Annals of Otology, Rhinology & Laryngology

http://aor.sagepub.com/

Laryngopharyngeal Reflux: Paradigms for Evaluation, Diagnosis, and Treatment

Zhen Gooi, Stacey L. Ishman, Jonathan M. Bock, Joel H. Blumin and Lee M. Akst
Ann Otol Rhinol Laryngol published online 1 May 2014
DOI: 10.1177/0003489414532777

The online version of this article can be found at:

http://aor.sagepub.com/content/early/2014/05/01/0003489414532777

Published by:

http://www.sagepublications.com

Additional services and information for Annals of Otology, Rhinology & Laryngology can be found at:

Email Alerts: http://aor.sagepub.com/cgi/alerts

Subscriptions: http://aor.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - May 1, 2014

What is This?

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
532777
research-article2014
AORXXX10.1177/0003489414532777Annals of Otology, Rhinology & LaryngologyGooi et al

Article
Annals of Otology, Rhinology & Laryngology

Laryngopharyngeal Reflux: Paradigms

19
The Author(s) 2014
Reprints and permissions:
for Evaluation, Diagnosis, and Treatment sagepub.com/journalsPermissions.nav
DOI: 10.1177/0003489414532777
aor.sagepub.com

Zhen Gooi, MBBS1, Stacey L. Ishman, MD, MPH2,

Jonathan M. Bock, MD3, Joel H. Blumin, MD3,
and Lee M. Akst, MD1

Abstract
Objective: This study aimed to describe current patterns for diagnosis and treatment of laryngopharyngeal reflux (LPR)
and analyze differences between laryngologists and non-laryngologists.
Methods: American Academy of OtolaryngologyHead and Neck Surgery and American Broncho-Esophagological
Association members were invited to complete an online survey regarding evaluation, diagnosis, and treatment of LPR.
Subgroup analysis was performed to identify differences between respondents who completed laryngology fellowships (LF)
and those who did not (NL).
Results: Of 159 respondents, 40 were LF. Video documentation of laryngopharyngeal exams was almost universal among
LF (97% vs 38%, P < .0001). Use of rigid (100%, P = .002) and flexible distal-chip technologies (94%, P = .004) was more
common among LF. Diagnostic criteria were similar between the groups, with symptoms of heartburn, globus, and throat
clearing thought most suggestive of LPR. Adjunctive tests most commonly used were barium esophagram and dual-probe
pH testing with impedance. Laryngology fellowship-trained respondents used dual pH probes with impedance more often
(P = .004). They were more likely to prescribe twice daily proton pump inhibitors with concurrent H2-blocker medication
initially (P = .004) and to treat for longer than 4 weeks (P = .0003).
Conclusion: Otolaryngologists are in agreement on symptoms and physical features of LPR; however, significant differences
exist between laryngologists and non-laryngologists on the use of adjunctive testing and treatment strategies.

Keywords
laryngopharyngeal reflux, symptoms and signs, treatment, diagnosis

Introduction
Laryngopharyngeal reflux (LPR) is recognized as the extra-
esophageal manifestation of reflux and is a commonly
treated condition in the field of otolaryngology. Although
efforts have been made to develop diagnostic criteria for
this clinical entity, no universally accepted system currently
exists. Variations in use of diagnostic investigations and
treatment also differ between practicing otolaryngologists.
In a survey of American Broncho-Esophagological
Association (ABEA) members in 2002, Book et al1 sought
to elicit respondents views on symptoms, physical find-
ings, and diagnostic tests pertaining to laryngopharyngeal
reflux. Respondents to this survey identified throat clearing,
persistent cough, heartburn, and voice quality change as
symptoms most indicative of reflux. Respondents broadly
agreed that physical signs of LPR are arytenoid erythema,
arytenoid edema, vocal cord erythema, and posterior com-
missure hypertrophy.1 The respondents to the 2002 survey
also considered flexible fiberoptic laryngoscopy to be the
most sensitive and specific diagnostic test for LPR and
regarded dual pH probe studies as the most valuable adjunc-
tive test.1
In the decade since that study was published, new knowl-
edge and new technologies have influenced how LPR is
diagnosed and managed. An increasing body of evidence
documents potential harm from prolonged proton pump
inhibitor (PPI) use even as the potential benefit of PPI in
1
Department of OtolaryngologyHead and Neck Surgery, Johns Hopkins
University, Baltimore, Maryland, USA
2
Department of OtolaryngologyHead and Neck Surgery, Cincinnati
Childrens Medical Center, Cincinnati, Ohio, USA
3
Department of Otolaryngology & Communication Sciences, Medical
College of Wisconsin, Milwaukee, Wisconsin, USA
Corresponding Author:
Lee M. Akst, MD, Johns Hopkins Outpatient Center, Department
of OtolaryngologyHead and Neck Surgery, 601 N. Caroline Street,
Baltimore, MD 21287, USA.
Email: lakst1@jhmi.edu

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
2 Annals of Otology, Rhinology & Laryngology

Table 1. Symptoms in Terms of Their Relationship to Reflux.a

Please rate each of the following symptoms in terms of their relationship to reflux (Scale: 1 to 5, where 1 = highly related,
3 = somewhat related, 5 = not related).

Answer Option 1 2 3 4 5
Dysphagia 13.0 35.6 39 8.9 3.4
Choking episodes 15.6 38.8 31.3 9.5 4.8
Persistent cough 29.1 47.3 18.9 4.1 0.7
Change in voice quality 21.1 38.8 26.5 10.9 2.7
Pain with phonation 33.4 11.7 33.1 35.9 15.9
Globus sensation 48.3 34.0 11.6 2.7 3.4
Throat clearing 50.0 36.5 9.5 2.0 2.0
Heartburn/dyspepsia 53.1 20.0 15.9 9.0 2.1
Postnasal drip 6.2 26.7 28.8 27.4 11.0
Nasal obstruction 0.7 1.4 21.9 41.1 34.9
a
All values are percentages.

LPR has been called into question.2,3 At the same time, pH
probe testing and transnasal esophagoscopy (TNE) have
entered more widespread practice. With these changes in
mind, the aim of this study was to characterize current pat-
terns in the diagnosis and treatment of LPR within the
broader otolaryngologic community, with particular atten-
tion to the role that has been adopted for use of new tech-
nologies in reflux care. A second aim was to examine any
significant differences between those with subspecialty
training in laryngology and other otolaryngologists in
approaches to LPR diagnosis, testing, and treatment.
Methods
This study was reviewed by the Johns Hopkins Medicine
Institutional Review Board and was granted exempt status.
A link to an online survey was published in an October 2012
edition of American Academy of OtolaryngologyHead
and Neck Surgery (AAO-HNS) The News, a weekly news-
letter emailed to members of the AAO-HNS. At that same
time, an email link was sent to ABEA members. Respondents
were directed to an online survey and were asked to answer
a series of multiple-choice questions related to their train-
ing, views on signs and symptoms of LPR, and patterns for
diagnosis and treatment of LPR. All questions were optional
and consent for participation was obtained at the beginning
of the survey. During analysis of those signs or symptoms,
which were most highly related to particular aspects of
reflux care, answers were stratified by the proportion of
respondents selecting 1highly related or 2 on the
5-point Likert-type scale. Similarly, those answer choices
that garnered the highest proportion of 4 or 5not
related were considered to be least related to a particular
aspect of reflux care. Tests were placed in rank order in
terms of utility for care, diagnosis, and treatment of reflux
patients based on these Likert-scale responses. Two-
sample t tests were used to assess for statistically signifi-
cant differences, defined as P < .05 between laryngology
fellowship-trained respondents (LF) and non-laryngology
fellowship-trained respondents (NL). The complete survey
is listed as an appendix.
Results
There was a total of 161 survey respondents; 2 were
excluded from the final analysis, as they were not practicing
otolaryngologists. Thirty-five percent of respondents were
in academic practice, 53% were community based, and 11%
classified their practices as a combination of academic and
community based. Forty respondents (26%) indicated that
they had completed laryngology fellowships, 146 respon-
dents (90%) indicated that they were AAO-HNS members,
and 64 were ABEA members (41%). Fifty percent of
respondents completed their training before 1993. Overall,
NL respondents had been practicing longer than LF respon-
dents (mean, 19.6 vs 11.4 years; P = .0001). Seventy-one
percent of respondents indicated that < 50% of their prac-
tice is devoted to laryngology/bronchoesophagology; 62%
of respondents also indicated that < 50% of their laryngo-
bronchoesophagology patients present with chief com-
plaints that are directly attributable to LPR.
When asked about the prevalence of LPR in respondents
laryngobronchoesophagology patients, 54% reported diag-
nosing LPR in 50%, 33% in 51% to 75%, and 13% in >
75% of their patients. The ratings of LPR-related patient
symptoms are shown in Table 1. The 4 most frequently
selected symptoms were throat clearing (87%), globus sen-
sation (82%), persistent cough (76%), and heartburn/dys-
pepsia (73%). The 4 symptoms thought to be least related to
reflux were nasal obstruction (76%), pain with phonation

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
Gooi et al 3

Table 2. Physical Exam Findings in Terms of Their Relationship to Reflux.a

Please rate each of the following physical exam findings in terms of their relationship to reflux (Scale: 1 to 5, where 1 = highly related,
3 = somewhat related, 5 = not related).

Answer Option 1 2 3 4 5
Pachydermia laryngis 41.7 26.4 22.9 5.6 3.5
Vocal cord paralysis/paresis 0 1.4 7.5 20.4 70.7
Vocal cord polyp 2.1 15.2 29.7 27.6 25.5
Vocal cord nodule 2.0 15.0 33.3 25.2 24.5
Laryngotracheal stenosis 11.5 14.9 37.8 23.6 12.2
Laryngeal carcinoma 2.1 9.7 29.2 42.4 16.7
Vocal cord erythema 17.0 42.9 25.9 8.2 6.1
Vocal cord edema 23.6 39.2 25.7 9.5 2.0
Ventricular obliteration 16.2 29.1 29.7 18.2 6.8
Posterior commissure hypertrophy 45.6 32.0 15.6 4.8 2.0
Arytenoid erythema 43.2 32.9 17.8 17.8 2.1
Arytenoid edema 46.6 33.8 14.2 4.1 1.4
Arytenoid blood vessel obliteration 9.4 21.7 46.4 14.5 8.0
Subcordal edema 15.5 27.0 35.8 16.2 5.4
a
All values are percentages.

(52%), postnasal drip (38%), and choking episodes (14%).
The ratings of reflux-related physical exam findings are
shown in Table 2. Respondents most highly ranked aryte-
noid edema (80%), posterior commissure hypertrophy
(77%), arytenoid erythema (76%), and pachydermia laryn-
gis (68%). Conversely, the physical exam findings thought
to be least related to LPR were vocal cord paralysis/paresis
(91%), laryngeal carcinoma (59%), vocal cord polyp (53%),
and vocal cord nodule (50%). There were no significant dif-
ferences in the selection of LPR-related symptoms and
physical signs between LF and NL respondents.
Fifty-three percent of respondents routinely video-doc-
umented their laryngeal examinations. There was a sig-
nificant difference in the video documentation of
laryngopharyngeal exams between LF (97%) and NL (38%,
P < .0001). Rigid laryngeal endoscopy, flexible fiberoptic
transnasal endoscopy, and distal-chip transnasal endoscopy
were available to 100%, 84.4%, and 94% of LF respon-
dents, respectively, whereas among NL respondents, these
diagnostic adjuncts were available to 78.4%, 95.2%, and
62.9%, respectively. The availability of rigid laryngeal
endoscopy (P = .002) and distal-chip transnasal endoscopy
(P = .004) was significantly higher among the LF compared
to the NL group.
Table 3 shows the most commonly obtained adjunctive
diagnostic tests for LPR. Eighty percent of LF and 69.4% of
NL indicated that they most commonly did not order any
further adjunctive diagnostic tests (P = .481). Review of the
survey tool in the appendix makes clear that several differ-
ent types of pH probe were available for selection by
respondents; the survey allowed for the separate selection
of pharyngeal and esophageal probes with or without
impedance testing. The most popular adjunctive diagnostic
tests were esophagogastroduodenoscopy (EGD), barium
esophagram, and dual pH probe with impedance.
Laryngology fellowship-trained respondents were more
likely to list dual pH probe with impedance among their top
3 choices for testing than were NL respondents (85.0% LF
vs 36.4% NL, P = .004). The least commonly ordered
adjunctive diagnostic tests were pharyngeal pH probe test-
ing, esophageal manometry, and wired single esophageal
pH probe.
When asked which tests were most sensitive and spe-
cific for diagnosis of LPR, dual pH probe with impedance
was selected most often, with dual pH probe (pharyngeal
and esophageal) and pharyngeal pH probe testing being
the next 2 most commonly selected tests. Tests thought
least sensitive or specific were wired or wireless (Bravo)
single esophageal pH probe, TNE, and EGD. No statisti-
cally significant differences existed between LF and NL
in their interpretation of the sensitivity and specificity of
these tests. The full results for ranking of perceived sensi-
tivity/specificity of diagnostic tools are shown in Table 4.
When respondents were asked what adjunctive tests they
obtained themselves without referral to a gastroenterolo-
gist, barium esophagram (67%) and TNE (47%) were the
tests most commonly listed by respondents. However, LF
respondents were significantly more likely to use TNE
without making a referral to a gastroenterologist com-
pared to NL respondents (80% vs 33.3%, P < .0001).
Greater than 80% of respondents overall referred patients
to a gastroenterologist for pH probe studies, esophageal
manometry, and EGD. Respondents offered a wide vari-
ety of explanations when identifying barriers to

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
4 Annals of Otology, Rhinology & Laryngology

Table 3. Adjunctive Diagnostic Tests Most Commonly Obtained to Further Validate or Investigate the Diagnosis of
Laryngopharyngeal Reflux.a

Which of the following adjunctive diagnostic tests do you most commonly obtain to further validate or investigate your diagnosis
of laryngopharyngeal reflux? (Rank as many tests as you obtain, starting with 1 being the most commonly obtained and 12 being the
least commonly obtained; please stop numbering when you have finished listing all of the tests you order. You do not have to rank
every test.)

Answer Option 1 2 3 4 5 6 7 8 9 11 12
None. I do not order other tests. 73.2 5.4 5.4 3.6 0.0 0.0 0.0 0.0 0.0 7.1 5.4
Barium esophagram 35.6 18.9 12.2 8.9 7.8 2.2 2.2 3.3 4.4 3.3 1.1
Endoscopy: esophagogastroduodenoscopy 11.1 39.5 16.0 13.6 8.6 4.9 2.5 3.7 0.0 0.0 0.0
Endoscopy: transnasal esophagoscopy 13.6 20.3 10.2 13.6 11.9 6.8 8.5 0.0 3.4 1.7 10.2
Esophageal manometry 0.0 6.4 19.1 10.6 12.8 10.6 6.4 8.5 12.8 6.4 6.4
pH probe: pharyngeal testing (Restech) 10.8 2.7 10.8 8.1 16.2 21.6 2.7 2.7 5.4 8.1 10.8
pH probe: esophageal, single-probe, wired 0.0 6.5 0.0 9.7 6.5 12.9 19.4 6.5 12.9 6.5 19.4
pH probe: esophageal, single-probe, wireless (Bravo) 2.6 7.9 18.4 5.3 5.3 15.8 10.5 21.1 5.3 5.3 2.6
pH probe: dual probe (pharyngeal and esophageal) 2.9 11.4 22.9 5.7 5.7 2.9 11.4 17.1 14.3 0.0 5.7
pH probe: dual probe (proximal and distal esophageal) 0.0 7.9 23.7 15.8 2.6 7.9 10.5 2.6 7.9 21.1 0.0
pH probe: dual probe with impedance 28.3 17.4 10.9 2.2 8.7 0.0 0.0 2.2 6.5 8.7 15.2
Other 15.4 15.4 0.0 23.1 0.0 0.0 0.0 0.0 0.0 15.4 30.8
a
All values are percentages.

Table 4. Tests Regarded as Most Sensitive and Specific for the Diagnosis of Laryngopharyngeal Reflux.a

Of the possible tests listed, which do you feel is most sensitive and specific for the diagnosis of laryngopharyngeal reflux? (Please rank
on a scale of 1 to 10, with 1 as the most sensitive/specific and 10 as the least sensitive/specific.)

Answer Option 1 2 3 4 5 6 7 8 9 10
Barium esophagram 2.8 9.9 9.9 2.8 7.0 8.5 7.0 19.7 19.7 12.7
Endoscopy: esophagogastroduodenoscopy 10.0 11.4 10.0 8.6 4.3 14.3 18.6 14.3 7.1 1.4
Endoscopy: transnasal esophagoscopy 10.7 5.4 14.3 10.7 3.6 8.9 26.8 12.5 3.6 3.6
Esophageal manometry 1.9 9.6 7.7 7.7 3.8 15.4 9.6 11.5 30.8 1.9
pH probe: pharyngeal testing (Restech) 26.3 10.5 14.0 8.8 22.8 12.3 3.5 1.8 0.0 0.0
pH probe: esophageal, single-probe, wired or wireless (Bravo) 2.0 7.8 5.9 31.1 29.4 15.7 0.0 5.9 0.0 2.0
pH probe: dual probe (pharyngeal and esophageal) 32.4 36.8 16.2 7.4 4.4 0.0 2.9 0.0 0.0 0.0
pH probe: dual probe (proximal and distal esophageal) 10.5 28.1 29.8 8.8 12.3 3.5 1.8 1.8 3.5 0.0
pH probe: dual probe with impedance 65.7 9.0 6.0 9.0 3.0 1.5 3.0 1.5 1.5 0.0
Other 30.0 10.0 0.0 0.0 10.0 0.0 0.0 0.0 0 50.0
a
All values are percentages.

performing pH probe testing as part of their practice
(Table 5). The most commonly selected options for most
important barrier were not enough time (33%), do not
believe it adds meaningfully to patient care (25%), and
concern for cost (22%). An almost equal number of
respondents indicated concern for patient tolerance (20%)
and being unfamiliar with interpretation (18%) as the
most important barrier for not performing pH probe test-
ing. A greater proportion of LF respondents indicated
not enough time as the most important barrier com-
pared with NL, whereas concern for cost was cited by a
greater proportion of NL as the most important barrier
(P=.08). When asked to identify the most important
barriers that prevented respondents from incorporating
TNE as part of their practice, concern for cost (49%),
unfamiliarity with interpretation (20%), concern for
patient tolerance (20%), and not enough time (17%) were
the most popular choices, as shown in Table 6.
A majority (82%) of respondents indicated that they
would treat presumed LPR empirically without further
testing more than 60% of the time. The most popular
empiric treatment options selected were twice daily PPI
(39%), once daily high-dose PPI (29%), and once daily
low-dose PPI (21%). Laryngology fellowship-trained
respondents were significantly more likely to prescribe
twice daily PPI with concurrent H2-blocker medication

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
Gooi et al 5

Table 5. Barriers Toward pH Probe Testing.a

If you do NOT currently perform your own pH probe testing as part of your practice, what are the barriers that have kept you
from doing so? Please rank in order of importance, from 1 to 7 (1 = most important barrier, 8 = least important barrier). If you do
perform your own pH probe testing, please skip this question.

Answer Option 1 2 3 4 5 6 7
Concern for cost 21.9 28.8 13.7 16.4 8.2 5.5 5.5
Concern for patient scheduling/convenience 8.8 25.0 23.5 13.2 14.7 10.3 4.4
Concern for patient tolerance 19.7 15.2 21.2 18.2 7.6 13.6 4.5
Do not believe it adds meaningfully to patient care 25.0 10.0 10.0 8.3 5.0 13.3 28.3
Not enough time 32.9 5.7 17.1 15.7 8.6 5.7 14.3
Unclear on appropriate indications 4.5 17.9 6.0 11.9 28.4 19.4 11.9
Unfamiliar with interpretation 18.4 14.5 14.5 13.2 10.5 14.5 14.5
a
All values are percentages.

Table 6. Barriers Toward Transnasal Esophagoscopy.a

If you do NOT currently perform transnasal esophagoscopy (TNE) as part of your practice, what are the barriers that have kept you
from doing so? Please rank in order of importance, from 1 to 7 (1 = most important barrier, 7 = least important barrier). If you do
perform TNE as part of your practice, then do not answer this question and skip to question 18.

Answer Option 1 2 3 4 5 6 7
Concern for cost 48.9 17.0 6.4 12.8 6.4 4.3 4.3
Concern for patient scheduling/convenience 7.1 19.0 26.2 19.0 14.3 11.9 2.4
Concern for patient tolerance 19.6 30.4 19.6 15.2 8.7 6.5 0.0
Do not believe it adds meaningfully to patient care 12.2 4.9 12.2 7.3 12.2 7.3 43.9
Not enough time 17.4 19.6 17.4 15.2 6.5 4.3 19.6
Unclear on appropriate indications 7.1 11.9 11.9 9.5 23.8 31.0 4.8
Unfamiliar with interpretation 20.4 14.8 13.0 13.0 14.8 14.8 9.3
a
All values are percentages.

initially (P = .004). The most common responses for dura- Discussion

tion of this empiric treatment trial were 2 months (43%), 3
months (34%), and 1 month (18%). Laryngology fellow-
ship-trained respondents were significantly more likely to
use empiric treatment duration of greater than 1 month
compared to NL respondents (P = .0003). When asked
what they would do for a patient who failed empiric treat-
ment for LPR, 37% of respondents indicated that they
would obtain further testing, 30% would refer to a gastro-
enterologist for further evaluation and management, 25%
would continue empiric treatment with an increased PPI
dose, and 5% indicated that they would prolong empiric
treatment with the same medication regimen. A greater
proportion of LF respondents chose further testing com-
pared to NL (51% vs 31%, P = .053), whereas NL more
commonly chose refer to gastroenterologist for further
evaluation and management (30% vs 18%, P = .115).
When respondents were asked their most commonly
ordered diagnostic test for a patient who failed an empiric
treatment trial for LPR, the top 3 overall selections were
EGD, barium esophagram, and esophageal dual pH probe
with impedance.
The current study examines practice patterns of otolaryn-
gologists in the diagnosis, adjunct testing, and treatment of
LPR. Overall, diagnosis and management of LPR remain
frustrating, without true gold standards against which to
measure current practice patterns.
Regarding diagnosis of LPR, strategies vary from clini-
cal diagnosis based on history and examination alone to
diagnosis based on response to empiric treatment and on pH
testing. Laryngology fellowship-trained and NL respon-
dents demonstrated broad agreement in which patient com-
plaints and exam findings they thought to be most related to
LPR. Heartburn, throat clearing, globus sensation, and per-
sistent cough were thought by respondents to correlate with
LPR. This symptom complex mirrors those symptoms
included on the reflux symptom index.4 Similarly, physical
findings thought to be highly related to LPR by respondents
mirror those included in the reflux finding score and include
arytenoid edema, posterior commissure hypertrophy,
pachydermia laryngis, and arytenoid erythema.5 Despite
this broad agreement on signs and symptoms, there are

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
6 Annals of Otology, Rhinology & Laryngology
statistically significant differences in practice patterns
between NL and LF respondents, particularly related to use
of diagnostic adjuncts and treatment strategies for LPR.
As knowledge evolves, recommendations have evolved
as well. It used to be that the recommended treatment for
suspected LPR was twice daily PPI for at least 2 months.6
With more recent concerns about the efficacy of PPI in
treatment of isolated LPR symptoms (in the absence of
heartburn) and with concern for PPI side effects, a more
recent recommendation from the gastroenterology and oto-
laryngology communities has been to restrict empiric treat-
ment of possible LPR without some further indication based
on signs or symptoms that reflux is indeed present; otolar-
yngology position statements support laryngeal exam as
being able to document reflux, whereas the most recent gas-
troenterology guidelines do not consider flexible laryngos-
copy as a credible tool for LPR diagnosis.2,3 In this changing
environment, an understanding of current practice patterns
in the diagnosis, evaluation, and treatment of reflux takes
on practical significance as current paradigms must be
understood before care can be optimized.
The finding that the vast majority of LF video-
documented their laryngeal examinations and that there is
increased availability of rigid laryngeal endoscopy and dis-
tal-chip transnasal endoscopy in LF practices in comparison
with NL practices is likely due to a combination of factors.
These include the cost of this equipment, emphasis on video
documentation, and need in any particular practice for
laryngeal stroboscopy, which would bring with it the neces-
sity of video documentation and increase the likelihood of
rigid endoscope and distal-chip technology availability.
These perceived costbenefit considerations may reduce
the likelihood that NL practices will invest in distal-chip
equipment and they fit with the finding of the current study
that concern for cost was the most commonly identified bar-
rier among NL practitioners not performing TNE as part of
their practice. There is evidence to show that TNE has
reduced overall patient costs compared to conventional
esophagoscopy due to the avoidance of anesthetic and oper-
ating room charges.7 When weighing the costs and benefits
of distal-chip technology, it is important to recognize that
both distal-chip technology and rigid laryngeal exam may
offer improved visualization of the larynx over flexible
fiberoptic exam.8,9 Although potentially meaningful with
regard to laryngeal lesions, the differences between these
technologies as applied to reflux are more uncertain.
Flexible exam may more often find signs of laryngeal tissue
irritation in asymptomatic patients than rigid exam,10 per-
haps suggesting reduced diagnostic specificity of flexible
laryngoscopy in diagnosis of LPR; however, regardless of
technique, there is a question as to whether laryngopharyn-
geal exam findings correlate with presence or absence of
reflux in the first place.11
Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
Moving beyond exam findings, although an almost equal
proportion of LF and NL indicated that no further adjunc-
tive diagnostic tests were obtained to validate the diagnosis
of LPR, it was noted that a statistically significantly larger
cohort of LF ordered pH probe: dual probe impedance stud-
ies as a diagnostic adjunct compared to NL. This is reflected
in results showing an increased likelihood of LF respon-
dents obtaining further testing and choosing pH probe stud-
ies as the preferred testing option compared to NL in the
event of empiric treatment failure. The AAO-HNS has put
forward that dual pH probe studies are the gold standard for
objectively documenting LPR.6 Nevertheless, it is also
acknowledged that the accuracy of pH probe testing is sub-
ject to variations in interpretation subject to positioning of
the probe and artifactual errors caused by the local environ-
ment of the pharynx or upper esophageal sphincter and the
inability to record non-acid reflux events.12 This uncertainty
in diagnostic criteria may account for NL more commonly
referring their patients to gastroenterologists and not using
pH probe studies themselves as diagnostic adjuncts in the
event of treatment failure, even as NL respondents indicate
that a pH probe: dual probe test is one of the most sensitive
and specific tests for the diagnosis of LPR. In this context,
it is interesting that both NL and LF respondents list con-
cern for interpretation as one of the most common reasons
for not performing their own pH probes.
The variation in treatment patterns of LPR observed in
the current study between LF and NL is a likely reflection
of ongoing evolvement in treatment recommendations by
both gastroenterological and otolaryngological professional
bodies. There seems to be some agreement between gastro-
enterology and otolaryngology communities that empiric
treatment is to be undertaken cautiously and not without
further evidence that reflux is related to patient complaints;
for instance, the American Gastroenterology Association
recommends against empiric treatment of extra-esophageal
complaints of reflux with proton pump inhibitors unless
there is concomitant patient complaint of heartburn.2 In
relatively recent practice guidelines for management of
hoarseness, empiric treatment with PPI was not recom-
mended unless there were symptoms of GERD or laryngeal
findings of inflammation to support reflux as a contributing
factor to voice complaints.3 It is unfortunate that these
guidelines do not suggest alternative strategies for treat-
ment of extra-esophageal complaints in the absence of
heartburn or laryngeal findings of reflux; otolaryngologists
have expressed concern that most clinical practice guide-
lines for reflux disease are heavily biased toward the gastro-
enterological literature.13 Meanwhile, even as these
guidelines recommend against empiric treatment, other
guidelines suggest that if LPR is to be treated, then trials of
therapy should be of twice daily PPI for at least 2 months to
be considered adequate.6
Gooi et al 7
Treatment patterns as revealed in this study do not
closely follow either of the above approaches. The majority
of respondents treat reflux empirically, without further test-
ing; this study does not assess whether these physicians are
seeking other evidence on history of exam such as com-
plaint of heartburn to justify empiric treatment; it is pre-
sumed that laryngoscopy is often performed, although
specificity of laryngoscopy findings for reflux may be low
as noted. It is surprising that the most common NL strategy
for empiric treatment seems to be once daily PPI rather than
twice daily PPI, as the total for once daily high-dose and
once daily low-dose therapies constitutes one-half of all
treatment regimens; although 77% of respondents choose 2
or 3 months as their most common length of empiric treat-
ment, nearly 1 in 5 respondents would treat empirically for
only 1 month. The observed variation in treatment patterns
for LPR refractory to an initial trial of medical therapy also
indicates the current state of the field, with no agreed-upon
standard for either initial empiric treatment or subsequent
evaluation of patients whose complaints are refractory to
empiric treatment. Similarly, the wide variation of responses
on the barriers toward the performance of TNE and pH
probe testing in the management of LPR is also reflective of
the lack of consensus of practitioners on the indications for
these tests. There is further need for well-designed studies
to establish an algorithm incorporating the use of these
investigative modalities in cases of diagnostic uncertainty
or treatment failure. To conclude, LF and NL respondents in
our survey are in broad agreement regarding the symptoms
and physical signs thought to be related to LPR. Laryngology
fellowship-trained respondents were more likely to video-
document their laryngeal examinations and to use TNE and
pH probe: dual probe with impedance compared to NL;
these differences are a likely reflection of increased expo-
sure from subspecialty training. Barriers that have been
identified among practitioners to the use of these technolo-
gies include lack of familiarity, cost, and uncertainty with
interpretation of results. There exists a need to refine clini-
cal practice guidelines for the diagnosis and treatment of
LPR in collaboration with gastroenterological specialties.
Appendix
Respondents were asked about the nature of their practice
(academic, community, and combination of academic and
community) and the year in which they completed their
training. They were asked to indicate if they had fellowship
training in laryngology, head and neck surgery, pediatric
otolaryngology, rhinology, facial plastic and reconstructive
surgery, otology, allergy, thoracic surgery, or sleep medi-
cine. Membership status in the American Academy of
Otolaryngologic Allergy, American Academy of
OtolaryngologyHead and Neck Surgery, American
Broncho-Esophagological Association, American Head and
Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
Neck Society, American Laryngological Association,
American Rhinologic Society, and American Society of
Pediatric Otolaryngology was elicited. Respondents were
then asked, What percentage of your clinical practice is
devoted to laryngology or bronchoesophagology? with
options presented (0%-25%, 26%-50%, 51%-75%, and
76%-100%). Next, they were asked, What percentage of
your laryngobronchoesophagology patients present with
chief complaints that you believe are directly or mainly
attributable to laryngopharyngeal reflux? with options pre-
sented (0%-25%, 26%-50%, 51%-75%, and 76%-100%),
followed by, What percentage of your laryngobroncho-
esophagology patients overall have laryngopharyngeal
reflux? with options presented (0%-25%, 26%-50%, 51%-
75%, and 76%-100%).
Respondents were then asked to rate the following symp-
toms of dysphagia, choking episodes, persistent cough,
change in voice quality, pain with phonation, globus sensa-
tion, throat clearing, heartburn and dyspepsia, postnasal drip,
and nasal obstruction in terms of their relationship to reflux
on a scale of 1 to 5 (where 1 = highly related, 3 = somewhat
related, and 5 = not related). Next, they were asked to rate
each of the following physical exam findings of pachydermia
laryngis, vocal cord paralysis/paresis, vocal cord polyp, vocal
cord nodule, laryngotracheal stenosis, laryngeal carcinoma,
vocal cord erythema, vocal cord edema, ventricular oblitera-
tion, posterior commissure hypertrophy, arytenoid erythema,
arytenoid edema, arytenoid blood vessel obliteration, and
subcordal edema in terms of their relationship toward reflux
on a scale of 1 to 5 (where 1 = highly related, 3 = somewhat
related, and 5 = not related). Respondents were asked if they
routinely performed video documentation of their laryngeal
examinations. They were asked if rigid laryngeal endoscopy,
flexible fiberoptic transnasal endoscopy, and distal-chip
transnasal endoscopy were available in their practice. Next,
respondents ranked the adjunctive diagnostic tests most com-
monly used to further validate or investigate the diagnosis of
laryngeal reflux in the order of 1 to 12, with 1 being the most
commonly obtained and 12 the least commonly obtained,
with options presented including, None. I do not order
tests, barium esophagram, esophagogastroduodenoscopy,
transnasal esophagoscopy, esophageal manometry, pHprobe:
pharyngeal testing (Restech), pH probe: esophageal, single
probe, wired, pH probe: esophageal, single probe, wireless
(Bravo), pH probe: dual probe (pharyngeal and esophageal),
pH probe: dual probe (proximal and distal esophageal), pH
probe: dual probe with impedance, and other (with respon-
dents specifying as a free text). Then, respondents were asked
to indicate in order from 1 to 10 with 1 being the most sensi-
tive/specific and 10 being the least sensitive/specific for the
diagnosis of LPR among thefollowing options: barium
esophagram, esophagogastroduodenoscopy, transnasal
esophagoscopy, esophageal manometry, pH probe: pharyn-
geal testing (Restech), pH probe: esophageal, single probe,
8 Annals of Otology, Rhinology & Laryngology
wired, pH probe: esophageal, single probe, wireless (Bravo),
pH probe: dual probe (pharyngeal and esophageal), pH
probe: dual probe (proximal and distal esophageal), pH
probe: dual probe with impedance, and other (with respon-
dents specifying as a free text). Respondents were then asked
to indicate yes or no if they performed the following tests as
part of their own practice without referral to a gastroenterolo-
gist: barium esophagram, esophagogastroduodenoscopy,
transnasal esophagoscopy, esophageal manometry, pH probe:
pharyngeal testing (Restech), pH probe: esophageal, single
probe, wired, pH probe: esophageal, single probe, wireless
(Bravo), pH probe: dual probe (pharyngeal and esophageal),
pH probe: dual probe (proximal and distal esophageal), pH
probe: dual probe with impedance, and other (with respon-
dents specifying as a free text). Next, respondents were asked
to indicate the barriers that have kept them from performing
their own pH probe testing as part of their own practice, rank-
ing a list of options from 1 to 7, with 1 being the most impor-
tant barrier and 7 the least important barrier, with options
presented including concern for cost, concern for patient
scheduling/convenience, concern for patient tolerance, do
not believe it adds meaningfully to patient care, not enough
time, unclear on appropriate indications, and unfamiliar with
interpretation. Next, respondents were asked to indicate the
barriers that have kept them from performing transnasal
esophagoscopy as part of their own practice, ranking a list of
options from 1 to 7, with 1 being the most important barrier
and 7 the least important barrier, with options presented
including concern for cost, concern for patient scheduling/
convenience, concern for patient tolerance, do not believe it
adds meaningfully to patient care, not enough time, unclear
on appropriate indications, and unfamiliar with interpreta-
tion. Next, respondents were asked how often they treated
empirically for a patient with presumed laryngopharyngeal
reflux without first obtaining any further testing, with options
presented as 0%-20%, 21%-40%, 41%-60%, 61%-80%, and
81%-100%. Respondents were then asked which options
they most often recommend for an empiric treatment trial in
addition to lifestyle modifications, with choices presented
including H2 receptor antagonist alone, once daily low-dose
proton pump inhibitor (PPI), once daily high-dose PPI, twice
daily PPI, once daily high-dose PPI and H2 receptor antago-
nist, twice daily PPI and H2 receptor antagonist, and other
(with respondents specifying as a free text). Respondents
were then asked, if they were treating a patient empirically,
what was the duration of their initial empiric trial, with
options given as < 1 month, 1 month, 2 months, 3 months, >
4 months, or other (with respondents specifying as a free
text). Next, they were asked, for patients who were treated
empirically for laryngopharyngeal reflux, what was the pro-
portion of patients who responded to the specified treatment
in their practice, with options presented as 0%-20%, 21%-
40%, 41%-60%, 61%-80%, and 81%-100%. Then, respon-
dents were asked, for patients who do not respond to an
Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014
empiric trial of treatment for presumed laryngopharyngeal
reflux, what would be the following next step, with options
presented including continue empiric treatment, with
increased dose of PPI, continue empiric treatment, with sta-
ble dose but increased length of trial, obtain further testing,
refer the patient to a gastroenterologist for further evaluation
and management, and other (with respondents specifying as
a free text). Last, respondents were asked what further testing
they would order for a patient who did not respond to an
empiric trial of treatment for presumed laryngopharyngeal
reflux on a scale of 1 to 9, with 1 being the most commonly
ordered test and 9 being the least commonly ordered test,
with options presented including barium esophagram, esoph-
agogastroduodenoscopy, transnasal esophagoscopy, esopha-
geal manometry, pH probe: pharyngeal testing (Restech), pH
probe: esophageal, single probe, wired, pH probe: esopha-
geal, single probe, wireless (Bravo), pH probe: dual probe
(pharyngeal and esophageal), pH probe: dual probe (proxi-
mal and distal esophageal), pH probe: dual probe with imped-
ance, and other (with respondents specifying as a free text).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Book DT, Rhee JS, Toohill RJ, Smith TL. Perspectives
in laryngopharyngeal reflux: an international survey.
Laryngoscope. 2002;112(8, pt 1):1399-1406.
2. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American
Gastroenterological Association Medical Position Statement
on the management of gastroesophageal reflux disease.
Gastroenterology. 2008;135(4):1383-1391.
3. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice
guideline: hoarseness (dysphonia). Otolaryngol Head Neck
Surg. 2009;141(3)(suppl 2):S1-S31.
4. Belfasky PC, Postma GN, Koufman JA. Validity and
reliability of the reflux symptom index (RSI). J Voice.
2002;16(2):274-277.
5. Belfasky PC, Postma GN, Koufman JA. The validity and
reliability of the reflux finding score (RFS). Laryngoscope.
2001;111(8):1313-1317.
6. Koufman JA, Aviv JE, Casiano RR, Shaw GY.
Laryngopharyngeal reflux: position statement of the com-
mittee on speech, voice, and swallowing disorders of the
American Academy of OtolaryngologyHead and Neck
Surgery. Otolaryngol Head Neck Surgery. 2002;127(1):
32-35.
7. Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal
esophagoscopy: a position statement from the American
Gooi et al 9

Bronchoesophagological Association (ABEA). Otolaryngol
Head Neck Surg. 2008;138(4):411-414.
8. Eller R, Ginsburg M, Lurie D, Heman-Ackah Y, Lyons K,
Sataloff R. Flexible laryngoscopy: a comparison of fiber
optic and distal chip technologiespart 2: laryngopharyngeal
reflux. J Voice. 2009;23(3):389-395.
9. Yanagisawa E, Yanagisawa K. Stroboscopic videolaryngos-
copy: a comparison of fiberoptic and telescopic documenta-
tion. Ann Otol Rhinol Laryngol. 1993;102(4, pt 1):255-265.
10. Milstein CF, Charbel S, Hicks DM, Abelson TI, Richter JE,
Vaezi MF. Prevalence of laryngeal irritation signs associated
with reflux in asymptomatic volunteers: impact of endoscopic
technique (rigid vs. flexible laryngoscope). Laryngoscope.
2005;115(12):2256-2261.
11. Vavricka SR, Storck CA, Wildi SM, et al. Limited diagnostic
value of laryngopharyngeal lesions in patients with gastro-
esophageal reflux during routine upper gastrointestinal endos-
copy. Am J Gastroenterol. 2007;102(4):716-722.
12. Harrell SP, Koopman J, Woosley S, Wo JM. Exclusion of
pH artifacts is essential for hypopharyngeal pH monitoring.
Laryngoscope. 2007;117(3):470-474.
13. Altman KW, Prufer N, Vaezi MF. A review of clinical practice
guidelines for reflux disease: toward creating a clinical protocol
for the otolaryngologist. Laryngoscope. 2011;121(4):717-723.

Downloaded from aor.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 14, 2014