voice_disorders_GERD

ORIGINAL ARTICLEV oice disorders and gastroesophageal refluxMAJA SEREG-BAHAR 1,RADO JANSA 2&IRENA HOCEVAR-BOLTEZAR 11Department of Otorhinolaryngology and Head and Neck Surgery,University Medical Centre,Ljubljana,Slovenia and 2Department of Gastroenterology,University Medical Centre,Ljubljana,SloveniaAbstractBackground .Gastroesophageal reflux (GER)can cause serious voice problems and laryngopharyngeal disorders influencing the patient’s quality of life.Methods .Forty-three patients with suspected laryngopharyngeal reflux (LPR)were included into a prospective study.The diagnosis was made on the basis of the patient’s history,the videoendolaryngoscopy,the oesophago-gastroscopy and the biopsy of the oesophageal mucosa.All the LPR patients were treated with esomeprasol for eight weeks.An acoustic analysis of the vowel /a/samples was performed in the LPR group before and after the treatment.Thirty-six patients with vocal fold polyps served as the control group for a subjective estimation of the voice problems.All the patients from both groups subjectively evaluated their voice problems using the Voice Handicap Index (VHI)questionnaire.Results .The results of VHI showed that the severity of the voice problems of the patients with LPR could be compared to that experienced by the patients with vocal fold polyps.Videoendolaryngoscopy and history proved LPR in all 43patients.Oesophago-gastroscopy combined with the histopathological examination of the oesophageal biopsy specimens detected signs of possible GER in 38patients (88%).The results of the videoendolaryngoscopy combined with a subjective and objective voice assessment,performed before and after treatment with a proton-pump inhibitor,showed a significant improvement in most of the studied parameters by the end of the therapy.Conclusions .In the diagnostics of LPR,the patient’s history and videoendolaryngoscopy demonstrated to be superior to oesophago-gastroscopy.Videoendolaryngoscopic assessment of the laryngeal mucosa,and oesophago-gastroscopy supplemented with a biopsy of the oesophageal mucosa,showed to be a convenient diagnostic method when GER and LPR were suspected.Esomeprasol proved to be very effective in the treatment of LPR.LPR should not be overlooked in the treatment of dysphonic patients.Key words:Histological findings,laryngopharyngeal reflux,oesophago-gastroscopy,proton-pump inhibitor,video-endolaryngoscopy,vocal fold polyps,voice handicap indexIntroductionThe backflow of gastric content into the oesophagusis termed gastroesophageal reflux (GER).GER thattravels proximally and penetrates the upper oeso-phageal sphincter to enter the laryngopharynx iscalled extraoesophageal or laryngopharyngeal reflux(LPR)(1).The number of occurrences of GER is increasing;in Slovenia,GER is estimated to be found in 20.5%of the population (2).The typical symptoms of GERdisease are heartburn and acid regurgitation.Extra-oesophageal reflux disease often results in atypicalmanifestations with oral,pharyngeal,laryngeal,andpulmonary disorders.LPR is known to contribute to posterior acid laryngitis,laryngeal contact ulcers or granuloma formation,epithelial dysplasia and laryn-geal cancer,chronic hoarseness,pharyngitis,sore throat,globus sensation,dysphagia,buccal burning,asthma,pneumonia,nocturnal choking and dental diseases.These manifestations are believed to be caused by direct contact of the gastric content and injury to the pharyngeal or laryngeal mucosal sur-faces.Acid reflux inside the distal oesophagus itself also stimulates vagally mediated reflexes leading to the disorders of bronchospasm and coughing (3).Damage to the larynx from coughing,voice abuse,intubation,or upper-respiratory-tract infection could predispose laryngeal mucosa to further injury Correspondence:Maja Sereg-Bahar MD,University Medical Centre,Department of Otorhinolaryngology and Head and Neck Surgery,Zaloska 2,SI-1000Ljubljana,Slovenia.Fax:'38615224815.E-mail:maja.sereg@kclj.siLogopedics Phoniatrics V ocology .2005;30:120Á124ISSN 1401-5439print/ISSN 1651-2022online #2005T aylor &FrancisDOI:10.1080/14015430500320182from extraoesophageal reflux.LPR has been impli-cated as being causative or contributory in laryngeal pathologic states such as vocal nodules,Reinke’s oedema,scar formation as in idiopathic subglottic stenosis,functional laryngeal movement disorders such as muscular tension dysphonia,paradoxical vocal fold motion and paroxysmal laryngospasm. LPR also lowers the cough threshold(4).It is estimated that as many as10%of the patients that are referred to an ENT specialist have symp-toms and signs that might be attributed to GER.In GER patients the occurrence of extraoesophageal symptoms is as high as67%(5).There are many patients with voice disorders who have LPR as the main or one of the important reasons for their dysphonia.According to the data from the Phoniatric Service in Ljubljana,among patients with voice disorders,35%have typical symptoms of GER,51%have symptoms of LPR and56%show laryngological signs of LPR.If the LPR is an important factor affecting voice quality,an improvement of the voice disorder would be ex-pected after treating the LPR(6).The diagnosis of LPR is based on the patient’s history,laryngeal findings,and reflux testing results. No single diagnostic method is completely reliable for a confirmation of LPR.Ambulatory24-hour double-probe(simultaneous oesophageal and phar-yngeal probes)pH-monitoring and impedance test-ing are the most useful tests.Oesophago-gastroscopy is used for screening of the oesophagus pathology. However,it is usually not used as the primary diagnostic tool for LPR(1).The aim of our study was to determine the importance of oesophago-gastroscopy in the diag-nostics of LPR-caused pathology.We also wanted to compare the extent of LPR-caused voice disorders before and after proton-pump inhibitor therapy,and make a comparison with the voice disorders in patients with vocal fold polyps.Patients and methodsA total of43patients(25women,18men)with laryngopharyngeal problems in whom GER was suspected were included in the study.They were 17Á78years old,with a mean of44years and a standard deviation of14.7years.A total of36patients(25women,11men)with vocal fold polyps served as the control group for a subjective estimation of the voice problems.They were24Á62years old,with a mean of39years and a standard deviation of9.8years.In these patients conservative treatment was not successful and sur-gery was necessary for the solution of their voice problems.The diagnosis of LPR-caused pharyngolaryngeal disease was made on the basis of the patient’s history and videoendolaryngoscopy using a rigid908Hop-kins8707DA laryngoscope(Karl Storz GmbH& Co.KG).The lesions of the laryngeal mucosa were evaluated using the Belafsky Reflux Finding Score (BRFS)(7).All the LPR patients were treated with esomepra-sol(40mg)once a day for eight weeks in combina-tion with appropriate dietary and lifestyle changes. The acoustic analysis of the voice samples was performed in the LPR group before and after the treatment.The voice samples of a sustained vowel/a/ at a habitual pitch and loudness,for duration of 3seconds,were analysed with a Multi-Dimensional Voice Program(Kay Elemetrics,USA).The average fundamental frequency(F0),jitter(JIT),shimmer (SH)and noise-to-harmonic ratio(NHR)were determined for every voice sample.JIT gives an evaluation of the very-short-term variability of the pitch period.SH gives an evaluation of the very-short-term variability of the peak-to-peak amplitude (loudness)within the analysed voice sample.NHR is an average ratio of the energy of the inharmonic components in the range1500Á4500Hz to the harmonic components’energy in the range70Á4500Hz,and represents a general evaluation of noise presence in the analysed signal.According to the recommendation of the European Laryngologi-cal Society,JIT and SH are used to estimate the phonation quality(8).All the patients from both groups subjectively evaluated their voice problems using the Voice Handicap Index(VHI)questionnaire before the treatment.The LPR patients also filled in the VHI questionnaire after the treatment(9).Before the treatment,the oesophago-gastroscopy and the biopsy of the mucosa in the lower third of the oesophagus were performed for all43LPR patients.Typical oesophagitis above the lower oeso-phageal sphincter,hiatal hernia or dysfunctional lower oesophageal sphincter indicated the possibility of GER.Intraepithelial eosinophils,basal zone thickening and papillary lengthening in the oesopha-geal biopsy specimen were supposed to be an indicator of the prolonged acid reflux(10,11).The biopsy was marked as positive when all three criteria were fulfilled.The results of the histologic examina-tion of the oesophageal specimens were compared to the results of the oesophagoscopy and videoendolar-yngoscopy.After the treatment,the LPR patients estimated the improvement of their symptoms using the visual analogue scale(VAS).The videoendolaryngoscopy with a rigid908laryngoscope and the assessment of the laryngeal mucosa using BRFS were also V oice disorders and gastroesophageal reflux121performed.All pre-treatment and post-treatment assessments of laryngeal mucosa were performed by the first author.In the LPR patients the results of the videoendo-laryngoscopy,VHI questionnaire and the acoustic analysis were compared,before and after the treat-ment with esomeprasol.In order to determine the seriousness of the voice problems in the LPR group, the results of the VHI questionnaire were also compared for the two groups:the LPR group and the group of patients with vocal fold polyps.The statistical analysis was performed using the t-test,the Wilcoxon Signed Ranks test,the paired t-test and the paired non-parametric test(SPSS,Version11.0).ResultsThe main symptoms of the LPR patients were hoarseness(40patients),throat clearing(30pa-tients),and globus pharyngeus sensation(15pa-tients),two of them being simultaneously present in all LPR patients.The VHI results showed that patients with vocal fold polyps assessed their voice problems as being worse in comparison to the voice problems of the LPR patients,but the significant difference appeared only in the physical subtest of VHI(T able I).The subjective VHI test performed in the LPR patients after the treatment showed a significant improvement in the overall results and in the results of all the subtests in comparison to the results of the test performed before the treatment(T able II).The acoustic analysis of the voice samples de-tected almost no change in F0and JIT and a statistically significant improvement in SH and NHR(T able II).On the basis of videoendolaryngoscopy,the le-sions of the laryngeal mucosa were evaluated using the BRFS before and after the treatment with esomeprasol(T able III).In all the LPR patients the BRFS was more than7before the treatment, indicating LPR.After the treatment,the BRFS significantly decreased:in26patients it was below 7(T able IV).After the treatment with esomeprasol the LPR patients estimated,using VAS,that their problems decreased by20%Á100%(mean67%). Oesophago-gastroscopy confirmed the possibility of GER in16LPR patients(37%).The histopatho-logical examination of the oesophageal biopsy speci-mens indicated prolonged acid reflux in an additional22patients(51%)in whom oesophago-scopy did not detect any macroscopic signs of reflux oesophagitis,hiatal hernia or dysfunctional lower oesophageal sphincter.Both examinations when combined detected signs of possible GER in 38patients(88%)(T able IV).In eight cases the biopsy was not relevant due to too small a specimen. Videoendolaryngoscopy and history proved extraoe-sophageal or LPR in all43patients.DiscussionThe results of the study confirmed that LPR can cause considerable voice problems which can be compared to the extent of the voice problems in patients having vocal fold polyps.The proper treat-ment with a proton-pump inhibitor can significantly reduce a patient’s problems.In the diagnostics of GER and LPR,the patient’s history and videoendolaryngoscopy are superior to the oesophago-gastroscopy.However,oesophago-gastroscopy supplemented with a biopsy of the oesophageal mucosa can also be a convenient diagnostic method when GER and LPR are sus-pected.T o the best of our knowledge,the combina-tion of these three procedures has not been used in the diagnostics of GER and LPR yet.The diagnosis of LPR is based on a patient’s symptoms,laryngeal findings,and reflux testing results.Some GER is physiologic,occurring mostly after meals.LPR should never be considered phy-siologic,even a single pharyngeal episode of pH B4.0is diagnostic of LPR(1).Therefore, ambulatory24-hour double-probe(simultaneousT able I.The results of the VHI questionnaire in the patients with vocal fold polyps(n036)and the patients with LPR(n043).Patients with vocal fold polyps(mean/SD)Patients withLPR(mean/SD)pVHI41.1/19.035.6/18.10.218 VHI-F subtest10.4/6.18.8/6.50.210 VHI-P subtest20.8/8.016.8/6.80.007 VHI-E subtest9.8/8.110.2/7.30.643T able II.The results of the VHI questionnaire,the BRFS and the acoustic analysis of voice samples in the LPR patients (n043)before and after the treatment with esomeprasol.Before treatment(mean/SD)After treatment(mean/SD)p VHI36.6/18.125.6/20.90.000 VHI-F subtest8.8/6.5 6.3/6.20.028 VHI-P subtest16.8/6.813.3/9.70.001 VHI-E subtest10.2/7.3 6.1/7.60.000 BRFS13/2.9 5.7/1.80.000 F0197/58.9199/55.60.731 JIT 1.1/1.11/1.10.172 SH 3.7/2.3 3.2/2.10.044 NHR0.13/0.050.11/0.050.025122M.Sereg-Bahar et al.oesophageal and pharyngeal probes)with pH-mon-itoring is the most suitable diagnostic method.On the other hand,several studies proved that evident signs of LPR can be detected,even in patients with negative24-hour pH-monitoring(12).It was also proved that pepsin is activated,even in values of pH higher than4(13).The examination is also un-pleasant for the patient.In Slovenia,the long duration of the24-hour pH-monitoring and the high incidence of GER have an effect on accessibility to the examination.These were the reasons why we tried to find a quick and simple diagnostic method that can be easily tolerated by patients.An endoscopic laryngeal examination usually reveals the signs of LPR.In the great majority of studies the BRFS was used in the evaluation of the clinical severity of LPR(5).The BRFS is an eight-item clinical severity scale based on the most common laryngopharyngeal findings(subglottic oe-dema,ventricular obliteration,hyperaemia,vocal fold oedema,diffuse laryngeal oedema,posterior commissure hypertrophy,granuloma,excessive endolaryngeal mucus).A score of more than7is indicative of LPR(7).There are also some studies which did not find a clear correlation of lesions of the laryngeal mucosa with the GER(14,15).Therefore, a combination of more diagnostic procedures is necessary to confirm the clinical suspicion of GER and LPR.In the present study,the results of the videoendo-laryngoscopy and the BRFS correlated very well with the histological findings of the oesophageal mucosa specimens.Videoendolaryngoscopy is a very simple method,which can be easily repeated and is well tolerated by the patients.Oesophago-gastroscopy is also better tolerated than24-hour pH-monitoring. LPR patients can be treated with changes to their diet and lifestyle,alginates and H2antagonists,and proton-pump inhibitors.According to the results of other studies,the treatment of LPR needs to be more aggressive and prolonged than the treatment for GER disease.It seems that the larynx is more susceptible to a reflux-related injury than is the oesophagus.It usually takes six months or more for the laryngeal findings of LPR to resolve,and some patients may require chronic treatment.As an alternative,there is the possibility of surgical treat-ment(1).The results of our study confirmed that the treatment with esomeprasol was very successful. Our patients assessed that their problems(dyspho-nia,globus pharyngeus sensation,throat clearing, etc.)decreased by67%after the two-month therapy. The BRFS also showed significant improvement by the end of the two-month therapy.In about two-thirds of the patients the BRFS was below7.Further improvement is expected with prolonged esomepra-sol treatment.The subjective assessment of voice problems and the acoustic analysis of voice samples confirmed the results of the videoendolaryngoscopy.After the treatment with esomeprasol,the VHI results and some of the voice parameters(SH,NHR)signifi-cantly improved.The comparison of the VHI resultsT able III.The assessment of the laryngeal mucosa lesions using videoendolaryngoscopy in the LPR patients(n043)before and after the treatment with esomeprasol.Before treatment (Number of patients)After treatment (Number of patients)Subglottic oedema(absent/present)27/1640/3 Ventricular obliteration(absent/partial/complete)8/31/437/6/0 Hyperaemia(absent/arytenoids only/diffuse)0/16/2713/29/1 Vocal fold oedema(absent/mild/moderate/severe)1/18/20/416/22/3/2 Diffuse laryngeal oedema(absent/mild/moderate/severe)2/24/16/123/20/0/0 Posterior commissure hypertrophy(absent/mild/moderate/severe)0/2/23/182/30/10/1 Granuloma(present)21Excessive endolaryngeal mucus(absent/present)10/3322/21 BRFS]74317Vocal fold nodules21Vocal fold polyp00T able IV.Thefindings of the oesophago-gastroscopy and histo-pathological examination of the oesophageal biopsy specimens inthe LPR patients(n043).NumberofpatientsOesophagitis above the lower oesophageal sphincter(sign1)12Hiatal hernia(sign2)13Dysfunctional lower oesophageal sphincter(sign3)2Gastritis16Possible GER(sign1or2or3)16Histological findings indicating prolonged acid reflux34Possible GER and/or histological findings indicating prolonged acid reflux 38V oice disorders and gastroesophageal reflux123between the group of LPR patients and the group of patients with vocal fold polyps showed that LPR had a large,negative influence on the patients’voice quality.The degrees of their functional and emo-tional problems related to voice were even compar-able to the voice problems of patients with an evident laryngeal pathology*vocal fold polyp.After the treatment,the typical LPR lesions on the laryngeal mucosa diminished to a large extent and the vocal function of the larynx was greatly improved.There-fore,LPR should not be overlooked in the treatment of dysphonic patients.ConclusionsLPR can cause serious voice disorders,globus pharyngeus sensation,or frequent coughing.The voice problems can be compared to the problems of patients with vocal fold polyps.Oesophago-gastro-scopy supplemented with a biopsy of the oesopha-geal mucosa can be a suitable method to prove the occurrence of GER.Videoendolaryngoscopy and the BRFS are superior in the diagnostics of LPR and correlate very well with the histological findings of the oesophageal mucosa specimens.The combina-tion of all three procedures is supposed to be a very successful method in the diagnostics of GER and especially LPR.Esomeprasol proved to be very effective in the treatment of LPR.Subjective and objective voice-assessment methods demonstrated an improvement by the end of the two-month therapy.LPR appears to have an important negative influence on voice quality and should not be over-looked in the treatment of dysphonic patients. 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