understanding laryngopharyngeal reflux disease
TRANSCRIPT
Silent Reflux
"Disclaimer: This slide set contains information on the topic based on recent published literature & international guidelines and not endorsed by AstraZeneca. Its the presenter's discretion to modify the slides suitably."
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.
LPR: Laryngopharyngeal reflux
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
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
Supine (nocturnal) reflux
Upright (daytime) reflux
Lower esophageal dysfunction
Upper esophageal sphincter dysfunction
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
Heartburn Regurgitation Dyspepsia
Hoarseness, Globus pharyngeus, Dysphagia, Cough, Chronic throat, clearing, Sore throat
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
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)
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
Esophagitis Laryngeal inflammation
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
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;
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 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
TEST Advantages Disadvantages
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
Easy to perform Relatively
noninvasive Prolonged
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
1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34.
TEST Advantages Disadvantages
Impedancemonitoring
Easy to perform Relatively
noninvasive Prolonged
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
1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34.
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
LPR: Laryngopharyngeal reflux
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
LPR: Laryngopharyngeal reflux
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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