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,
– Zenker’s 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 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

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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, 24–hour, 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
PPI’s
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
– PPI’s
• 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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What’s 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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