Clinical Review & Education

From The JAMA Network

Hoarseness and Laryngopharyngeal Reflux P. Marco Fisichella, MD, MBA

JAMA OTOLARYNGOLOGY–HEAD & NECK SURGERY Hoarseness and Laryngopharyngeal Reflux: A Survey of Primary Care Physician Practice Patterns Ryan Ruiz, BA; Seema Jeswani, MD; Kenneth Andrews, MD; Benjamin Rafii, MD; Benjamin C. Paul, MD; Ryan C. Branski, PhD; Milan R. Amin, MD IMPORTANCE Current approaches to the diagnosis and

subsequent management of specific voice disorders vary widely among primary care physicians (PCPs). In addition, sparse literature describes current primary care practice patterns concerning empirical treatment for vocal disorders. OBJECTIVE To examine how PCPs manage patients with

dysphonia, especially with regard to laryngopharyngeal reflux. DESIGN, SETTING, AND PARTICIPANTS Prospective, questionnaire-based study by an academic laryngology practice among academic PCPs from all major US geographic regions. MAIN OUTCOMES AND MEASURES A 16-question web-based survey, distributed via e-mail, concerning management and possible empirical treatment options for patients with dysphonia.

Hoarseness is a common presenting complaint to generalist physicians. Symptoms include altered vocal quality, pitch, or loudness.1 The lifetime prevalence of hoarseness is approximately 30%, and it is more common in women, middle age, and specific professions (singers and teachers) and is associated with repeated upper airway infections and gastroesophageal reflux disease (GERD).2 Recent neck operations (eg, carotid endarterectomy and thyroid surgery), radiation treatment, endotracheal intubation, tobacco abuse, and neurologic disorders (such as Parkinson disease, multiple sclerosis, and stroke) are also associated with hoarseness.1 Among patients presenting to primary care clinicians, the most common cause of hoarseness is viral laryngitis, which should resolve with symptomatic treatment in 2 to 3 weeks. If hoarseness persists for a longer time, a referral to a specialist is appropriate, but there is no consensus regarding when this should be done. The Table summarizes the main causes for hoarseness and their associated clinical features.3 Laryngopharyngeal reflux (LPR) may cause hoarseness and was reviewed by Ford.3 Laryngopharyngeal reflux occurs when gastroesophageal reflux is severe enough to have gastric contents reflux to the vocal cords, causing their irritation. Establishing a diagnosis jama.com

RESULTS Of 2441 physicians who received the e-mail broadcast, 314 (12.9%) completed the survey. Among those who completed the survey, 46.3% were family practitioners, 46.5% were trained in internal medicine, and 7.2% identified as specialists. Among all respondents, 64.0% preferred to treat rather than immediately refer a patient with chronic hoarseness (symptoms persisting for >6 weeks) of unclear origin. Reflux medication (85.8%) and antihistamines (54.2%) were the most commonly selected choices for empirical treatment. Most physician respondents (79.2%) reported that they would treat chronic hoarseness with reflux medication in a patient without evidence of gastroesophageal reflux disease. CONCLUSIONS AND RELEVANCE Most PCPs who responded to our survey report empirically treating patients with chronic hoarseness of unknown origin. Many physician respondents were willing to empirically prescribe reflux medication as primary therapy, even when symptoms of gastroesophageal reflux disease were not present. These data suggest that PCPs strongly consider reflux a common cause of dysphonia and may empirically treat patients having dysphonia with reflux medication before referral.

JAMA Otolaryngol Head Neck Surg. 2014;140(3):192-196. doi:10.1001 /jamaoto.2013.6533

of LPR is difficult because its presentation is similar to other causes of hoarseness, including smoking, allergens, and viral infections. Diagnostic tests such as laryngoscopy and pH monitoring may not be helpful because findings from these tests are not very specific.3 It is then reasonable to treat patients with suspected LPR empirically with proton-pump inhibitor (PPI) therapy for 3 months.3 About 50% to 75% of patients with both hoarseness and GERD (heartburn and regurgitation) will improve.4-6 When empirical treatment fails, referral to a specialist is appropriate. InJAMAOtolaryngology,Ruizetal7 reportedtheresultsofastudy in which 2241 academic primary care clinicians were surveyed regarding how they treat LPR. Only 314 physicians completed the survey (12.9%). This response rate is below the minimally acceptable response rate suggested by some journals.8 Nevertheless, Ruiz et al7 made 3 observations: 201 (64%) respondents empirically treated GERD for 6 weeks before referring patients with chronic hoarseness of unclear origin to specialists, 269 (85.8%) prescribed empirical antireflux therapy, and 249 (79.2%) would start empirical PPI therapy without evidence of concurrent GERD. Based on these results, most primary care clinicians empirically treat suspected LPR when patients first present with these (Reprinted) JAMA May 12, 2015 Volume 313, Number 18

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Clinical Review & Education From The JAMA Network

Table. Clinical Clues to Distinguish LPR From Other Causes of Hoarseness3 Allergy

Benign Vocal Fold Lesion

Malignant Vocal Fold Lesion

Acute/chronic or recurrent

Fluctuates

Constant

Progressive

Yes

Uncommon

No

From secondary muscle tension

Late (local and referred)

Edema, granuloma, erythema, pseudosulcus

Erythema, edema

Secretions (thick, discolored), edema

Edema, clear secretions, bluish mucosa

Nodules, polyps, cysts, scars

Ulcerative or exophytic (red-white mass), stiff

Smoking, obesity, diet or lifestyle

Systematic infection immunosuppression

LPR, allergy, smoking

Environmental, smoking

Smoking, vocal trauma, LPR

Smoking (common), LPR, ethanolism

LPR

Infection

Hoarseness characteristic

Fluctuates

Acute, resolves

Throat pain

Common (with cough, throat clearing)

Laryngeal findings Aggravating factors

Rhinosinusitis (Postnasal Drip)

Abbreviation: LPR, laryngopharyngeal reflux.

symptoms. However, when should patients with suspected LPR be referred to specialists? Referral should be considered if a serious underlying cause is suspected (laryngeal or head and neck cancer).1 Based on expert opinion, the American Academy of Otolaryngology– Head and Neck Surgery (AAO-HNS) recommends visualization of a patient’s larynx or referring the patient to a clinician who can visualize the larynx when hoarseness fails to resolve within 3 months after onset.1 The evidence base supporting these recommendations was limited, so referral by a clinician is reasonable at any time without waiting the 3 months. The AAO-HNS recommendations also suggest that empirical therapy for hoarseness should not be given in the absence of GERD. As highlighted by Ford, 3 LPR can be initially treated in patients with hoarseness and symptoms of esophageal reflux with lifestyle changes (weight loss, smoking and alcohol cessation), diet restrictions, and empirical PPI therapy for 3 months.3 If the symptoms resolve or improve, the dose of the empirical PPI medication is decreased or increased, respectively, and the patient is followed up for another 6 months.3 If hoarseness is unchanged or worsens after the initial PPI trial, a referral to a speARTICLE INFORMATION Author Affiliation: Harvard Medical School, Boston VA Healthcare System, Brigham and Women’s Hospital, Boston, Massachusetts. Corresponding Author: P. Marco Fisichella, MD, MBA, Boston VA Healthcare System, Harvard Medical School, 1400 VFW Pkwy, West Roxbury, MA 02132 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3)(suppl 2): S1-S31.

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cialist is recommended.3 The AAO-HNS recommendations support this approach by advising clinicians to not initiate antireflux therapy for patients with hoarseness without signs or symptoms of GERD. They also recommend that antireflux therapy be discontinued and prompt a referral to investigate alternative causes for hoarseness if hoarseness does not respond to antireflux therapy or if it worsens.1 The AAO-HNS recommendations also encourage clinicians to initiate antireflux therapy for patients with hoarseness and signs of chronic laryngitis. This recommendation does not have a strong evidence base because PPIs were nonsuperior to placebo for patients with chronic posterior laryngitis.4 There is a 40% placebo response rate in LPR trials, suggesting that some patients have functional disorders rather than GERD causing their hoarseness.5 In summary, it is reasonable for clinicians to initiate a 3-month course of empirical PPIs for patients with hoarseness and symptoms of esophageal reflux. Patients with hoarseness from suspected LPR who do not respond to a 3-month PPI trial or patients with hoarseness who lack reflux symptoms should be referred to a specialist because esophageal reflux is an unlikely cause of hoarseness.

2. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115(11):1988-1995. 3. Ford CN. Evaluation and management of laryngopharyngeal reflux. JAMA. 2005;294(12): 1534-1540. 4. Vavricka SR, Storck CA, Wildi SM, et al. Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy. Am J Gastroenterol. 2007;102(4):716-722.

6. Vaezi MF, Hicks DM, Abelson TI, Richter JE. Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): a critical assessment of cause and effect association. Clin Gastroenterol Hepatol. 2003;1(5):333-344. 7. Ruiz R, Jeswani S, Andrews K, et al. Hoarseness and laryngopharyngeal reflux: a survey of primary care physician practice patterns. JAMA Otolaryngol Head Neck Surg. 2014;140(3):192-196. 8. Johnson TP, Wislar JS. Response rates and nonresponse errors in surveys. JAMA. 2012;307(17): 1805-1806.

5. Vaezi MF, Richter JE, Stasney CR, et al. Treatment of chronic posterior laryngitis with esomeprazole. Laryngoscope. 2006;116(2):254-260.

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Hoarseness and laryngopharyngeal reflux.

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