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بسم الله الرحمن ارحيم

بسم الله الرحمن ارحيم. LARYNGOPHARYNGEAL REFLUX. Lega Natto , M.D. Nomenclature. GERD REFLUX LARYNGITIS GASTROLARYNGEAL REFLUX GASTROPHARYNGEAL REFLUX SUPRAESOPHAGEAL REFLUX LARYNGOPHARYNGEAL REFLUX. LPR.

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بسم الله الرحمن ارحيم

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  1. بسماللهالرحمنارحيم

  2. LARYNGOPHARYNGEAL REFLUX LegaNatto , M.D.

  3. Nomenclature • GERD • REFLUX LARYNGITIS • GASTROLARYNGEAL REFLUX • GASTROPHARYNGEAL REFLUX • SUPRAESOPHAGEAL REFLUX • LARYNGOPHARYNGEAL REFLUX

  4. LPR • Retrograde movement of gastric contents(acid and enzymes as pepsin) in to the laryngopharynx leading to symptoms referable to the larynx and hypopharynx.

  5. dysphonia Chronic cough Mild dysphagia Globuspharyngeus Throat clearance

  6. laryngospasm Vfgranuloma Laryngeal ca Subglotticstenosis

  7. LPR versus GERD • Only 35% reporting heartburn • Esophagitis on biopsy only 25% • UES problem in upright position during physical exertion. • Lower incidence of esophageal dysmotility • Less acid required to create symptoms

  8. Pepsin maintains damaging activity up to PH as high as 6. In vitro study

  9. Intrinsic differences between the esophagus an larynx Epithelium and physiology

  10. Axford SE , sharp N, Ross PE, et al. Cell biology of laryngeal epithelial defenses in health and disease: preliminary study. Ann OtolRhinolLaryngol 110: 1099-1108, 2001

  11. Pathophysiology • THEORY 1: DIRECT INJURY FROM ACID OR PEPSIN • LOW UES PRESSURES, ESPECIALLY AT NIGHT • DYSMOTILITY WITH POOR ACID CLEARANCE • THEORY 2: VAGALLY MEDIATED REFLEX -ACID IN LES EVOKES SYMPTOMS

  12. SYMPTOMS • HOARSENESS: 50-75% • THROAT-CLEARING • MUCUS, PHLEGM, PND • COUGH • SORE THROAT • VOCAL FATIGUE, BREAKS • DYSPHAGIA • GLOBUS: 25-50% • HALITOSIS

  13. Diagnosis • BARIUM SWALLOW • MANOMETRY • ESOPHAGOSCOPY

  14. Diagnosis of LPR • History and examination: • Reflux finding score (RFS) • Reflux severity index (RSI) • 24 hour dual sensor PH probe (gold standard) • Empiric trial of LPR

  15. PROBLEMS WITH THE GOLD STANDARD • EXPENSIVE • UNCOMFORTABLE • PROBE PLACEMENT • FALSE NEGATIVES • BILE REFLUX, NON-ACID REFLUX

  16. PULMONARY SYMPTOMS: ASTHMA, BRONCHIECTASIS • ~50% SEVERE ASTHMATICS HAVE DOCUMENTED GERD • ASPIRATION OF GASTRIC CONTENTS WITH ACID AND ENZYMATIC INJURY • NEURALLY MEDIATED REFLEX BRONCHOCONSTRICTION • ? LINK WITH OSA

  17. LPR IN DYSPLASIA / GLOTTIC CA OF THE LARYNX • 40 pts, dysplasia, T1-2 ca • Dual probe pH monitoring • Incidence of LPR: 85% • LPR in ‘normals’: 52% • No relationship between histology, smoking, or heartburn and level LPR • More LPR upright Lewin JS, Gillenwater AM, Garrett JD: Characterization of Laryngopharyngeal Reflux in Patients with Premalignant or Early Carcinomas of the Larynx: CANCER FEB 2003 p.1010-1014

  18. GERD AND LARYNGEAL CANCER: META-ANALYSIS • All studies 1966-2004: 15 identified Qadeer MA, Colabianchi N, Vaezi MF: Is GERD a Risk Factor for Laryngeal Cancer? LARYNGOSCOPE March 2005 p.486-491

  19. GERD AND LARYNGEAL CANCER: META-ANALYSIS • Reflux at least twice as common in laryngeal ca pts. • Suggests GERD may play role in carcinogenesis • Several case series: laryngeal ca in life non-smokers, non-drinkers with long hx GERD

  20. GERD likely has an etiologic role in laryngeal ca as an independent factor or co-factor in carcinogenesis • There may be a dose and length of exposure relationship

  21. Treatment of LPR • Diet modifications • Behavior modifications • Medicine: • PPI • WHAT DOSE? • FOR HOW LONG? • SUCCESS?

  22. MORE RAPID AND EFFECTIVE RELIEF THAN H2 BLOCKERS • HANSON: N = 233 • 96% RESPONSE TO ANTIREFLUX Rx • SHAW: N = 96 • PPI TREATMENT 12 WEEKS • SIGNIFICANT RESPONSE • ACCOUSTIC MEASURES IMPROVE FIRST • KOUFMAN: N = 40 IMPROVEMENT IN RSI AND RFS

  23. PPI • 4-6 months. • Bid, 30 min before meal. • Omeprazole (brand names: Losec®, • Lansoprazole (brand names: Prevacid • Esomeprazole (brand names: Nexium • Pantoprazole(brand names:Pantoloc • Rabeprazole(brand names: Pariet®)

  24. PPI RESISTANCE IN LPR • INABILITY TO KEEP GASTRIC pH >4 FOR >85% OF A 24 HR PERIOD • H2 BLOCKERS: RANITIDINE, CIMETIDINE, FAMOTIDINE • THEORY 1-INEFFECTIVE LES, ABSENT MOTILITY • PROKINETICS: METACLOPRAMIDE, BETHANECHOL, CISAPRIDE • THEORY 2-HIGHER BASAL OUTPUT OF ACID, ? FROM > ENZYMES

  25. ThankYou

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