Laryngopharyngeal Reflux 2

LARYNGOPHARYNGEAL REFLUX
(EXTRA-ESOPHAGEAL REFLUX)
BY :- DR SANJIV KUMAR
(MS-ENT FINAL YEAR STD)
DARBHANGA MEDICAL COLLEGE, LAHERIASARAI (BIHAR)
FOR MORE TOPICS, VISIT WWW.NAYYARENT.COM
www.nayyarENT.com
29-07-2012
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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29-07-2012
FACTORS AFFECTING LES TONE

Increased Tone
Protein Bethanecol Metaclopramide Antacids adrenergic drugs Acidification of distal esophagus
Decreased Tone
Fat Carbs ETOh Cigarettes Carmanitives
peppermint, spearmint
Theophylline CCB -adrenergic drugs Dopamine Sedatives
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29-07-2012
MECHANISMS RESULTING IN SYMPTOMS

Acid exposure results in direct mucosal damage Ulceration, hemorrhage, necrosis
Damage to mucociliary activity leads to increased viscosity Activated Pepsin (max @ pH 4.5) results in tissue damage
Laryngeal Chemoreflex sensory receptors in larynx --> laryngospasm Associated with bradycardia, central apnea and hypotension
Vagal Reflex Acid within distal esophagus --> laryngospasm, cough Associated with bronchospasm, increased secretions, tachycardia, hypertension Sudden infant Death Syndrome?
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29-07-2012
COMMON SYMPTOMS OF LPR
** Globus sensation
** Chronic throat clearing ** Dysphagia ** Sore throat
Vocal fatigue
Odynophagia Postnasal Drip Halitosis
** Excessive throat mucus

Hoarseness / Dysphonia Voice breaks Neck pain
Ear Pain
Laryngospasm Asthma exacerbation Loss of upper singing range
Chronic or nighttime cough
Prolonged warm up time for singers

Heartburn / regurgitation
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29-07-2012
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 reflux
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29-07-2012
PHYSICAL EXAM / LARYNGOSCOPY

Observations: Voice quality, throat clearing, cough, body habitus Psuedosulcus ventricular obliteration Erythema / hyperemia Polyps Pachydermia Laryngeus Webs Granuloma / granulation Leukoplakia Nodules / prenodules
Vocal fold edema

Diffuse laryngeal edema Posterior commisure hypertrophy Thick endolaryngeal mucus / inspisated secretions
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29-07-2012
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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29-07-2012
THE ASSOCIATION BETWEEN LARYNGEAL PSEUDOSULCUS AND LARYNGOPHARYNGEAL REUX

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 fold due 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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29-07-2012
OBJECTIVE TESTING
Voice Analysis Before and after therapy - ? significance Esophagram Useful for GERD, not LPR Hiatal hernia, erosive esophagitis, strictures, barretts, 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
29-07-2012 www.nayyarENT.com
10
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
11
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
12
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
13
MEDICAL MANAGEMENT
Behavioral Modification Antacids
H2 blockers
PPI Promotility agents Other
14
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)
15
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 PPIs Long term high dose H2 blockers not as effective nor as cost effective as PPIs
Commonly used:
Zantac (ranitidine) Pepcid (famotidine)
16
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 PPIs: Aciphex (Rabeprazole) Nexium (esomeprazole) Prevacid (lansoprazole) Prilosec (omeprazole) Protonix (pantoprazole)
17
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.
18
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
19
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
20
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
21
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
22
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)
23
DISORDERS IN INFANTS AND CHILDREN THAT ARE LIKELY REFLUX RELATED

Recurrent Croup Laryngospasm
Laryngomalacia
Hoarseness
Subglottic Stenosis
Aspiration
29-07-2012
Chronic Cough
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24
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
25

Laryngopharyngeal Reflux 2

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LARYNGOPHARYNGEAL REFLUX

DARBHANGA MEDICAL COLLEGE, LAHERIASARAI (BIHAR)

FOR MORE TOPICS, VISIT WWW.NAYYARENT.COM

FACTORS AFFECTING LES TONE

Theophylline CCB -adrenergic drugs Dopamine Sedatives

MECHANISMS RESULTING IN SYMPTOMS

COMMON SYMPTOMS OF LPR

** Excessive throat mucus

Chronic or nighttime cough

Prolonged warm up time for singers

THE REFLUX SYMPTOM INDEX

Difficulty swallowing foods, liquids or pills

PHYSICAL EXAM / LARYNGOSCOPY

Vocal fold edema

THE ASSOCIATION BETWEEN LARYNGEAL PSEUDOSULCUS AND LARYNGOPHARYNGEAL REUX

Acidification Testing (Bernstein Test)

TREATMENT: BEHAVIORAL MODIFICATION

MEDICAL TREATMENT OF LPR

PROTON PUMP INHIBITORS

Take 1 hour prior to eating

OTHER MEDICAL THERAPY

HOW TO TREAT LPR

LPR AND HEAD AND NECK CANCER

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

DISORDERS IN INFANTS AND CHILDREN THAT ARE LIKELY REFLUX RELATED

PEDIATRIC MANIFESTATIONS OF REFLUX

Whether treating them will help the laryngomalacia is not known

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