Laryngeal and voice disorders in patients with gastroesophageal symptoms . Correlation with pH-monitoring

PURPOSE: To investigate laryngeal and voice disorders in patients with gastroesophageal symptoms and their correlation with pHmonitoring. METHODS: A prospective study was carried out in patients attended at the Voice Disorder Outpatient Clinics of Botucatu Medical School in a five-year period and had vocal and gastroesophagic symptoms. Patients underwent videolaryngoscopy, auditory-perceptual vocal analyses, computerized acoustic vocal analysis and dual probe pH-monitoring for 24 hours. RESULTS: Fifty-seven patients were included (aged between 21 and 65 years; 45 women and 12 men), 18 had normal (31.6%) and 39 had abnormal pH-monitoring results (68.4%). Videolaryngoscopy recorded several laryngeal lesions for both patients with normal and abnormal pH-monitoring, but mostly for the latter group, highlighting posterior pachyderma. Auditory-perceptual vocal assessments identified vocal changes of several intensities for both groups but especially for patients with abnormal pH-monitoring results. All acoustic parameters, except f0, were abnormal for both groups, compared to the control population. CONCLUSION: Acoustic and perceptual vocal changes and laryngeal lesions were recorded for both patients with normal pH-monitoring results and patients with abnormal pH-monitoring results, evidencing the importance of clinical history and videolaryngoscopic findings for diagnosing acid laryngitis.


Introduction
Gastroesophageal reflux affects 20 to 40% of the population, leading to highly frequent otolaryngological symptoms such as postnasal and pharyngeal secretion, hoarseness, dysphagia, nocturnal laryngospasm, otalgia, chronic cough, sensation of a "ball" in the throat and bronchopneumonia [1][2][3] .Voice disorders have been emphasized for their presence among 50% patients with gastroesophageal reflux symptoms 3 .
During videolaryngoscopy, the most important changes for acid laryngitis have been: erythema and pachyderma in posterior glottis, edema and hyperemia of vocal folds, vocal nodules, pseudosulcus, cyst, polyp, hyperplasia of postcricoid mucosa, contact ulcer, erythema and/or edema of tracheobronchial tree segments, granuloma in posterior glottis and larynx secretion 4 .Some authors have also recorded functional disorders, in which the phonatory dynamics is compromised by acid reflux, including mucus propulsion retardation, aperiodic muco-undulatory movement, signs of muscular tension with hypercontraction of ventricular folds, irregular vibration of the mucosa of vocal folds and glottal closure.Such alterations peak with impaired vocal quality and justify the dysphonia shown by these patient 5 .
Several changes in the vocal characteristics can be diagnosed during speech assessments, sometimes early by means of auditory-perceptual and computerized acoustic analyses.The benefits of these analyses have been proved for GERD patients with vocal symptoms.Ross et al. 5 recorded increased musculoskeletal tension, abrupt vocal attack and varied degrees of dysphonia in auditory-perceptual analyses.As to acoustic measures, those authors did not notice changes in the fundamental frequency (f0) but found higher shimmer values, justifiable by the possible presence of laryngeal lesions like laryngeal edema, pseudosulcus and nodule.These lesions change the mass and the tension of vocal folds, influencing their vibration pattern and time, important prerequisites to control vocal intensity.
The laryngeal mucosa is known to be more sensitive to acid reflux than the esophageal mucosa since the esophagus has its own peristalsis, epithelium covered by a layer of keratin and is permanently bathed with secretions rich in bicarbonate, which give the mucosa higher protection 6 .The larynx, devoid of such protective agents, becomes more vulnerable to lesions, usually diagnosed even for patients with normal endoscopic and pHmonitoring results.
The pH-monitoring is considered the gold standard test for diagnosing the acid reflux disease 1,7 .It employs a dual probe, one of them positioned in the hypopharynx and the other one in the esophagus.Records are considered pathological when pH values are inferior to 4 at a frequency higher than 0.1% of the total measures performed during 24 hours 7 .However, some patients

Statistical analysis
For the results of videolaryngoscopic test, acoustic and perceptual-auditory vocal analysis and pH-monitoring, Student's t test was employed, considering 5% significance level.
Vocal abuse was identified for 33 patients (57.8%; n-12, normal pH-monitoring group; n-21, abnormal pH-monitoring group).Investigation relative to the profession of these patients detected some classes of professionals with high phonatory demand, which are shown in Figure 1, highlighting the largest number of teachers which corresponded to 13 patients (n-7, normal pH-monitoring group; n-6, abnormal pH-monitoring).Among the remaining professions are: sellers (n-8), traders (n-8), secretaries (n-3) and a pastor (n-1).The acoustic parameters of dysphonic patients with normal pH-monitoring results and abnormal pH-monitoring results, respectively, were compared to those of the control population of both sexes, as shown in Tables 3 and 4. Both patients with normal pH-monitoring results and patients with abnormal pH-monitoring results had acoustic parameter values far from the standard values, especially for jitter, shimmer, PPQ, APQ and SPI.

Discussion
Gastroesophageal reflux disease affects approximately 10 to 15% of the population and deserves attention since it evolves with esophageal and extraesophageal symptoms.The latter include otolaryngological symptoms, as well as chronic cough, globus sensation in the throat, secretion in the pharynx, gagging, dysphagia, laryngospasm and dysphonia [1][2][3]4,8 .
The diagnosis of gastroesophageal reflux disease (GERD) requires highly detailed clinical history while complimentary tests, commonly requested, include upper gastrointestinal endoscopy, electromanometry and 24-hour dual channel pH-monitoring.The latter has been highlighted by most authors, among the remaining tests, due to its accuracy for diagnosis 1,7 ; others, however, have stated that not even this test is decisive for GERD diagnosis, usually requiring therapeutic test for proving 9 .There are several arguments such as the position of probes installed in pHmonitoring, since the closer the pharyngeal probe is to the upper esophagic sphincter, the larger is the number of acidity cases.For patients with otolaryngological and gastroesophageal symptoms and with videolaryngoscopic changes characteristic of laryngeal reflux, the diagnosis of acid laryngitis leaves few doubts, even for those with normal pH-monitoring results, as noted for 30% of the patients in this study.
The main videolaryngoscopic findings for patients with acid laryngitis are hyperemia of vocal folds, edema, hyperplasia of lymphoid tissues in the base of the tongue, erosions of mucosae, granulomas, leukoplasia, epithelial thickness, polyps, nodules, and others 4,[8][9][10] .A large number of these lesions were recorded in the present study, highlighting pachyderma of posterior glottis (Figures 2 and 3).For some patients, more than one laryngeal lesion was diagnosed, almost always associated with pachyderma (Figure 4).This lesion is a frequent endoscopic finding for patients with gastroesophageal symptoms and seems to correspond to the site first exposed to acid reflux.For some patients, pachyderma precedes the emergence of other laryngeal lesions.
We believe that some lesions detected in acid laryngitis must be carefully interpreted since they can be identified even in patients without gastroesophageal symptoms.However, the close relationship between laryngeal lesion and acid reflux was previously demonstrated by some experimental studies in which the laryngeal mucosa of animals received direct irrigation of hydrochloric acid and histologically showed marked changes in its coverage 11  Those same authors also found important vocal changes in the auditory-perceptual analyses for patients with GERD.For Selby et al. 14 , treatment with proton-pump inhibitors for at least eight weeks may enhance vocal improvement, as observed for 44% of their patients.

Conclusion
Acoustic and perceptual vocal changes and laryngeal lesions were recorded for both patients with normal pHmonitoring results and patients with abnormal pH-monitoring results, evidencing the importance of clinical history and videolaryngoscopic findings for diagnosing acid laryngitis.
who are dysphonic and have relevant gastroesophageal symptoms have shown pH-monitoring results within normal patterns, raising doubts about the specificity of this test for diagnosing acid laryngitis.The aim of this study was to analyze videolaryngoscopic changes, vocal characteristics and their correlation with pHmonitoring results in dysphonic patients with gastroesophageal symptoms.Methods This prospective study included patients who were attended at the Voice Disorder Outpatient Clinics of Botucatu Medical School between 2006 and 2011 and had permanent dysphonia associated with gastroesophageal symptoms at a frequency equal or superior to twice a week including heartburn, burning sensation, acid reflux, epigastric pain and satiation.All patients filled the study protocol containing detailed questions about their voice.Then, they underwent videolaryngoscopy by means of a multifunctional system with image capturing (model Eco X-30-TFT/USB, Germany), attached to a 70º rigid Laryngeal and voice disorders in patients with gastroesophageal symptoms.Correlation with pH-monitoring Acta Cirúrgica Brasileira -Vol.27 (11) 2012 -823 telescope, 8 mm (Asap, Germany), and stroboscopic light source (Atmos, Germany), with image record in a DVD.They were also subjected to auditory-perceptual vocal analyses using GRBASI scale and computerized acoustics (Multi-speech 3700, MDVP, Kaypentax, USA) by skilled speech therapists.Acoustic measures were obtained from the sustained emission of vowel /a/ at basal frequency and intensity during three seconds.The analyzed acoustic parameters were: fundamental frequency (f0), jitter, PPQ, shimmer, APQ, SPI and NHR.Results were compared to those of patients without vocal or gastroesophageal symptoms and with adequate vocal quality according to auditory-perceptual analysis.The study was approved by the Human Research Ethics Committee of Botucatu Medical School (protocol 493/08), Finally, patients underwent dual-channel pH-monitoring during 24 hours.They were instructed to suppress, one week prior to the test, antacid medicines and proton-pump inhibitors, as well as acid food and juice during the investigation.To introduce the dual conductor of the pH-monitoring probe (model AL-2, Alacer Biomédica, Brazil), patients received topic anesthesia with gel xylocaine in the nasal cavity.The upper probe was kept in the hypopharynx region, at 25 cm from the lower esophageal sphincter (LES), while the lower probe was kept at five cm above the former.pH-monitoring was kept for 24 hours, recording the number of reflux episodes and the percentage of times pH was inferior to 4, according to DeMeester score 7 .Results were classified as normal when the recorded values were inferior to 14.7 associated with absence of reflux at the proximal sensor.Excluded from the study were carriers of neurologic, autoimmune, respiratory or endocrine diseases that might compromise laryngeal mucosae or vocal quality, as well as patients with history of prolonged tracheal intubation or laryngeal microsurgery.

FIGURE 1 -
FIGURE 1 -Profession of patients with vocal abuse.

Table 1
, with emphasis on pachyderma in posterior commissure.More than one change was detected in the videolaryngoscopic test for some patients of both groups.Patients with abnormal pHmonitoring results had a larger number of lesions; however, in 31% cases patients with normal pH-monitoring results reported gastroesophageal symptoms and had laryngeal lesions identified by videolaryngoscopy.Some of the major laryngeal lesions diagnosed for such patients are illustrated in Figures2 to 4.

TABLE 1 -
Correlation between videolaryngoscopic findings and pH-monitoring.

TABLE 3 -
Correlation between mean and standard deviation (SD) of acoustic parameters for patients with normal pH-monitoring results and controls of both sexes.

TABLE 4 -
Correlation between mean and standard deviation (SD) of acoustic parameters for patients with abnormal pH-monitoring results and controls of both sexes.

TABLE 5 -
Mean and standard deviation (SD) among acoustic parameters for patients with abnormal and patients with normal pH-monitoring results.Acta Cirúrgica Brasileira -Vol.27(11)2012-827 13normal pH-monitoring results -named objective, and 23 with normal pH-monitoring results, named symptomatic) and compared these data with values obtained for a control group composed of 64 volunteers.Those authors observed significant changes in the acoustic parameters of frequency disorder measures for both patients with abnormal pH-monitoring results and patients with normal pH-monitoring results, compared to controls, corroborating the results of the present study.High acoustic measures were also recorded by Pribuisiene et al.13for 108 patients with diagnosis of GERD and 90 controls, highlighting for men, respectively, percentage of jitter (0.25±0.13 versus 0.18±0.04)and percentage of shimmer (2.39±1.31versus 1.57±0.59).For women, the comparative values of such parameters were, respectively: percentage of jitter (0.36±0.44 versus 0.18±0.05)and percentage of shimmer (2.19±0.99versus 1.47±0.44).The values of f0 were similar to those for patients of the control group of both sexes.