Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease

Objective: T o de v elop a North American Society for Pediatric Ga str oen te rol og y , He pat olo gy , and Nut ri tio n (N ASP GH AN) and Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n (ES PGH AN ) int er nat io nal con se ns us on th e di agn os is an d ma nag em ent of gas tr oes op hag eal refl ux and gas tr oes op hag eal re flu x di sea se in th e ped ia tr ic po pu la tio n. Methods: An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which de v eloped these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-av ailable e vidence from PubMed, Cumulati ve Index to Nursing and Allied Health Literature, and bibliographies. The committee con v ened in face-to-face meetings 3 times. Consensus was achie v ed for all recommendations through nominal group technique, a structured, quantitati v e method. Articles were e v aluated using the Oxford Centre for Evidence-based Medicine Le vels of Evidence. Using the Oxford Grades of Recommendation, the quality of e vidence of each of the recommendations made by the committee was determined and is summarized in appendices. Results: More than 600 articles were re vie wed for this work. The document provides e vidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. Conclusions: Th is do cum ent is int end ed to be us ed in dai ly pra cti ce fo r th e de v el op me nt of fut ure cli ni cal pra ct ic e gu ide lin es and as a bas is for cli ni cal tr ia ls . JP GN 49 :49 8 – 54 7, 20 09 . Ke y Wo rd s: Cli nic al pra ct ic e gu id el ine s — Di agn os tic te sts — Ga str oes op hag ea l refl ux (GE R) — Ga str oes op hag ea l refl ux di sea se (GE RD ) — The rap eut ic mod al iti es. # 20 09 by Eu rop ea n Soc ie ty fo r Pe di atr ic Gas tr oen te ro log y , Hep at ol og y , and Nut rit io n and No rt h Am er ica n So ci ety for Pe dia tri c Ga str oen te rol og y , Hep at ol og y , an d Nu tr iti on

/pdf/pediatric-gastroesophageal-reflux-clinical-practice-359og269ui.pdf

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

The vocal quality of a patient is modeled by means of a Dysphonia Severity Index (DSI), which is designed to establish an objective and quantitative correlate of the perceived vocal quality The DSI is based on the weighted combination of the following selected set of voice measurements: highest Frequency (F-0-High in Hz), lowest intensity (I-Low in dB), maximum phonation time (Mm in s), and jitter (%). The DSI is derived from a multivariate analysis of 387 subjects with the goal of describing, purely based on objective measures, the perceived voice quality It is constructed as DSI = 0.13 x MPT + 0.0053 x F-0-High - 0.26 x I-Low - 1.18 x Jitter (%)+ 12.4. The DSI For perceptually normal voices equals +5 and for severely dysphonic voices -5. The more negative the patient's index, the worse is his or her vocal quality As such, the DSI is especially useful to evaluate therapeutic evolution of dysphonic patients. Additionally, there is a high correlation between the DSI and the Voice Handicap Index score.

The dysphonia severity index: an objective measure of vocal quality based on a multiparameter approach

The purpose of this study was to examine several factors of vocal quality that might be affected by changes in vocal fold vibratory patterns. Four voice types were examined: modal, vocal fry, falsetto, and breathy. Three categories of analysis techniques were developed to extract source‐related features from speech and electroglottographic (EGG) signals. Four factors were found to be important for characterizing the glottal excitations for the four voice types: the glottal pulse width, the glottal pulse skewness, the abruptness of glottal closure, and the turbulent noise component. The significance of these factors for voice synthesis was studied and a new voice source model that accounted for certain physiological aspects of vocal fold motion was developed and tested using speech synthesis. Perceptual listening tests were conducted to evaluate the auditory effects of the source model parameters upon synthesized speech. The effects of the spectral slope of the source excitation, the shape of the glottal excitation pulse, and the characteristics of the turbulent noise source were considered. Applications for these research results include synthesis of natural sounding speech, synthesis and modeling of vocal disorders, and the development of speaker independent (or adaptive) speech recognition systems.

http://linguistics.berkeley.edu/~kjohnson/LSA317/Childers&Lee1991.pdf

Vocal quality factors: analysis, synthesis, and perception.

ContextLaryngopharyngeal reflux (LPR) is a major cause of laryngeal inflammation
and presents with a constellation of symptoms different from classic gastroesophageal
reflux disease.ObjectiveTo provide a practical approach to evaluating and managing cases of
LPR.Evidence AcquisitionThe PubMed database and the Ovid Database of Systematic Reviews were
systematically searched for laryngopharyngeal reflux, laryngopharyngeal reflux fundoplication, laryngopharyngeal reflux PPI treatment, and gastroesophageal
reflux AND laryngitis. Pertinent subject matter
journals and reference lists of key research articles were also hand-searched
for articles relevant to the analysis.Evidence SynthesisReflux of gastric contents is a major cause of laryngeal pathology.
The pathophysiology and symptom complex of LPR differs from gastroesophageal
reflux disease. Laryngeal pathology results from small amounts of refluxate—typically
occurring while upright during the daytime—causing damage to laryngeal
tissues and producing localized symptoms. Unlike classic gastroesophageal
reflux, LPR is not usually associated with esophagitis, heartburn, or complaints
of regurgitation. There is no pathognomonic symptom or finding, but characteristic
symptoms and laryngoscopic findings provide the basis for validated assessment
instruments (the Reflux Symptom Index and Reflux Finding Score) useful in
initial diagnosis. There are 3 approaches to confirming the diagnosis of LPR:
(1) response of symptoms to behavioral and empirical medical treatment, (2)
endoscopic observation of mucosal injury, and (3) demonstration of reflux
events by impedance and pH-monitoring studies and barium swallow esophagram.
While pH monitoring remains the standard for confirming the diagnosis of gastroesophageal
reflux, the addition of multichannel intraluminal impedance technology improves
diagnostic accuracy for describing LPR events. Ambulatory multichannel intraluminal
impedance assessment allows for identification of gaseous as well as liquid
refluxate and detection of nonacid reflux events that are likely significant
in confirming LPR. Although some patients respond to conservative behavioral
and medical management, as is the case with gastroesophageal reflux, most
require more aggressive and prolonged treatment to achieve regression of symptoms
and laryngeal tissue changes. Surgical intervention such as laparoscopic fundoplication
is useful in selected recalcitrant cases with laxity of the gastroesophageal
sphincter.ConclusionsLaryngopharyngeal reflux should be suspected when the history and laryngoscopy
findings are suggestive of the diagnosis. Failure to respond to a 3-month
trial of behavioral change and gastric acid suppression by adequate doses
of proton pump inhibitor medication dictates need for confirmatory studies.
Multichannel intraluminal impedance and pH-monitoring studies are most useful
in confirming LPR and assessing the magnitude of the problem.

https://jamanetwork.com/journals/jama/articlepdf/201573/jcr50007.pdf

Evaluation and Management of Laryngopharyngeal Reflux

The Prevalence of Hypopharynx Findings Associated with Gastroesophageal Reflux in Normal Volunteers

https://www.cghjournal.org/article/S1542-3565(03)00177-0/pdf

Laryngeal Signs and Symptoms and Gastroesophageal Reflux Disease (GERD): A Critical Assessment of Cause and Effect Association

Total laryngectomy and total occlusion of the larynx with tracheostomy are associated with an impaired sense of taste and smell, an increased incidence of tracheobronchial infections, stomal encrustations, loss of nasal respiration, and loss of a human-sounding voice. A fundamental consideration in treating a patient whose larynx has been irreparably damaged is whether the goals of surgery should include replacement of the larynx to improve the patient's quality of life. An early attempt to treat laryngeal cancer with a partial laryngeal transplant1 was accompanied by rapid recurrence of the tumor, an outcome that quashed interest in the procedure for nearly . . .

Laryngeal transplantation and 40-month follow-up.

We have investigated the relationship between various voice qualities and several acoustic measures made from the vowel /i/ phonated by subjects with normal voices and patients with vocal disorders...

Acoustic Correlates of Vocal Quality

Purpose: Laryngopharyngeal reflux (LPR) is frequently treated with empiric proton-pump inhibitors (PPI), but the optimal dosing and duration is unknown. We performed an open label prospective cohort study to evaluate whether twice-daily (BID) PPI is more effective than once-daily (QD) PPI for the treatment of LPR.

Methods: Patients diagnosed with LPR based on ear, nose, and throat (ENT) symptoms and laryngoscopy findings were enrolled. Questionnaire assessed demographics, ENT symptoms, symptom severity, and exposure to other potential laryngeal irritants. Esophageal manometry, ambulatory 24-hour pH monitoring, and upper gastrointestinal endoscopy were performed before initiation of therapy. Patients were consecutively assigned to three groups: BID PPI (lansoprazole 30 mg BID), BID PPI + H2 receptor antagonist (H2RA; omeprazole 20 mg BID + ranitidine 300 mg each night), or QD PPI (esomeprazole 40 mg QD). Greater than 50% primary symptom improvement from baseline defined symptom response. At 2 month follow-up, the same PPI dose was continued for responders, and PPIs were doubled for nonresponders for an additional 2 months. Repeat symptom assessment and laryngoscopy performed at 4 month follow-up.

Results: Eighty-five patients were enrolled (median age 49 years, interquartile range 44.0 – 65.0; 76% white; 34% male). Treatment groups were BID PPI for 30 patients, BID PPI + H2RA for 30 patients, and QD PPI for 25 patients.

Response to Therapy: At 2 months, BID response occurred among 15 of 30 (50%) patients, BID + H2RA for 15 of 30 (50%), and QD for 7 of 25 (28%) (P = .03). No statistical difference found between the two BID PPI groups with and without H2RA. Among the QD group nonresponders, 7 of 13 (54%) achieved symptom response with additional 2 months of BID dosing. At 4 month follow-up, an additional 22% of responses were obtained from the two BID groups (43/60, 72%). The overall response rate for all three groups was 70% (54/77).

Predictors of Outcome: Pretherapy interarytenoid mucosa and true vocal folds abnormalities were associated with twofold increase in symptom response (odds ratio 1.99 and 1.96, respectively, P = .017).

Conclusion: BID PPI appears to be more effective than QD PPI in achieving clinical symptom response in suspected LPR. More response was achieved at 4 months compared with 2 months. Therefore, aggressive acid suppression with BID PPI for at least 4 months is warranted for treatment of LPR.

Douglas M. Hicks

Papers

The Prevalence of Hypopharynx Findings Associated with Gastroesophageal Reflux in Normal Volunteers

Laryngeal Signs and Symptoms and Gastroesophageal Reflux Disease (GERD): A Critical Assessment of Cause and Effect Association

Laryngeal transplantation and 40-month follow-up.

Acoustic Correlates of Vocal Quality

Laryngopharyngeal reflux: prospective cohort study evaluating optimal dose of proton-pump inhibitor therapy and pretherapy predictors of response.