LaryngoPharyngeal Reflux

(LPR)
1
Prepared by: Nibal Shawabkeh
Supervised by: Dr. Adel Adwan
2 Introduction

 The term REFLUX comes from the Greek word meaning “backflow,” usually
referring to the contents of the stomach

 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
3 Laryngopharyngeal Reflux (LPR)
 LPRD refers to retrograde flow of gastric contents to the upper aero-digestive
tract, which causes a variety of symptoms

 Contributes up to 50% of laryngeal complaints

 The injurious agents in the refluxed stomach contents are primarily acid and
activated pepsin.

 The damage caused by these materials can be extensive.

 Specific findings include: laryngeal hyperemia, posterior commissure

hypertrophy, pseudosulcus vocalis, and thick endolaryngeal mucus.
4 Synonyms for Laryngopharyngeal
Reflux (LPR)
 Atypical reflux
 Extraesophageal reflux
 Gastropharyngeal reflux
 Laryngeal reflux
 Pharyngoesophageal reflux
 Reflux laryngitis
 “Silent” reflux
5 Epidemiology

 Incidence 4%-10% in various studies

 No racial predilection
 Common in age > 40 yrs
 Up to 70% with hoarseness *
 75% - with subglottic stenosis
 20%-45%-shows Heartburn, Regurgitation and indigestion
6 Relevant anatomy and physiology

Lower
Various mechanisms acts
3 cm in length

Upper
Cricopharyngeus + circular
muscle fibers of esophagus
3 cm in length
7 Pathophysiology

Gastric contents (acid & pepsin)

LES

Backflows

UES

Laryngeal mucosa (post glottis)

Persistent and chronic Inflammation

Mucosal changes
8 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

9 CLASSIFICATION OF REFLUX

1. Physiologic
 Asymptomatic
 Postprandial
 No abnormal findings

2. Functional
 Asymptomatic
 Positive pH study

3. Pathologic
 Local symptoms
 Secondary manifestations of LPR
10 Patterns and Mechanism of LPR and
GERD

LPR GERD
No heartburn Heartburn
Daytime (“upright”) Nocturnal (“supine”)
refluxers refluxers
Normal esophageal Esophageal dysmotility
motility Prolonged acid
Normal acid clearance clearance
Majority without Can present with
esophagitis esophagitis
1 defect - UES 1 defect – LES
Clinical presentations Clinical presentations
11 Presentation/Symptoms

 Hoarseness – 70%

 Voice fatigue, breaking of the voice

 Cough – 50%

 Globus pharyngeus – 47%

 Frequent throat clearing, dysphagia, sore throat, wheezing, laryngospasm,

halitosis
12 Secondary problems

 LARYNGEAL
 Benign vocal cord lesions
 Functional voice disorders
 Leukoplakia, Ca Larynx
 Subglottic stenosis
 Laryngeal Stenosis
 Laryngospasm
 Laryngomalacia
 Delays healing following Post intubation injury
13 Secondary Problems

PHARYNGEAL
PULMONARY
Globus
Asthma
pharyngeus,
Bronchieactasis
Chronic sore
Chronic bronchitis
throat,
Pneumonia
Dysphagia,
Carcinoma
Zenker’s
Fibrosis
diverticulum

MISCELLANEOUS

• Chronic rhinosinusitis
• Otitis media in children
•Dental erosions
14
15 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

16 Diagnosis

 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
17 Symptom Questionnaire:
Reflux Symptom Index
18 Diagnosis

 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
19 reflux findings score (RFS)

Total severity score: 0 to 26

Score greater than 7 suggests
positive dual-probe pH study
20 Supraesophageal complications of
reflux disease

Normal Larynx Interarytenoid edema

21

Pseudosulcus vocalis

Erythema Ventricular obliteration

22

Posterior commissure hypertrophy

Thick endo-
laryngeal mucus

Ventricular obliteration Ventricular obliteration

23 Erythema/Hyperemia

Erythema

Vocal fold
edema
24 Laryngeal Edema Granuloma
25 Diagnosis

 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
26 Therapeutic Trial for SERD

 H2 receptor blockers
 Work great for GERD
 Generally don’t work for SERD (even high/double doses)
 Proton pump inhibitors
 Generally work for SERD often require double dosing
 Must use double dose PPI for therapeutic trial
 Duration: 2 weeks – 6 months (one month should be
sufficient to see improvement
 May still fail…
 Remember: Non-acid reflux!
27 Diagnosis

 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
 Distal esophageal
 Proximal esophageal
 Dual
 Pharyngeal
 Oropharyngeal
28 Ambulatory pH Monitoring
For this diagnostic test a small catheter is placed through the
nose into the throat and esophagus for a 24 hour period. The
catheter has multiple sensors on it to detect the presence of
acid in the esophagus and throat (drop in pH < 4). The
patient wears the catheter with a small computer recording
device on his/her waist home and comes back to the office
the next day to have the readings interpreted and the
catheter removed

Pharyngeal probe– 2 cm above UES

Proximal esoph. probe- below UES
Distal esoph. probe–5 cm above LES

Criteria's
pH < 4
Pharyngeal pH drop – oesophageal acid
exposure
pH drop rapid & sharp
Gold std to diagnose LPR
29 Treatment

Antireflux therapy

 Phase I : Lifestyle-dietary modification

Antacid therapy

 Phase II : Prokinetic
H2-blockers, PPI

 Phase III : Antireflux surgery

30 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

31 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

32 PHARMACOLOGICAL

DRUGS

ANTACIDS ANTISECRETORY PROKINETIC

Mixture of Al H2 Blockers Metoclopramide
hydroxide PPI’s Domperidone
& Mg trisilicate Mucosal protective Cisapride
33 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
34 Drug therapy

 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)
35
36 Surgery

 Laparoscopic Nissen
Fundoplication

 Indications
 Failed drug
treatment
 Complications

 Goal
 Restore
natural
integrity of LES
& maintain
normal
deglutition
37

End of Lecture
March 2014