LaryngoPharyngeal Reflux
(LPR)
Christopher Adhisasmita Yandoyo
030.012.055
Introduction
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
Laryngopharyngeal
LPRD refers to retrograde flow ofgastric contentsto
(LPR)
the upper Reflux
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.
Synonyms for
Laryngopharyngeal
Atypical reflux
Extraesophageal reflux
Reflux
(LPR)
Gastropharyngeal reflux
Laryngeal reflux
Pharyngoesophageal reflux
Reflux laryngitis
Silent reflux
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
Koufman JA et al : Reflux Laryngitis and its sequela:the diagnostic role of ambulatory 24-hr
pH monitoring. J Voice 2:78-79,1994
Relevant anatomy and
physiology
Lower
Various mechanisms acts
3 cm in length
Upper
Cricopharyngeus +
circular muscle fibers of
esophagus
3 cm in length
Anti reflux barrier
Oesophageal Acid Clearance
Increased by peristalsis of oesophagus & salivary bicarbonate
Decreased by abnormal oesophageal motility
Oesophageal peristalsis
Oesophageal Epithelial Resistance
Mucus : barrier to pepsin
Cell membrane, intercellular bridge
Metabolic buffering capacity of mucosa
Pathophysiology
8
Gastric contents
(acid & pepsin)
LES
Backflows
Persistent and
chronic
Inflammation
Laryngeal
mucosa (post
glottis)
UES
Mucosal changes
Etiopathologic 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
10
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.
11
CLASSIFICATION OF REFLUX
1. Physiologic
Asymptomatic
Postprandial
No abnormal findings
2. Functional
Asymptomatic
Positive pH study
3. Pathologic
Local symptoms
Secondary manifestations of LPR
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LPR and GERD
LPR
No heartburn
Daytime (upright)
refluxers
Normal esophageal
motility
Normal acid
clearance
Majority without
esophagitis
1 defect - UES
GERD
Heartburn
Nocturnal
(supine) refluxers
Esophageal
dysmotility
Prolonged acid
clearance
Can present with
esophagitis
1 defect LES
13
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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
Leukoplakia, Ca Larynx
Subglottic stenosis
Laryngeal Stenosis
Laryngospasm
Laryngomalacia
Delays healing following Post intubation injury
16
Secondary Problems
PHARYNGEAL
PULMONARY
Globus pharyngeus,
Chronic sore throat,
Dysphagia,
Zenkers diverticulum
Asthma
Bronchieactasis
Chronic bronchitis
Pneumonia
Carcinoma
Fibrosis
MISCELLANEOUS
Chronic rhinosinusitis
Otitis media in children
Dental erosions
17
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Diagnosis
Why is diagnosis of LPR often missed??
Low index of suspicion
Patients often dont have heartburn (esophagitis)
Variable / unrecognized findings
Chronic intermittent nature of LPR leads to decreased sensitivity of pH
monitoring
Inadequate duration &/or dosage of PPI
19
Diagnosis
Symptom questionnaire
Laryngeal examination / Laryngoscopy
Therapeutic trial
Endoscopy limited utility
Ambulatory 24-hr esophageal pH monitoring
20
Symptom Questionnaire:
Reflux Symptom Index (Belafski,
2002)
Total score: 0 to 45. Score greater than 13
suggests positive LPR
Belafsky, P. C., Postma, G. N., & Koufman, J. A. (2002). Validity and Reliability of the Reflux
Symptom Index (RSI).Journal of Voice,16(2), 274-277. doi:10.1016/s0892-1997(02)00097-8
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Diagnosis
Symptom questionnaire
Laryngeal examination / Laryngoscopy
Therapeutic trial
Endoscopy limited utility
Ambulatory 24-hr esophageal pH monitoring
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Reflux Findings Score (RFS)
Total severity score: 0
to 26 Score
greater than 7
suggests positive dualprobe pH study
Belafsky, P. C., Postma, G. N. and Koufman, J. A. (2001), The Validity and Reliability of the Reflux
Finding Score (RFS). The Laryngoscope, 111: 13131317. doi:10.1097/00005537-200108000-
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Supraesophageal complications
of
reflux disease
Normal Larynx
Interarytenoid edema
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Pseudosulcus vocalis
Erythema
Ventricular obliteration
25
Posterior commissure hypertrophy
Thick endolaryngeal mucus
Ventricular obliteration
Ventricular obliteration
Erythema/Hyperemia
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Erythema
Vocal fold edema
27
Laryngeal Edema
Granuloma
28
Diagnosis
Symptom questionnaire
Laryngeal examination / Laryngoscopy
Therapeutic trial
Endoscopy limited utility
Ambulatory 24-hr esophageal pH monitoring
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Therapeutic Trial for lpr
H2 receptor blockers
Work great for GERD
Generally dont work for LPRD (even high/double doses)
Proton pump inhibitors
Generally work for LPRD 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
Diagnosis
30
Symptom questionnaire
Laryngeal examination / Laryngoscopy
Therapeutic trial
Endoscopy limited utility
Ambulatory 24-hr esophageal pH monitoring
Distal esophageal
Proximal esophageal
Dual
Pharyngeal
Oropharyngeal
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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. probe5 cm above LES
Criteria's
Gold standard to diagnose LPR
pH < 4
Pharyngeal pH drop oesophageal acid exposure
pH drop rapid & sharp
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Ford CN. Evaluation and Management of Laryngopharyngeal [Link].2005;294(12):1534-1540.
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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
Dietary modification
35
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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PHARMACOLOGICAL
DRUGS
ANTACIDS
Mixture of Al
hydroxide
& Mg trisilicate
ANTISECRETORY
H2 Blockers
PPIs
Mucosal protective
PROKINETIC
Metoclopramide
Domperidone
Cisapride
Drug therapy
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Antisecretory
H2 Blockers
Ranitidine, Famotidine,
Reversibly reduces acid secretion, not helps in healing
PPIs
Near total acid suppression, promotes healing
Omeprazole (20-40mg OD)
Mucosal protective
Sucralfate, alginic acid
Drug therapy
38
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)
Surgery
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Laparoscopic Nissen
Fundoplication
Indications
Failed drug treatment
Complications
Goal
Restore natural integrity of
LES & maintain normal
deglutition
Thank you - Terima Kasih matur nuwun
