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4, T|e Roya| Co||ees ol 3ureors ol Ed|rour| ard lre|ard


221
C||r|ca| Rev|eW
Laryngopharyngeal reux:
A literature review
A. Y. Khen
1

3. R. heshmi
2
F. Elehi
1
Y. 7eriq
J

0. R. /ngrems
1
1
0earrmenr ol EhT, Poya| Suenr los|ra|,
heuorr, $ourn wa|es
2
0earrmenr ol /naesrnes|a, wexnam Park
los|ra|, $|ougn ur
J
0earrmenr ol EhT, Vayo los|ra|, Lanore,
Pak|sran
0orresonoenoe ro. /. V. rnan
4 0|os Y Suaoo, Tnornn|||, 0aro|ll 0F14 90Z
Ema||. anuar_mo|nQyanoo.oom
Laryngopharyngea| reux (LPR} |s a common cond|t|on encountered |n oto|aryngo|og|ca| pract|ce
|n the Un|ted K|ngdom. |t |s one of the most |mportant aet|o|og|ca| factors for many |nammatory
d|sorders of the upper aerod|gest|ve tract. The presentat|ons are d|verse and |nc|ude chron|c hoarse-
ness, sensat|on of a fore|gn body |n the throat, sore throat, dysphag|a, postnasa| dr|p, excess|ve
throat mucous, chron|c cough and throat c|ear|ng. LPR pat|ents may not comp|a|n of heartburn.
A|though LPR |s common, |ts d|agnos|s may not be easy, as |ts symptoms are non spec|c and
the |aryngea| nd|ngs are not a|ways assoc|ated w|th symptom sever|ty. Th|s art|c|e d|scusses an
overa|| v|ew of LPR |n terms of pathophys|o|ogy, c||n|ca| presentat|on, d|agnos|s and treatment
Keywords: Laryngopharyngeal reux, voice disorders, upper aerodigestive tract, heartburn
Surgeon, 1 August 2 221-225
|NTR00U6T|0N
Laryngopharyngeal reux (LPR) is a common
condition seen in otolaryngological practice in
the United Kingdom. While many names have
been advocated Ior reux induced laryngeal
disorders (Table 1), LPR is the term accepted
by the American Academy oI Otolaryngology:
Head and Neck surgery.
1
TALE 1. TERH8 U8E0 T0 EXPRE88 REFLUX-
|N0U6E0 LARYNCEAL 0|80R0ER8
Laryrop|aryrea| reux
Posler|or |aryr|l|s
0aslro-oesop|aea| reux
Reux |aryr|l|s
0aslro-oesop|aea|-|aryrea| reux
3upra oesop|aea| reux
Exlra oesop|aea| reux
The term reux comes Irom a Greek word
that means back ow`` and in LPR reIers to
the back ow oI stomach contents above the
upper oesophageal sphincter, causing symp-
toms related to the pharynx and larynx.
2
LPR
is one oI the Ioremost recognised aetiological
Iactors behind the development oI various in-
ammatory disorders oI the upper aerodiges-
tive tract.
3
Although heartburn (pain caused by
oesophagitis) is one oI the key symptoms oI
gastroesophageal reux disease (GORD), it is
oIten absent in patients with LPR.
3-5
This is be-
cause most individuals with LPR have normal
oesophageal acid clearance, which is a useIul
marker oI oesophageal motor Iunction. Conse-
quently in many oI the individuals with LPR,
the quantity oI acid Iound in the oesophagus
is below the level required Ior the diagnosis
oI GORD to be made. This 'physiological
or 'silent reux does not produce symptoms
such as heartburn. However, in contrast to
the oesophagus, the mucosa oI the larynx is
thin, Iragile, and poorly tailored to protect
itselI against acid and activated pepsin and
hence is less able to respond well to chemi-
cal trauma. The larynx and pharynx are also
devoid oI the acid clearance mechanism Iound
in the oesophagus and thus is Iar more liable to
peptic injury.
3,6,7
Hence the chemical trauma to
the larynx and pharynx creates a local mucosal
lesion. There is another proposed theory that
acid stimulates vagally-mediated reexes in
the distal oesophagus, leading to laryngopha-
ryngeal changes and presents with chronic
cough and throat clearing sensation.
8
Lewin
HW DO (2003) Iound no signicant association
between the occurrence oI heartburn and LPR
in their patients.
9
Their results support other
authors` ndings that heartburn may not be a
dependable marker oI LPR.
3,4,10
There is no agreement to clearly describe
the diIIerence between physiological events and
221-225
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@ 2006 $urgeon 4. 4,
pathological episodes.
11
The number oI reux episodes and
acid exposure times are important in diIIerentiating normal in-
dividuals Irom patients with LPR.
12
It is believed to be normal
Ior the oesophagus to experience as many as 50 reux episodes
a day.
3,13
For the larynx, as little as three reux incidents a week
have been considered to be linked with the development oI
notable disease.
3,6
This is because oI weakness in protection
oI the laryngeal epithelium as compared with that Iound in the
oesophagus, as discussed above.
6,14

LPR occurs most Irequently while the patient is in the erect
posture and is thereIore Iound most commonly in the daytime.
This diIIers Irom GORD where reux occurs more regularly
when the patient is supine, usually during night time.
1,3,15,16

This relationship between reux and body position has been
Iurther analysed by Lewin HW DO (2003) in their study, where the
Irequency oI reux occurrence was higher in the erect than the
supine position in 91 oI 34 patients. Their study supported a
contrast between the presentation oI LPR and that oI GORD.
9

The occurrence oI reux in patients with voice disorders may
reach up to 50.
17
Physical evidence oI LPR was present in
64 oI the cohort described by Reulbach HW DO (2001) in their
study oI 100 volunteers over the age oI 40 with no history oI
voice disorders.
18
Some authors think that LPR is a common condition in
patients with head and neck cancer, and suggest that LPR has
a role in the carcinogenesis process oI the squamous cell car-
cinoma oI the head and neck.
19-21
However, the precise method
responsible Ior the development oI cancer by LPR remains uni-
dentied. The increased incidence oI squamous cell carcinoma
oI the larynx and the oesophagus in heavy smokers and drink-
ers and the high association between tobacco and alcohol con-
sumption with GORD raises the possibility that GORD may be
related to the development oI upper aerodigestive carcinoma,
especially laryngeal carcinoma.
3
Lewin HW DO (2003), in their
study oI 40 patients with histologically conrmed moderate to
severe dysplasia or early carcinoma oI the larynx, established
objective evidence oI LPR in 85 oI patients. This strength-
ens the ndings Iurther that LPR is a Irequent event among
patients diagnosed with carcinoma oI the larynx. However, it
is important to note that others do not accept this hypothesis
and Ieel that there is neither any consensus on whether LPR is
linked with squamous cell carcinoma oI the larynx, nor is there
suIcient data ascertaining LPR as an ultimate risk Iactor Ior
cancer.
9

6L|N|6AL FEATURE8
Patients with LPR commonly present to general practitioners
(or other primary care doctors) and otolaryngologists with
symptoms oI dysphonia, a sensation oI a lump in the throat,
cough, chronic throat clearing, dysphagia, postnasal drip, ex-
cessive throat mucus and a strange taste in the mouth, but oIten
do not complain oI heartburn.
1,3,22
As noted above, this contrasts
with GORD where heartburn is a common symptom.
1,3,15,22-26
Previous work by Delahunty and Cherry (1968) established
that inammation, ulceration and the development oI granu-
lation tissue on the vocal Iold mucosa occurred aIter exces-
sive contact with gastric contents.
27
A more recent study has
shown that patients with chronic reux present with increased
interarytenoid or posterior glottic inammation or erythema,
hypertrophy oI the posterior commissure (cobblestoning), and
granulation tissue Iormation in severe cases.
28
KouIman HW DO
(1988) have proposed that laryngeal oedema (not erythema) is
the most regular laryngeal nding connected with reux.
26

0|ACN08|8
Although LPR is common, its diagnosis may not be easy be-
cause its symptoms are indistinct and the laryngeal ndings are
not always correlated with symptom severity.
29
Until recently, there has been no agreement about the suit-
able methodology to identiIy or measure LPR, and there is still
little consensus concerning the indications Ior treatment and
the most Iavourable evaluation oI treatment response.
3,7,30
Even
though 24-hour ambulatory pH monitoring (use oI a single
probe in the oesophagus) is a well recognized technique Ior
assessing GORD, it has not achieved the same level oI endorse-
ment Ior LPR. The level oI normal reux into the laryngophar-
ynx remains debatable.
7,10
ThereIore, the data explaining the
occurrence and pattern oI LPR are scarce and the signs and
symptoms oI LPR that may diIIerentiate it Irom GORD have
not been well dened.
9
Wiener HW DO (1986) were the rst to use concurrent
oesophageal and pharyngeal pH monitoring Ior diagnostic
evaluation oI patients with LPR symptoms.
22
In this technique,
two pH probe devices (pharyngeal and oesophageal) monitor
the acid reux. The pharyngeal probe is placed proximally at
the upper oesophageal sphincter and the oesophageal probe is
placed distally above the gastroesophageal junction. This en-
hanced technique precisely detects acid reux episodes above
the upper oesophageal sphincter. When guided by manometry,
double probe pH monitoring can now be considered the gold
standard Ior the diagnosis oI LPR.
7,16,31,32
BelaIsky HW DO (2001) developed an eight-item reux nding
score (RFS) (Table 2).
29
This score is based on objective nd-
ings observed during beroptic nasoendoscopy oI the larynx.
This aims to Iacilitate the standardisation oI the clinical nd-
ings oI LPR so that clinicians may improve on diagnosis, quan-
tiIy symptom severity, and measure therapeutic eIIectiveness oI
patients with this disorder. The score ranges Irom a minimum
oI zero (no abnormal ndings) to a maximum oI 26 (worst
score possible). It is essential to note that the RFS is simply a
clinical scale oI laryngeal inammation. The independent items
on RFS are not designed to individually Iorecast the presence
or absence oI LPR.
33
Other Iactors such as inIection, allergy,
neoplasia, auto-immune disorders and environmental toxins
may add to the inammation and hence contribute to an abnor-
mal RFS.
34
In a study oI 40 patients with LPR and 40 normal
control individuals, it was Iound that mean RFS Ior the normal
individual was 5.2, while the mean RFS Ior patients with con-
rmed LPR was 11.5. The authors concluded that RFS oI six
should be considered normal and RFS oI greater than seven is
statistically associated with LPR in 95 oI individuals.
33
A strong relationship between erythema and LPR has been
noted by some investigators.
35
In Iact, laryngeal erythema is a
rather non-specic nding that is considerably dependent on
the examination technique. However, laryngeal erythema can
be classied as isolated when limited to the mucosa overly-
ing the arytenoid and corniculate cartilages and diIIuse when
it extends over the entire larynx. In contrast with localised
erythema, diIIuse erythema is more expected to be associated
with LPR.
34
BelaIsky HW DO (2001) in their study oI 40 patients with
LPR, conrmed by dual probe (simultaneous oesophageal and
221-225
@ 2006 $urgeon 4. 4, T|e Roya| Co||ees ol 3ureors ol Ed|rour| ard lre|ard
223
pharyngeal) pH monitoring, Iound the most common signs in
persons with LPR was posterior laryngeal hypertrophy, which
was recognised in 85 oI all patients beIore the start oI any
treatment.
29
Partial or total obliteration oI laryngeal ventricle
(the space between true and Ialse vocal cords) as a result oI
swelling oI the true and Ialse cords is another important discov-
ery in 80 oI patients with pH documented LPR.
33
TALE 2. REFLUX F|N0|NC 860RE
6ond|t|on RF8
3uo|oll|c oedera 0= aoserl
2= preserl
verlr|cu|ar oo||leral|or 0= rore
2= parl|a|
1= corp|ele
Eryl|era/|yperaer|a 0= rore
2= arylero|ds or|y
1= d|lluse
voca| cord oedera 0= rore
1= r||d
2= roderale
3= severe
1= po|ypo|d
0|lluse |aryrea| oedera 0= rore
1= r||d
2= roderale
3= severe
1= ooslrucl|r
Posl corr|ssure |yperlrop|y 0= rore
1= r||d
2= roderale
Vocal Iold granulomas are recurrent benign lesions which
were once believed to occur as a result oI undue mechanical
trauma (endotracheal intubation, chronic cough and excessive
throat clearing) on the vocal process oI the arytenoid, but are
now being considered a consequence oI LPR.
36-38
Pseudo sul-
cus vocalis, also known as inIra-glottic oedema, is a pattern oI
oedema on the ventral surIace oI the vocal Iold that extends
Irom the anterior commissure to the posterior larynx. The
presence oI pseudo sulcus alone is suggestive oI a diagnosis
oI LPR.
39-41
Recently, it has been suggested that there is an association
between hypertrophy oI Waldeyer`s ring (palatine tonsils, pha-
ryngeal tonsils, lingual tonsil and intervening lymphoid tissue)
lymphatics and LPR.
42
Endoscopic ndings oI excessive throat
mucus may be related to LPR. This is named as 'water brash
and is dened as the abrupt lling oI the mouth with clear mu-
cous. Water brash is linked with the LPR. There is a release
oI salivary bicarbonate during an event oI acid reux. The
bicarbonate here acts as an endogenous antacid that provides a
protective response to neutralise stomach acid.
43
Galli HW DO (2003) in their study oI 33 patients with clinical
symptoms and signs oI LPR gave their patients a 60-day course
oI acid suppression therapy (20mg Omeprazole twice daily), at
the same time achieving a reasonable response in symptoma-
tology, as set out in the guidelines which came Iorward Irom
the 1997 Consensus ConIerence Report on LPR. Seventy three
per cent oI the patients were Iound to have a complete sympto-
matic improvement to acid suppression test, while partial im-
provement in 12 and no response in 15 was documented. In
spite oI the known resistance oI proton pump inhibitors in some
individuals, the 'Omeprazole test is possible in the initial as-
sessment oI LPR in outpatients, especially when double probe
pH monitoring study is not possible.
44-46

TREATHENT
The neutralisation oI the acidity oI the reux has been the
Ioundation oI the treatment oI LPR.
2
Generally, there are sev-
eral treatments Ior LPR such as changing liIestyle and dietary
modication to reduce reux, medicines to minimise stomach
acid and surgery to prevent reux in a Iew resistant cases.
47

L|festy|e Hod|cat|ons
Most people with LPR need to modiIy how and when they eat
as well as other day-to-day activities (Table 3).
48
TALE 3. L|FE8TYLE AN0 0|ETARY H00|F|6AT|0N8
3lop sro||r
Appropr|ale spac|r oelWeer rea|s
Avo|d eal|r W|l||r l|ree |ours ol oedl|re
LoW lal d|el
Reduce |rla|e ol collee, c|lrus ju|ces ard zzy dr|r|s
Reduce We||l |l ooese
L|r|l a|co|o| |rla|e
Avo|d ca|c|ur c|arre| o|oc|ers, l|eop|y|||re, arl|c|o||rer|cs, oela-
o|oc|ers, ard sore ca|c|ur supp|ererls |l poss|o|e, W||c| are l|ou|l
lo |rcrease aslr|c ac|d
Hed|ca| Treatment
Along with advice on liIestyle and dietary modications, most
oI the patients will require some Iorm oI medical therapy. The
aim oI the medical management oI LPR is neutralisation oI the
gastric juice acidity and the enhancement oI gastrointestinal
tract motility.
2
Treatment with proton pump inhibitors (PPI) is
required Ior the resolution oI laryngeal symptoms and physical
ndings oI patients with LPR.
Symptom resolution oI straightIorward LPR usually takes
place within two months oI therapy with PPI. Nonetheless, the
objective ndings oI LPR recover more slowly and continue
to get better Ior the period oI six months oI treatment. Voice
disorders may have numerous causes. ThereIore, the lack oI
ability oI proton pump inhibitors to entirely resolve the symp-
toms or physical ndings is likely. Treatment oI LPR oI more
221-225
T|e Roya| Co||ees ol 3ureors ol Ed|rour| ard lre|ard 221
@ 2006 $urgeon 4. 4,
than six months may be indicated to attain a Iull resolution oI
physical ndings and to reduce the risk oI the return oI symp-
toms. Termination oI treatment based on the presumption that
LPR symptoms are getting better alone may be premature. This
conclusion concurs with the view oI the Consensus ConIerence
Report on LPR (1997) that the suggested twice daily PPI treat-
ment be continued Ior a minimum period oI six months.
33
Besides the nature oI treatment, the dosage and duration
oI treatment is also oI great interest. A considerable number
oI patients on twice daily PPIs do not have satisIactory acid
suppression Ior curing the LPR.
49
As a consequence, this group
oI patients may need a higher dosage oI PPI or replacement by
H
2
receptor antagonists. LiIelong treatment with PPI in some
patients may be inevitable.
33

Ant|-Reux 8urgery
Fundoplication augments treatment oI LPR in Iew patients with
severe LPR or those who are intolerant to anti-reux medicine
or resistant to PPI.
33,50,51
This surgical treatment provides relieI
oI LPR symptoms Ior many years.
60N6LU8|0N
Although LPR is a common condition presenting in ENT set-
tings, the symptoms and signs may be complex. Most clinicians
rely on their clinical judgment Ior diagnosing this condition.
Proton pump inhibitors remain the standard treatment and
should be continued Ior a minimum oI six months.
6opyr|ght 8 June 200
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TRUE 0R FAL8E 0UE8T|0N8 (Answers at end of |ssue}
LPR occurs most commonly in the following:
3up|re poslure
Erecl poslure
0ayl|re
N||l l|re
Pal|erls W|l| vo|ce d|sorders
For the treetment of LPR:
Ved|ca| lrealrerl |s rol reeded
C|ares |r ||lesly|e ard d|el car |e|p |r r|r|r|z|r l|e syrplors
PPls do rol |ave ary ro|e
Neulra||sal|or ol l|e aslr|c ac|d |s rol recesssary
3ur|ca| |rlerverl|ors |||e lurdop||cal|or ray |ave lo oe carr|ed oul |r
pal|erls res|slarl lo arl|-reux red|c|re l|erapy
221-225