LARYNGOPHARYNGEAL

REFLEX DISEASE
DR SOORYA AJAY RAO
MBBS, MS ENT, DAA
APOLLO HOSPITALS, CHENNAI
RESPIRATORY RESEARCH FOUNDATION OF INDIA, CHENNAI
• Is an extra-esophageal variant of gastroesophageal reflux disease
(GERD).
• ‘Silent’ reflux: >80% of people with LPR do not have symptoms of
heartburn or an upset stomach.
Symptoms
• Dysphonia/Hoarseness
• Chronic cough
• Lump or FB sensation – ‘Globus’Throat
• discomfort/pain* – can be unilateral
• ‘discrete’Excessive throat-clearing
• Dysphagia – partial, intermittent &
• no weight loss
• ‘laryngospasm’ attacks
• Metallic (bad) mouth taste
• Dry mouth/Thick saliva/Excess saliva/PND
• LPR is believed to be caused by stomach acid/contents that bubbles
up into the throat as a result of GER
• Direct acid irritation causes soreness, cough and choking.
• Sensitivity in laryngeal and pharyngeal nerve endings upregulated by
the chronic inflammation.
• Delicate ciliated respiratory epithelium of the posterior
pharynx/pharynx damaged causing mucus stasis.
• Causing PND sensation & clearing of throat.
• Reflex Theory:Moderate response to anti-acid suppression therapy
• Successful response to Gabapentin & Pregabalin
• Common embryological origin of respiratory tract and digestive tract.
• Reflux irritation in oesophagus leads to an oesophagobronchial reflex.
• Refluxate with pepsin:Normal pH monitoring.Pepsin found in pharynx
and bronchial tree of patients with LPR
• Reflux Symptom Index (Belafsky et al 2002)
Self-administered 9-Qs survey.Each graded in severity 0-5.Score >13
shown to be correlated to positivity on pH study.
How is LPR diagnosed?
• Initial & primary diagnostic test:
• Trans-nasal (video) oesophagoscopy
• Common Laryngoscopic Signs:
• Generalised inflammation of pharynx
• Oedematous and inflamed larynx (arytenoids)
• Inflamed vocal cords
• Laryngeal findings are shown to be subjective(inter-rater
variability).‘No set guidelines for definitive diagnosis of LPR’
• The Reflux Finding Score. (Belafsky et al 2001)
To overcome inconsistency in the diagnosis of LPR.A scoring system
for documenting the physical findings and severity.The Reflux Finding
Score is based on 8 laryngoscopic findings.95% certain that a person
with a score higher than 7 has LPR.
24hr Multi-channel pH Monitoring
•
Ambulatory Dual-Channel pH monitoring:Gold standard for
diagnosing reflux, but less reliable in patients who have laryngeal
symptoms.
• Pharyngeal pH monitoring: (more accurate?)
• Studies show pharyngeal reflux was more frequent and in greater
quantity in patients with laryngeal signs.
• However, still inadequate sensitivity & specificity
Management of LPR Treatment is
‘empirical’:
•
Explanation & Reassurance
• Dietary & life-style advice
• Trial of PPI +/- Gaviscon
• Speech therapy
• Mention that >80% of patients presenting with throat symptoms may not
have classic reflux symptoms such as heartburn.
• Dietary advice:CaffeineDiet (eg, soda, spicy foods, fatty foods)Alcohol
(wine)Certain drugs (NSAIDs).
Lifestyle changes (& prevention measures):
• Follow a bland diet (low acid levels, low in fat, not spicy)
• Eat frequent, small meals
• Lose weight
• Avoid excess alcohol, tobacco, and caffeine
• Do not eat food less than 2 hours before bedtime
• Raise the head of the bed before sleeping.
• Avoid clearing of the throat
• Increase water intake
Empiric PPI Treatment
• Proton Pump Inhibitors (PPI) are considered the cornerstone of
pharmacological treatment of LPR.
• Placebo effect important in early period.
• Long-term and twice-daily dosage shown to be more effective.
• Optimal effect exerted when taken mins prior to meals.
• Significant physical exam improvements after 3 months of therapy.
• Addition of Histamine-2 receptor antagonist: An adjunctive treatment for
LPR to combat breakthrough histamine-regulated nocturnal acid production
(ranitidine 300 mg at bedtime).
• Gaviscon Advance: shown to be additive to PPI therapy.
• Nissen Fundoplication (endoscopic) is the primary surgical option.
• 90% 10-years success rate in GERD symptoms.
• For patients whose throat symptoms persist despite drug therapy.
• 70% improvement in LPR-related symptoms.
• Poorer success if failed anti-reflux medical therapy.
• Newer non-fundoplication endoscopic techniques:
• Bard EndoCinch System
• Enteryx liquid polymer injection
• Stretta Radio-frequency System
Refractory Cases
• 25% spontaneous recovery
50% chronic course with intermittent exacerbations and remissions
• In patients who show no improvement, other causes of symptoms and conditions that
can mimic LPR should be explored:
• Malignancy
• postnasal drip
• Allergies
• sinus inflammation
• various pulmonary diseases
• Smoking & alcohol
• Environmental irritants
What can happen if LPR is not treated?
• LPR is associated with and thought to contribute to various medical
conditions:
• Exacerbate Rhinosinusitis
• Laryngospasm
• Laryngotracheal stenosis
• Reinke’s edema
• Granulomas
• Worsening of asthma, emphysema and bronchitis.
• Laryngeal papilloma & carcinoma.
SUMMARY
• Combination of typical history (RSI) and laryngoscopic examination
(RFS) is is used for diagnosis.
• Controversy remains how to confirm the diagnosis of LPR.
• Management focuses on reassurance, explanation, dietary & lifestyle
changes.
• Empirical PPI Trial: twice-daily for 3 months.
• Patients whose symptoms do not respond to a PPI may be considered
for surgery but benefit from surgery is unpredictable.
• In refractory cases other causes & diagnoses should be entertained.
THANK YOU