What are they? 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 and into the back of the throat, reaching the larynx and pharynx.
Symptoms for GERD The most common is a burning sensation in the chest, usually after eating (AKA heartburn). This sensation can also be associated with position, sleep, or exercise. Others include: belching, dysphagia, odynophagia (pain on swallowing), water brash, sore throat, cough, bronchospasms, atypical chest pain, hoarseness, and asthma exacerbation. Symptoms are more common over night Most common symptoms in the elderly include dysphagia, vomiting, and respiratory problems, among others which all lead to restrictive respiratory problems.
Symptoms of LPRD Symptoms of the two may overlap, however, the pharynx, larynx, and lungs are more sensitive to stomach acid and digestive enzymes allowing less reflux to do more damage. Symptoms include: hoarseness, frequent throat clearing, sensation in the throat, bad/bitter taste in the mouth, referred ear pain, and post-nasal drip to name a few. Symptoms are commonly experienced during the day. Very few experience heartburn.
Common ENT Symptoms of LPRD:HoarsenessChronic (ongoing) coughFrequent throat clearingPain or sensation in throatFeeling of lump in throatProblems while swallowingBad/bitter taste in mouth (Especially in morning)Asthma-like symptomsReferred ear painPost-nasal dripSinging: Difficulty with high notesNighttime choking attacks
How is the voice affected? Hoarseness Vocal fatigue Oedema Ulceration Granulation Polypoid degeneration Vocal nodules Laryngospasm Arytenoid fixation Laryngeal stenosis Carcinoma of the larynx
GERD LPRDHeartburn Common InfrequentOesophagitis Common InfrequentOesoph. Abnormal NormalMotility Upright,Pattern Supine, nocturnal daytimeTreatment Regular dose PPI High dose PPI
Findings Red, irritated arytenoids Red, irritated larynx Small laryngeal ulcers Swelling of the VF Granulomas in the larynx
Definitive diagnostic for LPRD:The 24-hour Pharyngo-Oesophageal pH monitoring is the goldstandard for monitoring reflux events associated with LPRD.In LPRD patients, it is important that the upper channel is placedat the level of the laryngeal inlet.
Diagnosis Tests completed: – pH monitoring (AKA pH-metry) Takes 24 hours (over night) Measure acid in esophagus and throat Small, soft, fexible tube (pH probe) through the nose and into the throat which is connected to a small computer worn around the waist – Barium swallow Easiest, most cost effective However, may be misleading
Treatment Prevention/Lifestyle changes Medications Surgery
Treatment for LPRD:1. Stress:Take significant steps to reduce stress. Evenmoderate stress can dramatically increasethe amount of reflux.
2. Foods: It may be necessary to avoid or minimize some ofthe following foods:- Spicy, acidic and tomato-based foods like Mexicanor Italian food.- Acidic fruit juices such as orange juice, grapefruitjuice, cranberry juice, etc..- Fast foods and other fatty foods.- Caffeinated beverages (coffee, tea, soft drinks) andchocolate.
3. Mealtime:- Do not gorge at mealtime- Eat sensibly (moderate amount of food)- Eat meals several hours before bedtime- Avoid bedtime snacks- Do not exercise immediately after eating
4. Body Weight: Try to maintain a healthy body weight. Being overweight can dramatically increase reflux.
5. Night time Reflux: If the 24-hour pH monitoring demonstrates nocturnal reflux,elevate the head of your bed 4-6 inches with books, bricksor a block of wood to achieve a 10 degree slant.Do not prop the body up with extra pillows. This mayincrease reflux by kinking the stomach. Recent studies haveshown that reflux occurs much more often during the daywhen upright. Therefore, this suggestion may be much lessimportant than once believes.
6. Smoking:IF YOU SMOKE, STOP!!This dramatically increases reflux.
Medications reduce the acidity of the stomach contents increase the activity of the esophageal sphincters they will increase the motility of the stomach
Medications for LPRD:Over the counter antacid such as Quickeze ®, Gaviscon®or Mylanta®. Tums has the added benefit of containingcalcium.Medications such as H2Blockers (Axid®, Pepcid®,Tagament®, Zantac®), Proton pump inhibitors (Losec®,Somac®), or motility agents (Propulsid) .
Surgery Withsevere cases when meds and other tx are not successful. – Most common procedure: fundoplication, sewing a portion of the stomach around the esophagus to tighten its lower end. This operation can be done endoscopically.
Severe, long term affects Gastrointestinal bleeding Barrett’s esophagus – There is columnar epithelium in the esophagus where stratified squamous epithelium should be Laryngeal damage Cancer ??
Controversies- Clinical Findings Is subglottic stenosis caused by LPR and intubation?? Is reflux an inflammatory catalyst for many airway diseases?
Controversies- Diagnostic testing Does ph monitoring help with diagnosis. Use proton pump inhibitor as diagnostic tool.
Controversies- Treatment Twice day proton pump inhibitors
Controversies- Paediatric LPR Failure to thrive, oesophagitis and airway disturbance. Chronic cough Dysphonia Laryngomalacia Subglottic stenosis Apparent life-threatening events
Controversies- Paediatric LPR Tasker et al recently used pepsin assay to demonstrate high levels of pepsin in middle ears of 45 of 54 children requiring ventilation tubes.
References Center for Voice Disorders of Wake Forest University. (2003). Patient information sheet on reflux. http://www.bgsm.edu/voice/pt_info.html Columbia Presbyterian Medical Center. (2002). Laryngopharyngeal reflux disease and recommendations to prevent acid reflux. http://www.entcolumbia.org/lprd.htm Laryngopharyngeal reflux 2002: A new paradigm of airway disease.. James A Kaufman,MD. ENT Supplement. Levy, R.A., Meiner, S.E., & Stamm, L. (2002). Conservative management of GERD: a case study. Medsurg Nursing, 11, No. 4. Stemple, J., Gerdeman, B.K., & Glaze, L. (2002). Clinical Voice Pathology: Theory and Management. 3rd ed. Singular Publishing Voice Center. (2003). Reflux disease and its effects on the larynx. http://www.voice-center.com/reflux.html