Validity and Reliability of the Reflux Sign Assessment-10 (RSA-10).

OBJECTIVE: To develop and validate the Reflux Sign Assessment-10 (RSA-10) for documenting the physical findings of laryngopharyngeal reflux disease (LPRD). METHODS: Patients with LPRD at the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring and asymptomatic individuals were consecutively recruited from two European hospitals. Three experienced otolaryngologists rated RSA-10 in patients and controls for assessing internal validity. RSA-10 was rated within a 7-day period to assess test-retest reliability. Internal consistency was measured using Cronbach's α in patients and controls. Convergent validity was evaluated through a correlation analysis between RSA-10 and Reflux Finding Score (RFS). Interrater reliability was evaluated by comparing the RSA-10 evaluations of the three otolaryngologists through Fleiss kappa. Pre- to posttreatment change of RSA-10 was evaluated to assess responsiveness to change. The RSA-10 thresholds were examined by receiver operating characteristic analysis. RESULTS: Fifty-five patients completed the pre- to posttreatment evaluations from January 2020 to December 2023. A total of 115 asymptomatic individuals completed the study. RSA-10 reported high internal consistency reliability (α = 0.822) and test-retest reliability (rs = 0.725). The RSA-10 scores of patients were significantly higher than those of controls (p = 0.001), suggesting high internal validity. RSA-10 was significantly correlated with the RFS (rs = 0.771). The interrater reliability was adequate for sub- and total RSA-10 scores (k = 0.708). RSA-10 significantly improved from baseline to 3-month posttreatment (p = 0.001). An RSA-10 > 13 may be suggestive of LPRD. Both RSA-10 > 13 and Reflux Symptom Score-12 > 11 were associated with a sensitivity of 92.7% and a specificity of 97.3%. CONCLUSION: The RSA-10 is a reliable and valid clinical instrument for documenting the most prevalent laryngeal and extra-laryngeal findings associated with LPRD. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus.

OBJECTIVE: The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR. METHODS: Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician. RESULTS: After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h. CONCLUSION: A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:1614-1624, 2024.

Case report: Successive ipsilateral and contralateral laryngeal nerve palsy as probable manifestation of neuroborreliosis.

Neuroborreliosis is part of advanced stage of Lyme disease and often characterized by damage to the cranial and/or peripheral nerves. Involvement of one or both recurrent nerves is rare. Diagnosis is often difficult and based on a set of clinical manifestations, biological arguments, and cerebrospinal fluid (CSF) analysis. A 70-year-old man was referred to our Voice Clinic with a 3-month history of dysphonia caused by right vocal fold paralysis (VFP) without any cutaneous symptoms of tick bite or erythema migrans in the previous weeks and normal initial radiological examination (neck and thorax CT). Methylprednisolone had already been prescribed but without any clinical improvement. Late biological investigation 3 months after initial symptoms of VFP showed high IgG (93 U/mL; reference <10 U/mL) against Borrelia burgdorferi (BB), which was confirmed by two immunoblot markers (VIsE, p39 antigens). Therefore, a possible manifestation of Lyme disease with involvement of the right inferior laryngeal nerve was suspected, namely Lyme neuroborreliosis. However, given the spontaneous recovery of the patient after 7 months without any adapted antimicrobial regimen treatment, the diagnosis of neuroborreliosis was not confirmed by a lumbar puncture. Nineteen months later, the patient presented again for the same symptomatology but as left VFP. High IgG (68 U/mL) and IgM (>6, reference <0.90) levels against BB were confirmed by immunoblot. Subsequently, lumbar puncture was performed and revealed IgG against BB at 46.1 UA/mL (reference<5.5 UA/mL) in the CSF, with an extremely high IgG intrathecal synthesis antibody index (281.33, positive if > 1.5). Intrathecal antibody synthesis is the gold standard for Lyme neuroborreliosis demonstrating a specific immune response to BB in the central nervous system, but with the limitation of persistence for years after eradication. Our patient did not exhibit pleocytosis in the CSF. Therefore, two criteria of the European Federation of Neurological Societies (EFNS) guidelines are fulfilled for possible neuroborreliosis. Doxycycline treatment led to rapid recovery in less than 8 weeks and normal mobility of the left vocal fold. Because of this very uncommon clinical presentation with two successive episodes of VFP for no other obvious reason and serological evidence from the serum and CSF during the second episode, we consider it possible that the first episode of VFP could also have been a manifestation of neuroborreliosis. This case is the first report of possible relapse of laryngeal palsy successively on the right, and then the left side as a manifestation of Lyme neuroborreliosis.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians.

INTRODUCTION: To update the European guidelines for the assessment of voice quality (VQ) in clinical practice. METHODS: Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases. CONCLUSION: The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

Tele-rehabilitation in voice disorders during the pandemic: a consensus paper from the French Society of Phoniatrics and Laryngology.

OBJECTIVES: To establish a consensus protocol for telerehabilitation in speech therapy for voice disorders. METHODS: The study was conducted according to a modified Delphi method. Twenty speech therapist or laryngologist experts of the French Society of Phoniatrics and Laryngology assessed 24 statements of voice telerehabilitation with a 10-point visual analog scale ranging from 1 (totally disagree) to 10 (totally agree). The statements were accepted if more than 80% of the experts rated the item with a score of ≥ 8/10. The statements with ≥ 8/10 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: The French Society of Phoniatrics and Laryngology experts validated 10, 6, and 2 statements after the first, second and third voting round, respectively. Seven statements did not reach agreement threshold and were rejected. The validated statements included recommendations for setting (N = 4), medical/speech history (N = 2), subjective voice evaluations (N = 3), objective voice quality measurements (N = 3), and voice rehabilitation (N = 5). The experts agreed for a follow-up consisting of combined telerehabilitation and in-office rehabilitation. The final protocol may be applied in context of pandemic but could be assessed out of pandemic period for patients located in rural regions. CONCLUSIONS: This Delphi study established the first telerehabilitation protocol of the French Society of Phoniatrics and Laryngology for patients with voice disorders. Future controlled studies are needed to assess its feasibility, reliability, and the patient perception about telerehabilitation versus in-office rehabilitation.

Saliva Pepsin Concentration of Laryngopharyngeal Reflux Patients Is Influenced by Meals Consumed Before the Samples.

OBJECTIVES/HYPOTHESIS: To assess the impact of diet on the saliva pepsin concentration of patients with laryngopharyngeal reflux (LPR). STUDY DESIGN: Non-controlled Prospective Study. METHODS: Patients with positive LPR regarding hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were enrolled from three European Hospitals. Patients collected three saliva samples, respectively, in the morning (fasting), and 1 to 2 hour after lunch and dinner. Patients carefully detailed foods and beverages consumed during meals and before the pepsin samples. The 3-month treatment was based on the association of diet, proton pump inhibitors, alginate, or magaldrate regarding the HEMII-pH characteristics. Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were used for assessing the pre- to posttreatment clinical evolution. The Refluxogenic Diet Score and the Refluxogenic Score of a Dish (RESDI) were used to assess the refluxogenic potential of foods and beverages. The relationship between saliva pepsin concentration, HEMII-pH, RESDI, RSS, and RSA was investigated through multiple linear regression. RESULTS: Forty-two patients were included. The saliva pepsin concentration of the 24-hour period of testing was significantly associated with foods and beverages consumed during the testing period and the evening dinner (rs = 0.973, P < .001). RSS and RSA significantly improved throughout treatment. The level of saliva pepsin in the morning was a negative predictive factor of the therapeutic response regarding RSA and RSS (P < .036). CONCLUSIONS: Foods and beverages may significantly impact the saliva pepsin concentration of patients with LPR. Patients with high-level saliva pepsin in the morning had lower therapeutic response compared with those with low-level saliva pepsin. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:350-359, 2021.

Are the Acoustic Measurements Reliable in the Assessment of Voice Quality? A Methodological Prospective Study.

OBJECTIVE: Acoustic parameters are widely used as voice quality therapeutic outcomes in many laryngological diseases. The aim of this study is to explore the impact of changes in the nature and duration of the analyzed time interval and the vowel choice on the significance of the acoustic measurements used as therapeutic outcomes in two different diseases. STUDY DESIGN: A prospective case series. MATERIAL AND METHODS: From September 2013 to January 2018, patients with laryngopharyngeal reflux (LPR) disease were recruited and treated with pantoprazole, diet, and behavioral changes for 3 months. The reflux symptom index and reflux finding score were used for both diagnosis and assessment of treatment effectiveness. Simultaneously, patients with early idiopathic Parkinson's disease (IPD) were enrolled and benefited from a levodopa challenge test. An Iowa Oral Performance Instrument was used for objective outcomes in the assessment of levodopa effectiveness on muscular strength of IPD patients. Acoustic measurements were performed in both groups pre- and postmedication intake at different time intervals, including the "most stable" time intervals of 1 second, 2 seconds, 3 seconds, 4 seconds, and 5 seconds and a 1 second-time interval positioned at mid-production. We also measured acoustic parameters on the entire signal of three vowels and on the signal of each vowel being taken separately. RESULTS: A total of 80 LPR and 19 IPD patients met our inclusion criteria and completed the study protocol. LPR and IPD patients had significant clinical improvements throughout treatment, according to reflux symptom index, reflux finding score, and Iowa Oral Performance Instrument scores. The acoustic analysis revealed that acoustic parameters significantly improved from pre- to post-treatment and varied across methods used for measurement. The duration and position of the analyzed time interval in the production and the vowel on which the acoustic measures were made yielded considerable differences in the results. CONCLUSION: Depending on the time interval over which the acoustic parameters are measured, the clinically demonstrated effect of the medication may or may not be statistically demonstrated irrespective of the disease. According to the results of this study and regarding the lack of standardization of acoustic measurement methods, a line of thought is proposed to bypass the interval selection problem.

The Acoustic Voice Quality Index, Version 03.01, in French and the Voice Handicap Index.

OBJECTIVES: The Acoustic Voice Quality Index (AVQI), version 03.01, is a tool for quantitative assessment of the overall severity of dysphonia. Its computation includes six acoustic parameters, which are all analyzed with Praat freeware. It is based on recordings of a sustained vowel and part of a text read aloud. The psychometric qualities of this tool in various languages, including French, have been confirmed by numerous publications. However, studies investigating the correlation between tools for objective vocal assessment and voice-related quality of life show inconsistent results. Hence, the aim of this study was to contribute to the debate on measuring the correlations between the AVQI 03.01 score computed on French samples and the Voice Handicap Index (VHI). METHODS: Data from 78 patients were used; they were collected during initial vocal assessment and stored in the ear, nose, and throat caseload database of the University Hospital of Liège. The Spearman rank-order correlations (rs) between the VHI total score and subscores and the AVQI 03.01 scores for French samples were measured. The correlation between the diagnostic decisions ("normophonia" versus "dysphonia") of both tools was assessed using Cramer's phi. RESULTS: The Spearman correlation between AVQI 03.01 score and total VHI score, controlling for age, was moderate (rs = 0.62, P < 0.0001). The correlations between the AVQI 03.01 score and the functional, emotional, and physical subscores of the VHI were also moderate (rs = 0.643, 0.543, and 0.514, respectively, P < 0.0001). The correlation between the two instruments' diagnostic decisions ("normophonia" versus "dysphonia") was also moderate (φ = 0.52, P = 0.000). CONCLUSIONS: Although AVQI 03.01 scores were moderately correlated with the VHI total score and subscores, they measure two different things. The AVQI 03.01 assesses overall voice quality in terms of acoustic parameters, whereas the VHI assesses the multidetermined impact on the patient's everyday life. Both results should thus be taken into account, as part of a comprehensive vocal assessment.

Validation of the Acoustic Voice Quality Index, Version 03.01, in French.

OBJECTIVES: The Acoustic Voice Quality Index (AVQI), version 03.01, is a tool for quantitative assessment of the overall severity of dysphonia. It is based on the recordings of a sustained vowel and part of a text read aloud. For the Dutch sample, 34 syllables must be read aloud to balance the duration of the two tasks. The first part of this study thus aimed to determine how many syllables of a commonly used text in the French-speaking part of Belgium should be used to achieve the same balance. The psychometric qualities of the AVQI have been confirmed by numerous publications in various languages. However, its validation in French relies on a small cohort of patients, who were not native French speakers. Furthermore, version 03.01 of the AVQI has not yet been validated at all on French samples. Hence, the main aim of this study was to assess the criterion-related concurrent validity and diagnostic accuracy of the AVQI 03.01 applied to a sample of native French speakers. METHODS: For the first part of this study, the optimal part of the text to be used for the AVQI was identified, taking into account both its phonemic contents and its time balance with the sustained vowel. For the validation study, 90 recordings from the University Hospital of Liège's ENT caseload database were used, as well as 30 new recordings of normophonic individuals, composing a control group. Four judges assessed the recordings using the G parameter of the GRBAS scale. Once the intra- and inter-rater reliability of the perceptual ratings was confirmed, the AVQI 03.01's criterion validity was assessed on the French sample. The diagnostic accuracy of the AVQI 03.01 in French was measured, and the cut-off score allowing for the greatest diagnostic precision determined. RESULTS: The most appropriate syllable number of the text to be read aloud was found to be 27, in order to balance the time analyzed for both the sustained vowel and the continuous speech. Regarding the validation study, intra-rater reliability was substantial for each of the four vocologists (κmean = .778, P < 0.0001), and inter-rater reliability was high (W = .895, P < 0.0001). The Spearman correlation between the perceptual judgments and the AVQI 03.01 score was strong (rs = .84, P < 0.0001). The receiver operating characteristic-curve parameters indicated that the ideal cut-off score allowing for the highest diagnostic accuracy of the AVQI, version 03.01, applied to a French sample is 2.33, with a sensitivity of 59.8%, a specificity of 100%, an infinite positive likelihood ratio (LR+) and a negative likelihood ratio (LR-) of 0.4. CONCLUSIONS: This study confirms the external validity of the AVQI 03.01 when applied on a French 27-syllable sample. The AVQI 03.01 is a robust, ecologically valid objective measure of overall voice quality. The cut-off score to be used is 2.33. However, clinicians should be cautious when the AVQI score is lower than 2.33. The AVQI 03.01 does not yield a sufficiently low negative likelihood ratio to be sure that this score indeed indicates normophonia. Also, taking into account the limitations regarding the perceptual judgements used in this study, a replication study should be carried out in order to confirm the cut-off score.

Validity and reliability of the reflux symptom score.

OBJECTIVES/HYPOTHESIS: To develop and validate the Reflux Symptom Score (RSS), a self-administered patient-reported outcome questionnaire for patients with laryngopharyngeal reflux (LPR). STUDY DESIGN: Prospective controlled study. METHODS: A total of 113 patients with LPR were enrolled and treated with diet and 3 months of pantoprazole, alginate, and/or magaldrate depending on the LPR characteristics (acid, nonacid, or mixed). Eighty asymptomatic individuals completed the study. Patients and controls completed the RSS twice within a 7-day period to assess test-retest reliability. Internal consistency was measured using Cronbach's α for the RSS items in patients and controls. Validity was assessed by comparing the baseline RSS with the Reflux Symptom Index (RSI) and Voice Handicap Index (VHI). Seventy-seven patients completed the RSS at baseline and after 6 and 12 weeks of treatment to assess responsiveness to change. The RSS cutoff for determining the presence and absence of LPR was examined by receiver operating characteristic analysis. RESULTS: Test-retest reliability (rs = 0.921) and internal consistency reliability (α = 0.969) were high. RSS exhibited high external validity indicated by a significant correlation with the RSI (rs = 0.831). Internal validity was excellent based on the higher RSS in patients compared with controls (P = .001). RSS, RSI, and VHI scores significantly improved from pre- to posttreatment, indicating a high responsiveness to change. RSS >13 can be considered suggestive of LPR-related symptoms. RSS was not influenced by the occurrence of gastroesophageal reflux disease, LPR subtypes, or patient characteristics. CONCLUSIONS: RSS is a self-administered patient-reported outcome questionnaire that demonstrates high reliability and excellent criterion-based validity. RSS can be used in diagnosing and monitoring LPR disease. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:E98-E107, 2020.

Clinical and Acoustical Voice Quality Evolutions Throughout Empirical Treatment for Laryngopharyngeal Reflux Disease According to Gender: A Preliminary Study.

OBJECTIVE: To compare symptoms, signs, and acoustical voice quality changes throughout the 6-month course of empirical treatment between laryngopharyngeal reflux (LPR) males and females. MATERIALS AND METHODS: Forty clinically diagnosed LPR females and 40 males with a reflux finding score (RFS) >7 and a reflux symptom index (RSI) >13 were treated with pantoprazole and diet recommendations during 3 or 6 months according to their evolution. RSI, RFS, and acoustic parameters were assessed at baseline and 3 and 6 months posttreatment. A correlation analysis between videolaryngostroboscopic findings and acoustic measurements was performed. RESULTS: RSI, RFS, and many acoustic measurements (i.e., percent jitter, percent shimmer, phonatory fundamental frequency range, fundamental frequency variation, and peak-to-peak amplitude variation) significantly improved from baseline to 3 months posttreatment in male group. In female group, RSI and RFS total score significantly improved along the 3 first months of treatment. However, some clinical outcomes (i.e., RSI total score, hoarseness, cough, and globus) continued to improve from 3 to 6 months of treatment. We did not identify significant improvement of acoustic measurements in female group. The correlation study did not reveal significant correlation between videolaryngostroboscopic findings and acoustic measurements. CONCLUSION: This preliminary study suggests the occurrence of gender-related differences in the LPR therapeutic response. Further studies need to clarify whether females require a longer course of therapy than males.

Voice Quality as Therapeutic Outcome in Laryngopharyngeal Reflux Disease: A Prospective Cohort Study.

PURPOSE: To study the usefulness of voice quality as therapeutic outcome in laryngopharyngeal reflux disease. MATERIAL AND METHODS: A total of 80 patients with reflux finding score (RFS) > 7 and reflux symptom index (RSI) > 13 were treated with pantoprazole, diet, and lifestyle recommendations for 3 months. The therapeutic effectiveness was assessed with RSI; RFS; Voice Handicap Index; blinded Grade, Roughness, Breathiness, Asthenia, Strain, and Instability (GRBASI); aerodynamic and a panel of acoustic measurements before and after treatment. A correlation analysis between symptoms, videolaryngostroboscopic signs, and acoustic measurements was conducted. RESULTS: Compared to baseline, means of RSI, RFS, Voice Handicap Index, perceptual dysphonia, and roughness significantly decreased. Significant improvements of phonatory quotient, percent jitter, percent shimmer, Relative Average Perturbation, Pitch Perturbation Quotient, Phonatory F0 Range, Amplitude Perturbation Quotient, smooth Amplitude Perturbation Quotient, and Peak-to-Peak Amplitude Variation were found at the end of treatment. Studies of correlation did not identify relevant correlation between videolaryngostroboscopic signs, especially vocal folds edema, and objective voice quality evaluations. CONCLUSION: Voice quality assessments can help to better understand voice disorders and can be used as indicators of the treatment effectiveness in patients with laryngopharyngeal reflux-related symptoms.

Validity and Reliability of the Reflux Sign Assessment.

OBJECTIVE: To develop and validate the Reflux Sign Assessment (RSA), a clinical instrument evaluating the physical findings of laryngopharyngeal reflux (LPR). METHODS: A total of 106 patients completed a 3-month treatment based on the association of diet, pantoprazole, alginate, or magaldrate with the LPR characteristics (acid, nonacid, mixed). Forty-two asymptomatic individuals completed the study (control group). The RSA results and reflux finding score (RFS) were documented for the LPR patients at baseline and after treatment. Intrarater reliability was assessed through a test-retest blinded evaluation of signs (7-day intervals). Interrater reliability was assessed by comparing the RSA evaluations of three blinded otolaryngologists through Kendall's W. Responsiveness to change was evaluated through a comparison of the baseline and 3-month posttreatment findings. The RSA cutoffs for determining the presence and absence of LPR were examined by receiver operating characteristic (ROC) analysis. RESULTS: A total of 102 LPR patients completed the study (68 females). The mean age was 53 years. The mean RSA at baseline was 25.95 ± 9.58; it significantly improved to 18.96 ± 7.58 after 3 months of therapy (P < .001). RSA exhibited good intra- (r = 0.813) and interrater (Kendall's W = 0.663) reliabilities (N = 56). There was no significant association between the RSA, gastrointestinal endoscopy findings, and the types of reflux (acid, nonacid, or mixed) according to impedance-pH monitoring. An RSA >14 may be suggestive of LPR. CONCLUSION: The RSA is a complete clinical instrument evaluating both laryngeal and extralaryngeal findings associated with LPR. The RSA demonstrated high intra- and interrater reliabilities and responsiveness to change.

Development of scores assessing the refluxogenic potential of diet of patients with laryngopharyngeal reflux.

OBJECTIVE: To develop clinical tools assessing the refluxogenic potential of foods and beverages (F&B) consumed by patients with laryngopharyngeal reflux (LPR). METHODS: European experts of the LPR Study group of the Young-Otolaryngologists of the International Federation of Oto-rhino-laryngological societies were invited to identify the components of Western European F&B that would be associated with the development of LPR. Based on the list generated by experts, four authors conducted a systematic review to identify the F&B involved in the development of esophageal sphincter and motility dysfunctions, both mechanisms involved in the development of gastroesophageal reflux disease and LPR. Regarding the F&B components and the characteristics identified as important in the development of reflux, experts developed three rational scores for the assessment of the refluxogenic potential of F&B, a dish, or the overall diet of the patient. RESULTS: Twenty-six European experts participated to the study and identified the following components of F&B as important in the development of LPR: pH; lipid, carbohydrate, protein composition; fiber composition of vegetables; alcohol degree; caffeine/theine composition; and high osmolality of beverage. A total of 72 relevant studies have contributed to identifying the Western European F&B that are highly susceptible to be involved in the development of reflux. The F&B characteristics were considered for developing a Refluxogenic Diet Score (REDS), allowing a categorization of F&B into five categories ranging from 1 (low refluxogenic F&B) to 5 (high refluxogenic F&B). From REDS, experts developed the Refluxogenic Score of a Dish (RESDI) and the Global Refluxogenic Diet Score (GRES), which allow the assessment of the refluxogenic potential of dish and the overall diet of the LPR patient, respectively. CONCLUSION: REDS, RESDI and GRES are proposed as objective scores for assessing the refluxogenic potential of F&B composing a dish or the overall diet of LPR patients. Future studies are needed to study the correlation between these scores and the development of LPR according to impedance-pH study.

Awareness of European Otolaryngologists and General Practitioners Toward Laryngopharyngeal Reflux.

OBJECTIVES: To investigate the current trends in management of laryngopharyngeal reflux (LPR) among young European otolaryngologists and general practitioners (GP). METHODS: An international survey was sent to European general practitioners and all otolaryngologists under 45 years old from the 2017 IFOS meeting. This survey was conducted by the LPR Study Group of YO-IFOS (Young Otolaryngologists of the International Federation of Otolaryngological Societies). RESULTS: Among the 2500 attendees, 230 European otolaryngologists (response rate = 9%) completed the survey; an additional 70 GPs also completed the survey. GPs did not differentiate between gastroeosophageal reflux disease (GERD) and LPR, overstating GERD-related symptoms (ie, heartburn and regurgitations) in LPR clinical presentation and relying on gastrointestinal endoscopy for LPR diagnosis. Otolaryngologists also believe that GERD-related symptoms are prevalent in LPR. Knowledge of nonacid and mixed LPR and use of multichannel intraluminal impedance-pH monitoring are still limited in both groups. A therapeutic dichotomy exists between groups: GPs mainly use a 4-week once daily empiric proton pump inhibitors (PPIs) trial, while otolaryngologists use PPIs twice daily for a longer therapeutic period ranging from 8 to 12 weeks. More than 50% of GPs and otolaryngologists believe that they are not adequately knowledgeable and skilled about LPR. CONCLUSION: The majority of GPs and otolaryngologists do not believe themselves to be sufficiently informed about LPR, leading to different practice patterns and grey areas. The elaboration of international recommendations in the management of reflux is needed to improve practices.

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review.

OBJECTIVE: To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients-those who do not respond to anti-reflux medical treatment. METHODS: A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated. RESULTS: Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non-acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy. CONCLUSION: To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients. LEVEL OF EVIDENCE: 2a.

Perceptual, Aerodynamic, and Acoustic Characteristics of Voice Changes in Patients with Laryngopharyngeal Reflux Disease.

Laryngopharyngeal reflux (LPR) is an inflammatory condition suspected to be associated with dysphonia. In this study, we investigated multidimensional perceptual, aerodynamic, and acoustic voice changes in patients with clinically diagnosed LPR compared to healthy participants. We prospectively included 80 outpatients with Reflux Finding Score (RFS) >7 and Reflux Symptom Index (RSI) >13 from September 2013 to April 2016 and we compared clinical and voice quality assessments of these patients with 80 healthy participants. Statistically significant differences were found between groups with regard to Voice Handicap Index, perceptual voice quality (grades of dysphonia, roughness, strain, breathiness, asthenia, and instability), phonatory quotient, percentage jitter, percentage shimmer, peak-to-peak amplitude variation, standard deviation of fundamental frequency, and noise to harmonic ratio. Granulation score of RFS was found to affect the highest number of acoustic parameters. We did not identify significant correlation between vocal fold edema and objective voice quality measurements. This study supports that patients with LPR have significant deterioration of both subjective and objective voice quality compared to healthy participants.

Association between laryngopharyngeal reflux and benign vocal folds lesions: A systematic review.

OBJECTIVES: To investigate the role of laryngopharyngeal reflux (LPR) in the development of benign lesions of the vocal folds (BLVF). METHODS: PubMed, Cochrane Library, and Scopus were searched by three independent investigators for articles published between January 1990 and November 2018 providing substantial information about the role of LPR in the development of nodules, polyps, cysts, Reinke's edema, and sulcus vocalis. Inclusion, exclusion, diagnostic criteria and clinical outcome evaluation of included studies were analyzed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. RESULTS: Of the 155 relevant publications, 42 studies were included. Thirty-five were clinical studies and seven were experimental research studying the impact of reflux on vocal fold tissue. Only seven clinical studies utilized objective LPR diagnoses (pH monitoring), suggesting an association between LPR and the development of nodules, polyps, and Reinke's edema. These studies were characterized by a substantial heterogeneity due to discrepancies in inclusion/exclusion criteria, diagnostic methods, and clinical outcome evaluation. The few basic science studies on this topic support that LPR creates an environment that may predispose to BLVF through changes in defense mechanisms of the vocal folds, cell-to-cell dehiscence, inflammatory reaction of the vocal folds, and reaction to phonotrauma. CONCLUSIONS: Caustic mucosal injury from LPR could cause increased susceptibility of the vocal fold mucosa to injury and subsequent formation of nodules, polyps, or Reinke's edema. However, the heterogeneity and the low number of high-quality studies limit the ability to draw definitive conclusions. Future clinical and experimental studies are needed to better identify the role of reflux in development of BLVF. Laryngoscope, 129:E329-E341, 2019.