Short-Term Therapeutic Trial of Proton Pump Inhibitors in Suspected Extraesophageal Reflux

Pharyngoesophageal gastric acid reflux is thought to initiate chronic posterior laryngitis. The gold standard for measuring gastric reflux is dual-channel 24-hour pH monitoring. This is a time-consuming, inconvenient, expensive method that is not available in all areas. New therapeutic regimes that make use of proton pump inhibitors (PPIs) have proven to be therapeutically efficient for control of acid reflux. Twenty-four consecutive patients with chronic voice disorders and signs of posterior laryngitis were selected for therapy. Twenty-four hour pH monitoring was performed independently before the therapy. The trial therapy consisted of all patients receiving pantoprazole, 40 mg once daily for 6 weeks. Immediately following the therapy a statistically significant (p < 0.05) improvement was observed in all patients. This improvement was analyzed retrospectively by comparison with the results of 24-hour pH monitoring. In 71% of the patients the 24-hour pH-monitoring gave a positive result showing a high number of patients with extraesophageal reflux in our study group. Patients with positive results of pH-monitoring responded in a statistically significant manner (p < 0.05) to the pantoprazole therapy, whereas those patients without detected reflux did not. A 3-month follow-up of the patients with a positive result of the pH-monitoring confirmed the improvement. No patients reported adverse effects. A 6-week treatment with pantoprazole can be clinically justified. It helps to save time and reduce costs, allows for selection of reflux-negative patients for alternative therapy, and may prevent inadequate treatment of patients with false-negative pH monitoring. Twenty-four hour pH monitoring is still recommended for patients unresponsive to this trial therapy.     

Candida laryngitis appearing asleukoplakia and gerd

The symptoms and physical findings of reflux laryngopharyngitisare characteristic, but the mucosal alterations evident in the larynx are not exclusive to reflux. When conventional reflux management produces an equivocal response, other etiologic factors such as mycotic laryngitis, need consideration. The differential diagnosis of dysphonia in an immunocompromised patient always includes mycotic infections, but mycotic laryngitis can also occur in the immunocompetent host. Laryngeal candidiasis can produce physical findings, such as erythema and leukoplakia, that are similar to reflux laryngopharyngitis. Predisposing factors include previous radiation therapy, antibiotic therapy, corticosteroids, and any alteration in the mucosal barrier. Diagnosis is established by mucosal biopsy with special staining of the tissue to identify the characteristic hyphae. Treatment of mycoses can be difficult and long-term therapy is often required.     

Quantitative color analysis of laryngeal erythemain chronic posterior laryngitis

The purpose of this study was to quantitatively analyze the degree of erythema visible in the larynges of normal subjects and of patients with symptoms of chronic posterior laryngitis. Video-documented examinations of laryngoscopy were digitized and then analyzed using computer image analysis software that allowed quantification of average color values, hue, saturation, and brightness from digitized color images. Documented laryngoscopic images from 7 normal subjects and 64 patients complaining of chronic laryngitis symptoms were examined, and additional patient examinations which were obtained and documented during treatment for reflux laryngitis were analyzed. Analysis was made of five different areas of each laryngeal image: the right and left vocal folds, the right and left vocal processes, and the posterior arytenoid mucosa. Data analysis showed that average color value ratings of redness for the patients with chronic laryngitis were significantly (p <0 .0561) greater than the average values for normal subjects for the vocal folds. Color values for redness of the posterior laryngeal structures and vocal folds in the patients who were treated for reflux laryngitis were significantly (p < 0.05) reduced over time and correlated with the clinical response to treatment. The data suggest that computer color analysis of documented video-laryngoscopy examinations can provide quantitative data on degree of erythema and may be useful as a quantitative means of diagnosis and documentation of treatment outcome for reflux laryngitis.     

Perceptual and Acoustic Characteristics of Voice Changes in Reflux Laryngitis Patients

The aim of the study was to outline the multidimensional perceptual, subjective, and instrumental acoustic voice changes in the group of reflux laryngitis (RL) patients. Data of multidimensional voice assessment of 108 RL patients and 90 healthy persons of the control group were subjected to comparative analysis. A slight hoarseness according to the GRB (G-grade, R- rough, B-breathy) scale was prevailing in the RL patients group. Statistically significant difference (P < 0.001) between RL patients group and the control group was found of all voice parameters measured, with the patients having worse results--increased mean jitter, shimmer, normalized noise energy, voice handicap index (VHI), and decreased parameters of phonetogram. The results of the study demonstrated that multidimensional voice assessment documented deteriorated voice quality and restricted phonation capabilities in the tested group of RL patients.     

Laryngopharyngeal Symptoms and Gastroesophageal Reflux Disease

The incidence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal symptoms is greater than expect. A prospective study was performed to investigate the incidence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in patients with laryngopharyngeal symptoms. Laryngologic evaluation with nasopharyngeal and laryngeal endoscopy and gastroenterologic evaluation with esophagogastroduodenoscopy including measurement of pH value were performed in 46 patients. Therapeutic intervention included general antireflux precautions and antireflux medication, and eradication of Helicobacter pylori in selected cases. Posterior laryngitis was present in 33 patients. GERD was present in 25 patients, hiatus hernia in 4 patients, H pylori-positive gastritis in 11 patients, and Barrett's metaplasia in 2 patients. Increasing evidence shows that GERD may cause laryngopharyngeal symptoms. Otherwise laryngopharyngeal symptoms can be predictors of GERD. Medical antireflux treatment is also effective for laryngopharyngeal symptoms.     

Treatment of laryngeal contact ulcers and granulomas: A 12-year retrospective analysis

Multiple etiological factors including gastroesophageal reflux, hyperfunctional voice use, and endotracheal intubation have been implicated in the development of posterior laryngeal ulcers and granulomas. The optimal approach to treatment of these lesions remains controversial. The mainstay of treatment at Vancouver General Hospital has been aggressive medical management of gastroesophageal reflux, with complimentary voice therapy offered to patients suspected of having significant hyperfunctional phonation. The authors reserve Botulinum toxin injection or surgical excision for patients who fail initial therapy. They conducted a retrospective analysis of their voice clinic records from 1985–1997 to examine the efficacy of this approach. They identified 76 patients with the diagnosis of contact ulcer or granuloma. Fifty-two patients had follow-up data available for review. Ninety-four percent of patients were treated nonsurgically: 35 patients were treated solely by dietary and medical therapy to control gastroesphageal reflux, 10 patients were treated by a combination of medical gastroesophageal reflux control and voice therapy, 3 patients had Botox injections, 2 patients had surgical excision of granuloma, 1 patient had a Kenalog injection, and 1 patient underwent laparoscopic fundoplication. Overall, 77% of patients had complete resolution, whereas 11% had partial resolution and another 11% had no significant improvement. The data supports control of gastroesophageal reflux as a central component in treatment of posterior laryngeal ulcers and granulomas.     

Acid reflux and hoarseness

The aim of this study was to investigate the prevalence of acid reflux in patients complaining of hoarseness where no organic disease or functional dysphonia could be found. We also aimed to determine whether anti-reflux treatment improved their symptoms. Patients were not selected on the basis of symptoms of reflux. Fifty patients with hoarseness took part in a prospective study that sought to establish objectively whether acid reflux was present. All patients were given a 6-week course of ranitidine and Gaviscon. Patients were asked to score their voice quality before and after treatment. Although 72% of patients complained of heartburn more than once a week, only 40% proved to have acid reflux. Although subjective improvement after anti-reflux treatment was found in a larger proportion of those with than without proven reflux, the conclusions that can be drawn are limited as there were no satisfactory objective measurements of voice or controls.     

Vocal Tract Discomfort and Dysphonia in Patients Undergoing Empiric Therapeutic Trial with Proton Pump Inhibitor for Suspected Laryngopharyngeal Reflux

Introductionthe aim of this study was to evaluate the correlation among dysphonic and vocal tract discomfort symptoms in patients who underwent empiric therapeutic trial with proton pump inhibitor (PPI) for a suspected laryngopharyngeal reflux (LPR).Materials and methodsA total of 34 patients with suspected LPR were enrolled in this study. All of them were evaluated using the reflux finding score, the reflux symptom Index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) before and after the PPI treatment.ResultsA significant difference was found between pretreatment and posttreatment reflux finding score, RSI, VTDS, and VoiSS scores. Significant correlations among RSI, VTDS, and VoiSS before the PPI treatment were found.ConclusionPPI treatment determined a significant improvement of symptoms related to dysphonia and vocal tract discomfort in patients with suspected LPR, in addition, significant correlations among the RSI, VTDS, and VoiSS scores were demonstrated thus suggesting that LPR might influence the response of questionnaires not specifically developed in order to assess the complains in LPR patient.     

Documentation of progress in voice therapy: perceptual, acoustic, and laryngostroboscopic findings pretherapy and posttherapy

The effect of voice therapy in a group of chronically dysphonic patients with diverse diagnoses was studied according to the normal clinical procedure. The results were evaluated by perceptual rating, acoustic analysis, and the assessment of laryngostroboscopic recordings. Although the group effects for the differences between posttherapy and pretherapy data were clearly significant, the effects of voice therapy for the individual patients were divergent. For each of the three evaluation methods, a significant improvement was found for about 40% to 50% of the patients. The diversity of the therapy outcome among the patients could not be explained by the pretherapy status nor by age, gender, or diagnosis groups. In general, the perceptual ratings and the acoustic parameters from the baseline data were clearly correlated. However, these characterizations of the voice were only moderately correlated with the visual evaluation of the vocal fold vibrations. Relations among the three evaluation tools for the changes caused by voice therapy were very weak. The low correlation among the three methods suggests that a multidimensional evaluation of the voice is necessary to give a complete picture of the therapy outcome.     

Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders

The objective of this study was to establish a standard clinical evaluation tool for assessment by palpation of extrinsic laryngeal muscular tension (ELMT) and investigate the relationship between ELMT and different voice disorder diagnosis categories, particularly muscle misuse dysphonia (MMD), and the presence or absence of gastroesophageal reflux (GER). A palpation technique and tension grading system for four separate muscle groups (suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal) were established. 465 patients, 65% female and 35% male, were assessed sequentially and ELMT results were analyzed in relation to diagnosis and reflux status. A strong relationship was found between thyrohyoid muscle tension and both GER and MMD (p < or = 0.01). Thyrohyoid muscle tension is the only group that demonstrated a significant relationship with MMD. No significant difference in the ELMT scores was found between GER and non-GER patients, although a possible causal relationship was found between MMD type 3 and reflux. It is postulated that palpation of extrinsic laryngeal muscles can yield important information about internal laryngeal postures and diagnosis of muscle misuse voice disorders, particularly MMD type 3 (anteroposterior supraglottic compression). Integration of this technique into routine laryngeal examination can be a significant aid to diagnostic accuracy.     

Acoustic Analysis Findings in Objective Laryngopharyngeal Reflux Patients

OBJECTIVE: The aim of this study was to identify the effects of objective laryngopharyngeal reflux (LPR) on the acoustic parameters of patients by comparing their voice samples with that of control subjects. STUDY DESIGN: Prospective study in two tertiary reference hospitals. METHODS: 48 consecutive patients with symptoms related to LPR and 64 control subjects were included in the study. Suspected LPR patients underwent a 24-hour ambulatory pH monitoring, and 25 (52%) of them were shown to have objective LPR. Acoustical evaluation results of objective LPR patients were compared with that of symptomatic LPR patients and control subjects. RESULTS: All frequency perturbation values obtained from objective and symptomatic LPR patients were higher than the control subjects (P<0.01). Mean fundamental frequency, amplitude perturbation measures, and noise-to-harmonics ratio were not significantly different between groups. CONCLUSION: LPR patients have significantly different frequency perturbation values than control subjects.     

Prolonged Ulcerative Laryngitis

Acute and prolonged laryngitis commonly are diagnosed and treated by primary care physicians. These ailments come to the attention of the otolaryngologist when symptoms are prolonged despite treatment. Since the beginning of 1991, the senior authors (RTS, JRS) have recognized a clinical syndrome defined by prolonged hoarseness, prolonged laryngeal inflammation, and vocal fold ulceration. Patients are frequently young, nonsmokers, and nondrinkers who have had an upper respiratory infection prior to, or associated with, the onset of laryngeal symptomatology. Patients may be affected for up to 1 year despite aggressive medical therapy. This review of 14 patients highlights the features of this previously undescribed entity.     

The Voice Performance After Septoplasty With Surgical Efficacy Demonstrated Through Acoustic Rhinometry and Rhinomanometry

ObjectiveTo demonstrate the surgical efficacy of septoplasty using acoustic rhinometry (AR) and anterior rhinomanometry (ARM) and to evaluate the effect of septoplasty on voice performance through subjective voice analysis methods.Materials and MethodsThis prospective study enrolled a total of 62 patients who underwent septoplasty with the diagnosis of deviated nasal septum. Thirteen patients with no postoperative improvement versus preoperative period as shown by AR and/or ARM tests and three patients with postoperative complications and four patients who were lost to follow-up were excluded. As a result, a total of 42 patients were included in the study. Objective tests including AR, ARM, acoustic voice analysis and spectrographic analysis were performed before the surgery and at 1 month and 3 months after the surgery. Subjective measures included the Nasal Obstruction Symptom Evaluation questionnaire to evaluate surgical success and Voice Handicap Index-30 tool for assessment of voice performance postoperatively, both completed by all study patients.ResultsAmong acoustic voice analysis parameters, F0, jitter, Harmonics-to-Noise Ratio values as well as formant frequency (F1-F2-F3-F4) values did not show significant differences postoperatively in comparison to the preoperative period (P > 0.05). Only the shimmer value was statistically significantly reduced at 1 month (P < 0.05) and 3 months postoperatively (P < 0.05) versus baseline. Statistically significant reductions in Voice Handicap Index-30 scores were observed at postoperative 1 month (P < 0.001) and 3 months (P < 0.001) compared to the preoperative period and between postoperative 1 month and 3 months (P < 0.05).ConclusionIn this study, first operative success of septoplasty was demonstrated through objective tests and then objective voice analyses were performed to better evaluate the overall effect of septoplasty on voice performance. Shimmer value was found to be improved in the early and late postoperative periods.     

Some aerodynamic and acoustic characteristicsof acute laryngitis

The purpose of the present study was to describe the effects ofacute laryngitis on some aerodynamic, acoustic, and perceptual measures. Eleven subjects with diagnosed acute laryngitis due to upper respiratory infection were recorded during a laryngitic episode and 1 week to 10 days after amelioration of the laryngitic condition. Fundamental frequency values, collapsed across the five vowels, were significantly reduced in the laryngitic compared with the normal speaking condition. The decrease in fundamental frequency associated with acute laryngitis suggests an increase in the mass of the vocal folds. In addition, aerodynamic values differed significantly for the laryngitic condition compared with the normal speaking condition, suggesting the presence of laryngeal hypofunction. Perceptual data indicated that speakers in the laryngitic condition were judged to have a hoarse voice when compared with the normal speaking condition.     

Chronic dysphonia secondary to gastroesophageal reflux disease (GERD): Diagnosis using simultaneous dual-probe prolonged pH monitoring

The association of chronic dysphonia with gastroesophageal reflux has been reported in the otalaryngologic literature; unfortunately, these reports are primarily anecdotal. Because of the difficulty in documenting reflux, patients are often left without a definitive diagnosis or therapy. The purpose of this paper is to report on an objective method of documenting gastroesophageal reflux disease by using ambulatory esophageal and hypopharyngeal pH monitoring. 70% of the subjects who underwent simultaneous dual-probe pH monitoring evidenced reflux in the hypopharynx in both an upright and supine position. All of the subjects had erythema of the arytenoid cartilages on indirect examination; so this appears to be of clinical diagnostic significance.     

Comparison of fundamental frequency and perturbation measurements among three analysis systems

The need for standardization of procedures in approaches to voice measurement has been recently emphasized. The purpose of this study was to determine the extent to which the acoustic perturbation measurements from three different analysis systems agree when standardized recording and analysis procedures are used. High-quality acoustic voice recordings from 20 patients were analyzed. The results showed that, although fundamental frequency measurements were in strong agreement among the three systems tested, frequency and amplitude perturbation measurements were not in agreement. The underlying approaches to perturbation measurement appeared to be sufficiently different to produce different results. An argument is made for a standardized set of acoustic signals representing normal, dysphonic, and synthesized voices with known characteristics to facilitate testing of new acoustic analysis systems and confirm measurement accuracy and sensitivity.     

Acoustic Analysis of Voice Quality with or without False Vocal Fold Displacement After Cordectomy

Conventional cordectomy by means of a laryngofissure is one of the therapeutic options for treatment of early glottic cancer. To improve the poor voice quality related to this kind of operation, many authors have developed different techniques to repair the mucosal defect. We analyzed voice quality acoustically and compared it after cordectomy alone and after cordectomy with the reconstruction of the vocal cord in a group of 14 patients affected by T1 glottic carcinoma. All the patients underwent postoperative speech therapy. Three patients who underwent cordectomy with reconstruction showed the presence of diplophonia, while two patients without reconstruction showed the presence of bitonality. The differences of the acoustic parameters (jitter, shimmer, harmonic-to-noise ratio) between the two groups of patients were not statistically significant. Reconstruction of the vocal cord does not seem to improve voice quality after cordectomy even in combination with postoperative speech therapy.     

A comparison of type I thyroplasty and arytenoid adduction

Glottal incompetence is a common laryngeal disorder causing impaired swallowing and phonation. The resultant voice has been characterized as weak and breathy with a restricted pitch range. Currently, medialization thyroplasty and arytenoid adduction are two of the surgical treatments for patients with glottal incompetence. However, few studies have evaluated the changes in objective measures of speech with type I thyroplasty and arytenoid adduction. In this study, 59 patients with glottal incompetence underwent either type I thyroplasty or arytenoid adduction. Acoustic (jitter, shimmer, and harmonics-to-noise ratio) and aerodynamic (airflow, subglottic pressure, and glottal resistance) measures were obtained both pre- and postoperatively. No significant differences were found among acoustic or aerodynamic measures for operation type. However, a significant pre/postsurgery effect was observed for translaryngeal airflow. In addition, no significant differences were found among the measures for patients with traditional compared with nontraditional operative indications. Patients who developed glottal insufficiency due to previous laryngeal surgery (e.g., vocal fold stripping) demonstrated no statistically significant improvement in acoustic or aerodynamic measures following thyroplasty or arytenoid adduction.     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.