YAJOT-01923; No of Pages 6

American Journal of Otolaryngology–Head and Neck Medicine and Surgery xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with

comparison to medications☆
Jin Yang a,⁎, Salem Dehom b, Stephanie Sanders a, Thomas Murry c, Priya Krishna c, Brianna K. Crawley c
a
Loma Linda University School of Medicine, Loma Linda, CA, USA
b
Loma Linda University School of Public Health, Loma Linda, CA, USA
c
Voice and Swallowing Center-Loma Linda University Medical Center, Loma Linda, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine if an anti-reflux induction program relieves laryngopharyngeal reflux (LPR) symptoms
Received 3 September 2017 more effectively than medication and behavioral changes alone.
Available online xxxx Study design: Retrospective study.
Setting: Tertiary care academic center.
Keywords:
Subjects and methods: A database was populated with patients treated for LPR. Patients were included in the study
Laryngopharyngeal reflux
group if they completed a two-week anti-reflux program (diet, alkaline water, medications, behavioral modifica-
Cough
Induction diet
tions). Patients were included in the control group if they completed anti-reflux medications and behavioral
Proton pump inhibitors modifications only. Patients completed the voice handicap index (VHI), reflux symptom index (RSI), cough se-
Reflux symptom index verity index (CSI), dyspnea index (DI) and eating assessment tool (EAT-10) surveys and underwent laryngoscopy
for examination and reflux finding score (RFS) quantification.
Results: Of 105 study group patients, 96 (91%) reported subjective improvement in their LPR symptoms after an
average 32-day first follow-up and their RSI and CSI scores improved significantly. No significant differences
were found in VHI, DI, or EAT-10 scores. Fifteen study patients who had previously failed adequate high-dose
medication trials reported improvement and their CSI and EAT-10 scores improved significantly. Ninety-five per-
cent of patients with a chief complaint of cough reported improvement and their CSI scores improved significant-
ly from 12.3 to 8.2. Among 81 controls, only 39 (48%) patients reported improvement after an average 62-day
first follow-up. Their RSI scores did not significantly change.
Conclusion: The anti-reflux program yielded rapid and substantial results for a large cohort of patients with LPR. It
compared favorably with medication and behavioral modification alone. It was effective in improving cough and
treating patients who had previously failed medications alone.
© 2017 Published by Elsevier Inc.

1. Introduction
The diagnosis of laryngopharyngeal reflux (LPR) is common in clin-
ical practice. It was reported to be present in N50% of patients with la-
ryngeal complaints at an academic voice center [1]. In a recent survey,
N60% of a community-dwelling population had either GERD or laryn-
geal symptoms and N20% had both [2]. Symptoms caused by LPR in-
clude chronic cough, dysphonia, dysphagia, post-nasal drip, globus,
constant throat clearing, laryngospasm and a multitude of other
extraesophageal maladies [3,4].
Empiric treatment of LPR with antireflux medication such as proton
pump inhibitors (PPI) has increased in popularity over the past twenty
☆ Presented at Western Medical Research Conference, Carmel, California, USA on Jan. 27,
2017.
⁎ Corresponding author.
E-mail address: jiyang@llu.edu (J. Yang).
years. Between 1990 and 2001, PPI prescription increased 14 fold, ac-
counting for a significant percentage of healthcare costs [5,6]. A typical
treatment for LPR in clinical practice is a course of twice daily PPI for
at least 2 months [7]. Many studies have supported the effectiveness
of PPIs in treating LPR-related symptoms. One meta-analysis of random-
ized controlled trials showed that patients treated with a PPI had a sig-
nificantly higher response rate and reflux symptom index (RSI)
improvement than those who received placebo [8]. In a study by Jin et
al., treatment with PPIs improved objective voice measures including
jitter, shimmer, and harmonic-to-noise ratio after 1–2 months treat-
ment, and maintained results even after 3–4 months [9]. Most studies
agree that patients must continue their medication regimen for at
least 2–6 months to achieve reduction in symptoms. However, these
studies have been contradicted by others in the literature due to dis-
crepancies in method of diagnosis, contributing factors, management
regimens, and outcome measures that are often subjective and vary
widely.

https://doi.org/10.1016/j.amjoto.2017.10.014
0196-0709/© 2017 Published by Elsevier Inc.

Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014
2 J. Yang et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery xxx (2017) xxx–xxx
Though some studies support the use of PPIs for LPR, other studies
call into question their efficacy or outline the potential dangers of PPI
use over protracted periods of time. First, PPIs have been shown to be
more beneficial for patients with possible LPR in the setting of typical
GERD than for those without it [10]. Second, patients may not universal-
ly respond to PPIs: many are PPI resistant or have non-acid reflux [11].
Third, the literature does not conclusively support using PPIs to improve
LPR symptoms and objective voice measures. A double-blinded, ran-
domized controlled trial showed no significant difference between PPI
and placebo groups in improving RSI and RFS [7] and, in contrast to Jin
et al., Hamdan et al. showed that PPI use did not improve acoustic ab-
normalities [9,12]. In addition, long term use of PPIs has been associated
with such adverse effects as osteoporosis, infections, malabsorption,
malignancy, kidney disease and dementia, sparking great concern in pa-
tients though proof of causation is largely absent [13–16]. But the pre-
scription of anti-reflux medications for LPR treatment continues.
The anti-reflux induction diet was introduced by Dr. Koufman in
2011 [17]. It is comprised of low-acid, low-fat foods to the exclusion of
all foods and drinks with a pH less than five for a minimum two week
period. The purpose is to provide a basis for what will be a long-term
lifestyle change to potentially alter the mechanism and minimize the
effects of LPR. The induction diet ends with transition to a similar but
less stringent maintenance diet intended to eliminate the need for
daily PPIs. This diet/lifestyle approach could provide an alternative for
patients refractory to PPIs or who wish to avoid side effects of long
term PPI use. In her prospective study of 20 patients who failed PPIs,
19 patients improved on this low acid diet and 3 became completely
asymptomatic [16]. Our study sought to address whether this induction
diet would be effective in reducing LPR symptoms in a larger patient
population. We present the outcomes of a regimen combining the in-
duction diet with anti-reflux medications in a larger group. We compare
these results with a group who received standard anti-reflux treatment
in our practice.
2. Methods
Loma Linda University IRB granted approval for a retrospective review
of patients treated for laryngopharyngeal reflux (LPR) at our academic
tertiary referral center. A database was assembled by initially including
all patients over age 18 diagnosed with primary LPR from 12/2011 to 6/
2016 at the Loma Linda Voice and Swallowing Center (LLVSC). Diagnosis
was based on the presence of signs and symptoms or pH probes
(nasopharyngeal pH probes at our center with positive Ryan scores and
adequate symptom correlation or outside reports of positive pH probe
results) demonstrating LPR or GERD (with extraesophageal symptoms).
Patients who had negative pH probe results, and who had other contrib-
uting pathology (radiation, vocal fold lesions, sinonasal pathology, airway
stenosis, etc.) were excluded. Patients who were simultaneously treated
for or found to have allergic rhinitis, glottic insufficiency, or vocal fold
atrophy were also excluded as these other treatments could cause the
LPR-directed treatments to appear more effective. We divided all patients
meeting criteria into two groups: those who were prescribed the LPR
induction program and those who were prescribed only anti-reflux
medications and behavioral modifications.
Patients prescribed the LPR induction program (Table 1) were
included in our study group. The LPR induction program consists of a
two-week induction diet [17], high dose anti-reflux medications (PPI
40 mg qD and/or H2 blocker 300 mg qHS), with at least 16 oz of alkaline
Table 1
Anti-reflux program.
Two-week induction diet [17]
High dose anti-reflux medications (PPI 40 mg qD and/or H2 blocker 300 mg qHS)
At least 16 oz of alkaline water (pH N 8) daily [18]
Behavior modifications (Table 2)
Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014
water (pH N 8) daily [18], and behavioral modifications, including
weight loss, smoking cessation, alcohol avoidance, and eating no less
than 3 h before lying down [19]. If patients preferred or presented
with PPI 40 mg BID instead of 40 mg qD, their medication regimen
was maintained. At the end of two weeks, these patients were
instructed to begin reintroducing foods back into their diet slowly in
order to monitor rebound symptoms and to subsequently determine
which foods were causing problems so that these could be avoided.
They were asked to return within a month of beginning treatment in
order to gauge initial success with the induction diet and to help guide
transition to the maintenance phase, if appropriate. We retrospectively
excluded only patients who failed to follow up within 2 months or who
reported to have not been 100% adherent to the treatment protocol.
There were no other exclusion criteria for our study group.
Our control group was comprised of the remainder of our patients
who were prescribed a course of high dose PPIs (40 mg qD), or both
high dose PPIs and H2 blockers (300 mg qHS) with LPR behavioral mod-
ifications (Table 2) [19]. If patients preferred or presented with PPI 40 mg
BID instead of 40 mg qD, their medication regimen was maintained.
These patients were largely seen prior to the introduction of the anti-
reflux induction program into our practice and standard follow-up for
this group was three months, consistent with reports that treatment
requires at least 2 months to take effect [7]. We excluded patients who
failed to follow up within 3 months in order to bring this group as close
as possible to our study group. Patients were also excluded if they report-
ed being noncompliant with their medications and behavioral modifica-
tions. There were no other exclusion criteria for our control group.
For both study and control groups, information including routine de-
mographics, previous treatment with antireflux medication (dosage
and duration), medical comorbidities, smoking status, and 24-hour pH
probe studies was gathered. At each of their clinic visits, patients were
asked to complete the VHI-10 [20] and RSI [21]. Additional question-
naires were added at the time the induction program was introduced
and these included the CSI [22], DI [23], and EAT-10 [24]. In addition,
an otolaryngologic history and physical exam was completed accompa-
nied by a videostroboscopic exam, which was assigned a Reflux Finding
Score (RFS) [25]. Information about patients' subjective symptom
improvement was collected during their first follow-up visit.
Two subgroups were isolated from the treatment group for further
scrutiny. The first included all patients in the treatment group who
had failed a complete course of 40 mg qD or higher dosage PPI for
N6 weeks before presenting to our center and completing the LPR in-
duction program. Six weeks was chosen in order to exclude patients
who had completed longer courses than the popular 14 day trial. The
second group was comprised of treatment group patients presenting
with the chief complaint of cough who had also completed the CSI ques-
tionnaire pre- and post-induction program. Pre-and post-induction pro-
gram questionnaire scores and symptom results were analyzed
separately for the above two cohorts.
The RFS was assigned to every exam collected from patients in the
treatment group. They were not collected from the control group be-
cause most exams were not available for review. Two different attend-
ing laryngologists performed the scoring blinded to the patient, date
of exam, and treatment period. Using only patients who had both pre-
and post-induction program exams within two months of each other,
overall change in RFS, inter-rater reliability, and intra-rater reliability
(20% blinded repeat grading) were calculated.
Table 2
Behavior modifications [19].
Weight loss
Smoking cessation
Alcohol avoidance
Minimizing tight clothing/belts
Eating no less than 3 h before lying down
Taking PPI 30–60 min before meals
 J. Yang et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery xxx (2017) xxx–xxx 3

Overall descriptive statistics including means, medians, ranges and Table 4

standard deviations for continuous variables and frequencies for cate- Survey scores for study and control groups pre-treatment and post-treatment.

gorical variables were calculated. Univariable comparisons between Pre-treatment Post-treatment P-value
pre-and post-treatment for the treatment group, control group, high Study group (N = 105)
dose PPI trial group, cough group, and pH probe group were performed VHI 7.89 6.7 0.077
with paired t-tests for continuous variables. A significance level of 0.05 RSI 19.74 14.38 2.07E−10*
was used for two group comparisons. Tukey adjusted post hoc test CSI 9.58 7.47 0.008*
DI 9.4 8.02 0.31
was used to calculate the percent agreement between patients' reported
EAT-10 9.24 7.81 0.08
improvement and their RSI score improvement.
Failed prior PPI (N = 16)
VHI 10.81 9.88 0.49
RSI 20.13 16.5 0.15
3. Results CSI 14.73 10.22 0.04*
DI 15.29 14.67 0.54
Two hundred and sixty nine patients presented to the LLVSC with EAT-10 8.45 7.17 0.02*
symptomatic LPR and were given the induction program between 10/ Cougher (N = 37)
2014 and 6/2016. Of those, the following patients were excluded from VHI 9.34 8.26 0.27
the study group: 130 patients who had no follow up within two months, RSI 20.7 16.42 0.001*
22 patients who followed up within two months but failed to complete CSI 12.29 8.16 0.005*
DI 11.52 9.52 0.11
the induction program, 3 patients who had negative pH probe results,
EAT-10 9.39 8.7 0.16
and 9 patients who had other pathological contributors for their symp-
toms (Table 3). Among the remainder of the study group who were in- Control group (N = 81)
VHI 9.93 12.31 0.006*
cluded, 15 underwent pH probe testing, the majority at our Center, with
RSI 17.43 17.35 0.989
positive Ryan scores and symptom correlation. Twenty-two patients
Abbreviations: VHI, voice handicap index; RSI, reflux symptom index; CSI, cough severity
who followed up within two months but reported b 100% compliance
index; DI, dyspnea index; EAT-10, eating assessment tool.
with the program had an average age of 61 (range = 32–84, median Note: paired t-test is used and a P-value of 0.05 is selected for significant difference.
= 62) and an average BMI of 28 (range = 18–49, median = 27). Four
of them were male and eighteen were female. Among them, eleven
had respiratory comorbidities (COPD, bronchitis, asthma, allergies), Thirty-seven patients in the treatment group presented with a
one was an active smoker, five were diagnosed with GERD, two had di- chief complaint of cough. Twenty reported cough symptoms lasting
abetes, and one had anxiety. The RSI score for this cohort decreased in- for N1 year, 16 for N 8 weeks and less than a year, and 1 for
significantly from 18.3 to 15.8 (P = 0.08). 5 weeks. Twenty-three of 37 had tried some form of therapy: 16
Of the 105 patients who completed the program and were included had PPI ± H2 blockers, 2 had gabapentin or amitriptyline, 2 had
in the study group, 28 were male and 77 were female. Their mean age over-the-counter cough suppressants, and 3 had tried herbal reme-
was 60 (range = 17–84, median = 63) and mean BMI was 29 (range dies. Thirty-five patients reported subjective improvement with the in-
= 17–45, median = 28). The average first follow up after receiving duction program after a mean 31 days follow-up (range = 15–63,
the induction program was 32 days (range = 7–63, median = 28). In median = 26). Their CSI scores improved significantly from 12.29 to
just this period of time, 96 (91%) patients reported significant subjective 8.16 (Table 4).
improvement or complete resolution of their LPR symptoms. Nine (9%) Two hundred and four patients presented at LLVSC with symptom-
patients did not endorse improvement, one of whom had success upon atic LPR and were given a course of high dose PPIs (40 mg qD or BID),
a second trial of the same program. There were significant differences in or both high dose PPIs and H2 blockers (300 mg qHS) with LPR behav-
RSI and CSI scores pre-and post-induction program for patients who ioral modifications (Table 2) between 12/2011 and 6/2016. Of those, the
completed the induction program (Table 4, Fig. 1). No significant differ- following patients were excluded from the control group: 99 patients
ences were found in their VHI, DI, or EAT-10 scores. The RFS scores did who had other pathological contributors for their symptoms or were
not significantly change after treatment over this time period. Inter- non-compliant with medications, 21 patients who had no follow up
rater reliability was fair and intra-rater reliability was both significant within three months, and 3 patients who had negative pH probe results.
and correlated (intraclass correlation 0.67; 95% CI 0.3–0.87). Our control group was comprised of 81 patients (40% of our initial
Of note, 79 (75%) patients in the treatment group had been on some cohort), 19 male and 62 female. They had a mean age of 59 (range =
form of anti-reflux medications (H2 blocker, PPI or both) prior to begin- 17–88, median = 61) and mean BMI of 29 (range = 18–44, median
ning this regimen. Specific regimen information was available for six- = 29). After an average of 62 days first follow up (range = 14–93, me-
teen of these patients who reported they had completed at least dian = 63), 39 (48%) patients reported subjective improvement of LPR
6 weeks of high-dose PPI ± H2 blocker but failed to improve symptom- symptoms. However, RSI scores did not change significantly in this time
atically prior to beginning the anti-reflux induction program. Of those, period and VHI significantly worsened from a mean of 9.93 to 12.31
15 (94%) reported subjective improvement and one reported no im- (Table 4, Fig. 1). Of the 42 who reported no subjective improvement
provement after an average of 38 days follow-up (range = 15–44, me- with medications, they had an average of 57 days follow-up (range =
dian = 37). This group showed significant improvement in CSI and 14–93, median 63). Their VHI score worsened significantly (P = 0.02)
EAT10 scores and none in VHI, RSI, or DI (Table 4). from 13.7 to 16.0 and their RSI score worsened insignificantly (P =
0.14) from 20.6 to 21.4. As our clinic no longer had access to recorded
videostroboscopic exams from the control group, we were unable to de-
Table 3
Additional diagnoses for patients excluded from the study group. termine a cause for this score increase. There were not enough CSI, DI, or
EAT10 data gathered for statistical analysis.
Allergies, rhinitis, post-nasal drip
Tukey adjusted post hoc test showed no significant demographic dif-
Esophageal pathology: eosinophilic esophagitis, cricopharyngeal web, esophageal
stricture ferences (age, gender disparity, BMI) between study and control groups.
Neurogenic cough In addition, the percent agreement between patients' subjective im-
Muscle tension dysphonia provement and their improvement in RSI scores was significantly corre-
Hyoid bone syndrome lated in both the study and control groups, demonstrating consistency
Vocal fold paralysis
between the two measures (Table 5).

Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014
4 J. Yang et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery xxx (2017) xxx–xxx

Fig. 1. Survey scores for study and control groups pre-treatment and post-treatment.

4. Discussion The induction program produced greater short-term relief than

medications, alone. Even the 21 patients who did not completely com-
The purpose of our study was to report the rapid rate of alleviation of ply with the program showed RSI scores trending toward improvement,
LPR-related symptoms in patients who completed the anti-reflux induc- while controls did not. Though we intended to determine if age, BMI,
tion program of diet, alkaline water, medications, and behavioral mod- smoking status, or medical comorbidities contributed to the success of
ification. We compared them with a similar group of patients who the induction program, we were unable to do so because the large ma-
completed only medications and behavioral modification. We were jority of our patients improved significantly within three to four weeks.
also interested in investigating how patients who had previously failed The result of this study indicating that anti-reflux medications are
anti-reflux medications alone and patients with a chief complaint of incompletely effective short-term is consistent with previous work.
cough responded to the induction program. This investigation demon- With empiric PPI treatment, one study reported that only 29% of pa-
strated that patients who completed the induction program had a tients showed significant improvement in RSI after 4 weeks and
higher response rate (92%) with significant improvement in RSI scores 12 weeks of treatment was required to reach 75% [26]. Another study
over patients on anti-reflux medications alone such as PPI and/or found that after 2 months of high dose PPI treatment, around 50% of pa-
H2RB (48%). This study suggests that the induction program is more ef- tients responded and an additional 22% (72%) responded after 4 months
fective than medications alone in ameliorating LPR symptoms over a [27]. It is difficult to convince patients to comply with medications for
short period of time. this protracted period of time with such a significant latency period es-
pecially in light of recent publications warning against long-term use of
PPIs. The promise of a maintenance program to help wean medications
is comforting to patients.
The results of a cohort of patients from the treatment group who
Table 5
Percent association between patients' reported improvement and their RSI score change.
failed previous high dose PPI treatment were analyzed separately to
serve as an internal control of this study. The number of patients in
RSI improved P-value the treatment group who had previously completed adequate trials of
No Yes anti-reflux medications was likely much higher, but we only included
N % N % patients who were confirmed through our records to have completed
an adequate high-dose trial. Fifteen of these patients who had failed re-
All samples
Subjective improvement No 31 47.0% 17 15.5% b0.001* ported subjective improvement and one reported no improvement over
Yes 35 53.0% 93 84.5% about one month. PPI resistance, or reflux unresponsive to antacids, is
not uncommon in practice. One study determined that 44% of LPR pa-
Study group
Subjective improvement No 5 16.7% 2 2.9% 0.014* tients have PPI resistance [11]. With a 1.5 to 2 times standard PPI
Yes 25 83.3% 67 97.1% dose, an improvement in RFS score has been seen in patients refractory
to PPI but with no corresponding improvement in 24-hour impedance
Control group
Subjective improvement No 26 72.2% 15 36.6% 0.002* monitoring [28]. The high success rate in our study indicates the poten-
Yes 10 27.8% 26 63.4% tial for the induction program to be used as an alternative therapy for
Abbreviations: RSI, reflux symptom index.
PPI resistant patients, as in our group of 16. It suggests that the “low-
Note: Tukey adjusted post hoc test is used and a P-value of 0.05 is selected for significant acid, low fat diet” may have a mechanism that differs from that of
difference. medications.

Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014
 J. Yang et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery xxx (2017) xxx–xxx
Another cohort of patients presented with a chief complaint of
cough. Within 4 weeks of treatment, 35 of 37 patients reported subjec-
tive improvement in cough and their CSI scores decreased significantly,
though they did not fall to a “normal level”. Though cough does tend to-
ward improvement, all but one of these patients were “chronic
coughers” and most had failed other treatment regimens. After months
or years with no improvement, these patients significantly improved
within four weeks. Chronic cough over 8 weeks is a common presenting
complaint and has been attributed to LPR, post-nasal drip, and cough-
variant asthma [29]. Cough is often difficult to treat and takes longer
to resolve than other typical LPR symptoms with medications alone.
One study determined that after 4 weeks of PPI treatment, patients
had improvement in their LPR-health-related quality of life survey in
the categories of voice, swallowing, and acid reflux but not in cough
and throat clearing. It took a total of 12-weeks of high-dose PPI therapy
to improve cough significantly [30]. The induction program used in this
study produced rapid results for chronic cough patients in the treatment
group.
Our study did not address long-term efficacy and success with main-
tenance off anti-reflux medications. The adverse effects of long term PPI
use are generally acknowledged but guidelines as to the length of treat-
ment for specific pathologic states have not been clearly defined. Relapse
of LPR symptoms have been observed 6 weeks after completing a 12-
week PPI trial, supporting a role for lifestyle change in producing lasting
results without medication [26]. Our study was not designed to detect
whether patients could maintain their success after stopping the medi-
cations begun during the induction program, though this was a goal
when patients began treatment. Presumably, lifestyle changes such as
these are the tools that will allow weaning of medications thereby
decreasing time on PPIs and reducing potential long-term side effects.
Many factors are likely to influence the success or failure of the in-
duction program. Difficulty in adherence to this program could be due
to patient motivation, perceived severity of symptoms, previous dietary
habits, and financial limitations. The possible reasons that 130 (48%)
patients did not follow up within 2 months of starting the induction
program are difficult to determine and quantify: patients might have
had success or failure with the program and decided that they had no
need for follow up, or they might have found the program too challeng-
ing. In attempting to address this question, we scrutinized the 21
patients who followed up within 2 months but did not adhere to the
program. They had a similar demographic profile to patients who
adhered to the program and over half of them (11) had pulmonary
comorbidities. Further study to investigate the socioeconomic reasons
for noncompliance to this program may help us better understand its
applicability.
The mechanism of the success of the induction program, particularly
the diet, is not clear. Bioactive mediators such as pepsin and stress
proteins, and protective proteins such as carbonic anhydrase and E-
cadherin are proposed contributors to the pathophysiology of LPR
[31–34]. The presence of pepsin and peptic activity up to pH 6.5 have
been found within laryngopharyngeal biopsy specimens of LPR patients
[35]. The induction diet's exclusion of acidic food items may help reduce
the incidence of pepsin activation in the laryngopharynx, reducing
inflammation and damage. The program may support healing and
reinstitution of esophageal and pharyngeal defenses against reflux.
Further investigation of pepsin and pH levels in patients pre-and post-
induction treatment is needed to support a claim that reduction in
peptic damage is one of the mechanisms of success for the induction
program.
This study possesses the limitations of a retrospective study. In prac-
tice, the overwhelming majority of patients who returned responded
favorably to the induction program but a large number did not return
at all. A prospective study is needed to further characterize the benefit
of this induction program and its long-term success, though this study
supports its use in reducing LPR symptoms, including cough, in a short
time.
Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014
5
5. Conclusion
This induction program consisting of low-acid/low-fat diet, alkaline
water, medications, and behavioral changes demonstrated swift efficacy
in ameliorating LPR symptoms, including cough. This combination
proved effective in patients who reported previous medication failures.
This program is a low-risk alternative to the standard medical treatment
of LPR. It could prove powerful in the effort to reduce widespread long-
term PPI use, though further study is required.
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Please cite this article as: Yang J, et al, Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications,
American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2017), https://doi.org/10.1016/j.amjoto.2017.10.014