The effect of anti-reflux treatment on subjective voice measurements of patients with laryngopharyngeal reflux.

OBJECTIVE: To assess the impact of anti-reflux treatment and speech therapy on subjective voice measurements of patients with laryngopharyngeal reflux. METHODS: This paper reports a prospective study of patients seen in a voice clinic over a three-year period who were being treated for laryngopharyngeal reflux. Patients were assessed at presentation using the reflux symptom index and voice symptom scale, and were reassessed at three months and six months post-treatment. Treatment entailed twice daily proton pump inhibitor therapy and speech therapy. RESULTS: The study comprised 74 patients. The reflux symptom index and voice symptom scale scores significantly improved following treatment at both three and six months. There was a correlation between improved reflux symptom index scores and improved voice symptom scale scores. CONCLUSION: Treatment of laryngopharyngeal reflux with twice daily proton pump inhibitors and speech therapy resulted in improved subjective voice measurements for patients.

Is there a role for flexible oesophagogastroscopy in upper aerodigestive tract squamous cell carcinoma?

INTRODUCTION: There is growing evidence to suggest that reflux (both laryngopharyngeal and gastroesophageal) has a role in the development of upper aerodigestive tract squamous cell carcinoma. This study discusses the role of identifying reflux in this patient group, and its prevalence. METHODS: Prospective review of patients with head and neck cancer undergoing flexible oesophagogastroscopy as part of their diagnostic investigation. RESULTS: Forty-five consecutive patients were identified. All patients were found to have evidence of oesophagitis, with 28 having oesophageal erosions and two Barrett's oesophagitis. CONCLUSION: Flexible oesophagogastroscopy is a useful test in patients with upper aerodigestive tract squamous cell carcinoma.

Outcome of surgical fundoplication for extra-oesophageal symptoms of reflux.

BACKGROUND: The role of surgery in the management of extra-oesophageal symptoms of gastro-oesophageal reflux (EOR) is unclear. In this retrospective study we studied patients who had surgical fundoplication for EOR symptoms from 1995 to 2005. We analysed outcome with respect to symptomatic improvement and patient satisfaction. METHODS: From our database of 240 patients who had surgical fundoplication for gastro-oesophageal reflux disease, 51 patients who had predominantly EOR symptoms were identified. All the patients had objective evidence of reflux and had been offered surgery because of failure of medical therapy and/or of development of complications. Patients were asked to score their symptoms before and after surgery using the Reflux Symptom Index, and to record their use of medicine before and after operation, their experience with surgery and their overall quality of life using a written questionnaire. RESULTS: Forty of the 51 patients were available for analysis. Common symptoms were cough and breathlessness (32/40), throat clearing/postnasal drip (31/40), sensation of lump in the throat (29/40), and voice problems (22/40). Of these forty patients, 34 (85%) had associated classical symptoms as well. Mean follow up at the time of questionnaire was 53.3 (6-120) months. The mean Reflux Symptom Index score improved from 22.80 (SD 10.80) to 11.83 (SD 9.91) (p < 0.0001, paired t-test). Six of the 39 responders (15.3%) said they would not have had the operation knowing what they know now and that problems related to the operation outweighed any benefits. These problems included gas bloating, inability to retch and dysphagia lasting up to one year after surgery. Twenty-five percent of the 40 patients described their overall quality of life as excellent, 32.5% as good, 32.5% as satisfactory and 10% as bad. CONCLUSION: Surgery can be an effective treatment in the majority of patients with extra-oesophageal symptoms of reflux.

Acid reflux management: ENT perspective.

Otolaryngological manifestations of acid reflux include a wide range of pharyngeal and laryngeal symptoms; and the constellation of symptoms has been called laryngopharyngeal reflux. This is a prospective study in a cohort of patients with various throat symptoms suggestive of laryngopharyngeal reflux (LPR) who underwent flexible oesophago-gastroscopy, as a principal investigation. The aims were to look at the most reliable symptom(s) and sign(s), the diagnostic role of flexible oesophago-gastroscopy and the treatment response in these patients. The endoscopy score of 0 to 3 was based on endoscopic findings and the treatment response was measured from 0 to 100 per cent improvement of symptoms, as described by the patients. There were a total of 303 patients, 174 females and 129 males with ages ranging from 19 to 88 years. Seventy-five per cent had had symptoms for more than a year. Fifteen per cent were smokers. Globus, voice change, sore throat, dysphagia and cough were the predominant symptoms. Most patients, however, presented with a complex of various other secondary symptoms. The endoscopic findings were abnormal in 98 per cent of patients. Apart from the finding of non-specific hyperaemia, usually of the posterior larynx (13 per cent), lesions of the larynx and vocal folds were surprisingly uncommon. Proton pump inhibitors (PPI) were prescribed in 90 per cent of patients. A total of 233 (76.8 per cent) responded to treatment. The improvement of symptoms ranged from 25 per cent in 36 (23 per cent), 50 per cent in 60 (20 per cent), 75 per cent in 59 (19 per cent) and 100 per cent in 78 (26 per cent) patients. Accumulative analysis of variance showed a significant difference between treatment responders and non-responders (p <0.04). In a logistic regression model patients with globus, voice change and gastric prolapse were more likely to respond to treatment (p <0.04). It can be concluded that voice change, sore throat, globus and cough choking are the most reliable symptoms of laryngopharyngeal reflux. Voice change and globus symptoms can be of predictive value in terms of successful treatment response. Flexible oesophago-gastroscopy (FOG) is a simple, safe and reliable way of assessment in these cases and treatment with PPI can be effective in the majority of patients.

Surgical voice restoration following ablative surgery for laryngeal and hypopharyngeal carcinoma.

Surgical voice restoration is an important part of functional rehabilitation of patients following ablative surgery for laryngeal and hypopharyngeal carcinoma. The aim of this retrospective study was to assess the functional status with regard to speech of a cohort of 100 patients (age ranged 34-84 years), who underwent laryngectomy and laryngopharyngectomy over a 10-year period (1989-1999). Ninety-two patients consented to surgical voice restoration. Primary tracheoesophageal punctures were performed in 70 and secondary punctures in 22 (mainly after jejunal flap reconstruction). Nine patients were excluded from this analysis (seven patients died prior to assessment, one had the prosthesis removed at her request and one patient had insufficient follow-up). Tracheoesophageal speech was assessed in the remaining 83 patients using a rating scale measuring the number of syllables per breath, use of voice and intelligibility by non-professional listeners. Currently, Provox 2 valves are being used in the majority of patients. Overall tracheoesophageal speech results were good in 45/83 (54.2 per cent), average in 22/83 (26.5 per cent) and poor in 15/83 (18 per cent). One patient could not develop tracheoesophageal speech. The majority of laryngectomy patients had good speech but in patients who had complex reconstructions tracheoesophageal speech was mostly rated as average. Average to good speech in more than two-thirds of the cohort of patients show that surgical voice restoration is a highly successful and valuable technique to restore speech functions after ablative surgery for laryngeal and hypopharyngeal carcinoma.

Endobronchial tuberculosis masquerading as foreign body aspiration.

Endobronchial tuberculosis is a rare manifestation of pulmonary mycobacterial disease. We present a case in which an endobronchial tuberculous granuloma resulted in acute respiratory distress simulating foreign body aspiration.

Dysphonia as an atypical presentation of gastro-oesophageal reflux.

We present three cases of dysphonia in which gastro-oesophageal reflux (GOR) appeared to be a precipitating factor. In all cases reflux was clinically occult. We discuss the theory and implications of GOR presenting atypically with laryngeal symptoms, and outline our current approach to laryngeal symptoms of clinically evident or occult GOR.

Paradoxical vocal cord motion: an unusual cause of stridor.

Stridor due to obstructive causes is relatively common. Functional airway obstruction with paradoxical vocal cord motion is uncommon. Only 12 cases have been reported in the literature in the past 15 years. The majority were young female patients. We have recently encountered two cases. Lack of awareness of this condition caused several problems in management.

Flexible oesophagogastroscopy in otolaryngology.

We describe a technique of flexible endoscopy of the upper aerodigestive tract which provides excellent visualization for diagnostic and therapeutic purposes in ENT practice. With the present day need to reduce costs it is helpful to reduce inpatient workload and perform procedures as day cases where appropriate. The previous criticisms of flexible oesophagoscopy by ENT surgeons are unfounded and indeed there are situations where flexible endoscopy is superior to rigid examination. We would recommend that tuition in the use of the flexible gastroscope should be an integral part of ENT training.

The role of fibreoptic oesophagogastroscopy in E.N.T. practice.

Fibreoptic endoscopy has only recently become used as a diagnostic tool for the E.N.T. surgeon but it has not been widely used in the investigation of pharyngeal disease. During a two-year period at Warwick Hospital 53 patients have undergone flexible fibreoptic endoscopy using a gastroscope, with visualization of the pharynx, larynx and upper G.I. tract as far as the duodenum. This report describes the technique employed, details the endoscopic findings in 53 patients, and discusses the indications for the technique and the advantages that it holds for the E.N.T. surgeon in the diagnosis and management of pharyngeal disease.

Peroperative colonoscopy in massive rectal bleeding.

Massive rectal bleeding can pose a difficult problem in management. We describe a new technique employing peroperative colonic irrigation and direct colonoscopy to identify the source of the bleeding, so avoiding blind colonic resection.

Pyeloduodenal fistula: a case report and review of the literature.

A case of the rare condition of pyeloduodenal fistula is presented--the thirty-second case so far recorded in the literature. The authors consider that this instance shows some of the features typical of the cases so far reported. The literature is reviewed and the aetiology, presentation, diagnostic methods and treatment are briefly discussed.