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.

Implication and Management of Incidental Oropharyngeal Papillomas-A Retrospective Case Series Review.

INTRODUCTION: Incidental papillomas of the pharynx can be found while examining the nasopharynx, oropharynx, and hypopharynx for other disorders of the head and neck. Purpose of the study is to explore the location, biopsy protocol, and decision to perform office-based versus operative management via potassium titanyl phosphate (KTP) laser when an oropharyngeal papilloma is discovered incidentally. METHODS: A retrospective review of the senior author's patient population was performed using Current Procedural Terminology and/or International Classification of Diseases codes to identify patients who had KTP laser removal of incidental oropharyngeal papillomas. Patients were included based on the incidental nature of the papilloma and confirmed pathology report of squamous papilloma. Demographics, presenting complaint, lesion location, pathological analysis, type of intervention, and outcomes were recorded. When available, human papillomavirus (HPV) subtype was noted. RESULTS: A total of 26 cases were identified, 13 females and 13 males. The median age at time of surgery was 58 years (range: 21-77). The most common presenting symptoms were difficulty swallowing and throat pain. The most common locations were the base of tongue, uvula, tonsils, and the soft palate. Of the 26 patients, 23 patients received KTP laser ablation therapy as an office-based procedure, while the remaining 3 were performed under general anesthesia in the operating room. Only 5 patients had a recorded recurrence that required reoperation. There were no operative or postoperative complications. There were 16 biopsy samples tested for HPV, where 12 were negative for HPV and 4 were positive for HPV. CONCLUSION: Oropharyngeal papillomas, when present, can be found incidentally during examination of the oropharynx for other symptoms. Office-based biopsy and KTP laser is a safe and efficient means of identifying and removing most oropharyngeal papillomas.

Laryngeal Electromyographic Findings in a Cohort of Recalcitrant Chronic Neurogenic Cough Patients.

OBJECTIVES: To evaluate the laryngeal electromyography findings of bilateral thyroarytenoid muscles in 10 patients with chronic, intractable coughing. METHODS: This is a retrospective cohort case series. Clinical records were reviewed for demographic information, symptoms, and findings on bilateral laryngeal EMG for 10 patients referred for chronic coughing. RESULTS: All thyroarytenoid muscles tested demonstrated electromyographic evidence of neuropathy, with signs of denervation and reinnervation. There was reduced recruitment in all 20 thyroarytenoid muscles studied. In addition, polyphasic motor units were seen in all thyroarytenoid muscles, with increased amplitude in 18 of 20 thyroarytenoid muscles and increased duration in 17 of 20 thyroarytenoid muscles. Additionally, there was electromyographic evidence of synkinesis in 19 of 20 thyroarytenoid muscles studied, a sign of aberrant reinnervation. CONCLUSION: Patients with intractable coughing, despite numerous modalities of treatment, potentially have bilateral neuropathy of the recurrent laryngeal nerves suggesting the potential peripheral as well as central neuropathic changes as the etiology.

Oto-tricho-tussia: An Unexpected Cause of Cough.

Chronic cough is a frequently encountered condition with multiple etiologies. In patients with neurogenic chronic cough, peripheral laryngopharyngeal hypersensitivity of the vagus nerve stimulates the cough reflex. We present three cases of "Oto-tricho-tussia," describing hair within the ear canal stimulating Arnold's branch of the vagus nerve and triggering the urge-to-cough. All three patients experienced significant improvement or complete resolution of their cough symptoms after removal of the hair resting on their tympanic membrane and external auditory canal. We encourage ear canal examination and promotion of proper ear cleaning habits as this is an easily treatable consideration for the cause of chronic cough.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux.

Importance: Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions. Objective: To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions. Design, Setting, and Participants: This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI). Main Outcomes and Measures: Recorded change in the RSI after 6 weeks of treatment. Results: Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68). Conclusions and Relevance: Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Symptomatic vallecular cysts: diagnosis and management with the KTP laser.

UNLABELLED: The objective of this study is to discuss the evaluation and treatment of patients with vallecular cysts removed via potassium titanyl phosphate (KTP) laser therapy. This is a retrospective cohort study with longitundinal follow-up. Clinical records were reviewed for demographic information, symptoms, and findings on laryngoscopy of nine patients having had KTP laser surgery for vallecular cysts. Nine patients (six female, three male) had vallecular cysts removed via KTP laser. The average age at the time of removal was 61, with a range of 34-95 years. The most common preoperative symptom was dysphagia, present in two-thirds of patients. The most common physical exam finding was a smooth, rounded vallecular cyst with reproduction of symptoms upon palpation of the lesion. More than half of the patients had a history of laryngopharyngeal reflux disease and were being treated with acid-reducing medication. Only, patient #1 had a history of trauma. All but two patients had a vallecular cyst located on the right side. Four of the patients underwent treatment in the office procedure room and five in the operating room. The average age of those treated in the office was 71 and 53 in the operating room. 89 % of patients had complete resolution of symptoms post operatively. Patient #4, treated in the office, continued to experience the symptoms but was lost to follow-up. No complications or adverse events were noted. KTP laser removal of vallecular cysts is a successful treatment option for symptomatic patients. Furthermore, the ability to remove such lesions in an office setting is advantageous, cost-effective, and convenient. LEVEL OF EVIDENCE: Level 4.

Comparison of trans-nasal laryngoscopic office based biopsy of laryngopharyngeal lesions with traditional operative biopsy.

The objectives of this study are to compare the pathological results from office-based biopsy (OBB) and operative biopsy (ORB) of laryngopharyngeal lesions from 26 patients. Lesion location, specimen concordance, efficacy, cost savings, and patient management are discussed. OBB can provide a sample of laryngopharyngeal tissue that can be used to diagnose lesions in these sites. This study design is retrospective review and involved retrospective analysis and chart review of 26 cases of patients who had an OBB followed by and ORB of the same site; oropharyngeal or laryngopharyngeal lesion. CPT 31576 was to identify patients. Twenty six patients had both OBB and operative biopsy performed of a lesion within the oropharynx and laryngopharynx. All OBB attempts resulted in diagnostic tissue samples. Vocal fold biopsy (69 %) was most common. The most common OBB diagnosis was squamous cell carcinoma or moderate-to-severe dysplasia (54 %). OBB and ORB pathological results were the same in 81 % of patients. Of the benign samples obtained by OBB, 83 % of the ORB were deemed benign. Of the non-benign samples obtained via OBB, 80 % of the ORB were deemed non-benign in the operating room samples. Office-based biopsy is a simple procedure that can be performed in an outpatient setting, avoiding an operating room and the need for general anesthesia. Comparison of results from OBB to ORB together with patient characteristics resulted in very reliable results that can help to guide further patient management.