lpr by dr. ss nayyar

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 7www.nayyarENT.com

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 ResistanceXerostomia

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 12www.nayyarENT.com

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 15www.nayyarENT.com

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 TherapyVocal 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

ANTISECRETORYH2 Blockers

PPI’sMucosal protective

PROKINETICMetoclopramide

DomperidoneCisapride

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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. 37www.nayyarENT.com

Surgery Laparoscopic Nissen Fundoplication

IndicationsFailed drug treatmentComplications

GoalRestore 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 1st 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 44www.nayyarENT.com

Thank You

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