Predicting Obstructive Sleep Apnea Status With the Reflux Symptom Index in a Sleep Study Population.

OBJECTIVES/HYPOTHESIS: Otolaryngologic symptoms of obstructive sleep apnea (OSA) and their diagnostic utility are not well studied. We aimed to elucidate the prevalence of otolaryngologic symptoms among patients being evaluated for OSA. Given findings that the Reflux Symptom Index (RSI) was strongly associated with OSA status, we evaluated the diagnostic utility of the RSI for predicting OSA status. STUDY DESIGN: Cross-sectional. METHODS: We recruited 101 adults presenting for ambulatory polysomnograms to the Northwestern Sleep Disorders Center from July 2017 to July 2018. The Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Leicester Cough Questionnaire (LCQ), RSI, Gastroesophageal Reflux Disease Questionnaire, Sino-Nasal Outcome Test-22, Nasal Obstruction Symptom Evaluation, Eustachian Tube Dysfunction Questionnaire 7, and Headache Impact Test were administered. Polysomnogram results were subsequently obtained. Patients with OSA (apnea-hypopnea index ≥ 5) and without OSA were compared. RESULTS: Of the 101 participants, 98 had valid sleep study results. Of those, 72 were diagnosed with OSA and 26 were not. The two groups differed significantly in age and body mass index (BMI). Of the questionnaires, only the RSI and LCQ means differed significantly, with worse symptoms in the OSA group (P = .003 and .014, respectively). Upon univariate regression, age, BMI, and RSI were associated with OSA status. Using regression coefficients, a clinical score of 2 (RSI) + 1.5 (BMI) + age yielded a diagnostic model (C-statistic = 0.807, P < .001). A threshold score of 104.21 was 76.4% sensitive and 73.1% specific. CONCLUSIONS: Patients with OSA have worse symptoms of laryngopharyngeal reflux as measured by the RSI. The addition of the RSI to the recognized factors of age and BMI improves diagnostic utility for OSA. LEVEL OF EVIDENCE: 2 Laryngoscope, 2020.

Are chronic cough and laryngopharyngeal reflux more common in obstructive sleep apnea patients?

OBJECTIVES/HYPOTHESIS: To assess if there is a significant difference in the prevalence and severity of chronic cough symptoms in obstructive sleep apnea (OSA) patients versus non-OSA patients and examine this relationship in regard to laryngopharyngeal reflux (LPR) symptoms. STUDY DESIGN: Prospective cohort study. METHODS: Patients referred to Northwestern Medicine Sleep Lab for home sleep testing were enrolled. Patients filled out the Leicester Cough Questionnaire (LCQ) and Reflux Symptom Index (RSI) before completing sleep testing. Home sleep testing results were reviewed, and patients were separated into non-OSA and OSA groups by standard Apnea-Hypopnea Index (AHI) criteria. Demographic characteristics and questionnaire scores of the two groups were compared. The relationship between OSA severity, as determined by AHI, and LCQ and RSI scores was assessed. RESULTS: Of the 52 patients enrolled, 33 patients met criteria for OSA and 19 patients did not. Comparing patients without OSA versus those with OSA, there was a significant difference in mean LCQ score (129.9 vs. 120.0, respectively; P = .02), implying worse cough symptoms among OSA patients, and mean RSI score (3.2 vs. 11.2, respectively; P = .0013), implying worse upper-airway reflux symptoms among OSA patients. There was a significant correlation between LCQ score and AHI (r = -0.39, P = .0061) and between RSI score and AHI (r = 0.37, P = .0078). CONCLUSIONS: OSA patients demonstrate worse chronic cough and LPR-related quality of life versus non-OSA patients. Furthermore, the severity of these quality-of-life measures was correlated with the severity of the AHI. Chronic cough and particularly the pharyngeal LPR symptoms may be associated with the presence and severity of OSA. LEVEL OF EVIDENCE: 2 . Laryngoscope, 129:1244-1249, 2019.

Oropharyngeal pH Testing Does Not Predict Response to Proton Pump Inhibitor Therapy in Patients with Laryngeal Symptoms.

OBJECTIVES: Predicting response to proton pump inhibitor (PPI) therapy in patients with laryngeal symptoms is challenging. The Restech Dx-pH probe is a transnasal catheter that measures oropharyngeal pH. In this study, we aimed to investigate the prognostic potential of oropharyngeal pH monitoring to predict responsiveness to PPI therapy in patients with laryngeal symptoms. METHODS: We conducted a physician-blinded prospective cohort study at a single academic institution between January 2013 and October 2014. Adult patients with Reflux Symptom Index scores (RSI) ≥13 off PPI therapy were recruited. Patients underwent video laryngoscopy and 24-h oropharyngeal pH monitoring, followed by an 8- to 12-week trial of omeprazole 40 mg daily. Prior to and following PPI therapy, patients completed various symptom questionnaires. The primary outcome was the association between PPI response and oropharyngeal pH metrics. PPI response was separated into three subgroups based on the post-treatment RSI score and % RSI response: non-response=RSI ≥13; partial response=post-treatment RSI <13 and change in RSI <50%; and complete response=post-treatment RSI <13 and change in RSI ≥50%. The primary analysis utilized a multinomial logistic regression controlling for the pre-treatment RSI score. A secondary analysis assessed the relationship between the change in RSI (post-pre) and oropharyngeal pH metrics via ordinary least square regression. RESULTS: Thirty-four patients completed the study and were included in final analysis. Symptom response to PPI therapy was as follows: 50% no response, 15% partial response, and 35% complete response. Non-responders had a higher pre-treatment RSI (P<0.01). There were no significant differences in oropharyngeal acid exposure (below pH of 4.0, 5.0, 5.5, 6.0, and RYAN scores) between responder types. The secondary analysis noted a trend between lower PPI response and a greater total percent time below pH of 5.0 (P=0.03), upright percent time below pH of 5.0 (P=0.07), and RYAN supine (corrected; P=0.03), as well as an association between PPI response and greater decreases in the Anxiety Sensitivity Inventory (P<0.01), Brief Symptom Inventory-18 (P<0.01), and Negative Affect Scale (P<0.01). CONCLUSIONS: Oropharyngeal pH testing did not predict laryngeal symptom response to PPI therapy. Contrary to hypothesis, our study signaled that the degree of oropharyngeal acid exposure is inversely related to PPI response. In addition, reduction in negative affect and psychological distress parallels PPI response.

Abilities of Oropharyngeal pH Tests and Salivary Pepsin Analysis to Discriminate Between Asymptomatic Volunteers and Subjects With Symptoms of Laryngeal Irritation.

BACKGROUND & AIMS: It has been a challenge to confirm the association between laryngeal symptoms and physiological reflux disease. We examined the ability of oropharyngeal pH tests (with the Restech Dx-pH system) and salivary pepsin tests (with Peptest) to discriminate between asymptomatic volunteers (controls) and subjects with a combination of laryngeal and reflux symptoms (laryngeal ± reflux). METHODS: We performed a physician-blinded prospective cohort study of 59 subjects at a single academic institution. Adult volunteers were recruited and separated into 3 groups on the basis of GerdQ and Reflux Symptom Index scores: controls (n = 20), laryngeal symptoms (n = 20), or laryngeal + reflux symptoms (n = 19). Subjects underwent laryngoscopy and oropharyngeal pH tests and submitted saliva samples for analysis of pepsin concentration. Primary outcomes included abnormal acid exposure and composite (RYAN) score for oropharyngeal pH tests and abnormal mean salivary pepsin concentration that was based on normative data. RESULTS: Complete oropharyngeal pH data were available from 53 subjects and complete salivary pepsin data from 35 subjects. We did not observe any significant differences between groups in percent of time spent below pH 4.0, 5.0, 5.5, 6.0, or RYAN scores or percent of subjects with positive results from tests for salivary pepsin (53% vs 40% vs 75%; P = .50, respectively). The laryngeal + reflux group had a significantly higher estimated mean concentration of salivary pepsin (117.9 ± 147.4 ng/mL) than the control group (32.4 ± 41.9 ng/mL) or laryngeal symptom group (7.5 ± 11.2 ng/mL) (P = .01 and P = .04, respectively). CONCLUSIONS: By using current normative thresholds, oropharyngeal pH testing and salivary pepsin analysis are not able to distinguish between healthy volunteers and subjects with a combination of laryngeal and reflux symptoms.

Brand name and generic proton pump inhibitor prescriptions in the United States: insights from the national ambulatory medical care survey (2006-2010).

Introduction. Proton pump inhibitors (PPI) are one of the most commonly prescribed medication classes with similar efficacy between brand name and generic PPI formulations. Aims. We determined demographic, clinical, and practice characteristics associated with brand name PPI prescriptions at ambulatory care visits in the United States. Methods. Observational cross sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) of all adult (≥18 yrs of age) ambulatory care visits from 2006 to 2010. PPI prescriptions were identified by using the drug entry code as brand name only or generic available formulations. Descriptive statistics were reported in terms of unweighted patient visits and proportions of encounters with brand name PPI prescriptions. Global chi-square tests were used to compare visits with brand name PPI prescriptions versus generic PPI prescriptions for each measure. Poisson regression was used to determine the incidence rate ratio (IRR) for generic versus brand PPI prescribing. Results. A PPI was prescribed at 269.7 million adult ambulatory visits, based on 9,677 unweighted visits, of which 53% were brand name only prescriptions. In 2006, 76.0% of all PPI prescriptions had a brand name only formulation compared to 31.6% of PPI prescriptions in 2010. Visits by patients aged 25-44 years had the greatest proportion of brand name PPI formulations (57.9%). Academic medical centers and physician-owned practices had the greatest proportion of visits with brand name PPI prescriptions (58.9% and 55.6% of visits with a PPI prescription, resp.). There were no significant differences in terms of median income, patient insurance type, or metropolitan status when comparing the proportion of visits with brand name versus generic PPI prescriptions. Poisson regression results showed that practice ownership type was most strongly associated with the likelihood of receiving a brand name PPI over the entire study period. Compared to HMO visits, patient visits at academic medical centers (IRR 4.2, 95% CI 2.2-8.0), physician-owned practices (IRR 3.9, 95% CI 2.1-7.1), and community health centers (IRR 3.6, 95% CI 1.9-6.6) were all more likely to have brand name PPIs. Conclusion. PPI prescriptions with brand name only formulations are most strongly associated with physician practice type.

Thoracic duct embolization: a new treatment for massive leak after neck dissection.

Chylothorax results from injury to the thoracic duct or one of its branches. It is an uncommon but possibly serious complication of thoracic or head and neck surgery. We report a case of thoracic duct transection complicating a total laryngectomy with bilateral selective neck dissection for subglottic squamous cell carcinoma. High-output Jackson Pratt drainage was noted, resulting in patient hypovolemia that was unresponsive to volume resuscitation. Treatment consisted of percutaneous embolization of the thoracic duct proximal to the transection that subsequently normalized chylous output.

Influenza and the vocal performer: update on prevention and treatment.

SUMMARY: Upper respiratory tract infections (URIs) are a major cause of morbidity among vocal arts professionals, both from their acute impairment of the vocal mechanism and their predisposing influence for the development of serious vocal sequelae. In this review, we present some of the salient features of currently available treatments effective against influenza, the virus family responsible for the most serious form of URI. At present, these include an inactivated vaccine and four antiviral drugs, each approved in the United States and many other countries for the prevention and treatment of influenza. A live attenuated vaccine is also available, and other vaccines and antiviral drugs are under development. This review details the current options available for treating both influenza and noninfluenza related URIs in the professional voice user.

Operating room versus office-based injection laryngoplasty: a comparative analysis of reimbursement.

BACKGROUND: Injection laryngoplasty (IL) continues to evolve as new indications, techniques, approaches, and injection materials are developed. Although historically performed under local or general anesthesia in the operating room suite, IL is now increasingly being performed in an office-based setting. This report presents the results of a reimbursement analysis comparing office-based versus operative IL. OBJECTIVE: The objective of this study was to compare the reimbursement of office-based injection laryngoplasty with the reimbursement of performing the same procedure in the operating room. DESIGN: The authors conducted reimbursement and outcome analysis through retrospective office chart and hospital record review. METHODS: A retrospective review was performed of the hospital records of patients having undergone injection laryngoplasty at the University of Pittsburgh Voice Center from July 1998 through March 2005. Group I included patients who underwent IL in the operating room, whereas group II included those who had office-based IL. A reimbursement analysis for both groups was then performed comparing surgeon fees, anesthesia, and hospital charges and reimbursement. The clinical efficacy of IL performed in either office versus operating room settings was measured by comparing the pre- and postintervention Voice Handicap Index-10 scores for all patients. A predictive model of potential cost savings is developed based on the results of the analysis. RESULTS: Average reimbursement was 2,505 dollars for group I (n = 108) and 496 dollars for group II (n = 50). This reimbursement differential was preserved across the various insurance types examined. There was no significant difference in Voice Handicap Index-10 change after surgery between group I and II. CONCLUSIONS: Office-based IL is both clinically and financially effective, providing patients with a convenient and flexible alternative to operating room-based intervention for glottal insufficiency.

Development and validation of the vocal tremor scoring system.

BACKGROUND: Essential tremor (ET) occurs in approximately 4% of the population, and 25% of patients with ET have vocal tract involvement referred to as essential tremor of voice (ETV). Treatment of vocal tremor has a variable success rate most likely as a result of inaccurate identification of the affected area(s). A vocal tremor assessment system was developed to standardize the evaluation and scaling of vocal tremor. Applying this system clinically can help determine who will benefit most from botulinum toxin injection treatment. The Vocal Tremor Scoring System (VTSS) can also be used as a tool to determine treatment efficiency for all treatment modalities of ETV, including surgery, medications, and implantable devices. STUDY DESIGN: The authors studied instrument development and validation. METHODS: A clinical consensus conference was conducted to develop an assessment tool for standardized rating of vocal tremor location and severity. The assessment tool was then tested for reliability using video-perceptual analysis. Once validated, the assessment tool was applied to 10 examinations of patients with vocal tremor who had been treated with botulinum toxin A (BtxA) injections of the thyroarytenoid muscle(s) to determine the ability of the scoring instrument to predict treatment outcome. RESULTS: : The VTSS is based on severity scores for different anatomic sites within the vocal tract. The assessment areas of the VTSS are the palate, base of tongue, pharyngeal walls, larynx, supraglottis, and true vocal cords. Statistical analysis of the video-perceptual analysis results showed that the anatomic sites with the best interrater agreement were the true vocal folds, palate, base of tongue, and supraglottis. Overall, the VTSS demonstrated a level of interrater reliability of at least 0.914 at all sites. Intrarater reliability was excellent. The consensus group also analyzed 10 standardized examinations and the scores from both reviewer groups were then compared and found to have a reliability of at least 0.6 at each site. Pretreatment VTSS scores of 10 patients with ETV who underwent BtxA therapy were then compared with treatment response. The VTSS predicted the favorable treatment outcome 100% of the time when the score given to the true vocal folds was equal or greater to the mean of the scores given to the other sites. CONCLUSION: The VTSS represents the first standardized system for rating anatomic site(s) and severity of vocal tremor. This tool will allow improved communication between otolaryngologists, facilitate research in vocal tremor treatments, and establish a descriptive system for assessing vocal tremor. Using this assessment tool for patients with vocal tremor increases optimal patient selection and success rate for intralaryngeal botulinum toxin treatment.

Diagnosis and management of laryngopharyngeal reflux disease.

PURPOSE OF REVIEW: A practical approach for the evaluation and management of laryngopharyngeal reflux is provided. RECENT FINDINGS: In the absence of definite diagnostic criteria, laryngopharyngeal reflux disease remains a subjective entity. The development and validation of various assessment instruments (the reflux symptom index and reflux finding score) are beginning to remedy this problem. A diagnosis of laryngopharyngeal reflux disease is usually based on response of symptoms to empirical treatment. Investigative modalities such as pH monitoring and, more recently, impedance studies are generally reserved for treatment failures. In contrast to gastroesophageal reflux disease, laryngopharyngeal reflux disease rarely responds to behavior modification alone, or in combination with low-dose histamine-2 receptor antagonists. Laryngopharyngeal reflux disease usually requires more aggressive and prolonged treatment to achieve regression of both symptoms and laryngeal findings. Surgical intervention may play a useful role in selected patients with persistent acid or nonacid reflux. SUMMARY: Laryngopharyngeal reflux is suspected when the history and laryngoscopy findings are suggestive of the diagnosis. Failure to respond to an empiric treatment suggests the need for confirmatory studies and consideration of alternative diagnoses. pH monitoring and multichannel impedance studies are the most useful modalities for directing further investigations or therapy.