LPR Laryngopharyngeal Reflux

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LPR Laryngopharyngeal Reflux

  1. 1. Laryngopharyngeal Reflux By :- Dr. Supreet Singh Nayyar, AFMC Visit www.nayyarENT.com for more presentations www.nayyarENT.com 1
  2. 2. Introduction• The term 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 www.nayyarENT.com 2
  3. 3. Epidemiology• Incidence 4%-10% in various studies• No racial predilection• Common in age > 40 yrs• Upto 55%- 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 www.nayyarENT.com 3
  4. 4. Relevant anatomy and physiology• Lower – Various mechanisms acts – 3 cm in length• Upper – Cricopharyngeus + circular muscle fibers of esophagus – 3 cm in length www.nayyarENT.com 4
  5. 5. Anti reflux barrier• Oesophageal Acid Clearance – Increased by peristalsis of oesophagus & salivary bicarbonate – Decreased by abnormal oesophageal motility & xerostomia – Oesophageal peristalsis • Primary • Secondary• Oesophageal Epithelial Resistance – Mucus : barrier to pepsin – Cell membrane, intercellular bridge – Metabolic buffering capacity of mucosa www.nayyarENT.com 5
  6. 6. Cause of symptoms• Retrograde reflux of gastric acid• Damage to cilia from reflux contents - mucous stasis• Gastroesophageal reflux - neurally mediated chronic cough• Defect in carbonic anhydrase iso enzyme III• Deglutitive pharyngo laryngeal abnormalities www.nayyarENT.com 6
  7. 7. PathophysiologyGastric contents (acid & pepsin) LES Backflows UES Laryngeal mucosa (post glottis)Persistent and chronic Inflammation Mucosal changes www.nayyarENT.com 7
  8. 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 www.nayyarENT.com 8
  9. 9. 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. www.nayyarENT.com 9
  10. 10. Etiology• Abnormal esophageal motility – Neuromuscular disease – Laryngectomy – Ethanol• Reduced Mucosal Resistance Xerostomia Sicca syndrome Oral cavity radiotherapy Esophageal radiotherapy www.nayyarENT.com 10
  11. 11. Delayed gastric emptying• Outlet obstruction ulcers, neoplasm, neurogenic• Diet (fat)• Tobacco• Alcohol www.nayyarENT.com 11
  12. 12. Increased intra abdominal pressure• Tight clothing (eg. corsets, belts)• Diet: Overeating, carbonated beverages• Obesity• Pregnancy• Occupation• Exercise www.nayyarENT.com 12
  13. 13. Gastric hyper secretion• Stress: Trauma, surgery, lifestyle• Tobacco• Alcohol• Drugs• Diet www.nayyarENT.com 13
  14. 14. Smoking & Alcohol Smoking Alcohol• LES pressure Yes Yes• Mucosal resistance Yes Yes• Gastric emptying delay delay• Gastric hypersecretion Yes Yes• Oesophageal dysmotility (-) (+) www.nayyarENT.com 14
  15. 15. CLASSIFICATION OF REFLUX1. Physiologic • Asymptomatic • Postprandial • No abnormal findings2. Functional • Asymptomatic • Positive pH study3. Pathologic • Local symptoms • Secondary manifestations of LPR4. Secondary www.nayyarENT.com 15
  16. 16. LPR and GERD• LPR • GERD – Day time/ upright reflux – Nocturnal/supine reflux – No oesophagitis / heart – Heartburn burn – Intermittent episodes of – Dysmotility & prolonged reflux esophageal acid exposure – UES dysfunction – LES dysfunction – No protection www.nayyarENT.com 16
  17. 17. Presentation/Symptoms• Hoarseness – 70%• Voice fatigue, breaking of the voice• Cough – 50%• Globus pharyngeus – 47%• Frequent throat clearing, dysphagia, sore throat, wheezing, laryngospasm, halitosis www.nayyarENT.com 17
  18. 18. Secondary problems• LARYNGEAL – Benign vocal cord lesions – Functional voice disorders – Leucoplakia, Ca Larynx – Subglottic stenosis – Laryngeal Stenosis – Laryngospasm – Laryngomalacia – Delays healing following Post intubation injury www.nayyarENT.com 18
  19. 19. Secondary Problems• PHARYNGEAL • PULMONARY – Globus pharyngeus, – Asthma – Chronic sore throat, – Bronchieactasis – Dysphagia, – Chronic bronchitis – Zenker’s diverticulum – Pneumonia MISCELLANEOUS – Carcinoma – Fibrosis • Chronic rhinosinusitis • Otitis media in children • OSA • Dental erosions www.nayyarENT.com 19
  20. 20. 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 www.nayyarENT.com 20
  21. 21. Reflux Symptom Index (RSI) www.nayyarENT.com 21
  22. 22. Investigations• IDL/FOL• Videostroboscopy• 24hour, ambulatory, double probe pH metry• Barium oesophagography• DL scopy www.nayyarENT.com 22
  23. 23. FOL• Post laryngitis – Erythema – Mucosal hypertrophy – Vocal cord granulomas, nodules• Oedema• Thick endo laryngeal mucus www.nayyarENT.com 23
  24. 24. www.nayyarENT.com 24
  25. 25. Video stroboscopy www.nayyarENT.com 25
  26. 26. Ambulatory, 24–hour, double-probe ph Monitoring• Instructions- – Stop antireflux drugs – Document – meals and symptoms• Double probe – Simultaneous pharyngeal & oesophageal• Positions – distal 5cm above LES, proximal just above UES www.nayyarENT.com 26
  27. 27. Contd…• Parameters • Criterias – % upright time/total – pH < 4 time/recumbent time with pH < – Pharyngeal pH drop – 4 oesophageal acid exposure – No. of refluxes with pH < 4 – pH drop rapid & sharp – Periods of longest acid exposure• Advantages • Disadvantages – Gold std to diagnose LPR – Discomfort – Vasovagal episodes www.nayyarENT.com 27
  28. 28. Barium Oesophagography• To identify motility disorders of esophagus• Oesophageal lesions• Spontaneous reflux• Hiatus hernia• Lower oesophageal sphincter disorder www.nayyarENT.com 28
  29. 29. Treatment Antireflux therapy• Phase I : Lifestyle-dietary modification Antacid therapy• Phase II : Prokinetic H2-blockers, PPI• Phase III : Antireflux surgery www.nayyarENT.com 29
  30. 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 www.nayyarENT.com 30
  31. 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 www.nayyarENT.com 31
  32. 32. Voice Therapy Vocal Hygiene -Reduce/eliminate throat clearing and coughing. -Encourage conservative voice use -Initiate new functioning voicing behaviors. -Production of voice with an extreme forward focus.Resonant voice therapy (RVT): most often employed for LPR/granulomas www.nayyarENT.com 32
  33. 33. Voice therapy• Developed by Verdolini & Lessac.• Resonant Voice: involves oral vibratory sensations in the context of easy phonation.• Goal: “…to achieve the strongest, cleanest possible voice with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2000)”.• How? Pt. Is asked to monitor the “feel” and to concentrate on auditory feedback www.nayyarENT.com 33
  34. 34. PHARMACOLOGICAL DRUGS ANTACIDS ANTISECRETORY PROKINETIC Mixture of Al H2 Blockers Metoclopramide hydroxide PPI’s Domperidone& Mg trisilicate Mucosal protective Cisapride www.nayyarENT.com 34
  35. 35. 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 www.nayyarENT.com 35
  36. 36. • 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) www.nayyarENT.com 36
  37. 37. Evaluation and Managementof Laryngopharyngeal Reflux Charles N. Ford, MD JAMA. 2005;294:1534-1540. www.nayyarENT.com 37
  38. 38. SurgeryLaparoscopic Nissen Fundoplication Indications Failed drug treatment Complications Goal Restore natural integrity of LES & maintain normal deglutition www.nayyarENT.com 38
  39. 39. PAEDIATRIC LPR• Incidence - 18% of all infants• 70% in TO fistula, neurological diseases• Children < 3y more prone for reflux www.nayyarENT.com 39
  40. 40. Natural history of reflux• In majority it is self limited• Improves by 1st yr of life others can be benefited by positional treatment• If persists after 3 yrs of age needs medical or surgical treatment www.nayyarENT.com 40
  41. 41. Symptomatology• Mechanisms – Microaspiration – Oesophageal reflux• Manifest as – Chronic cough – Asthma – Hoarseness – Laryngomalacia – Subglottic stenosis – Apnea www.nayyarENT.com 41
  42. 42. Diagnosis• History• Examination• Laryngoscopy & bronchoscopy• Prolonged double probe pH metry www.nayyarENT.com 42
  43. 43. Treatment• Similar as adult except – Burping – Positional management – PPIs – lack of long term experience – No surgical intervention before 3 years www.nayyarENT.com 43
  44. 44. What’s new• Pepsin detection in throat sputum by immunoassay – 100% sensitive & 89% specific• Reflux laryngitis is associated with down- regulation of mucin gene expression.• Bifurcated, triple-sensor pH probe allows identifying true hypopharyngeal reflux episodes• Oropharyngeal aerosol-detecting pH probe www.nayyarENT.com 44
  45. 45. Thank Youvisit www.nayyarENT.com for more presentations www.nayyarENT.com 45

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