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Silent Reflux

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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
LPR

GERD encompasses instances in which the disease is defined by associated extraesophageal syndromes such as asthma, LPR and chronic cough.
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.

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 410% of patients presenting to otolaryngologists have reflux-associated diseases.1 Approximately >50% of patients with hoarseness have reflux-associated diseases.1

There are no epidemiological studies to confirm the prevalence and otolaryngologic consequences of LPR.

1. Ford CN. JAMA. 2005;294:1534-40.

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

Acid reflux

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.

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 irritation Decreased salivary epidermal growth factor

Not all patients with GERD will develop LPR.

1. Sataloff RT, Hawkshaw MJ, Gupta R. Discov Med. 2010 Sep;10(52):213-24.

LPR: Laryngopharyngeal reflux

Silent reflux

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

GERD

LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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):32734; 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.

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

GERD

LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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):32734; 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.

Supine (nocturnal) reflux

Upright (daytime) reflux

Lower esophageal dysfunction

Upper esophageal sphincter dysfunction

GERD

LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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):32734; 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.

Heartburn Regurgitation Dyspepsia

Hoarseness, Globus pharyngeus, Dysphagia, Cough, Chronic throat, clearing, Sore throat

GERD

LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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):32734; 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.

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)
LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

GERD

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):32734; 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.

Esophagitis

Laryngeal inflammation

GERD

LPR
LPR: Laryngopharyngeal reflux; GERD: gastroesophageal reflux disease

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):32734; 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.

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

GERD

LPR
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):32734; 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 Endoscopy

Advantages  Easy visualization of mucosal damage and erosions

Disadvantages  Poor sensitivity, specificity, positive predictive value  Requires sedation  High cost

Laryngoscopy

 No sedation required  No specific laryngeal  Direct visualization of signs for reflux the larynx  High interrater  and laryngeal pathology 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 pH monitoring

Advantages     Easy to perform Relatively noninvasive Prolonged monitoring Ambulatory

Disadvantages  Catheter-based, may have up to 30% rate of false negatives  Wireless system (Bravo) is costly  No pH predictors of treatment response in LPR  Current design underestimates reflux by about 30% in acidic medium (pH <3.5)  Requires modified diet  Does not detect acid  Not studied in LPR

Bilirubin monitoring

Easy to perform Relatively noninvasive Prolonged monitoring Ambulatory Good correlation with gastric bile acid  concentrations     

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34.

TEST Impedance monitoring

Advantages      Easy to perform Relatively noninvasive Prolonged monitoring Ambulatory Measures acidic and nonacidic gas and liquid reflux (combined with pH)

Disadvantages  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

Classic reflux symptoms are absent in up to 50% of patients with LPR symptoms.
LPR: Laryngopharyngeal reflux; PPis: proton pump inhibitors;

1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):327-34.

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.

A RFS score greater than 11 in the proper clinical situation is strongly suggestive of LPR.
1. Barry DW and Vaezi MF. Cleveland Clinic Journal of Medicine. 2010;77(5):32734. 2. Postma GN, and Halum SL. GI Motility online (2006) doi:10.1038/gimo46 LPR: Laryngopharyngeal reflux;

Findings Subglottic edema Ventricular obliteration Erythema/hyperemia Vocal cord edema Diffuse laryngeal edema Posterior commissure hypertrophy Granuloma/granulation Thick endolaryngeal mucus/other

Score 2 = present; 0 = absent 2 = partial; 4 = complete 2 = arytenoids only; 4 = diffuse 1 = mild; 2 = moderate; 3 = severe; 4 = polypoid 1 = mild; 2 = moderate; 3 = severe; 4 = obstructing 1 = mild; 2 = moderate; 3 = severe; 4 = obstructing 2 = present; 0 = absent 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

Reflux

symptom index (RSI) : a nine-item scoring system that is an easy selfadministered and reliable instrument that can help the clinician detect patients suffering from LPR and monitor their treatment

A RSI score greater than 13 in the proper clinical situation is strongly suggestive of LPR.
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 LPR: Laryngopharyngeal reflux

Within the last MONTH, how did the following problems affected the patient? Hoarseness or a problem with your voice Clearing your throat Excess throat mucus or postnasal drip Difficulty swallowing food, liquids, or pills Coughing after you ate or after lying down Breathing difficulties or choking episodes Troublesome or annoying cough Sensations of something sticking in your throat or a lump in your throat

0 = no problem 5 = severe problem 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 5 5 5 5 5 5 5 5 5

Heartburn, chest pain, indigestion, or stomach 0 acid coming up Total

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

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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