Laryngopharyngeal Reflux

By :- Dr. Supreet Singh Nayyar, AFMC

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Introduction
The term REFLUX comes from the Greek word meaning
backflow, usually referring to the contents of the
stomach

AAOHNS adopted the terminology LPR- Laryngopharyngeal
Reflux in 2002

GERD: an abnormal amount of reflux up through the
lower sphincters and into the esophagus.

LPRD: when the reflux passes all the way through the
upper sphincter reaching the larynx and pharynx without
belching or vomiting


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Epidemiology
Incidence 4%-10% in various studies
No racial predilection
Common in age > 40 yrs
Upto 55%- with hoarseness *
75% - with subglottic stenosis
20%-45%-shows Heartburn, Regurgitation and
indigestion

* Koufman JA et al : Reflux Laryngitis and its sequela:the diagnostic role of ambulatory
24-hr pH monitoring. J Voice 2:78-79,1994

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Relevant anatomy and physiology
Lower
Various mechanisms
acts
3 cm in length

Upper
Cricopharyngeus + circular
muscle fibers of esophagus
3 cm in length




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Anti reflux barrier
Oesophageal Acid Clearance
Increased by peristalsis of oesophagus & salivary bicarbonate
Decreased by abnormal oesophageal motility & xerostomia
Oesophageal peristalsis
Primary
Secondary

Oesophageal Epithelial Resistance
Mucus : barrier to pepsin
Cell membrane, intercellular bridge
Metabolic buffering capacity of mucosa
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Cause of symptoms
Retrograde reflux of gastric acid

Damage to cilia from reflux contents - mucous stasis

Gastroesophageal reflux - neurally mediated
chronic cough

Defect in carbonic anhydrase iso enzyme III

Deglutitive pharyngo laryngeal abnormalities
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Pathophysiology
Gastric contents (acid & pepsin)

LES

Backflows

UES

Laryngeal mucosa (post glottis)


Persistent and chronic Inflammation


Mucosal changes

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Etiologic factors
Decreased lower esophageal sphincter pressure

Abnormal esophageal motility

Abnormal or reduced mucosal resistance

Delayed gastric emptying

Increased intra abdominal pressure

Gastric hyper secretion of acid or pepsin
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Reduced LES pressure
Hiatus hernia
Diet: fat, chocolate, mints, onion, milk product,
cucumber
Tobacco
Alcohol
Drug: Theophylline, Nitrates, Dopamine, Narcotics
(Morphine,Mepheridine), Diazepam, Calcium
channel blockers, Alph-adrenergic blockers,
Anticholinergics, progesterone.

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Etiology
Abnormal esophageal motility
Neuromuscular disease
Laryngectomy
Ethanol

Reduced Mucosal Resistance
Xerostomia

Sicca syndrome

Oral cavity radiotherapy

Esophageal radiotherapy

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Delayed gastric emptying
Outlet obstruction
ulcers, neoplasm, neurogenic
Diet (fat)
Tobacco
Alcohol

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Increased intra abdominal pressure
Tight clothing (eg. corsets, belts)

Diet: Overeating, carbonated beverages

Obesity

Pregnancy

Occupation

Exercise
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Gastric hyper secretion

Stress: Trauma, surgery, lifestyle

Tobacco

Alcohol

Drugs

Diet

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Smoking & Alcohol
Smoking Alcohol
LES pressure Yes Yes
Mucosal resistance Yes Yes
Gastric emptying delay delay
Gastric hypersecretion Yes Yes
Oesophageal dysmotility (-) (+)
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CLASSIFICATION OF REFLUX
1. Physiologic
Asymptomatic
Postprandial
No abnormal findings
2. Functional
Asymptomatic
Positive pH study
3. Pathologic
Local symptoms
Secondary manifestations of LPR
4. Secondary
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LPR and GERD
LPR
Day time/ upright reflux

No oesophagitis / heart
burn

Intermittent episodes of
reflux

UES dysfunction

No protection
GERD
Nocturnal/supine reflux

Heartburn

Dysmotility & prolonged
esophageal acid
exposure

LES dysfunction



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Presentation/Symptoms
Hoarseness 70%

Voice fatigue, breaking of the voice

Cough 50%

Globus pharyngeus 47%

Frequent throat clearing, dysphagia, sore
throat, wheezing, laryngospasm, halitosis
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Secondary problems
LARYNGEAL
Benign vocal cord lesions
Functional voice disorders
Leucoplakia, Ca Larynx
Subglottic stenosis
Laryngeal Stenosis
Laryngospasm
Laryngomalacia
Delays healing following Post intubation injury
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Secondary Problems
PHARYNGEAL
Globus pharyngeus,
Chronic sore throat,
Dysphagia,
Zenkers diverticulum
PULMONARY
Asthma
Bronchieactasis
Chronic bronchitis
Pneumonia
Carcinoma
Fibrosis

MISCELLANEOUS

Chronic rhinosinusitis
Otitis media in children
OSA
Dental erosions

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Diagnosis
Why is diagnosis of LPR often missed??

Low index of suspicion

Patients often dont have heartburn (esophagitis)

Variable / unrecognized findings

Chronic intermittent nature of LPR leads to decreased
sensitivity of pH monitoring

Inadequate duration &/or dosage of PPI

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Reflux Symptom Index (RSI)

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Investigations
IDL/FOL

Videostroboscopy

24hour, ambulatory, double probe pH metry

Barium oesophagography

DL scopy

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FOL
Post laryngitis
Erythema
Mucosal hypertrophy
Vocal cord
granulomas, nodules

Oedema

Thick endo laryngeal
mucus


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Video stroboscopy
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Ambulatory, 24hour, double-probe ph
Monitoring
Instructions-
Stop antireflux drugs
Document meals and
symptoms
Double probe
Simultaneous
pharyngeal &
oesophageal
Positions distal 5cm
above LES, proximal
just above UES


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Contd
Parameters
% upright time/total
time/recumbent time with pH <
4
No. of refluxes with pH < 4
Periods of longest acid
exposure

Criteria's
pH < 4
Pharyngeal pH drop
oesophageal acid exposure
pH drop rapid & sharp

Advantages
Gold std to diagnose LPR
Disadvantages
Discomfort
Vasovagal episodes
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Barium Oesophagography
To identify motility disorders of esophagus

Oesophageal lesions

Spontaneous reflux

Hiatus hernia

Lower oesophageal sphincter disorder

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Treatment
Antireflux therapy

Phase I : Lifestyle-dietary modification
Antacid therapy

Phase II : Prokinetic
H2-blockers, PPI

Phase III : Antireflux surgery

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Lifestyle modifications
Stop smoking

Elevate the head of the bed on blocks(15-20cm)

Reduce body weight

Avoid tight-fitting clothing

Avoid lying down after meals

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Dietary modification
Avoid fat, caffeine, chocolate, mints,
carbonated drinks, fat, mints chocolate, milk
product, onion, cucumber

Avoid alcohol

Avoid overeating

Avoid ingestion of food and drink 2 hours before
bed time
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Voice Therapy

Vocal Hygiene
-Reduce/eliminate throat clearing and
coughing.

-Encourage conservative voice use

-Initiate new functioning voicing
behaviors.

-Production of voice with an extreme
forward focus.

Resonant voice therapy (RVT): most often employed for
LPR/granulomas

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Voice therapy
Developed by Verdolini & Lessac.

Resonant Voice: involves oral vibratory sensations in the
context of easy phonation.

Goal: to achieve the strongest, cleanest possible
voice with the least effort and impact between the vocal
folds to minimize the likelihood of injury and maximize
the likelihood of vocal health (Stemple et al., 2000).

How? Pt. Is asked to monitor the feel and to
concentrate on auditory feedback
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PHARMACOLOGICAL
DRUGS
ANTACIDS
Mixture of Al
hydroxide
& Mg trisilicate
ANTISECRETORY
H2 Blockers
PPIs
Mucosal protective
PROKINETIC
Metoclopramide
Domperidone
Cisapride
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Drug therapy
Antisecretory
H2 Blockers
Ranitidine, Famotidine,
Reversibly reduces acid secretion, not helps in healing
PPIs
Near total acid suppression, promotes healing
Omeprazole (20-40mg OD)

Mucosal protective
Sucralfate, alginic acid

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Antacids
Immediate relief of symptoms
Reduces acidity
Not helps in healing
Antacid mixture

Prokinetic
Symptomatic relief, not helps in healing
Increases gastric emptying
Metoclopramide (5-10mg tds), Domperidone
(10-20mg tds)

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Evaluation and Management
of Laryngopharyngeal Reflux
Charles N. Ford, MD
JAMA. 2005;294:1534-1540.
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Surgery
Laparoscopic Nissen Fundoplication

Indications
Failed drug treatment
Complications

Goal
Restore natural integrity of
LES & maintain normal
deglutition
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PAEDIATRIC LPR
Incidence - 18% of all
infants

70% in TO fistula,
neurological diseases

Children < 3y more
prone for reflux

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Natural history of reflux
In majority it is self limited

Improves by 1
st
yr of life others can be
benefited by positional treatment

If persists after 3 yrs of age needs medical
or surgical treatment
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Symptomatology
Mechanisms
Microaspiration
Oesophageal reflux

Manifest as
Chronic cough
Asthma
Hoarseness
Laryngomalacia
Subglottic stenosis
Apnea
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Diagnosis
History

Examination

Laryngoscopy & bronchoscopy

Prolonged double probe pH metry
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Treatment
Similar as adult except

Burping

Positional management

PPIs lack of long term experience

No surgical intervention before 3 years
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Whats new
Pepsin detection in throat sputum by
immunoassay
100% sensitive & 89% specific

Reflux laryngitis is associated with down-
regulation of mucin gene expression.

Bifurcated, triple-sensor

pH probe allows
identifying true hypopharyngeal reflux episodes

Oropharyngeal aerosol-detecting pH probe
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Thank You
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