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Laryngopharyngeal (LPR) Reflux & GERD

Laryngopharyngeal (LPR) Reflux & GERD. April 15, 2012 AAO-PA Course With assistance from Lee Akst, MD Nina Desell, CRNP. Stacey L. Ishman, MD, MPH Department of Otolaryngology. Disclosures. Relevant Financial Disclosures None Non-FDA Approved uses None. Objectives.

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Laryngopharyngeal (LPR) Reflux & GERD

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  1. Laryngopharyngeal (LPR)Reflux & GERD April 15, 2012 AAO-PA Course With assistance from Lee Akst, MD Nina Desell, CRNP Stacey L. Ishman, MD, MPHDepartment of Otolaryngology

  2. Disclosures Relevant Financial Disclosures None Non-FDA Approved uses None

  3. Objectives • To define and contrast laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD) • To review the diagnostic tools available for LPR and GER including pharyngeal pH probes. • To understand the treatment options for GER and LPR.

  4. Why are we talking about LPR? • Increasing recognition of LPR: 1990-2001 • Visits for reflux up 306% (especially Oto) • PPI prescriptions increased 14-fold • Survey of 1854 people • 26% reported GERD & laryngeal symptoms concurrently, suspicious for LPR • Increased clinical investigation, increased basic science studies, and increased discussion Altman et al. Laryngoscope 115:1145-53, 2005 Connor et al. J Voice 21:189-202, 2007 Courtesy of Lee Akst, MD

  5. Gastroesophageal Reflux • Effortless regurgitation of gastric contents • Adults • 25%-40% in the United States to some degree at some point • About 10% experience GERD weekly or daily • Children • 60-80% of infants • 85% resolves by 6-12 mo; 5% pathologic

  6. Gastroesophageal Reflux Classification • Physiologic • Functional • Pathologic • Secondary

  7. Physiologic GER • No abnormalities on diagnostic studies • Asymptomatic • Rarely occurs during sleep • Often occurs in the upright position postprandial. Courtesy of Nina Deselll, CRNP

  8. Functional GER • Silent or asymptomatic reflux • Identified by esophageal pH monitoring Courtesy of Nina Deselll, CRNP

  9. Pathologic GER Traditional GERD • Symptomatic • Causes complications in the GI and respiratory tracts • Clinically quantified Courtesy of Nina Deselll, CRNP

  10. Secondary GER • Product of another disorder • neurologic disease • esophageal dysmotility • structural Courtesy of Nina Deselll, CRNP

  11. Symptoms of GERD • #1 = persistent heartburn • Regurgitation of acid (esp asleep/bending) • Bitter taste in the mouth • Persistent dry cough • Hoarseness (especially in the am) • Sensation throat tightness as if food is stuck there • Wheezing

  12. Symptoms of GERD - Pediatric • In Children • Repeated vomiting • Coughing • Esophagitis, hematemesis • FTT from losses or inadequate intake • Respiratory complications-asthma, cyanosis, ALTE, pneumonia • Anemia • Especially occurring > 1 year of age

  13. GERD ≠ LPR Google Image search for “Heartburn” Courtesy of Lee Akst, MD

  14. LPR • Gastric content reach the larynx or pharynx • Also called • extraesophageal reflux • "atypical" reflux • gastropharyngeal reflux • laryngeal reflux • pharyngoesophageal reflux • supraesophagealreflux Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  15. LPR • Laryngeal damage secondary to: • Acid • Activated pepsin (active @ pH ≥ 5.0) • Laryngeal mucosa is injured with much lower levels of acid/pepsin exposure • Laryngeal mucosa can easily be damaged irreversibly Courtesy of Nina Deselll, CRNP

  16. LPR • 20 to 60 percent of patients with LPR have head and neck symptoms without any appreciable heartburn Courtesy of Nina Deselll, CRNP

  17. LPR Effect on the Airway: Mechanisms? • Microaspirationwith stimulation of the laryngeal adductor reflux • Microaspirationwith chemical pneumonitis • Stimulation of an esophageal-vagal and/or autonomic reflex that results in/potentiates bronchial constriction Courtesy of Nina Deselll, CRNP

  18. GERD Esophageal dysmotility Dysfunction of the LES LPR Dysfunction of the UES Good esophageal motility Etiology GERD vs LPR Courtesy of Nina Deselll, CRNP

  19. LPR UES is known as the pharyngoesophagealjunction

  20. Common LPR Symptoms • Globus sensation (a lump in the throat) • Chronic laryngitis • Dysphonia • Chronic sore throat • Chronic cough • Constant throat clearing • Granuloma of the true vocal cords

  21. Additional LPR symptoms • Aerophagia • Buccal burning • Cervical pain • Choking sensation • Dysphagia • Food sticking in throat • Halitosis • Otalgia • Pharyngeal tightness

  22. Laryngopharyngeal reflux Symptoms exacerbated with • Endotracheal intubation • Vocal abuse • Upper respiratory infection Exacerbation can sometimes cause dysphonia Courtesy of Nina Deselll, CRNP

  23. LPR Diagnosis • Some controversy: • DoesLPR exist without esophageal complaints • If you believe it does: • Our challenge is to figure out when LPR complaints relate to reflux and when they relate to other causes

  24. Approaches to Diagnosing LPR • Patient symptoms • Physical exam • Empiric treatment • pH probes What is the evidence? Courtesy of Lee Akst, MD

  25. LPR: Etiology • Symptoms Associated with LPR • Dysphagia • Globus • Intermittent airway obstruction • Chronic airway obstruction • Wheezing LPR Position Statement, AAO-HNSF, July 2002 • Chronic dysphonia • Intermittent dysphonia • Vocal fatigue • Voice breaks • Chronic throat clearing • Excessive throat mucus • “Postnasal drip” • Chronic cough Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  26. LPR: Etiology • Conditions associated with LPR • Reflux laryngitis • Subglottic stenosis • Carcinoma of the larynx • Intubation injury • Contact ulcers & granulomas • Posterior glottic stenosis • Arytenoid fixation • Paroxysmal laryngospasm • Paradoxical vocal fold motion • Exacerbation of asthma • Globuspharyngeus • Vocal nodules • Polypoid degeneration • Laryngomalacia • Pachydermialaryngis • Recurrent leukoplakia • Sudden infant death syndrome • Sinusitis • Otitis media • Sleep apnea Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  27. Diagnosis - Symptoms • The symptoms of LPR are variable and often intermittent or chronic-intermittent • Most common are • Hoarseness • Globuspharyngeus • Dysphagia • Cough • Chronic throat clearing • Sore throat Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  28. Weaken/Relax the LES • Lifestyle:alcohol, tobacco, obesity • Medications: Calcium channel blockers, theophylline, nitrates, antihistamines • Diet:Fatty/fried foods, chocolate, garlic, onions, caffeine, acid/spicy foods, mint • Eating habits: - large meals, before bed • Other medical conditions: Hiatal hernia, pregnancy, DM, rapid weight gain Emedicine

  29. Diagnosis - Symptoms Reflux Symptom Index. RSI>10 suggests LPR Belafsky et al. J Voice 16:274-7, 2002

  30. Diagnosis - Symptoms • Problem – these symptoms are non-specific • Other sources of laryngopharyngeal inflammation or irritation can mimic LPR • Environmental irritants / inhalants • URI • Allergies • Vocal overuse or abuse • Etc. • So, symptoms may be unreliable . . . Courtesy of Lee Akst, MD

  31. Reflux Finding Score RFS ≥ 11 suggests LPR Validated on pH probe + LPR patients Intra-observer reliability Inter-observer reliability Diagnosis - Exam Belafsky et al. Laryngoscope 111:1313-7, 2001

  32. Diagnosis - Exam • Laryngeal findings attributed to LPR seen in 86% of normal controls • Flexible scopes may ↑ sensitive, but ↓specific in noting arytenoidirritation, ventricular obliteration, pseudosulcus, etc. • So, exam may not be specific enough Hicks et al. J Voice 16:564-579, 2002 Milstein et al. Laryngoscope 115:2256-61, 2005

  33. Diagnosis – Confirmatory Testing • Signs & symptoms are not very specific • Confirmation testing is frequently employed • Empiric response to treatment • pH probe studies • Controversy here too

  34. Diagnosis – AAO Statement • Ambulatory 24-hour double-probe (simultaneous esophageal and pharyngeal) pH monitoring remains the gold standard for the diagnosis of LPR when the diagnosis is in question • In addition, double-probe pH testing is often used to evaluate drug efficacy Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  35. Diagnosis – AAO Statement • Other diagnostic tests, such as barium esophagraphy or esophagoscopy, are far less sensitive for LPR • Even though barium studies and esophagoscopy are not usually used to diagnose LPR, it may be advisable to screen the esophagus for related pathology with one of these methods Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  36. Treatment • Response to empiric PPI should confirm dx • Multiple studies show improvement in signs & symptoms of LPR • Dose response: BID therapy > qD therapy, 4 months > 2 months • Vocal quality (Jitter, shimmer, and NHR) improved over baseline by 1-2 moswith tx, and improvement maintained at 3-4 mos Karkos, Wilson. Laryngoscope 116:144-8, 2006 Park et al. Laryngoscope 115:1230-8, 2005 Jin et al. Laryngoscope 118: 938-41, 2008

  37. Treatment • However • Many randomized controlled trials with placebo controls don’t show a difference • Most symptoms canimprove over time, even in placebo group • Acoustic abnormalities did not change significantly with PPI therapy Karkos, Wilson. Laryngoscope 116:144-8, 2006 Noordzij et al. Laryngoscope 112:2192-5, 2002 Hamdan et al. Acta Otolaryngol 121:868-72, 2001

  38. Treatment • The good news: empiric txappears to be more effective clinically than placebo Am J Gastroent 2006;101:2646–2654) Courtesy of Lee Akst, MD

  39. Treatment • The bad news: Treatment is a fairly poor confirmation of LPR as the cause of pt complaints • Somewhat worse: It doesn’t help us manage non-responders • Worse yet: Empiric treatment is not without side effects Courtesy of Lee Akst, MD

  40. Treatment – Side Effects • Limits calcium absorption • Ostepenia • Hip fracture • Increases pneumonia risk • Confounder • Increased pneumonia may actually be due to reflux itself and not treatment • Decreases efficacy of plavix Adapted from Lee Akst, MD

  41. AOR with >1 year of PPI therapy is 1.44 Dose-dependent Duration dependent Treatment – Side Effects

  42. Treatment – Side Effects • PPI may cause reflux in normal volunteers  Rebound Acid Hypersecretion (RAHS) • 120 healthy volunteers • Placebo vsNexium for 8w • Then 4 weeks of placebo with symptom reporting • ≥ 1 symptom: 44% Nexiumvs15% Placebo • Statistically significant for each week 9 - 12 Gastroenterology 2009;137:80–87 Courtesy of Lee Akst, MD

  43. Treatment – Conclusions “The causal relationship of GERD with (cough, laryngitis, asthma) in the absence of a concomitant, esophageal GERD syndrome remains controversial and unproven.” No otolaryngologist on the panel

  44. Treatment – Conclusions • Grade B: Treat EER if accompanied by GERD • Grade D: “Recommend against, fair evidence that it is ineffective or harms outweigh benefits” for potential EER in absence of GERD

  45. GI Summary Recs • Final statement: • Nonetheless, empirical treatment with BID PPIs for 2 months remains a pragmatic clinical strategy for subsets of these patients if they have a concomitant esophageal GERD syndrome. Failing such a trial, etiologies other than GERD should be explored

  46. Treatment – AAO 2002 2002 AAOHNS LPR Position Statement • H2-blockers and proton pump inhibitors (PPIs) have been used to treat both GERD & LPR • In general, treatment for LPR needs to be more aggressive and prolonged than that for GERD • Type of treatment is dependent on the symptoms and severity of LPR and on the patient response to treatment Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  47. Treatment – AAO 2002 2002 AAOHNS LPR Position Statement • Mild/Intermittent: Can be treated with dietary lifestyle modifications as well as with H2- antagonists such as ranitidine • But they go on to say that: • “The majority of patients with LPR, however, require at least twice-daily dosing with PPIs” • And “In some patients, it is necessary to treat with both a PPI and an H2-antagonist” Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  48. Treatment – AAO 2002 2002 AAOHNS LPR Position Statement • Within 2 to 3 months of treatment, most patients report significant symptomatic improvement; however, it takes 6 months or longer for the laryngeal findings of LPR to resolve Koufman et al. AAO-HNSF LPR Position Statement. OtoHead Neck Surg 127:32, 2002.

  49. Treatment of LPR/GERD • Lifestyle:Alcohol, tobacco, obesity • Medications: Calcium channel blockers, theophylline, nitrates, antihistamines • Diet:Fatty/fried foods, chocolate, garlic, onions, caffeine, acid/spicy foods, mint • Eating habits: Large meals, before bed • Other medical conditions: Hiatal hernia, pregnancy, DM, rapid weight gain Emedicine

  50. More about pH probes • Single vs dual vs triple

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