LaryngoPharyngeal Reflux (LPR), also known as silent reflux, occurs when stomach contents reflux through the upper sphincter into the larynx and pharynx without belching or vomiting. It contributes to up to 50% of laryngeal complaints and can cause damage to laryngeal tissues through exposure to acid and pepsin. Diagnosis involves symptom questionnaires, laryngeal examination, therapeutic trials of PPIs, and 24-hour pH monitoring of the esophagus and pharynx. Treatment consists of lifestyle modifications, antisecretory drugs like PPIs, and possibly antireflux surgery for severe or treatment-resistant cases.

1. LaryngoPharyngeal Reflux
(LPR)
Prepared by: Nibal Shawabkeh
Supervised by: Dr. Adel Adwan
1

2. Introduction
 The term REFLUX comes from the Greek word meaning “backflow,” usually
referring to the contents of the stomach
 GERD: an abnormal amount of reflux up through the lower sphincters and
into the esophagus.
 LPRD: when the reflux passes all the way through the upper sphincter
reaching the larynx and pharynx without belching or vomiting
2

3. Laryngopharyngeal Reflux (LPR)
 LPRD refers to retrograde flow of gastric contents to the upper aero-digestive
tract, which causes a variety of symptoms
 Contributes up to 50% of laryngeal complaints
 The injurious agents in the refluxed stomach contents are primarily acid and
activated pepsin.
 The damage caused by these materials can be extensive.
 Specific findings include: laryngeal hyperemia, posterior commissure
hypertrophy, pseudosulcus vocalis, and thick endolaryngeal mucus.
3

4. Synonyms for Laryngopharyngeal
Reflux (LPR)
 Atypical reflux
 Extraesophageal reflux
 Gastropharyngeal reflux
 Laryngeal reflux
 Pharyngoesophageal reflux
 Reflux laryngitis
 “Silent” reflux
4

5. Epidemiology
 Incidence 4%-10% in various studies
 No racial predilection
 Common in age > 40 yrs
 Up to 70% with hoarseness *
 75% - with subglottic stenosis
 20%-45%-shows Heartburn, Regurgitation and indigestion
5

6. Relevant anatomy and physiology6
Lower
Various mechanisms acts
3 cm in length
Upper
Cricopharyngeus + circular
muscle fibers of esophagus
3 cm in length

7. Pathophysiology
Gastric contents (acid & pepsin)
LES
Backflows
UES
Laryngeal mucosa (post glottis)
Persistent and chronic Inflammation
Mucosal changes
7

8. Etiologic factors
 Decreased lower esophageal sphincter pressure
 Abnormal esophageal motility
 Abnormal or reduced mucosal resistance
 Delayed gastric emptying
 Increased intra abdominal pressure
 Gastric hyper secretion of acid or pepsin
8

9. CLASSIFICATION OF REFLUX
1. Physiologic
 Asymptomatic
 Postprandial
 No abnormal findings
2. Functional
 Asymptomatic
 Positive pH study
3. Pathologic
 Local symptoms
 Secondary manifestations of LPR
9

10. Patterns and Mechanism of LPR and
GERD
10
LPR
No heartburn
Daytime (“upright”)
refluxers
Normal esophageal
motility
Normal acid clearance
Majority without
esophagitis
1 defect - UES
Clinical presentations
GERD
Heartburn
Nocturnal (“supine”)
refluxers
Esophageal dysmotility
Prolonged acid
clearance
Can present with
esophagitis
1 defect – LES
Clinical presentations

11. Presentation/Symptoms
 Hoarseness – 70%
 Voice fatigue, breaking of the voice
 Cough – 50%
 Globus pharyngeus – 47%
 Frequent throat clearing, dysphagia, sore throat, wheezing, laryngospasm,
halitosis
11

12. Secondary problems
LARYNGEAL
Benign vocal cord lesions
Functional voice disorders
Leukoplakia, Ca Larynx
Subglottic stenosis
Laryngeal Stenosis
Laryngospasm
Laryngomalacia
Delays healing following Post intubation injury
12

13. Secondary Problems13
PHARYNGEAL
Globus
pharyngeus,
Chronic sore
throat,
Dysphagia,
Zenker’s
diverticulum
PULMONARY
Asthma
Bronchieactasis
Chronic bronchitis
Pneumonia
Carcinoma
Fibrosis
MISCELLANEOUS
• Chronic rhinosinusitis
• Otitis media in children
•Dental erosions

14. 14

15. Diagnosis
 Why is diagnosis of LPR often missed??
 Low index of suspicion
 Patients often don’t have heartburn (esophagitis)
 Variable / unrecognized findings
 Chronic intermittent nature of LPR leads to decreased sensitivity of pH
monitoring
 Inadequate duration &/or dosage of PPI
15

16. Diagnosis
 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
16

17. Symptom Questionnaire:
Reflux Symptom Index
17

18. Diagnosis
 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
18

19. reflux findings score (RFS)19
Total severity score: 0 to 26
Score greater than 7 suggests
positive dual-probe pH study

20. Supraesophageal complications of
reflux disease
20
Normal Larynx Interarytenoid edema

21. 21
Erythema Ventricular obliteration
Pseudosulcus vocalis

22. 22
Ventricular obliteration
Posterior commissure hypertrophy
Thick endo-
laryngeal mucus
Ventricular obliteration

23. Erythema/Hyperemia23
Erythema
Vocal fold
edema

24. Laryngeal Edema24
Granuloma

25. Diagnosis
 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
25

26. Therapeutic Trial for SERD
H2 receptor blockers
Work great for GERD
Generally don’t work for SERD (even high/double doses)
Proton pump inhibitors
Generally work for SERD often require double dosing
Must use double dose PPI for therapeutic trial
Duration: 2 weeks – 6 months (one month should be
sufficient to see improvement
May still fail…
Remember: Non-acid reflux!
26

27. Diagnosis
 Symptom questionnaire
 Laryngeal examination / Laryngoscopy
 Therapeutic trial
 Endoscopy – limited utility
 Ambulatory 24-hr esophageal pH monitoring
 Distal esophageal
 Proximal esophageal
 Dual
 Pharyngeal
 Oropharyngeal
27

28. Ambulatory pH Monitoring28
Pharyngeal probe– 2 cm above UES
Proximal esoph. probe- below UES
Distal esoph. probe–5 cm above LES
Gold std to diagnose LPR
Criteria's
pH < 4
Pharyngeal pH drop – oesophageal acid
exposure
pH drop rapid & sharp
For this diagnostic test a small catheter is placed through the
nose into the throat and esophagus for a 24 hour period. The
catheter has multiple sensors on it to detect the presence of
acid in the esophagus and throat (drop in pH < 4). The
patient wears the catheter with a small computer recording
device on his/her waist home and comes back to the office
the next day to have the readings interpreted and the
catheter removed

29. Treatment
Antireflux therapy
 Phase I : Lifestyle-dietary modification
Antacid therapy
 Phase II : Prokinetic
H2-blockers, PPI
 Phase III : Antireflux surgery
29

30. Lifestyle modifications
 Stop smoking
 Elevate the head of the bed on blocks(15-20cm)
 Reduce body weight
 Avoid tight-fitting clothing
 Avoid lying down after meals
30

31. Dietary modification
 Avoid fat, caffeine, chocolate, mints,
carbonated drinks, fat, mints chocolate, milk product, onion, cucumber
 Avoid alcohol
 Avoid overeating
 Avoid ingestion of food and drink 2 hours before bed time
31

32. PHARMACOLOGICAL32
DRUGS
ANTACIDS
Mixture of Al
hydroxide
& Mg trisilicate
ANTISECRETORY
H2 Blockers
PPI’s
Mucosal protective
PROKINETIC
Metoclopramide
Domperidone
Cisapride

33. Drug therapy
 Antisecretory
 H2 Blockers
 Ranitidine, Famotidine,
 Reversibly reduces acid
secretion, not helps in healing
 PPI’s
 Near total acid suppression,
promotes healing
 Omeprazole (20-40mg OD)
 Mucosal protective
 Sucralfate, alginic acid
33

34. Drug therapy
 Antacids
 Immediate relief of symptoms
 Reduces acidity
 Not helps in healing
 Antacid mixture
 Prokinetic
 Symptomatic relief, not helps in healing
 Increases gastric emptying
 Metoclopramide (5-10mg tds), Domperidone
(10-20mg tds)
34

35. 35

36. Surgery
 Laparoscopic Nissen
Fundoplication
 Indications
 Failed drug
treatment
 Complications
 Goal
 Restore
natural
integrity of LES
& maintain
normal
deglutition
36

37. 37
End of Lecture
March 2014