Unmet needs in treating laryngo-pharyngeal reflux disease: where do we go from here?

Objective. This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.Purpose. The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm.For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.Action Statements. The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy.The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as su...

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“…Alternative diagnosis and confirmation of laryngeal inflammation should be sought by laryngoscopy. 228…”

Section: Guideline Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Stachler

Francis

Schwartz

et al. 2018

Otolaryngol.--head neck surg.

228

204

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“…In patients with persistent nocturnal symptoms, the addition of an H 2 RA at bedtime may be indicated to control NAB and associated esophageal acidification [10,[55][56][57], despite the likely development of tolerance [58]. Although management options have been recommended by an expert panel for patients with persistent symptoms while on PPIs [59••], refractory GERD is still one of the unmet clinical needs, which also include the need for a significant improvement in symptom control and faster assured healing, especially in patients with grade C and D erosive esophagitis, Barrett's esophagus, and extra-esophageal manifestations of GER [4,7,8,10,60,61].…”

Section: Acid Suppression In Gerd Ppi Efficacy and Unmet Needsmentioning

confidence: 99%

Acid Suppressant Therapy: a Step Forward with Potassium-Competitive Acid Blockers

Scarpignato

Hunt

2021

Curr Treat Options Gastro

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Purpose of the review The introduction of H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) into clinical practice has been a real breakthrough in the treatment of acid-related diseases. PPIs are now the standard of care for the treatment of gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), Helicobacter pylori infection, NSAID-associated gastroduodenal lesions, and upper gastrointestinal bleeding (UGIB). However, despite their effectiveness, PPIs display some intrinsic limitations, which underlie the unmet clinical needs that have been identified over the past decades. Recent findings To address these needs, new long-acting compounds (such as tenatoprazole and AGN 201904-Z) and new PPI formulations, including instant release omeprazole (IR-omeprazole) and dexlansoprazole modified release (MR), have been developed. However, a major advance has been the development of the potassium-competitive acid blockers (P-CABs), which block the K+,H+-ATPase potassium channel, are food independent, are reversible, have a rapid onset of action, and maintain a prolonged and consistent elevation of intragastric pH. Vonoprazan and tegoprazan are the two marketed P-CABs while two other compounds (namely fexuprazan and X842) are under active development. Available for almost 6 years now, a considerable experience has been accumulated with vonoprazan, the efficacy and safety of which are detailed in this paper, together with the preliminary results of the other members of this new pharmacologic class. Summary Based on the available evidence, erosive reflux disease, H. pylori infection, and secondary prevention of NSAID gastropathy can be considered established indications for vonoprazan and are being explored for tegoprazan and fexuprazan. In the treatment of severe (LA C & D) reflux esophagitis and H. pylori eradication, vonoprazan proved to be superior to PPIs. Other uses of P-CABs are being evaluated, but clinical data are not yet sufficient to allow a definitive answer on its efficacy and possible superiority over the current standard of care (i.e., PPIs). The most notable indication of upper GI (non-variceal) bleeding, where vonoprazan would prove superior to PPIs, has not yet been explored. The safety of P-CABs in the short-term overlaps that of PPIs, but data from long-term treatment are needed.

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“…1,2 With prolonged exposure to gastric contents however, the esophageal mucosal barrier begins to break down and the disease state known as gastroesophageal reflux disease (GERD) manifests. 3 In some instances, refluxate can retrogradely travel beyond the esophagus, moving from the stomach to the pharynx and larynx in a pathological disorder termed laryngopharyngeal reflux (LPR). Postma and colleagues have found that after just two or three episodes of LPR, 4 symptoms including dysphagia, hoarseness, frequent throat clearing, postnasal drip (PND), sore throat, and chronic cough, can manifest.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…Postma and colleagues have found that after just two or three episodes of LPR, 4 symptoms including dysphagia, hoarseness, frequent throat clearing, postnasal drip (PND), sore throat, and chronic cough, can manifest. 3 Therefore, LPR seems to cause reflux-related disease with a lower reflux burden than GER. The current management of these disease states reflects this difference: intermittent treatment of GERD is often sufficient, while LPR patients exhibit disease that is refractory to PPIs and other therapies.…”

Section: Introductionmentioning

confidence: 99%

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The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

Brown

Kuhar

Plitt

et al. 2020

Ann Otol Rhinol Laryngol

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Objective: This study explored the impact of laryngopharyngeal reflux (LPR) on quality-of-life outcomes captured by Sino-Nasal Outcome Test (SNOT-22) and Reflux Symptom Index (RSI) in patients with chronic rhinosinusitis (CRS) and patients with symptoms of LPR. Methods: In a retrospective chart review, SNOT-22 and RSI scores were analyzed in patients seen at a tertiary care center with CRS, LPR, or both CRS and LPR. SNOT-22 items were grouped into sleep, nasal, otologic, and emotional symptom subdomains. Results: A total of 138 patients (36 with CRS alone, 60 with LPR alone, and 42 with both CRS and LPR) were included. Compared to patients with CRS alone, those with CRS and LPR (CRS+LPR) had higher SNOT-22 total (50.54 ± 19.53 vs 35.31 ± 20.20, P < .001), sleep (19.61 ± 9.31 vs 14.42 ± 10.34, P < .022), nasal (17.38 ± 7.49 vs 11.11 ± 8.52, P < .001), otologic subdomains (9.17 ± 5.07 vs 5.53 ± 5.14, P < .002), and RSI (22.06 ± 9.42 vs 10.75 ± 8.43, P < .003). Patients with LPR alone had higher RSI compared to those with CRS (18.48 ± 9.77 vs 10.75 ± 8.43, P < .037). RSI and SNOT-22 scores were positively correlated irrespective of patient group (R = 0.289, P = .003). Conclusion: Compared to patients with CRS or LPR alone, those with CRS+LPR demonstrated higher RSI and total and subdomain SNOT-22 scores. Patients with LPR alone had elevated SNOT-22 despite absent endoscopic evidence of sinusitis.

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Unmet needs in treating laryngo-pharyngeal reflux disease: where do we go from here?

Cited by 8 publications

References 84 publications

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Acid Suppressant Therapy: a Step Forward with Potassium-Competitive Acid Blockers

The Impact of Laryngopharyngeal Reflux on Patient-reported Measures of Chronic Rhinosinusitis

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