laryngopharyngeal reflux 2
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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
29-07-2012
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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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FACTORS AFFECTING LES TONE
Increased Tone
ProteinBethanecolMetaclopramideAntacidsadrenergic drugsAcidification of distal
esophagus
Decreased Tone
FatCarbsETOhCigarettesCarmanitives
peppermint, spearmintTheophyllineCCB -adrenergic drugsDopamineSedatives
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MECHANISMS RESULTING IN SYMPTOMS
Acid exposure results in direct mucosal damageUlceration, hemorrhage,
necrosis
Damage to mucociliary activity leads to increased viscosity
Activated Pepsin (max @ pH 4.5) results in tissue damage
Laryngeal Chemoreflexsensory receptors in larynx -->
laryngospasmAssociated with bradycardia,
central apnea and hypotension
Vagal ReflexAcid within distal esophagus -->
laryngospasm, cough Associated with bronchospasm,
increased secretions, tachycardia, hypertensionSudden infant Death Syndrome?
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COMMON SYMPTOMS OF LPR
** Globus sensation
** Chronic throat clearing
** Dysphagia
** Sore throat
** Excessive throat mucus
Hoarseness / Dysphonia
Voice breaks
Neck pain
Chronic or nighttime cough
Vocal fatigue
Odynophagia
Postnasal Drip
Halitosis
Ear Pain
Laryngospasm
Asthma exacerbation
Loss of upper singing range
Prolonged warm up time for singers
Heartburn / regurgitation
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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 reflux29-07-2012
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PHYSICAL EXAM / LARYNGOSCOPY
Observations:
•Voice quality, throat clearing, cough, body habitus
Psuedosulcus
ventricular obliteration
Erythema / hyperemia
Vocal fold edema
Diffuse laryngeal edema
Posterior commisure hypertrophy
Thick endolaryngeal mucus / inspisated secretions
Granuloma / granulation
Leukoplakia
Nodules / prenodules
Polyps
Pachydermia Laryngeus
Webs
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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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THE ASSOCIATION BETWEEN LARYNGEAL PSEUDOSULCUS AND
LARYNGOPHARYNGEAL REFLUX
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 folddue 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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OBJECTIVE TESTING
Voice Analysis
• Before and after therapy - ? significance
Esophagram
• Useful for GERD, not LPR• Hiatal hernia, erosive esophagitis, strictures,
barrett’s, 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
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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
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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
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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
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MEDICAL MANAGEMENT
Behavioral Modification
Antacids
H2 blockers
PPI
Promotility agents
Other
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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)
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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 PPI’s
Long term high dose H2 blockers not as effective nor
as cost effective as PPI’s
Commonly used:
• Zantac (ranitidine)• Pepcid (famotidine)29-07-2012
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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 PPI’s:
• Aciphex (Rabeprazole)• Nexium (esomeprazole)• Prevacid (lansoprazole)• Prilosec (omeprazole)• Protonix (pantoprazole)
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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.
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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
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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
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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
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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
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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)
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DISORDERS IN INFANTS AND CHILDREN THAT ARE LIKELY REFLUX RELATED
Recurrent Croup
Laryngospasm
Laryngomalacia
Hoarseness
Subglottic Stenosis
Aspiration
Chronic Cough29-07-2012
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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
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