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The Efficacy of Proton Pump Inhibitor Therapy for

Treating Laryngopharyngeal Reflux: A Systematic
Review
Wendy Kellam
Pacific University

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Kellam, Wendy, "The Efficacy of Proton Pump Inhibitor Therapy for Treating Laryngopharyngeal Reflux: A Systematic Review"
(2013). School of Physician Assistant Studies. Paper 459.

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The Efficacy of Proton Pump Inhibitor Therapy for Treating
Laryngopharyngeal Reflux: A Systematic Review
Abstract
Background: Laryngopharyngeal reflux (LPR) is the backflow of stomach contents into the throat. The
current standard of care is to treat patients with a proton pump inhibitor (PPI) twice daily for up to 6 months
or longer. Two meta-analyses were completed in 2006 and found no evidence PPI therapy is better than
placebo for chronic laryngitis. Since that time new tools have been created to measure outcomes in this field of
research, the Reflux Finding Score (RFS) and Reflux Symptom Index (RSI). Using these standardized
measures are researchers able to demonstrate PPI therapy is efficacious in the treatment of LPR?

Method: An exhaustive literature search using the Medline, EBMRM, and CINAHL search engines was
conducted from 2006-present with the following search terms: laryngopharyngeal reflux, proton pump
inhibitors, extraesophageal, laryngitis, globus, throat clearing, and chronic cough. Randomized controlled
trials comparing PPI to placebo for the treatment of laryngopharyngeal reflux in adults were included. Trials
were excluded if completed before 2006 or if they were previously evaluated in a meta-analysis. Studies were
evaluated for quality using the GRADE criteria. Results: Three studies met inclusion criteria and were
evaluated in this systematic review. A double-blind, randomized, placebo-controlled trial with 82 participants
demonstrated a statistically significant reduction in the total RSI scores after 12 weeks of treatment, this effect
disappeared once treatment was stopped. Another double-blind, randomized, placebo-controlled trial with 41
participants found no difference from baseline in any of their outcome measures. Finally a double-blind,
randomized, placebo-controlled trial found statistically significant reduced RSI at week 12. This was the only
study able to demonstrate improvement in the RFS after 12 weeks of treatment.

Conclusion: The use of proton pump inhibitors for LPR continues to be a topic surrounded with controversy.
Current research supports a trial of twice daily PPI for at least 3 months if the patient is also experiencing
symptoms of GERD. Patients with throat symptoms alone are unlikely to find relief from PPI therapy and
should be evaluated for other possible etiologies. The purpose of this review is to evaluate the latest placebo
controlled RCT using the RFS1and RSI2to evaluate the efficacy of PPI therapy for LPR.

Degree Type
Capstone Project

Degree Name
Master of Science in Physician Assistant Studies

Keywords
Laryngopharyngeal reflux, proton pump inhibitor, Reflux Symptom Index, Reflux Finding Score

Subject Categories
Medicine and Health Sciences

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 NOTICE TO READERS

This work is not a peer-reviewed publication. The Masters Candidate author of this
work has made every effort to provide accurate information and to rely on authoritative
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The Efficacy of Proton Pump Inhibitor Therapy for Treating
Laryngopharyngeal Reflux: A Systematic Review

Wendy K. Kellam

A Clinical Graduate Project Submitted to the Faculty of the

School of Physician Assistant Studies

Pacific University

Hillsboro, OR

For the Masters of Science Degree, August 10, 2013

Faculty Advisor: Eric Foote, PA

PA-C
Clinical Graduate Project Coordinator: Annjanette Sommers, PA
PA-C,
C, MS

1
BIOGRAPHY
Wendy Kellam is a self-proclaimed Oregonian. She received a Bachelor of Science
degree from the University of Wisconsin-Milwaukee in 1999 with a major in
Communication Sciences and Disorders. She received a Masters of Art from Ball State
University in 2001 in Speech Language Pathology. She spent her 10-year career as an
SLP working with adults in acute care where she became captivated with the art of
medicine. She would like to thank her partner in life Tom Slominski; without his
patience, love and support her dream of becoming a PA would never have happened.

2
ABSTRACT
Background: Laryngopharyngeal reflux (LPR) is the backflow of stomach contents into
the throat. The current standard of care is to treat patients with a proton pump inhibitor
(PPI) twice daily for up to 6 months or longer. Two meta-analyses were completed in
2006 and found no evidence PPI therapy is better than placebo for chronic laryngitis.
Since that time new tools have been created to measure outcomes in this field of research,
the Reflux Finding Score (RFS) and Reflux Symptom Index (RSI). Using these
standardized measures are researchers able to demonstrate PPI therapy is efficacious in
the treatment of LPR?

Method: An exhaustive literature search using the Medline, EBMRM, and CINAHL
search engines was conducted from 2006-present with the following search terms:
laryngopharyngeal reflux, proton pump inhibitors, extraesophageal, laryngitis, globus,
throat clearing, and chronic cough. Randomized controlled trials comparing PPI to
placebo for the treatment of laryngopharyngeal reflux in adults were included. Trials
were excluded if completed before 2006 or if they were previously evaluated in a meta-
analysis. Studies were evaluated for quality using the GRADE criteria.

Results: Three studies met inclusion criteria and were evaluated in this systematic
review. A double-blind, randomized, placebo-controlled trial with 82 participants
demonstrated a statistically significant reduction in the total RSI scores after 12 weeks of
treatment, this effect disappeared once treatment was stopped. Another double-blind,
randomized, placebo-controlled trial with 41 participants found no difference from
baseline in any of their outcome measures. Finally a double-blind, randomized, placebo-
controlled trial found statistically significant reduced RSI at week 12. This was the only
study able to demonstrate improvement in the RFS after 12 weeks of treatment.

Conclusion: The use of proton pump inhibitors for LPR continues to be a topic
surrounded with controversy. Current research supports a trial of twice daily PPI for at
least 3 months if the patient is also experiencing symptoms of GERD. Patients with throat
symptoms alone are unlikely to find relief from PPI therapy and should be evaluated for
other possible etiologies. The purpose of this review is to evaluate the latest placebo
controlled RCT using the RFS1and RSI2to evaluate the efficacy of PPI therapy for LPR.

Keywords: Laryngopharyngeal reflux, proton pump inhibitor, Reflux Symptom Index,

Reflux Finding Score

3
TABLE OF CONTENTS
BIOGRAPHY .................................................................................................................... 2
ABSTRACT ....................................................................................................................... 3
LIST OF TABLES ............................................................................................................ 5
LIST OF ABBREVIATIONS .......................................................................................... 5
BACKGROUND ............................................................................................................... 6
METHODS ........................................................................................................................ 9
RESULTS .......................................................................................................................... 9
Lam et al 2010 .......................................................................................................................................................... 10
Fass et al 2009 .......................................................................................................................................................... 10
Reichel et al 2008 .................................................................................................................................................... 11
DISCUSSION .................................................................................................................. 12
CONCLUSION ............................................................................................................... 15
REFERENCES ................................................................................................................ 16

4
LIST OF TABLES
Table 1: GRADE Quality of Assessment and Summary of Findings

LIST OF ABBREVIATIONS
GERD Gastroesophageal reflux disease
LPR Laryngopharyngeal reflux
PPI Proton pump inhibitor
RCT Randomized controlled trial
RFS Reflux Finding Score
RSI Reflux Symptom Index

5
 The Efficacy of Proton Pump Inhibitor Therapy for the Treatment of
Laryngopharyngeal Reflux: A Systematic Review

BACKGROUND
Laryngopharyngeal reflux (LPR) is the backflow of stomach contents into the

throat. It is commonly identified in otolaryngologist offices and diagnosed in almost 10%

of their patient population. 1 Additionally, 50% of patients with voice disorders may have

LPR. 2 Other terms used to describe this condition include: posterior laryngitis,

extraesophageal reflux, reflux laryngitis, or supraesophageal reflux. Most clinicians are

more familiar with gastroesophageal reflux disease (GERD), the backflow of stomach

contents into the esophagus, which typically results in heartburn and regurgitation.

Patients with LPR and GERD differ in many ways. The majority of patients with LPR do

not experience the characteristic heartburn of GERD; they tend to reflux during the day

while upright versus at night while lying flat; and dysfunction is believed to originate in

the upper esophageal sphincter versus the lower esophageal sphincter. 3

The larynx does not have the protective mechanisms of the esophagus to defend

against acid exposure leading to irritation of the laryngeal mucosa and subsequent

symptoms of chronic cough, hoarseness, dysphagia, globus (sensation of lump in the

throat), frequent throat clearing and throat discomfort. 2,3 Making an accurate diagnosis

can be difficult, as these same symptoms can be attributed to allergies, environmental

triggers, smoking, and vocal abuse. 2,4 If left untreated LPR can lead to severe

complications such as contact ulcers, granulomas and stenosis. 2 Some researchers are

connecting LPR with increased incidence of adenocarcinoma of the larynx.5,6

The position statement of the American Academy of Otolaryngology-Head and

Neck Surgery7 on LPR states that a diagnosis can be made based on a correlation between

6
clinical symptoms of the disease and laryngeal findings on endoscopy. Signs specific for

LPR include true/false vocal fold erythema/edema; posterior cricoid wall erythema;
8
posterior commissure erythema/edema; and posterior pharyngeal wall erythema/edema.

Often clinically no testing is undertaken and patients suspected of having LPR are treated

empirically with proton pump inhibitor therapy and resolution of their symptoms is

considered diagnostic. 9 Despite its lack of sensitivity and specificity for LPR the gold

standard for diagnosis is 24-hour double probe pH monitoring with the upper probe

positioned in the hypopharynx. 8,10 This test can be performed if a patient is refractory to

proton pump inhibitor (PPI) treatment. 8,11

The treatment of LPR, recommended by otolaryngologists, advocates for lifestyle

3
modification along with the initiation of PPI twice daily for a minimum of 6 months.

The lack of randomized controlled trials supporting this treatment makes it controversial.
12,13
The twice daily dosing is necessary because PPIs are unable to suppress acid for

greater than 16.8 hours. 14 Symptoms improve within 2-3 months but the laryngeal injury

caused by the acid exposure requires prolonged treatment. 15 Lifestyle modifications

include: elevating the head of bed 6 inches, smoking cessation, low fat diet, weight loss,

avoid lying down within 3 hours of eating, small frequent meals, bicarbonate gum

chewing, preferential sleeping on the left side, and avoidance of refluxogenic foods. 16

Finally, if patients have failed all avenues of treatment and symptoms are severe,

laparoscopic fundoplication surgery may be warranted.17

The American Gastroenterological Association4 reported poor sensitivity and

specificity of endoscopy and pH monitoring for LPR results in over diagnosis and over

treatment of the condition. Furthermore, they recommend PPI therapy should only be

7
utilized if the patient is also experiencing symptoms of GERD, and it should not exceed a

treatment period of 2 months. They therefore dispute the efficacy of using PPI therapy for

patients with symptoms of LPR alone. 4,18 Finally they site the lack of randomized
4,12,13
controlled trials supporting PPI therapy for LPR.

Belfasky et al2,15 created the Reflux Finding Score (RFS) and Reflux Symptom

Index (RSI) to standardize both the laryngeal findings and symptoms of acid reflux in

patients so outcomes in this area of research could be more accurately measured. The

RFS is a severity scale with 8 items: subglottic edema; ventricular obliteration;

erythema/hyperemia; vocal fold edema; diffuse laryngeal edema; posterior commissure

hypertrophy; granuloma/granulation tissue; and thick endolaryngeal mucus. The possible

score ranges from a minimum of 0 to a maximum of 26. A score of greater than 7 is 95%

sensitive for LPR. The RSI is a self-administered 9-item severity scale for symptoms of

LPR. Patients rank each of the nine symptoms on a scale from 0 to 5, 0 being no

problem and 5 being a severe problem. The symptoms assessed include: hoarseness,

throat clearing, post-nasal drip, dysphagia, breathing difficulties, chronic cough, lump in

the throat, and heartburn. A score of greater than 13 is considered abnormal.

Two meta-analyses were completed in 2006 demonstrating that PPI therapy for
12,13
LPR was no better than placebo. Qadeer et al12 evaluated data from 8 randomized

controlled trials (RCTs) using either a primary outcome of 50% or greater reduction in

LPR symptoms, or complete symptom resolution. Only one of the studies analyzed used

a standardized tool to measure outcomes. This lack of standardization resulted in

significant heterogeneity. 12,19 Proton pump inhibitor therapy was once thought to have a

low side effect profile but research is emerging demonstrating that it can lead to

8
infectious complications and nutritional deficiencies. 20 It is imperative that clinicians

determine the appropriate dosage and length of treatment required for LPR. The purpose

of this review is to evaluate the latest placebo controlled RCT using the RFS and RSI to

evaluate the efficacy of PPI therapy for LPR.

METHODS
An exhaustive literature search using the Medline, EBMRM, and CINAHL search

engines was conducted from 2006-present with the following search terms:

laryngopharyngeal reflux, proton pump inhibitors, extraesophageal, laryngitis, globus,

throat clearing, and chronic cough. Randomized controlled trials comparing PPI to

placebo for the treatment of LPR in adults were included. Trials were excluded if

completed before 2006, or if they were previously evaluated in a meta-analysis. Studies

written in foreign language and not translated were also excluded. Relevant articles were

assessed for quality using the Grading of Recommendations, Assessment, Development

and Evaluation (GRADE) 21.

RESULTS
A systematic literature review resulted in 102 potential articles for consideration.

Five additional articles were obtained from the bibliography of UpToDate on the topic of

LPR22. After duplicates were removed 82 remained. Seventy-five were excluded based

on review of title or abstract. There were 7 full text articles assessed for eligibility of

which 4 were excluded because they did not use a control group for comparison, or

measured an outcome other than LPR symptoms such as the amount of pepsin in the

sputum. The remaining 3 articles met all inclusion and exclusion criteria (Table 1). 19,23,24

9
Lam et al 2010
This prospective, double-blind, randomized, placebo controlled study19 was

conducted in China. A total of 82 participants were enrolled but only 40 were analyzed in

each arm. The average age was 46.86 and 28% were male. The patients were gathered

from an outpatient otolaryngologist office and diagnosed with LPR via videostroboscopy.

Participants were included if they met the following criteria; the presence of at least 1 of

the following: hoarseness, globus, throat discomfort, and throat clearing for at least 1

month in the preceding 1 year; and endoscopic evidence of LPR with a RFS > 7 and

absence of upper respiratory infection in the past 4 weeks or allergic causes of laryngitis.

Participants were excluded if they were younger than 18, had an identifiable laryngeal

pathology other than LPR, a history radiotherapy, gastroesophageal surgery, or if they

were on acid suppressive therapy within the previous 4 weeks. Patients were randomized

in a 1:1 fashion using computer-generated random numbers. The treatment group

received rabeprazole 20mg twice daily for 12 weeks and implemented lifestyle

modifications. Outcomes were measured using the RFS and RSI. There was no

statistically significant difference in RFS between the treatment and placebo groups.

There was statistically significant improvement between the treatment and placebo

groups RSI at week 6 and week 12. This effect could no longer be demonstrated at week

18, which was 6 weeks after discontinuing the treatment. The authors conclude that

patients with LPR require longer treatment duration with PPI. The funding for this

research was provided by EISAI Company Limited the developers of rabeprazole.

Fass et al 2009
This prospective, double-blind, randomized, placebo controlled study23 was

conducted in the United States. There were a total 41 participants and all were analyzed

10
as part of the data. Twenty-four patients were allocated to the treatment group and 17 to

the placebo group. The average age was 63.25 and 58% were male. The patients were

gathered from an outpatient otolaryngology clinic and diagnosed with LPR via

videostroboscopy. Participants were included in the study if they met any of the

following criteria, had posterior laryngitis in combination with: hoarseness, cough, throat

clearing, throat discomfort and globus; and GERD related laryngeal mucosal changes.

Participants were excluded if they were currently on anti-reflux treatment, had a history

of prior reflux or esophageal surgery, had been intubated in the preceding 3 months, had

been diagnosed with oropharyngeal or laryngeal cancer, were pregnant, or had an allergy

to PPI. They also excluded patients with any severe comorbidities. The authors provide

no information on how the randomization process was conducted. The treatment group

received esomeprazole 20mg twice daily for 12 weeks combined with implementing

lifestyle modifications. Outcomes were measured using the RFS, a daily voice use diary,

the Laryngopharyngeal Reflux Health-Related Quality of Life Questionnaire (LPR-

HRQL), the Short Form 36 (SF-36), and acoustic voice measurements. The study found

no statistically significant difference between the treatment group and placebo group for

any of the outcomes measured. They also found no difference in a subgroup analysis of

patients with abnormal esophagogastroduodenoscopy (EGD) findings at baseline. The

study was partially funded by Astra-Zeneca the makers of esomeprazole.

Reichel et al 2008
This prospective, double-blind, randomized, placebo controlled trial24 was

conducted in Germany. A total of 62 participants were enrolled and 58 were analyzed at

the studies completion. Thirty-one were allocated to the treatment group and 31 to the

placebo group. The average age was 48.7 and 51% were male. The patients were

11
gathered from an outpatient otolaryngologist office and diagnosed with LPR via

videostroboscopy. Participants were included in the study if they had a RFS of greater

than 7 and a RSI of greater than 13. Participants were excluded if they were younger than

18, had a history of laryngeal malignancy or gastrointestinal surgery, or if they had the

need for continuous anticoagulation therapy with warfarin or aspirin. They were also

excluded if they were treated with PPI or any other anti-reflux medication within the

previous 3 months, were pregnant or lactating, had an allergy to a PPI, had a drug or

alcohol addiction or any psychiatric disease. Patients were randomized in a 1:1 ratio, and

the placebo pill was identical to the esomeprazole. The treatment group received

esomeprazole 20mg twice daily for 12 weeks. No lifestyle modifications were

implemented. Outcomes were measured using the RFS and RSI. The treatment and

placebo groups demonstrated statistically significant improvement in the total RFS and

RSI at week 6. There was no difference however, when the treatment group was

compared to the placebo group. At 12 weeks the RSI of both study groups demonstrated

improvement with a stronger effect in the treatment group. The study was funded by

Astra-Zeneca the makers of esomeprazole.

DISCUSSION
The treatment of LPR with PPI therapy continues to be a highly controversial

topic between the fields of otolaryngology and gastroenterology. 4,5,25,26 The lack of

adequate diagnostic testing and a proliferation of weak evidence for treatment leaves the

practicing clinician with little guidance and their patients filled with frustration.11,25,27

Proton pump inhibitor therapy once thought to be an extremely safe treatment option, is

now demonstrating complications related to respiratory infections, Clostridium difficile

12
infections, and bone fractures with prolonged use.20 Two of the studies in this review

demonstrate significant improvement in symptoms after 12 weeks of treatment.19,24

Reichel et al24 found patients improved the most in the symptom category of heartburn.

Lam et al19 also noted the most improvement in heartburn, chest pain, indigestion, and

excess throat mucus. These symptoms are characteristic of patients with classic GERD.

Therefore, it appears, that patients with LPR and concomitant GERD symptoms, will

achieve the greatest benefit from PPI therapy.25 It is important to consider other etiologies

such as nonacid refluxate, sinusitis, vocal abuse, allergies, or other environmental agents

if a patients symptoms do not respond to an initial 3-month trial of treatment.3,25,28

Shorter duration trials have been used to question the efficacy of PPI therapy but in the

Reichel et al study the placebo effect that was seen at 6 weeks disappeared at 12

weeks.24,25 This raises the question as to whether or not it is appropriate to discontinue

PPI therapy prematurely after a trial of only 2 months.5

All three studies19,23,24 used the RFS to evaluate laryngeal finding outcomes. Only

Reichel et al24 was able to demonstrate a statistically significant improvement in

laryngeal findings after 12 weeks of treatment when compared to placebo. They found

the greatest improvement in posterior commissure hypertrophy (P <0.01). This is

considered one of the most characteristic findings of LPR. 1 Lam et al19 was unable to

demonstrate a difference in laryngeal findings at 6, 12, or 18 weeks. When they

compared baseline characteristics of the treatment group at 12 weeks the RFS was lower

overall, specifically in vocal cord edema and laryngeal edema. Similar changes were

found in the placebo group however, with decreased overall scores, and decreased vocal

cord edema and laryngeal edema subgroup scores. Even at week 18, patients in the

13
placebo group continued to demonstrate improvement. The authors attribute lifestyle

modifications to the ongoing decrease in RFS. The Fass et al study23 showed no

improvement in total RFS after 12 weeks of treatment. They found no difference between

the treatment group and the placebo group and no difference could be observed within the

groups when compared to baseline.

Lam et al19 and Reichel et al24 utilized the RSI to measure symptom outcomes.

Lam et al measured reduced total RSI scores at week 6 and 12. The most improvement

between the groups was in breathing difficulties or choking episodes, troublesome or

annoying cough, and globus. By week 18 a statistical difference could no longer be

calculated. The authors believe this indicates PPI therapy for LPR requires treatment

longer than 3 months. At 6 and 12 weeks when the treatment groups were compared to

their baselines both studies demonstrated a statistically significant improvement in

heartburn symptoms, but not throat symptoms. Fass et al23used two health care quality of

life questionnaires, the LPR-HRQL and the SF-36 combined with a voice use diary, and

evaluated acoustic voice parameters to monitor improvement in symptoms. No

statistically significant difference could be found at baseline, 6, or 12 weeks, between the

treatment and control groups or within either group.

While the studies by Fass et al,23 Lam et al,19 and Reichel et al24 all provided

important findings in the management of LPR with PPI therapy they also had limitations.

All the studies had a small sample size. They were funded fully or in part by

pharmaceutical companies. Publication bias seems less likely for Fass et al23 due to the

lack of outcomes in their study. All studies chose to use 20mg twice daily as a dosing

schedule. The current standard of care for LPR is 40mg twice daily. 11 Reichel et al24

14
chose 20mg because the typical practice for primary care providers in Germany is to start

patients at a low dose. Fass et al used 20mg because there is no approved indication for

40mg PPI twice daily. The RFS1 can be subject to examiner bias; the Reichel et al study24

did not randomize their videostroboscopic exams and used only one blinded examiner for

all patients. Therefore only the medication aspect of the study was double-blinded. The

pharmaceutical company who funded the study was also involved in their randomization

process further contributing to a publication bias. Ongoing research for LPR needs to

have larger sample sizes, to study patients taking 40mg daily, and to follow patients for a

minimum of 6 months. Diagnostic tests need to be refined so the inclusion criteria for

research studies can be more objective.9,25,27

CONCLUSION
The use of proton pump inhibitors for LPR continues to be a topic surrounded

with controversy. The overall combined quality of the studies reviewed was low based on

the GRADE criteria. 21 The research supports a trial of twice daily PPI for at least 3

months if the patient is also experiencing symptoms of GERD. 25 Patients with throat

symptoms alone are unlikely to find relief from PPI therapy and should be evaluated for

other possible etiologies such as non-acid reflux, allergies, sinusitis, environmental

triggers, smoking, and vocal abuse. 3 Until the medical community is able to develop a

diagnostic test sensitive and specific enough to accurately detect LPR the inclusion

criteria used in research will continue to dilute the findings. 25,27 Further RCT that mirror

the 40mg twice daily dosage used in clinical practice are needed, along with larger

sample sizes, longer duration of study, and funding provided by an unbiased source.

15
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Accessed November 12, 2012.

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perception parameters of the voice in laryngopharyngeal reflux. Neurogastroenterology & Motility.

2010;22(2):134-141.

24. Reichel O, Dressel H, Wiederanders K, Issing WJ. Double-blind, placebo-controlled trial with

esomeprazole for symptoms and signs associated with laryngopharyngeal reflux. Otolaryngology - Head &

Neck Surgery. 2008;139(3):414-420.

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 Quality Assessment Summary of Findings
Changes from baseline Statistically
Downgrade Criteria Number of Patients Quality Importance
after 12 weeks Significant
Mean Differences
No. of Publication Treatment Placebo P value of
Design Limitations Indirectness Imprecision Inconsistency Study standard error of the mean
Studies bias likely (total) (total) <0.05
(P value)

REFLUX FINDING SCOR

Fass et al23 24 17 (0.40) NO Low Moderate
3 3 RCT No serious No serious Serious Serious Bias Lam et al19 42 40 0.54 0.69 (.017) YES Low Moderate
limitations indirectness imprecisiona inconsistenciesb unlikely
Reichel et al24 30 28 2.28 0.98 YES Low Moderate

REFLUX SYMPTOM INDEX

2 RCT No serious No serious Serious Serious Lam et al24 42 40 -3.73 1.18 (.002) YES Low Moderate
2 Bias likelyc
limitations indirectness imprecisiona inconsistenciesb Reichel et al24 30 28 6.48 2.34 YES Low Moderate

LPR-HRQL
1 RCT No serious No serious Serious No serious
1 Bias likelyc Fass et al23 24 17 26 15.472 NO Low Low
limitations indirectness imprecisiona inconsistencies

SHORT FORM 36
1 RCT No serious No serious Serious No serious
1 Bias likelyc Fass et al23 24 17 All 8 domains P>0.05 NO Low Low
limitations indirectness imprecisiona inconsistencies

Acoustic Measurements

No serious No serious Serious No serious Bias

1 1 RCT Fass et al23 24 17 All 5 measures P>0.05 NO Low Low
limitations indirectness imprecisiona inconsistencies unlikely

Voice Diary
No serious No serious Serious No serious
1 1 RCT Bias likelyc Fass et al23 24 17 59.093 20.81 NO Low Low
limitations indirectness imprecisiona inconsistencies
TABLE 1 Characteristics of Reviewed Studies, GRADE profile
aLacked precision secondary to all data provided as P values as well as small sample sizes.
b Fass et al23 placebo group had more males and were older than the treatment group. The placebo group also had more severe reflux symptoms and a higher # of acid reflux events and total acid exposure time than the treatment group.
c The RSI, LPR-HRQL, SF-36, and voice diary are all subject to recall bias. All the studies were funded fully or in part by pharmaceutical companies. Fass et al23 demonstrates less likelihood of publication bias due to the lack of positive outcomes.

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