Laryngopharengeal Reflux in Gastroesophageal Reflux Disease: Does " Silent Laryngopharengeal Reflux " Really Exist? Lpr Was Assessed by Reflux Symptoms Score (rsi) and Reflux Finding Score (rfs). Accordingly, Patients Are Classified Into: Group I = 25 Patients with Manifest Lpr, and Group Ii = 25 Co

Background: Gastroesophageal reflux disease (GERD) is a disorder resulting from the reversed flow of gastroduodenal contents into the esophagus, and producing different symptoms, while la-ryngopharyngeal reflux (LPR) is a disorder resulting from the reversed flow of gastric contents into the hypopharynx. The aim of this work is to evaluate LPR in cases of GERD. Methods: The present study was performed on fifty GERD patients diagnosed by gastroscope.


Introduction
Gastroesophageal reflux disease (GERD) is diagnosed clinically or histologically due to abnormal exposure of the oesophagus to gastric contents [1].Extraesophageal manifestations are the complicated GERD primarily involving the neighboring organs [2].Laryngopharyngeal reflux (LPR) is common, but its diagnosis may be difficult, for its symptoms are nonspecific and its laryngoscopic signs are not always correlated with symptom severity [3].Little gastric content can induce laryngitis as laryngeal tissue is more vulnerable to such injury than oesophageal one [4].There is neither pathognomonic symptom nor sign for LPR, but both reflux symptoms index (RSI) and reflux finding score (RFS) were validated for its diagnosis [5].

Patients and Methods
This study was conducted on adult patients with GERD diagnosed at Gastrointestinal Endoscopy Unit, Faculty of Medicine, Cairo University.Exclusion criteria: a) Patients giving history of peptic ulcer disease or anti ulcer medications or previous anti ulcer surgery, b) Patients having local laryngopharyngeal affection and those having causes inducing GERD like allergy, alcohol, tobacco, drugs.
The selected patients were divided into 2 groups: Group I: patients complaining of any of the LPR symptoms, and Group II: control cases who were not complaining of any of the LPR symptoms.
All patients were subjected to: a) History taking, including evaluation of GERD symptoms as heart burn, regurgitation, halitosis, dysphagia and dyspepsia, and LPR symptoms, defined as RSI, including hoarseness, throat clearing, postnasal drip, dysphagia, irritant cough, dyspnea, and globus, as designed by Belafsky et al. (2002) [6], and shown in Table 1.Score > 13 is suggestive of LPR.b) Oesophagogastroduodenoscope using Olympus endoscopy for evaluating GERD, where Los Angeles classification was applied [7] and GERD oesophagitis was graded as follows: A: One (or more) mucosal break ≤ 5 mm, that does not extend between the tops of two mucosal folds, B: One (or more) mucosal break > 5 mm long that does not extend between the tops of two mucosal folds, C: One (or more) mucosal break that is continuous between the tops of ≥2 mucosal folds but which involves ˂75% of the circumference, and D: One (or more) mucosal break which involves ≥ 75% of the esophageal circumference.It was also done to examine the presence of contributing factors of GERD as hiatus hernia, and the presence of any complications as Barrett's esophagus, stricture, and esophageal carcinoma.c) Direct fiberoptic laryngoscopy for examination of LPR signs defined as RFS and designed by Belafsky et al. (2002) [6], and shown in Table 2. Score > 5 is considered abnormal.
The study was approved by the institutional ethical committee, and all patients provided an informed consent.

Results
This study was a cross sectional study, conducted on attendants of Gastrointestinal Endoscopy Unit, Faculty of          GERD was diagnosed in 17.4% of attendants (86/494 patients).GERD patients were then divided into 2 groups: Group I: constituted of 25 patients (29.1%) having LPR.All reported by symptoms and were confirmed by laryngoscope, therefore termed as "Manifest LPR", and Group II: GERD patients without LPR symptoms which constituted of 61 patients (70.9%), however, 25 patients where further examined by laryngoscope to serve as control group.Most of the control group (23/25 patients; 92%) were laryngoscopically free while 2 only (8%) had LPR.Accordingly, group II is subdivided into IIA who are "LPR-free", and IIB who are defined as "Silent LPR" respectively.
Demographic features of the studied groups are shown in Table 3.None of the demographic features showed a statistical difference between the 2 groups.Obesity was higher in Group I than in Group II but without recording a statistical difference, however, it is worth noting that obesity was reported by most of the studied patients (39/50 patients; 78%).
Gastrointestinal symptoms of the studied groups are shown in Table 4. Heart burn and regurgitation were the commonest symptoms (80% each) however, halitosis, dysphagia and nausea, which were less common, were significantly higher in Group I than in Group II (p = 0.01, 0.01 and 0.037 respectively).
LPR symptoms in manifest LPR (Group I) are illustrated in Figure 1.The mean score was 16.48.Oesophagogastroduodenoscopic examination of the studied groups is shown in Table 5. Laryngoscopic examination (RFS) of the studied groups is shown in Table 6.Laryngoscopy detected positive signs of LPR in 2 patients in Group II (Group IIB).Both recorded erythema, vocal fold edema and diffuse laryngeal edema, while ventricular obliteration, posterior commissure hypertrophy and thick endolaryngeal mucus were detected in one of them.They recorded mean RFS = 7. Therefore termed as silent LPR.
Correlation between GERD grade and LPR symptom index and LPR finding score are illustrated in Figures 2(a

Discussion
GERD is a common disease that may present with disabling symptoms [8].GERD was defined as backflow of gastric contents causing disturbing symptoms and/or complications.It was classified into esophageal and extraesophageal syndromes.Recently, it became patient-centered approach independent of the laryngoscopic examination, subclassification of the disease into discrete entities e.g.laryngitis, cough, etc. and also Barrett's esophagus [9].
In this study, GERD accounts for 17.4% among attendants of gastroscope unit.This figure is intermediate.It was higher than that recorded in Asia (˂5%) [10], and lower than that recorded in USA, being the 3rd digestive disease, and with the highest economic burden [11].However, it was variably recorded in the western world as reported by Farrokhi et al. and Hershcovici et al. i.e. approximately 35% -40% and 10% -20% respectively [4] [12].
In this study, neither sex nor age predilection was recorded in GERD.This is similar to Dent [10].However,   El-Serag found GERD increased with age (highest in the 60 -69 years range, with a slight decrease afterwards), meanwhile, women had a slightly higher risk at age >50 years [13].Similarly, Lee attributed this to the progressive decrease in abdominal lower eosophageal sphincter length and esophageal clearance and motility [14].Also, Johnson recorded severe erosive esophagitis ranging from 12% in patients aged <21 years to 37% in patients    aged >70 years, and conversely, found ranging from 82% in patients aged <21 years to 34% of those aged >70 years [15].
Heartburn was reported by 3/4 of the studied patients (38/50 patients; 76%), comparably present in Groups I and II (20 patients; 80% and 18 patients; 72% respectively), meanwhile grade A was more in Group II than in Group I (19 patients; 76% versus 15 patients; 60% respectively), while grades B, C & D (moderate & severe) are more in the Group I than in Group II.This confirmed the fact that heartburn was the only symptom related to GERD and LPR severity [21].
Haematemesis was reported by 4 patients (8%), comparably present in Groups I and IIA.It is worth noting that they were following up their underlying oesophageal varices, complication of cirrhosis.This agrees with El-Serag who related history of haematemesis to positive GERD endoscopic examination [13].
Regarding LPR, manifest LPR was present in 25 patients (29%) which is lower than that reported in an international survey (60%) [22].Also, Merati documented significant relation between acid reflux events and LPR (p = 0.003) [23].LPR was not significantly related to either sex or age.On the contrary, Patigaroo et al. in their LPR study, found gender and age predilection (male:female = 2:3, and patients mostly-40%-belonged to age range 31 -40 yrs) [24].Mean age recorded in manifest LPR was slightly higher than GERD (40.4 versus 40.1 years).This was higher than that recorded by previous studies i.e. 38 and 32.4 years [24] [25].In this study, postnasal drip and throat clearing were the most prevalent symptoms (96% each).Throat clearing is the most related symptom to LPR [21].They were followed by dysphagia, hoarseness (68% each), and globus (56%).This agrees with other studies which stated that sore throat, hoarseness, and choking cough are the most reliable symptoms of LPR [26] [27].While annoying cough and post prandial/positional cough were the least symptoms (48% and 40% respectively).This figure is close to that recorded in previous studies e.g.Irwin et al. (48%) who stated that chronic cough can be the sole symptom of GERD [28], and Patigaroo et al. (56%).GERD is generally considered one of the three main causes of chronic cough [29].Also, 70% of LPR are found in patients with dysphagia [30].
Hiatus hernia was present in 11 patients (22%), comparably detected in both groups (6 and 5 patients in Groups I and II respectively).It was documented for its high specificity (95%) in predicting GERD [16], even stated as a sine qua non for GERD, and that both were formerly considered synonyms [40].Also, Fein et al. detected it in 75.6% of GERD [41].
None of the patients showed esophageal carcinoma.This agrees with the fact its risk is low despite being strongly associated with GERD [44].
Pseudosulcus was detected in 6 patients (12%), all belonged to Group I.It is confirmed as a strong predictor (90%) for LPR [49].
In this study, both RSI and RFS were significantly correlated with GERD grade (p = 0.015 and 0.005 respectively), and RSI was a significant predictor for RFS (p = 0.00), despite the stated fact that the endoscopic laryngeal signs do not correlate with LPR symptom severity, and treatment is recommended to continue for ≥6 months or until complete resolution of signs [3] [50].Also accurate clinical assessment of LPR is likely to be difficult because laryngoscopic signs may show inter-observer variation [51].Meanwhile, mild LPR can be confused with other laryngeal conditions [5].LPR was detected in healthy people [33], reaching up to 86% of asymptomatic GERD volunteers [52].

Conclusion
RSI is a significant predictor for RFS, and both, RSI and RFS, are significantly proportionate to GERD, yet Silent LPR did exist among control patients.
month, how did the following problems affect you?
ate or after lying down.
Sensations of something sticking in your throat or a lump in your throat.
pain, indigestion, or stomach acid coming up.Total = 45 University from May 2012 to June 2013.
) and (b) respectively.Predictability of RSI according to RFS is illustrated in Figure3.

Figure 1 .
Figure 1.LPR symptoms of Group I.

Table 3 .
Demographic features of the studied groups.

Table 4 .
Gastrointestinal symptoms of the studied groups.

Table 5 .
Oesophagogastroduodenoscopic examination of the studied groups.

Table 6 .
Laryngoscopic examination of the studied groups.