Personalized Treatments Based on Laryngopharyngeal Reflux Patient Profiles: A Narrative Review

Abstract

Objective: To review the current findings of the literature on the existence of several profiles of laryngopharyngeal reflux (LPR) patients and to propose personalized diagnostic and therapeutic approaches.

Methods: A state-of-the art review of the literature was conducted using the PubMED, Scopus, and Cochrane Library databases. The information related to epidemiology, demographics, clinical presentations, diagnostic approaches, and therapeutic responses were extracted to identify outcomes that may influence the clinical and therapeutic courses of LPR.

Results: The clinical presentation and therapeutic courses of LPR may be influenced by gender, age, weight, comorbidities, dietary habits and culture, anxiety, stress, and saliva enzyme profile. The clinical expression of reflux, including laryngopharyngeal, respiratory, nasal, and eye symptoms, and the hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring profile of patients are important issues to improve in patient management. The use of more personalized therapeutic strategies appears to be associated with better symptom relief and cures over the long-term. The role of pepsin in LPR physiology is well-established but the lack of information about the role of other gastrointestinal enzymes in the development of LPR-related mucosa inflammation limits the development of future enzyme-based personalized diagnostic and therapeutic approaches.

Conclusion: Laryngopharyngeal reflux is a challenging ear, nose, and throat condition associated with poor therapeutic responses and a long-term burden in Western countries. Artificial intelligence should be used for developing personalized therapeutic strategies based on patient features.

Keywords: future; gastroesophageal; head neck surgery; laryngeal; laryngopharyngeal; otolaryngology; personalized; reflux; therapy; treatment; voice.

Figure 1

Reflux symptom score. The questionnaire is subdivided into three parts according to the complaints: ear, nose, and throat (part 1, 9 items); digestive (part 2, 9 items); and respiratory (part 3, 4 items) symptoms. The frequency and severity of each symptom are rated on a 5-point scale. Regarding the frequency, 0 = patient did not have the complaint over the past month; 1, 2, 3, 4 = patient had the complaint 1–2, 2–3, 3–4, 4–5 times weekly over the past month; 5 = patient had the complaint daily over the past month. Regarding the severity, 0 = the complaint was absent and 5 = the complaint was very troublesome when it occurs. For each item, the severity score is multiplied by the frequency score to obtain a symptom score ranging from 0 to 25. The sum of these symptom scores is calculated to obtain the final RSS score (ranging from 0 to 550; with the possibility for the physician and the patient to add 3 symptoms not identified in the RSS, leading to a maximum possible score of 625). The RSS also assesses the symptoms’ impact on quality of life. The total quality of life score is calculated as the sum of each item score. For example, a patient who reports a very mild dysphonia voice problem every day of the week will have a score of item 1 of 5 × 1 = 5, while the impact on quality of life will range from 0 (no impact) to 5 (severe impact). In the case of very severe daily nausea, the score of item “nausea” will be 5 × 5 = 25, with a QoL item score of 5.

Figure 2

Reflux sign assessment. The tool is subdivided into three parts according to the sign localization: oral cavity, pharynx, and larynx. The occurrence of vocal fold granuloma (+2), keratosis (+2), or ulceration (+2) may be considered in the last item of the score. Because of the low prevalence, the following items were removed from the initial version of RSA (in the RSA validation paper): edema/erythema of the vocal folds, nasopharyngeal erythema, and subglottic edema/erythema. The total score is calculated as the sum of each item score. The maximum score is 61.

Figure 3

pH-impedance tracing profiles. Three main profiles of LPR patients at the HEMII-pH may be observed: patients with only daytime and upright hypopharyngeal reflux episodes (A,B); patients with a mixed profile including daytime/upright and nighttime/supine pharyngeal episodes (C); and patients with a reverse tracing consisting of supine and upright pharyngeal reflux events (D). Abbreviations: HEMII-pH = hypopharyngeal esophageal multichannel intraluminal impedance-pH monitoring; LPR = laryngopharyngeal reflux.

Figure 4

Typical and atypical signs associated with laryngopharyngeal reflux. Laryngopharyngeal reflux may present with laryngeal, pharyngeal, oral, and nasal signs, including coated tongue (1), anterior pilar erythema (1), laryngeal erythema (2), heterogeneous erythema of the posterior oropharyngeal wall (3), nasopharyngeal erythema (4), tongue tonsil hypertrophy (5), sticky throat mucus (6), nasal mucosa dryness (7), and mulberry inferior turbinate (8,9).

Figure 5

Personalized algorithm for reflux management. The RSS-QoL thresholds were determined through receiver operating characteristic [51]. Abbreviations: ETT = empirical therapeutic trial; HEMII-pH = hypopharyngeal–esophageal multichannel intraluminal impedance-pH monitoring; mo = months; PPI = proton pump inhibitor; QoL = quality of life; RSA = reflux sign assessment; RSS = reflux symptom score.