Laryngopharyngeal Reflux

( LPR )
Literature Reading
Tita Puspitasari

Supervisor : Ongka M Syaifudin,dr.,M.Kes.,SpTHT-

KL (K)

DEPT OF OTORHINOLARYNGOLOGY HNS

SCHOOL OF MEDICINE PADJADJARAN UNIVERSITY
BANDUNG
2015
 Definition
Laryngopharyngeal reflux (LPR) is defined as the reflux of
gastric content into larynx and pharynx, where it comes
in contact with tissues of the upper aerodigestive tract.
10% of patients visiting otolaryngology clinic
have reflux-attributed disease.
Up to 55% of patients with hoarseness have
reflux into their laryngopharynx
In ENT-HNS Dept Hasan Sadikin Hospital
Bandung, laringofaryngeal reflux patient come
to an outpatient clinic between January
December 2013 were 332 people.

Laryngopharyngeal Reflux: Overview and Clinical Implications Iman Naseri, MD Northeast

Florida Medicine 2011
 Pathophysiology
Reflux of gastric contents : Esophagus,
laryngopharyng
Reflux of gastric contents into the esophagus, is
a normal physiologic phenomenon
That ocurs in most people, particularly after
meals. up to 50 reflux episodes a day (below
pH 4)
Esophageal symptoms and complications arise
when reflux is prolonged and/or there is a
breakdown in the defense mechanisms
(GERD)
 When gastric reflux travels more proximal
into the laryngopharynx, it is termed
laryngopharyngeal reflux (LPR)
The laryngopharynx appears to be more
sensitive to injury by gastric reflux
Three reflux episodes per week or less into
the laryngopharynx results in severe
damage of the laryngeal epithelium
 Reflux laryngeal symptoms + induce extraesophageal
pathology by several different mechanisms:
1. The microaspiration theory: Direct contact acid +
pepsin with the epithelium
2. The Trauma theory: to cause injury and that an
additional factor, such as vocal abuse or concomitant
viral infection to induce mucosal lesions
3. The esophageal-bronchial reflex: distal esophagus
stimulates vagally mediated reflexes chronic cough
laryngeal symptoms and lesions
 ETIOLOGY

Physical
Life Style
Improper Diet
functioning of Irritants tomato,
esophageal citrus, NSAID,
sphincters, aspirin
(UES,LES) chocolate, fatty
Hiatalhernia. foods, spices, coffee.
Abnormal Overeating
esophageal Smoking
contractions. Alcohol
Slow emptying of consumption, etc.
the stomach
Peter C. Belafsky, MD, PhD, MPH Catherine J. Rees, MD Identifying and Managing Laryngopharyngeal
Reflux, 2009 6

Differences between LPR and GERD

GERD LPR
Esophagitis Laryngitis
Heartburn Hoarseness
Have supine Typically have upright
(nocturnal) reflux and (daytime) reflux good
esophageal dysmotility esophageal motor
function and no
esophagitis
Dysfunction of the Upper esophageal
lower esophageal sphincter
sphincter (LES)
(LES)
 Diagnosis of LPR

Based on a constellation of patient

Symptoms RSI Score
Clinical evaluation with visualization
of the laryngopharynx RSF Score
Dual-probe ambulatory 24-hour pH
monitoring considered by many as
the gold-standard evaluation
 The most widely used quality of life (QOL)
instrument related to LPR in the
otolaryngologic literature is the reflux
symptom index (RSI) developed by
Belafsky et al
A score > 1 3 suggests the presence of
LPR.
 Reflux Finding Score
While indirect laryngoscopy with a mirror may be adequate,
endoscopy of the larynx and pharynx is an easily implemented is an
opportunity for recording and photodocumentation

A score of> 7 suggests LPR.

Signs of The LPR :

Posterior laryngitis with thickening and edema of the laryngeal
posterior commissure and postcricoid mucosa
Granuloma of the vocal process
Stenoses of the larynx or subglottis
Pseudosulcus, vocal fold edema,. and thickened mucous
Subglotic Edema

Sub glotic Edema , extend

from the anterior commissure
to the posterior larynx
0:absent
2:present

ENDOSCOPY THT-KL RSHS 2011

13
Ventricular Obliterasi

Relatively frequent finding (80%)

Swelling of the true and false vocal
folds
Partial:2
reduced ventricular space
Complete:4
no ventricular space.

ENDOSCOPY THT-KL RSHS 2011

14
Erytema/ Hyperemia
NONSPECIFICFINDINGS
Depends on the video
endoscopic
Equipment

Isolated erythema of the

arytenoids : 2
Diffuse laryngeal erythema : 4

ENDOSCOPY , THT-KL RSHS 2011

Vocal Fold Edema

1. Mild
2. Moderate
3. Severe/sessile
4. Polypoid
degeneration

ENDOSCOPY , THT- KL RSHS 2011

16
Diffuse Laryngeal Edema

Is judge by the size of the

airway relative to the size
Of the larynx
1. Mild
2. Moderate
3. Severe
4. Obstructing

ENDOSCOPY , THT-KL RSHS 2011

Posterior Commisure Hypertrophy

The most frequent findings

85%
Score:
1. Mild, slight moustache
app
2. Moderate, straight line
3. Severe, bulging
4. Obstructing: obliteration

ENDOSCOPY , THT-KL RSHS 2011

18
Thick Endolaryngeal Mucus
Granuloma
Thick
endolaryngeal
mucus granuloma
Score
Absent:0
Present:2

19
ENDOSCOPY , THT - KL RSHS 2011
 Tonsil Lingual Staging

MILD SEVERE

Hypertrophy grd Hypertrophy grd

1 3
MODERATE
ENDOSCOPY ,THT-KL RSHS 2011
 MII
Multichannel intraluminal impedance (MII) is a catheter-based
method to detect intraluminal bolus movement within the
esophagus.
This approach is based on changes in resistance to
alternating current between a series of metal electrodes
produced by intraluminal gas, liquid, or bolus.
Combined with manometry, it provides information on the
functional (ie, bolus transit) component of manometrically
detected contractions.
When combined with pH testing, it allows for the detection of
gastroesophageal reflux independent of pH (ie, both acid and
non-acid reflux).
 This approach is based on changes in
resistance to alternating current
between a series of metal electrodes
produced by intraluminal gas, liquid,
or bolus.
 TNE or EGD
Transnasal esophagoscopy and
esophagogastroduodenoscopy (EGD) are useful in
detecting characteristic associated mucosal injury,
esophagitis, and Barrett esophagus.
Overall, EGD and 24-hour pH-monitoring studies
have proven less useful in detecting LPR than in
identifying GERD.
While EGD reveals esophageal lesions in 50% of
typical GERD patients, it is abnormal in less than
20% of LPR laryngitis patients.23 T
 TREATMENT OF LARYNGOPHARYNGEAL
REFLUX

The goal is :
To eliminate symptoms,
Heal mucosal lesions,
Manage complications
Maintain symptom remission.

Control of intragastric acid secretion and reduction of

pharyngeal and laryngeal acid exposure is directly
related to mucosal healing and symptom relief.
 MANAGEMENT LPR
Treatment should combine :
Patient Education
Lifestyle Modification
and diet
Pharmacologic Therapy
Surgery

Management of laryngopharyngeal reflux: an unmetmedical needF. ZERBIB* & D.

STOLLNeurogastroenterol Motil 2010
26
 Patient Education
Educating patient about the recurring
nature and chronicity of LPR
Optimal schedule for long-term
medical management

Management of laryngopharyngeal reflux: an unmet medical need F. ZERBIB* & D. STOLL,2010

27
 LifeStyleModification
1. WeightLoss

. Diet and weight loss will decrease intraabdominal

pressure, stomach distension, and LES relaxations.
. The goal of a body mass index approximately 25
kg/m2
2. Dietary Factors

Common mucosal irritant : Citrus juices, tomato products,

coffee, tea, cola, spicy foods, and alcohol
Carminatives : chocolate or peppermint LES pressure,
the frequency of reflux
Carbonate beverages are not only acidic reflux by
gaseous gastric
Fatty or fried foods promote reflux.
Recommended that patients eat small meals that are low in
fat.
3. Medications

Such as anticholinergics, sedatives, tricyclic

antidepressants, potassium tablets, iron sulphate, and
nonsteroidal anti-inflammatory drugs decrease LES
pressure promoting reflux and thus should be avoided
4. Smoking tobacco :
Decreases LES pressure, promoting reflux.
Toxic irritants in tobacco affect laryngeal mucous
membranes + mucous viscosity causing excessive
throat dearing.
Smoking-associated cough will increase
intra-abdominal pressure increasing reflux events

5. Tight-fitting clothes :Will increase intta-abdominal

pressure
 6. Sleep issues :
Head elevation 6-8 inches
Use gravity to gastric
clearance during sleeeping
period

Lying down in bed on the

left side
Reflux frequency
decreased

Stop eating 2 3 hours

before go to sleep

Management of laryngopharyngeal reflux: an unmet medical need 32

F. ZERBIB* & D. STOLL,2010
 Pharmacologic Therapy

PPIs
H2-receptor Antagonists
Prokinetic Agents
Mucosal Cytoprotectants

Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer

33
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
 Proton Pump Inhibitors (PPI)
PPI : omeprazole, lansoprazole, rabeprazole,
pantoprazole, esomeprazole
Once-daily dosing in the morning is more
effective than dosing in the evening for all PPIs
with respect to the suppression intragastric
acidity and daytime gastric acid secretion.
All PPIs are very safe drugs with an minimal
adverse effect

Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer

34
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
Proton Pump Inhibitors (PPI)
Inhibit the H+ /K+ A1Pase enzyme that catalyses acid
secretion in the parietal cells, prevent secretion of HCl
Have shown variable results
Shaw et al. reported objective improvement in two-
thirds of reflux-laryngitis patients after 3 months of
omeprazole
El-Serag et al. performed the first prospective placebo-
controlled trial of PPis for the treatment of LPR
reporting significant improvement with BID PPI
compared to placebo
 Proton Pump Inhibitors (PPI)
Some studies showed that the PPI is more effective at
reflux laringofaring compared with H2 receptor
antagonists.

Omeprazole and Lansoprazol equally effective against

the disease and the degree of improvement of quality of
life of patients with chronic rhinosinusitis caused by
reflux laringofaring (Kurniawati, Madiadipoera)
Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer
36
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
 H2-Receptor Antagonists
H2 receptor antagonists, such as Cimetidine, Ranitidine, Famotidine,

Nizatidine.

They competitively inhibit the binding of histamine to the basolateral

membrane of parietal cells to suppress acid production

It is recommended that H2 receptor antagonists are taken 1 hour prior

to the activity that causes reflux symptoms.

Higher doses given twice or four times a day may increase efficacy
 H2-Receptor Antagonists
No effect on LES pressure or esophageal
clearance

Side effect only < 4 % patients

Ranitidine has proven a more potent

inhibitor of gastric secretion than
cimetidine

Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer

38
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
 Prokinetic Agents
Accelerate esophageal clearance and
gastric emptying
Increase lower esophageal sphincter
pressure
Adverse effect : Venticular arrythmias and
diarrhea
Cisapride, Itopride, Metoclopramide,
Domperidone, Tegaserod

Virtue of Adding Prokinetics to Proton Pump Inhibitors in the Treatment of Laryngopharyngeal Reflux
Disease: Prospective Study Waleed F. Ezzat, MD, Samya A. Fawaz, MD, Hanaa Fathey, MD,39 and Ahmed El
Demerdash, MDJournal of Otolaryngology-Head & Neck Surgery, 2011
 Mucosal Cytoprotectants
Sucralfate is a polysulfated salt of sucrose that
may be helpful as an adjunct in protecting
injured mucosa from harmful effects of pepsin
and acid.

Mucosal protective agents binds to inflamed tissue

Blocking diffusion of gastric acid & pepsin across

the mucosal barrier

Protecting the esophageal mucosa

Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer

40
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
 Mucosal Cytoprotectants
Administered 4 times daily

May relieve GERD symptoms but do not play a role in LPR

management
Side effect :
- Magnesium-containing antacids diarrhea
- Aluminium-containing antacids constipation
Safe for pregnant woman

Management of laryngopharyngeal refl ux with proton pump inhibitors Christina Reimer

41
Peter Bytzer Department of Medical Gastroenterology, Kge University Hospital, Denmark,
 Surgery
In a fundoplication procedure, a
portion of the stomach is wrapped
around the distal esophagus in an
effort to reduce reflux through the GE
junction by improved competence of
the LES.
Complete (i.e., 360 degrees) wrap, as
in the Nissen or Rossetti procedure,
Partial (i.e., 270 degrees) wrap, as in
the Toupet or Bore procedures. The
most common reported GE junction
operation for EER is the Laparoscopic
Nissen Lundoplication (LNF).

http://www.webmd.com/heartburn-gerd/fundoplication-surgery-for-gastroesophageal-reflux-disease-gerd
 Indication :
Symptoms associated with weak acid and nonacid
reflux
Do not respond to medical therapy
The majority of studies also demonstrate
significant improvement of symptoms and signs of
LPR in medically refractory patients treated with
INF.
 Complications
The most concerning ofLPRcomplications:
Airway obstruction,
Laryngospasm
Paradoxical vocal fold motion
Granuloma,
Stenosis larynx
Polypoid degeneration
Laryngeal carcinoma.
 Complications

Laryngeal lesions such as granulomas and

subglottic stenosis often show drastic
improvement or resolution with antireflux therapy
alone, so in the case of a safe airway, initial
medical management of reflux is generally
warranted.
 Conclusions
Laryngopharyngeal reflux (LPR) is defined as the reflux of
gastric content into larynx and pharynx, where it comes in
contact with tissues of the upper aerodigestive tract.
Diagnosis of LPR : RSI Score, RSF Score, dual-probe
ambulatory 24-hour pH monitoring
Treatment of LPR : Patient Education, Lifestyle
Modification and diet, Pharmacologic Therapy, Surgery

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Thank You