sppa 6400 voice disorders - tasko reflux & the voice

SPPA 6400 Voice Disorders - Tasko

Reflux & the Voice


What is reflux?


Reflux = “Backflow” 7% of US population have daily complaints of

heartburn (Talley 1992). 18 million self-medicate with antacids at least

twice weekly


Gastroesophageal Reflux Disease (GERD) vs. Laryngopharyngeal Reflux (LPR)

GERD involves lower esophageal sphincter dysfunction LPR involves both upper and lower esophageal sphincter

dysfunction Until recently, LPR often considered to be under-

diagnosed/under-treated Koufman (1991, 2000) reports

LPR present in 4-10% of attendees of otolaryngology clinic (Koufman, 1991)

LPR present in 55% of patients with hoarseness (Koufman, 2000)


Conditions reported to be associated with reflux Reflux laryngitis

(posterior) Subglottic stenosis Carcinoma of the larynx Carcinoma of esophagus Contact ulcers and

granulomas Laryngospasm Paradoxical Vocal Cord

Motion

Globus pharyngeus Vocal nodules Reinke’s edema Recurrent leukoplakia Recurrent pneumonitis Pharyngitis Asthma


Why is LPR not recognized? Patients with LPR usually deny symptoms of

heartburn or regurgitation (silent reflux) Findings of LPR on laryngeal exam vary

considerably Traditional tests for GERD lack both sensitivity and

specificity for LPR Therapeutic trials using traditional antireflux therapy

often fail (false negatives)


How is LPR Identified? Patient symptoms Vocal and Laryngoscopic signs Ambulatory 24 hour double/triple probe pH monitoring

Considered by some to be diagnostic “Gold Standard” Multichannel intraluminal impedance (MII)

measures presence of liquid and gaseous events in upper aerodigestive tract

Barium esophagram Esophagoscopy Esophageal manometry Trial period of acid suppression treatment (PPI for at least

three months)NOTE: Signs and symptoms are not pathognomonic


Symptoms of LPRKoufman (1991) Chronic dysphonia (92 %) Intermittent dysphonia Vocal fatigue Nocturnal choking Chronic throat clearing Excessive throat mucus Chronic cough (44%) Dysphagia (27%) Globus pharyngeus (33 %)

Book et al. (2002) Throat clearing (98%) Persistent cough (97%) Globus pharyngeus (95%) Hoarseness (95%)


Reflux Symptom Index

The Reflux Symptom Index A score > 10 may indicate significant refluxA score > 13 definitely abnormal


Typical GI Patient vs. Typical ENT Patient (Koufman, 1991)

GI ENTSymptomsheartburn and/or regurgitation Y N

hoarseness, dysphagia, globus, throat clearing, cough etc. N Y

Findingsendoscopic esophagitis Y Nlaryngeal inflammation N Y


Laryngoscopic Signs


The Reflux Finding Score (Belafsky et al. 2002)

‘Groove’ along the full margin of the vocalfold

Diminished size of the ventricle revealed by aswelling of the ventricular bands

Erythema (redness)Hyperemia (increased blood flow to tissue)

Edema localized in the vocal folds

Edema throughout the larynx

Granuloma or granulation tissue anywhere inthe larynx

Thick, white endolaryngeal mucus on the vocal foldsor elsewhere in the endolarynx.

Score of 7 or greater: likely to have LPR


LPR: Tissue Changes

Interarytenoid bar

Vocal fold edema

Interarytenoid granuloma

Granulomas


LPR: Tissue Changes


From Vavricka et al. (2007)(A) posterior pharyngeal wall

cobblestoning(B) interarytenoid bar with

erythema(C) posterior commissure with

erythema and surface irregularity

(D) posterior cricoid wall edema(E) arytenoid complex with apex

edema, erythema, and medial wall erythema

(F) true vocal folds with edema(G) false vocal folds erythema,(H) anterior commissure erythema(I) epiglottis erythema(J) aryepiglottic fold edema.


Diagnostic value of laryngeal signs?

Vavricka et al. (2007)


Diagnostic value of laryngeal signs?

Hicks et al. (2002)


GI ENT

Diagnostic tests

Abnormal esophageal radiography Y sometimes

Esophageal pH monitoring Y Y

Pharyngeal pH monitoring N Y

Pattern of reflux

Supine (nocturnal) Y sometimes

Upright (awake) sometimes Y



pH monitoring +/- MII “Gold standard” for GERD Some problems for diagnosing LPRProblems Double/triple probe is required Probe placements effects measures Disagreement about threshold values There can be both liquid and gaseous refluxate – gas

can be more problematic for LPR but not well monitored

Non-acid (alkaline) refluxate


Are we good at diagnosing LPR?Issues Which signs, which symptoms? Specificity and sensitivity Examination procedures Differential diagnosis


Clinical Decision Making

From Ford (2005)


Treatment


Common anti-reflux Meds

Antacids buffers pH e.g. Tums, Rolaids Not considered very effective

with LPR

H2 antagonists Blocks histamine action which

decreases acid production e.g. Tagamet, Ranitidine,

Zantac Not preferred for LPR

Proton Pump Inhibitor (PPI) Blocks action of proton pump Most potent acid suppression

medication e.g. Omeprazole (Prilosec),

Nexium, Prevacid Drug of choice for LPR


From Ford (2005)


Conventional treatment for suspected LPR Dietary modification

No eating/drinking within 3 hrs of bedtime Avoid overeating or reclining after meals Avoid fried foods and adhere to low fat diet Avoid coffee, tea, chocolate, mints and soda (refluxogenic) Avoid caffeine of all kinds Avoid alcohol especially in the evening Avoid spicy, tomato based products, fruit juices

Lifestyle modification Elevate head of bed 4-6 inches Avoid wearing tight fitting clothing or belts Cease tobacco use

Medication Omeprazole (PPI) 20 mg b.i.d. (am and pm) Treatment should continue for at least 3 months (up to 6 mos.)


GIENT

Response to treatment

Dietary or lifestyle modification Y sometimes

Rate of success with H2 blockers 85% 65%

Rate of success with omeprazole 99% 99%

Assuming adequate dosage and duration of therapy



Cochrane Database

From Cochrane Reviews (2005)

Also Williams et al. (2004)


Fundoplication (Nissen) tightens LES by wrapping the upper part of the

stomach around the lower part of the esophagus. Procedure may

Be open (external incisions) Use endoscopy (small external incisions)

reports of 90 % of patients undergoing the endoscopic Nissen fundoplication are symptom free after surgery.

Suggestions that Tx is more effective for GERD vs. LPR


Case Illustrations

sppa 6400 voice disorders - tasko reflux & the voice

Documents

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voice disorders taskohow

voice disorders taskowhy

voice disorders taskowhat

pathognomonic sppa

hoarseness koufman

patient symptomsvocal

typical ent patient