Understanding Laryngopharyngeal Reflux Disease

Silent Reflux

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LPR is an extraesophageal variant of GERD that affects the larynx and pharynx.1-3

The Montreal definition of GERD differentiated the manifestations of GERD into esophageal and extraesophageal syndromes.4

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34. 2. Ford CN. JAMA. 2005;294:1534-40. 3. Sataloff RT, Hawkshaw MJ, Gupta R. Discov Med. 2010 Sep;10(52):213-24. 4. Vakil N, van Zanten SV, Kahrilas P, et al. Am J Gastroenterol. 2006 Aug;101(8):1900-20. 5. Bansal A, Kahrilas PJ. Best Pract Res Clin Gastroenterol. 2010 Dec;24(6):961-8.

GERD encompasses instances in which the disease is defined by associated extraesophageal syndromes such as asthma,

LPR and chronic cough.

LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

1. Vakil N, van Zanten SV, Kahrilas P, et al. Am J Gastroenterol. 2006 Aug;101(8):1900-20.

GERD: gastroesophageal reflux disease

Under-reported An estimated 4–10% of patients

presenting to otolaryngologists have reflux-associated diseases.1

Approximately >50% of patients with hoarseness have reflux-associated diseases.1

1. Ford CN. JAMA. 2005;294:1534-40.

There are no epidemiological studies to confirm the prevalence and otolaryngologic consequences of LPR.

LPR: Laryngopharyngeal reflux

Multifactorial LPR might result from

direct injury or by a secondary mechanism.

The association between LPR and GERD is yet to be established.

Anatomical proximity provides the basis for assuming a causal association between acid reflux and LPR.

1. Ford CN. JAMA. 2005;294:1534-40. LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

Mucosal damage from direct contact with acid and pepsin.1,2

Traumatic injury to the laryngeal mucosa via vagally mediated reflexes.1,3

1. Sataloff RT, Hawkshaw MJ, Gupta R. Discov Med. 2010 Sep;10(52):213-24.2. Koufman JA. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease. Ear, Nose & Throat Journal. FindArticles.com. 16 Jan, 2011. http://findarticles.com/p/articles/mi_m0BUM/is_9_81/ai_92281754. 3.Lai YC, Wang PC, Lin JC. World J Gastroenterol. 2008 Jul 28;14(28):4523-8. Ford CN. JAMA. 2005;294:1534-40.

Acid reflux

Alteration in the four physiological barrier that protect the upper aerodigestive tract against reflux injury:4

the upper esophageal sphincter

esophageal motor function with acid clearance

esophageal mucosal tissue resistance

the lower esophageal sphincter

1. Sataloff RT, Hawkshaw MJ, Gupta R. Discov Med. 2010 Sep;10(52):213-24.2. Koufman JA. Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease. Ear, Nose & Throat Journal. FindArticles.com. 16 Jan, 2011. http://findarticles.com/p/articles/mi_m0BUM/is_9_81/ai_92281754. 3.Lai YC, Wang PC, Lin JC. World J Gastroenterol. 2008 Jul 28;14(28):4523-8. Ford CN. JAMA. 2005;294:1534-40.

Nonacid reflux pathways:Bile reflux also may cause laryngeal

irritationDecreased salivary epidermal growth

factor

1. Sataloff RT, Hawkshaw MJ, Gupta R. Discov Med. 2010 Sep;10(52):213-24.

Not all patients with GERD will develop LPR.


Silent reflux

GERD LPR

Is retrograde flow of gastric contents into the esophagus

Significant esophagitis and heartburn

>45 reflux episodes/ day

Is the retrograde flow of gastric contents to the laryngopharynx

do not have esophagitis

one or two episodes/ week

1. Koufman JA et al. Otolaryngol Head Neck Surg 2002;127:32-35; 2. Barry DW et al. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34; 3. Ford CN. JAMA. 2005;294:1534-40; 4. Postma GN et al. GI Motility online. 2006; doi:10.1038/gimo46; 5. http://www.ntuh.gov.tw/ENT/DocLib4/Laryngopharyngeal%20reflux%2020100421.pdf; 6. Koufman JA. Ear, Nose & Throat Journal. 2011. http://findarticles.com/p/articles/mi_m0BUM/is_9_81/ai_92281754.

LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux

disease

GERD LPR

Significant esophagitis and heartburn

>45 reflux episodes/ day

Prolonged period of acid exposure

Dysmotility and prolonged esophageal acid clearance

do not have esophagitis

one or two episodes/ week

Short period of acid exposure

No dysmotility and prolonged esophageal acid clearance



disease

GERD LPR

Supine (nocturnal) reflux

Upright (daytime) reflux

Lower esophageal dysfunction

Upper esophageal sphincter dysfunction



disease

GERD LPR

Heartburn Regurgitation Dyspepsia

Hoarseness, Globus pharyngeus, Dysphagia, Cough, Chronic throat, clearing, Sore throat



disease

GERD LPR

Barium esophagography, Radionucleotide

scanning, Bernstein acid perfusion

test Esophagoscopy with

biopsy Impedence testing pH probe monitoring

Barium esophagography, Radionucleotide scanning, Bernstein acid perfusion test Esophagoscopy with biopsy, Impedence testing pH probe monitoring Laryngoscopy examination Laryngeal sensory testing Reflux Finding Score (RFS) Reflux Symptom Index (RSI)



disease

GERD LPR

Esophagitis Laryngeal inflammation



disease

GERD LPR

H2-antagonists and PPIs

Short term PPIs- Once daily Symptoms resolve

in less than 2 weeks

H2-antagonists and PPIs

Aggressive and for long-term

PPIs- Twice daily Symptoms resolve

in few months

LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease ; PPis: proton pump

inhibitors;


LPR diagnosis and management remain controversial because1

Lack of data related to techniques in confirming definitive diagnosis and causative factors

Laryngeal signs and symptoms are frequently associated with GERD. Diagnosis is a

challenge combined with low awareness level

1. Johnson DA. J Clin Gastroenterol. 2008 May-Jun;42(5):589-93.

LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease ; Ppis:ENT: ears nose and throat; CP; consulting physician; GP: general

physicians

Ford CN. JAMA. 2005;294:1534-40. LPR: Laryngopharyngeal reflux

TEST Advantages Disadvantages

Endoscopy Easy visualization of mucosal damage and erosions

Poor sensitivity, specificity, positive predictive value

Requires sedation High cost

Laryngoscopy No sedation required Direct visualization

of the larynx and laryngeal

pathology

No specific laryngeal signs for reflux

High interrater variability

May contribute to overdiagnosis of reflux

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34.

Rigid telescopic view shows a larynx with large bilateral granulomas based on the medial surfaces of the arytenoids (top). A prominent pseudosulcus (arrowhead) represents typical infraglottic edema associated with LPR.

1.Ford CN. JAMA. 2005;294:1534-40. LPR: laryngopharyngeal reflux


pH monitoring

Easy to perform Relatively

noninvasive Prolonged

monitoring Ambulatory

Catheter-based, may have up to 30% rate of false negatives

Wireless system (Bravo) is costly

No pH predictors of treatment response in LPR

Bilirubinmonitoring



monitoring Ambulatory Good correlation

with gastric bile acid concentrations

Current design underestimates reflux by about 30% in acidic medium (pH <3.5)

Requires modified diet

Does not detect acid Not studied in LPR



Impedancemonitoring



monitoring Ambulatory Measures acidic and

nonacidic gas and liquid reflux (combined with pH)

Catheter-based False-negative rate

unknown but most likely similar to catheter-based pH monitoring

Unknown clinical relevance when abnormal on PPI therapy

Unknown importance in LPR


Classic reflux symptoms are absent in up to 50% of patients with LPR symptoms.

LPR: Laryngopharyngeal reflux; PPis: proton pump inhibitors;

A RFS score greater than 11 in the proper clinical situation is strongly suggestive of LPR.

Reflux Finding Score (RFS): a scoring system for documenting the physical findings and severity of disease on a standardized scale and is based on eight laryngoscopic findings:subglottic edema, ventricular edema, erythema,

vocal cord edema, diffuse laryngeal, edema, hypertrophy of the posterior commissure, granuloma or granulation tissue, and thick endolaryngeal mucus.

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34. 2. Postma GN, and Halum SL. GI Motility online (2006) doi:10.1038/gimo46

LPR: Laryngopharyngeal reflux;

Findings Score

Subglottic edema 2 = present; 0 = absentVentricular obliteration 2 = partial; 4 = completeErythema/hyperemia 2 = arytenoids only; 4 = diffuse

Vocal cord edema1 = mild; 2 = moderate;3 = severe; 4 = polypoid

Diffuse laryngeal edema1 = mild; 2 = moderate;3 = severe; 4 = obstructing

Posterior commissure hypertrophy

1 = mild; 2 = moderate;3 = severe; 4 = obstructing

Granuloma/granulation 2 = present; 0 = absentThick endolaryngeal mucus/other

2 = present; 0 = absent

Total

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34. 2. Postma GN, and Halum SL. GI Motility online (2006) doi:10.1038/gimo46


1. Belafsky PC, Postma GN, Koufman JA. J Voice, 2002;16:274-277.2. Postma GN and Halum SL. GI Motility online (2006) doi:10.1038/gimo46

A RSI score greater than 13 in the proper clinical situation is strongly suggestive of LPR.

Reflux symptom index (RSI) : a nine-item scoring system that is an easy self-administered and reliable instrument that can help the clinician detect patients suffering from LPR and monitor their treatment


Within the last MONTH, how did the following problems affected the patient?

0 = no problem5 = severe problem

Hoarseness or a problem with your voice 0 1 2 3 4 5

Clearing your throat 0 1 2 3 4 5

Excess throat mucus or postnasal drip 0 1 2 3 4 5

Difficulty swallowing food, liquids, or pills 0 1 2 3 4 5

Coughing after you ate or after lying down

0 1 2 3 4 5

Breathing difficulties or choking episodes 0 1 2 3 4 5

Troublesome or annoying cough 0 1 2 3 4 5

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

0 1 2 3 4 5

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

0 1 2 3 4 5

Total1. Belafsky PC, Postma GN, Koufman JA. J Voice, 2002;16:274-277. 2. Postma GN and Halum SL. GI Motility online (2006) doi:10.1038/gimo46

GERD encompasses instances in which the disease is defined by associated extraesophageal syndromes such as asthma, LPR and chronic cough.

There are no epidemiological studies to confirm the prevalence and otolaryngologic consequences of LPR.

Multifactorial and LPR might result from direct injury or by a secondary mechanism.

Symptoms are nonspecific, and therefore laryngoscopy is often recommended

No specific test to confirm the diagnosis of LPR Endoscopy Laryngoscopy pH monitoring Bilirubin monitoring Impedance monitoring

Reflux Finding Score Reflux symptom index (RSI)

LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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Understanding Laryngopharyngeal Reflux Disease