laryngopharyngeal reflux 2

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LARYNGOPHARYNGEAL REFLUX(EXTRA-ESOPHAGEAL REFLUX)

BY :- DR SANJIV KUMAR (MS-ENT FINAL YEAR STD)

DARBHANGA MEDICAL COLLEGE, LAHERIASARAI (BIHAR)

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29-07-2012

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BARRIERS TO REFLUX

Upper Esophageal Sphincter (final barrier) C-shapped : cricopharyngeus, thyropharyngeus,

cervical esophagus

Lower Esophageal Sphincter ( most critical)

Esophageal Acid Clearance Peristalsis & gravity

Epithelial Resistance Factors Mucus + aqueous layer.

Esophageal epithelium > respiratory epithelium

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FACTORS AFFECTING LES TONE

Increased Tone

ProteinBethanecolMetaclopramideAntacidsadrenergic drugsAcidification of distal

esophagus

Decreased Tone

FatCarbsETOhCigarettesCarmanitives

peppermint, spearmintTheophyllineCCB -adrenergic drugsDopamineSedatives

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MECHANISMS RESULTING IN SYMPTOMS

Acid exposure results in direct mucosal damageUlceration, hemorrhage,

necrosis

Damage to mucociliary activity leads to increased viscosity

Activated Pepsin (max @ pH 4.5) results in tissue damage

Laryngeal Chemoreflexsensory receptors in larynx -->

laryngospasmAssociated with bradycardia,

central apnea and hypotension

Vagal ReflexAcid within distal esophagus -->

laryngospasm, cough Associated with bronchospasm,

increased secretions, tachycardia, hypertensionSudden infant Death Syndrome?

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COMMON SYMPTOMS OF LPR

** Globus sensation

** Chronic throat clearing

** Dysphagia

** Sore throat

** Excessive throat mucus

Hoarseness / Dysphonia

Voice breaks

Neck pain

Chronic or nighttime cough

Vocal fatigue

Odynophagia

Postnasal Drip

Halitosis

Ear Pain

Laryngospasm

Asthma exacerbation

Loss of upper singing range

Prolonged warm up time for singers

Heartburn / regurgitation

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THE REFLUX SYMPTOM INDEX Within the past month, how did the following problems affect you? Rank

them from 0 (no problem) to 5 (severe problem).

Hoarseness or a problem with your voice

Clearing your throat

Excess throat mucus or post nasal drip

Difficulty swallowing foods, liquids or pills

Coughing after you have eaten or after lying down

Breathing difficulties or choking episodes

Troublesome or annoying cough

Sensations of something sticking in your throat or a lump in your throat

Heartburn, chest pain, indigestion, or stomach acid coming up

> 10: high likelihood of a positive dual-channel pH probe study showing reflux29-07-2012

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PHYSICAL EXAM / LARYNGOSCOPY

Observations:

•Voice quality, throat clearing, cough, body habitus

Psuedosulcus

ventricular obliteration

Erythema / hyperemia

Vocal fold edema

Diffuse laryngeal edema

Posterior commisure hypertrophy

Thick endolaryngeal mucus / inspisated secretions

Granuloma / granulation

Leukoplakia

Nodules / prenodules

Polyps

Pachydermia Laryngeus

Webs

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SANDIFERS SYNDROME

Spasmodic torsional dystonia, arching of the back and rigid opisthotonic posturing, mainly involving the neck, back, and upper extremities, associated with either GERD or a hiatal hernia

Posturing, typically occuring shortly after feeding, that lasts 1-3 minutes

Age: observed from infancy to early childhood. Most children outgrow symptoms by early childhood. Mentally impaired individuals may have persistence of symptoms into adolescence

Often confused with a seizure disorder

Incidence: < 1% of children with reflux

Pathophysiology: ?

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THE ASSOCIATION BETWEEN LARYNGEAL PSEUDOSULCUS AND

LARYNGOPHARYNGEAL REFLUX

Psuedosulcus Vocalis Pattern of infraglottic edema on the

ventral surface of the vocal fold

Sulcus Vergeture a depression in the mucous membrane

of the free edge of the true vocal folddue to adherence of the epithelium to the vocal ligament owing to absence of the lamina propria

70% of patients with documented LPR had

Pseudosulcus (not pathogneumonic, but close)

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OBJECTIVE TESTING

Voice Analysis

• Before and after therapy - ? significance

Esophagram

• Useful for GERD, not LPR• Hiatal hernia, erosive esophagitis, strictures,

barrett’s, esophageal rings, compression, motility disorders, diverticula, cricopharyngeal spasm, aspiration

EGD

• In pts with GERD, may be helpful to find Barretts, strictures, esophagitis early• Should patients with LPR without symptoms of GERD be referred to have EGD?

FEEST

• Can provide direct visualization of LPR

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OBJECTIVE TESTING

Manometry

• Useful for GERD and surgical planning of antireflux surgery, not for LPR• May show ineffective esophageal motility, low LES tone

Reflux Scan

• Radionucleotide study ( oral technetium)• Low senstivity for LPR

Acidification Testing (Bernstein Test)

• NGT with HCL + H2O titrated until symptoms occur

Brochoalveolar lavage

• Good to track pulmonary complications of reflux + aspiration• Look for lipid-laden macrophages ( shown to be increased in children with pulm complications of aspiration

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OBJECTIVE TESTING

pH Probe Testing

Gold standard

Placed 5 cm above LES (for GERD), and above UES (for LPR)

•Confirmed by manometry, flouroscopy or

endoscopy

Positive test: pH 4 (controversial)

Negative studies do not rule out LPR, because vagally mediated reflexes may be causing symptoms.

Most authors recommend empiric therapy without pH probes.

In LPR, can have normal pH @ LES

Limitations

•invasive test, •limited senstivity•high false negative rate• limited reproducibility

Indications

•GERD symptoms•partial responses to treatment• continued laryngitis despite treatment•patients who want proof,•evaluation of patients after

fundoplication•intubated patients with altered mental

status

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TREATMENT: BEHAVIORAL MODIFICATION

Avoid Eating 3 hours before lying down

No tobacco products

No alcohol, fried foods, fatty foods,

chocolate, caffeine, spicy foods,

peppermints

Avoid tight fitting clothes

Elevate HOB 6-8 inches

Chew gum for 1 hour after food intake

Walk for 1 hour after food intake

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MEDICAL MANAGEMENT

Behavioral Modification

Antacids

H2 blockers

PPI

Promotility agents

Other

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MEDICAL TREATMENT OF LPR

Antacids Neutralize pH, increase LES tone Sought out by patients prior to seeking medical attention Increase pH, thus deactivate pepsin

Gaviscon Alginic acid Helps with GERD, but does not increase LES tone

Common Antacids Maalox (aluminum hydroxide/magnesium hydroxide/simethicone) Mylanta (aluminum hydroxide/magnesium hydroxide/simethicone) Tums (calcium carbonate)

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H2 BLOCKERS

Competitive histamine type 2 receptor blocker

• Reduced acid secretion and pepsin production

Can be used for minor LPR, adjunctive treatment,

or in weaning patients from PPI’s

Long term high dose H2 blockers not as effective nor

as cost effective as PPI’s

Commonly used:

• Zantac (ranitidine)• Pepcid (famotidine)29-07-2012


PROTON PUMP INHIBITORS

Inhibit Hydrogen-Potassium ATPase

• Last step in Acid production in parietal cell

More effective than H2 blockers

Take 1 hour prior to eating

Common PPI’s:

• Aciphex (Rabeprazole)• Nexium (esomeprazole)• Prevacid (lansoprazole)• Prilosec (omeprazole)• Protonix (pantoprazole)

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PROMOTILITY AGENTS

Reglan (Metaclopramide)

• Dopamine antagonist

Erythromycin

Increases LES tone, gastric emptying and esophageal clearance

May be helpful for those with DM, dystrophia myotonica, anorexia secondary to delayed gastric emptying times in these conditions.

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OTHER MEDICAL THERAPY

Sulcrafate

• Salt of sucrose• Increases mucosal resistance to trauma, promotes healing in

duodenal ulcers

Bethanechol

• Cholinergic• Increases LES tone, decreased GER, improves salivary flow,

improves GI motility, detrusor muscle tone

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HOW TO TREAT LPR

Behavioral modifications

Start with PPI

• Mild LPR can be given trial of H2 blocker, or OTC meds• Can increase to BID, and add H2 blocker• Refer to GI with increasing needed dose• Workup structural causes of GERD/LPR

Treat for 6-8 weeks, with reevaluation. Then attempt at weaning.

Weaning:

• Downgrade from PPI to H2 blocker• BID to Qdaily• Continuation of behavioral modification

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SURGICAL TREATMENT

For those who fail medical therapy

Replacing LES into abdomen, and

augmentation of LES into better barrier

Nissen Fundoplication

• 360o wrap of gastric fundus around intraabdominal esophagus• > 73% show dramatic improvement

of LPR symptoms

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SEQUELAE OF LPR

Chronic Laryngitis (> 3mo)

Contact Ulcer

Laryngeal Granuloma

• Treat with PPI, behavioral modifications, voice therapy, possibly with intralaryngeal Botulinum toxin for refractory cases, then surgery

Suglottic Stenosis

• Strong association btw LPR & SGS. • Causal or synergistically with other causes of SGS

• 5 of 7 patients with idiopathic SGS had signs of reflux• Evaluation of SGS should always include evaluation of LPR

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LPR AND HEAD AND NECK CANCER

Reflux not established as a carcinogen

May contribute to complications of surgical management and radiation treatment of SCCA.

High incidence of LPR and GERD ( documented by pH probes) exists in patients with SCCA of the head and neck.

Bile acid and acidic conditions can be tumorigenic in the esophagus (through over expression of COX 2)

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DISORDERS IN INFANTS AND CHILDREN THAT ARE LIKELY REFLUX RELATED

Recurrent Croup

Laryngospasm

Laryngomalacia

Hoarseness

Subglottic Stenosis

Aspiration

Chronic Cough29-07-2012


PEDIATRIC MANIFESTATIONS OF REFLUX

100 % of patients with laryngomalacia had at least 1 episode of reflux in a 24 hour period

Whether this is causal is not known. However, reflux is known to harm respiratory epithelium in an already compromised airway

Whether treating them will help the laryngomalacia is not known

29-07-2012

laryngopharyngeal reflux 2

Health & Medicine

esophageal reflux

symptoms of gerd

throat clearing

throat excess throat

chronic throat

throat heartburn

esophageal rings

laryngopharyngeal reflux