhile, standard values for oropharyngeal pH-monitoring have been established through healthy subjects, and a positive Ryan Score has been considered synonymous for the presence of LPR [10][11][12]. Recently, we proposed a novel scoring system for LPR, which combines four validated diagnostic methods, namely RSI, RFS, oropharyngeal pH-metry and transnasal esophagoscopy [13]. As the Horvath Score simultaneously comprises sensitive and specific tests, as well as subjective and objective criteria, it is associated with a much higher probability to identify true LPR than any other method used in the past.…”