Reflux & the Voice

SPPA 6400 Voice Disorders - Tasko

What is reflux?

SPPA 6400 Voice Disorders - Tasko

Reflux = “Backflow”
 7% of US population have daily complaints of
heartburn (Talley 1992).
 18 million self-medicate with antacids at least
twice weekly

SPPA 6400 Voice Disorders - Tasko

 Gastroesophageal Reflux Disease (GERD) vs.
Laryngopharyngeal Reflux (LPR)

 GERD involves lower esophageal sphincter dysfunction

 LPR involves both upper and lower esophageal sphincter
dysfunction
 Until recently, LPR often considered to be under-
diagnosed/under-treated
 Koufman (1991, 2000) reports
 LPR present in 4-10% of attendees of otolaryngology clinic
(Koufman, 1991)
 LPR present in 55% of patients with hoarseness (Koufman,
2000)

SPPA 6400 Voice Disorders - Tasko

Conditions reported to be associated with
reflux
 Reflux laryngitis  Globus pharyngeus
(posterior)  Vocal nodules
 Subglottic stenosis
 Reinke’s edema
 Carcinoma of the larynx
 Recurrent leukoplakia
 Carcinoma of esophagus
 Contact ulcers and  Recurrent pneumonitis
granulomas  Pharyngitis
 Laryngospasm  Asthma
 Paradoxical Vocal Cord
Motion

SPPA 6400 Voice Disorders - Tasko

Why is LPR not recognized?
 Patients with LPR usually deny symptoms of
heartburn or regurgitation (silent reflux)
 Findings of LPR on laryngeal exam vary
considerably
 Traditional tests for GERD lack both sensitivity and
specificity for LPR
 Therapeutic trials using traditional antireflux therapy
often fail (false negatives)

SPPA 6400 Voice Disorders - Tasko

How is LPR Identified?
 Patient symptoms
 Vocal and Laryngoscopic signs
 Ambulatory 24 hour double/triple probe pH monitoring
 Considered by some to be diagnostic “Gold Standard”
 Multichannel intraluminal impedance (MII)
 measures presence of liquid and gaseous events in upper
aerodigestive tract
 Barium esophagram
 Esophagoscopy
 Esophageal manometry
 Trial period of acid suppression treatment (PPI for at least
three months)
NOTE: Signs and symptoms are not pathognomonic
SPPA 6400 Voice Disorders - Tasko
Symptoms of LPR
Koufman (1991) Book et al. (2002)
 Chronic dysphonia (92 %)  Throat clearing (98%)
 Intermittent dysphonia
 Persistent cough (97%)
 Vocal fatigue
 Globus pharyngeus (95%)
 Nocturnal choking
 Hoarseness (95%)
 Chronic throat clearing
 Excessive throat mucus
 Chronic cough (44%)
 Dysphagia (27%)
 Globus pharyngeus (33 %)

SPPA 6400 Voice Disorders - Tasko

 Reflux Symptom Index

The Reflux Symptom Index

A score > 10 may indicate significant reflux
A score > 13 definitely abnormal
SPPA 6400 Voice Disorders - Tasko
Typical GI Patient vs. Typical ENT Patient
(Koufman, 1991)
GI ENT
Symptoms
heartburn and/or regurgitation Y N

hoarseness, dysphagia, globus,

throat clearing, cough etc. N Y

Findings
endoscopic esophagitis Y N
laryngeal inflammation N Y
SPPA 6400 Voice Disorders - Tasko
Laryngoscopic Signs

SPPA 6400 Voice Disorders - Tasko

 The Reflux Finding Score (Belafsky et al. 2002)
‘Groove’ along the full margin of the vocal
fold

Diminished size of the ventricle revealed by a

swelling of the ventricular bands

Erythema (redness)
Hyperemia (increased blood flow to tissue)

Edema localized in the vocal folds

Edema throughout the larynx

Granuloma or granulation tissue anywhere in

the larynx

Thick, white endolaryngeal mucus on the vocal folds

or elsewhere
SPPA 6400 Voice Disorders in the endolarynx.
- Tasko

Score of 7 or greater: likely to have LPR

LPR: Tissue Changes

Interarytenoid bar Interarytenoid granuloma

SPPA 6400 Voice Disorders - Tasko

Vocal fold edema Granulomas

LPR: Tissue Changes

SPPA 6400 Voice Disorders - Tasko

From Vavricka et al. (2007)
(A) posterior pharyngeal wall
cobblestoning
(B) interarytenoid bar with
erythema
(C) posterior commissure with
erythema and surface
irregularity
(D) posterior cricoid wall edema
(E) arytenoid complex with apex
edema, erythema, and medial
wall erythema
(F) true vocal folds with edema
(G) false vocal folds erythema,
(H) anterior commissure erythema
(I) epiglottis erythema
(J) aryepiglottic fold edema.
SPPA 6400 Voice Disorders - Tasko
Diagnostic value of laryngeal signs?

SPPA 6400 Voice Disorders - Tasko

Vavricka et al. (2007)
Diagnostic value of laryngeal signs?

SPPA 6400 Voice Disorders - Tasko

Hicks et al. (2002)
Typical GI Patient vs. Typical ENT Patient
(Koufman, 1991)
GI ENT
Diagnostic tests
Abnormal esophageal radiography Y sometimes
Esophageal pH monitoring Y Y
Pharyngeal pH monitoring N Y

Pattern of reflux
Supine (nocturnal) Y sometimes
Upright (awake) sometimes Y

SPPA 6400 Voice Disorders - Tasko

pH monitoring +/- MII
 “Gold standard” for GERD
 Some problems for diagnosing LPR
Problems
 Double/triple probe is required
 Probe placements effects measures
 Disagreement about threshold values
 There can be both liquid and gaseous refluxate – gas
can be more problematic for LPR but not well
monitored
 Non-acid (alkaline) refluxate

SPPA 6400 Voice Disorders - Tasko

Are we good at diagnosing LPR?
Issues
 Which signs, which symptoms?

 Specificity and sensitivity

 Examination procedures

 Differential diagnosis

SPPA 6400 Voice Disorders - Tasko

Clinical Decision Making

SPPA 6400 Voice Disorders - Tasko

From Ford (2005)
Treatment

SPPA 6400 Voice Disorders - Tasko

 Common anti-reflux Meds
Antacids
 buffers pH
 e.g. Tums, Rolaids
 Not considered very effective
with LPR
H2 antagonists
 Blocks histamine action which
decreases acid production
 e.g. Tagamet, Ranitidine,
Zantac
 Not preferred for LPR
Proton Pump Inhibitor (PPI)
 Blocks action of proton pump
 Most potent acid suppression
medication
 e.g. Omeprazole (Prilosec),
Nexium, Prevacid
SPPA 6400 Voice Disorders - Tasko
 Drug of choice for LPR
SPPA 6400 Voice Disorders - Tasko

From Ford (2005)

Conventional treatment for suspected LPR
 Dietary modification
 No eating/drinking within 3 hrs of bedtime
 Avoid overeating or reclining after meals
 Avoid fried foods and adhere to low fat diet
 Avoid coffee, tea, chocolate, mints and soda (refluxogenic)
 Avoid caffeine of all kinds
 Avoid alcohol especially in the evening
 Avoid spicy, tomato based products, fruit juices
 Lifestyle modification
 Elevate head of bed 4-6 inches
 Avoid wearing tight fitting clothing or belts
 Cease tobacco use
 Medication
 Omeprazole (PPI) 20 mg b.i.d. (am and pm)
 Treatment should continue for at least 3 months (up to 6 mos.)

SPPA 6400 Voice Disorders - Tasko

 Typical GI Patient vs. Typical ENT Patient
(Koufman, 1991)
GI ENT
Response to treatment
Dietary or lifestyle modification Y sometimes
Rate of success with H2 blockers 85% 65%
Rate of success with omeprazole 99% 99%

Assuming adequate dosage and duration of therapy

SPPA 6400 Voice Disorders - Tasko

 Cochrane Database

From Cochrane Reviews (2005)

Also Williams et al. (2004)

SPPA 6400 Voice Disorders - Tasko

Fundoplication (Nissen)
 tightens LES by wrapping the upper part of the
stomach around the lower part of the esophagus.
 Procedure may
 Be open (external incisions)
 Use endoscopy (small external incisions)
 reports of 90 % of patients undergoing the
endoscopic Nissen fundoplication are symptom
free after surgery.
 Suggestions that Tx is more effective for GERD
vs. LPR

SPPA 6400 Voice Disorders - Tasko

Case Illustrations

SPPA 6400 Voice Disorders - Tasko