1

LaryngoPharyngeal Reflux (LPR)

Prepared by: Nibal Shawabkeh

Supervised by: Dr. Adel Adwan

2 Introduction

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

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

3 Laryngopharyngeal Reflux (LPR)

LPRD refers to retrograde flow of gastric contents to the upper aero-digestive

tract, which causes a variety of symptoms

Contributes up to 50% of laryngeal complaints

The injurious agents in the refluxed stomach contents are primarily acid and activated pepsin.

The damage caused by these materials can be extensive.

Specific findings include: laryngeal hyperemia, posterior commissure hypertrophy, pseudosulcus vocalis, and thick endolaryngeal mucus.

4 Synonyms for Laryngopharyngeal Reflux (LPR)

Atypical reflux

Extraesophageal reflux

Gastropharyngeal reflux

Laryngeal reflux

Pharyngoesophageal reflux

Reflux laryngitis

“Silent” reflux

5 Epidemiology

Incidence 4%-10% in various studies

No racial predilection

Common in age > 40 yrs

Up to 70% with hoarseness *

75% - with subglottic stenosis

20%-45%-shows Heartburn, Regurgitation and indigestion

6 Relevant anatomy and physiology

LowerVarious mechanisms acts 3 cm in length

UpperCricopharyngeus + circular muscle fibers of esophagus3 cm in length

7 Pathophysiology

Gastric contents (acid & pepsin)

LES Backflows UES

Laryngeal mucosa (post glottis)

Persistent and chronic Inflammation

Mucosal changes

8 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

9 CLASSIFICATION OF REFLUX

1. Physiologic Asymptomatic

Postprandial

No abnormal findings

2. Functional Asymptomatic

Positive pH study

3. Pathologic Local symptoms

Secondary manifestations of LPR

10 Patterns and Mechanism of LPR and GERD

LPRNo heartburnDaytime (“upright”) refluxersNormal esophageal motilityNormal acid clearanceMajority without esophagitis1 defect - UESClinical presentations

GERDHeartburnNocturnal (“supine”) refluxersEsophageal dysmotilityProlonged acid clearanceCan present with esophagitis1 defect – LESClinical presentations

11 Presentation/Symptoms

Hoarseness – 70%

Voice fatigue, breaking of the voice

Cough – 50%

Globus pharyngeus – 47%

Frequent throat clearing, dysphagia, sore throat, wheezing, laryngospasm, halitosis

12 Secondary problems

LARYNGEAL Benign vocal cord lesions Functional voice disorders Leukoplakia, Ca Larynx Subglottic stenosis Laryngeal Stenosis Laryngospasm Laryngomalacia Delays healing following Post intubation injury

13 Secondary Problems

PHARYNGEALGlobus pharyngeus, Chronic sore throat, Dysphagia, Zenker’s diverticulum

PULMONARYAsthmaBronchieactasisChronic bronchitisPneumoniaCarcinomaFibrosis

MISCELLANEOUS

• Chronic rhinosinusitis• Otitis media in children•Dental erosions

14

15 Diagnosis

Why is diagnosis of LPR often missed??

Low index of suspicion

Patients often don’t have heartburn (esophagitis)

Variable / unrecognized findings

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

Inadequate duration &/or dosage of PPI

16 Diagnosis

Symptom questionnaire

Laryngeal examination / Laryngoscopy

Therapeutic trial

Endoscopy – limited utility

Ambulatory 24-hr esophageal pH monitoring

17 Symptom Questionnaire:Reflux Symptom Index

18 Diagnosis

Symptom questionnaire

Laryngeal examination / Laryngoscopy

Therapeutic trial

Endoscopy – limited utility

Ambulatory 24-hr esophageal pH monitoring

19 reflux findings score (RFS)

Total severity score: 0 to 26Score greater than 7 suggests positive dual-probe pH study

20 Supraesophageal complications of reflux disease

Normal Larynx Interarytenoid edema

21

Erythema Ventricular obliteration

Pseudosulcus vocalis

22

Ventricular obliteration

Posterior commissure hypertrophy

Thick endo-laryngeal mucus

Ventricular obliteration

23 Erythema/Hyperemia

Erythema

Vocal fold edema

24 Laryngeal Edema

Granuloma

25 Diagnosis

Symptom questionnaire

Laryngeal examination / Laryngoscopy

Therapeutic trial

Endoscopy – limited utility

Ambulatory 24-hr esophageal pH monitoring

26 Therapeutic Trial for SERD

H2 receptor blockers Work great for GERD Generally don’t work for SERD (even high/double doses)

Proton pump inhibitors Generally work for SERD often require double dosing Must use double dose PPI for therapeutic trial Duration: 2 weeks – 6 months (one month should be

sufficient to see improvement May still fail…

Remember: Non-acid reflux!

27 Diagnosis

Symptom questionnaire

Laryngeal examination / Laryngoscopy

Therapeutic trial

Endoscopy – limited utility

Ambulatory 24-hr esophageal pH monitoring Distal esophageal

Proximal esophageal

Dual

Pharyngeal

Oropharyngeal

28 Ambulatory pH Monitoring

Pharyngeal probe– 2 cm above UESProximal esoph. probe- below UESDistal esoph. probe–5 cm above LES

Gold std to diagnose LPR

Criteria'spH < 4Pharyngeal pH drop – oesophageal acid exposurepH drop rapid & sharp

For this diagnostic test a small catheter is placed through the nose into the throat and esophagus for a 24 hour period. The catheter has multiple sensors on it to detect the presence of acid in the esophagus and throat (drop in pH < 4). The patient wears the catheter with a small computer recording device on his/her waist home and comes back to the office the next day to have the readings interpreted and the catheter removed

29 Treatment

Antireflux therapy

Phase I : Lifestyle-dietary modification

Antacid therapy

Phase II : Prokinetic

H2-blockers, PPI

Phase III : Antireflux surgery

30 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

31 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

32 PHARMACOLOGICAL

DRUGS

ANTACIDS Mixture of Al

hydroxide & Mg trisilicate

ANTISECRETORYH2 Blockers

PPI’sMucosal protective

PROKINETICMetoclopramide

DomperidoneCisapride

33 Drug therapy

Antisecretory H2 Blockers

Ranitidine, Famotidine,

Reversibly reduces acid secretion, not helps in healing

PPI’s

Near total acid suppression, promotes healing

Omeprazole (20-40mg OD)

Mucosal protective Sucralfate, alginic acid

34 Drug therapy

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)

35

36 Surgery

Laparoscopic Nissen Fundoplication

Indications

Failed drug treatment

Complications

Goal

Restore natural integrity of LES & maintain normal deglutition

37

End of Lecture

March 2014