Laryngopharyngeal reflux

Current testing has high interrater variability, leading to overdiagnosis and inappropriate treatment with acid-suppressive medications, resulting in societal and patient burden of cost, frequent referrals to numerous providers, and delay in diagnosis and treatment. Based on our review of important clinical articles in the gastroenterology literature and the common practice of general gastroenterologists, our approach in patients with suspected LPR starts with a 2-month trial of PPI therapy, and if there is no improvement in symptoms, we recommend that patients undergo pH monitoring off all acid-suppressive therapy. If pH testing is negative, it is unlikely that reflux is the cause of the laryngeal symptoms, and focus should be shifted toward the evaluation of alternative etiologies and treatment of functional laryngeal disorder with the use of neuromodulators. Laryngopharyngeal reflux (LPR) is similar to another condition — GERD — that results from the contents of the stomach backing up (reflux). But the symptoms of LPR are often different than those that are typical of gastroesophageal reflux disease (GERD).

Inflamed laryngeal tissue affected by laryngopharyngeal reflux (LPR) is more easily damaged from intubation, has a high risk of progressing to contact granulomas, and may evolve to symptomatic subglottic stenosis. Various symptoms, functional and structural abnormalities that involve the larynx, and other contiguous structures positioned proximal to the esophagus constitute the spectrum of these disorders. Patients presenting with extraesophageal reflux-related signs and symptoms may account for up to 10% of an otolaryngologist’s practice. There is an epidemic of sorts running rampant among singers. Symptoms include reduced range, raspy sound, discomfort when singing, a continuous lump in the throat as well as reduced vocal stamina.

If you are experiencing any of these symptoms, then it may well be that you are suffering from acid reflux. A pH of 4 has been used as a threshold in the distal esophageal pH monitoring [23]. There is a pH gradient in the esophagus when reflux occurs due to the neutralization of refluxed material by swallowed saliva. It is well known that the larynx is more susceptible to injury by lowered pH than the esophagus, as the larynx lacks both extrinsic and the intrinsic epithelial defenses of the esophagus [24]. The esophageal protective mechanisms include peristalsis, a mucosal structure that can better tolerate exposure to acid, and bicarbonate production, which helps prevent overacidity [6].

Laryngopharyngeal reflux (LPR) refers to retrograde movement of gastric contents into the larynx, pharynx, and upper aerodigestive tract [1] and is commonly associated with a number of voice disorders, particularly among singers [2-4]. Common symptoms of LPR include hoarseness, throat clearing, the perception of excessive mucous accumulation within the throat, difficulty swallowing, breathing difficulties, globus sensation, cough, persistent “tickle” sensation within the throat, sore throat, and regurgitation [1, 5]. Less common upper airway symptoms include worsening asthma, wheezing, shortness of breath, dental hypersensitivity, laryngospasm, nausea, otalgia, muscle spasms, bronchospasm from aspiration, and halitosis [6].

lpr acid reflux vocal

The most commonly performed surgery is called the Nissen Fundoplication. It is done by wrapping the top part of the stomach around the junction between the stomach and esophagus and sewing it in place.

Silent reflux, or laryngeal-pharyngeal reflux (LPR), is similar, but without the heartburn and indigestion. , in a randomized controlled study, showed that actively training the diaphragm muscle by breathing exercise can improve reflux disease.

Indeed, recently, Pearson and colleagues [Pearson et al. 2011] highlighted that, although acid can be controlled by proton pump inhibitor (PPI) therapy, all of the other damaging factors (i.e. pepsin, bile salts, bacteria and pancreatic proteolytic enzymes) remain potentially damaging on PPI therapy and may have their damaging ability enhanced. Particularly, pepsin can damage all extragastric tissues at pH up to 6 [Ludemann et al. 1998].

  • Of note, considering that pharyngeal and laryngeal cancer might represent LPR complications, a statistically significant reduction in squamous cell carcinoma volume was observed in hamsters that received alginate prior to known carcinogen [7,12-dimethylbenzanthracene (DMBA)] and human pepsin application, compared with hamsters painted with DMBA and human pepsin alone.
  • These laryngeal receptors for pepsin may be another future target for intervention.
  • Surgery should be indicated in select patients, in which high-volume refluxate and incompetence of LES are demonstrated with esophageal pathophysiological evaluations.

Finally, voice therapy can be used to treat the effects of laryngopharyngeal reflux. Research has shown that people who take a proton pump inhibitor and participate in voice therapy show faster symptom improvement than people who only take medication. Is chronic gastroesophageal reflux a causative factor in glottic carcinoma?

Coffee has been reported to precipitate reflux episodes [Brazer et al. 1995]. A Norwegian case-control study reported a negative association between GERD and coffee (odds ratio [OR] 0.5; 95% confidence interval [CI] 0.4-0.6) among subjects who drank 4-7 cups per day compared with those who did not drink coffee [Nilsson et al. 2004]. In the same study, consumption of dietary fibers was found to be a protective factor [Nilsson et al. 2004]. In a large cross-sectional population-based study, consuming bread and fibers at least two meals per day caused a 50% reduction in reflux symptoms [Terry et al. 2001]. Likewise, in another cross-sectional study, high fiber intake correlated with a reduced risk of GERD symptoms [El-Serag et al. 2005].

It is necessary then to determine if antireflux medications are warranted, necessary, and effective. Aside from symptom-driven diagnosis, additional objective data is needed in order to better understand the participant-specific manifestations of LPR [1, 5, 17-20]. This study examines the relationship between laryngopharyngeal reflux (LPR) symptoms and oropharyngeal pH levels in singers. We hypothesized that reported symptoms would correlate with objective measures of pH levels from the oropharynx, including the number and total duration of reflux episodes.

In adults and children, irritating acidic juices may back up from the stomach into the esophagus (swallowing passage) and throat. This is frequently called gastroesophageal reflux disease or GERD.

lpr acid reflux vocal

Many other publications have addressed the pathogenesis of voice disorders and otolaryngologic manifestations of LPR, as well as its prevalence (Sataloff et al., 2006a; Koufman, 1991; Ross et al., 1998; Gumpert et al., 1998; Halstead, 1999; Grontved and West, 2000). Yet, definitive epidemiological studies to confirm the prevalence and otolaryngologic consequences of LPR are still lacking. Consequently, while many physicians believe the condition is still under-diagnosed, many also suspect over-diagnosis and misdiagnosis in many patients. More recently laryngeal rehabilitation therapies have been applied in cases of chronic cough associated with GERD, with significant symptom improvement [Pacheco et al. 2013]. Carvalho de Miranda Chaves and colleagues [Carvalho de Miranda Chaves et al. 2012] showed, by performing esophageal manometry, that inspiratory muscle training incremented LES pressure in patients with GERD after an 8-week program.

lpr acid reflux vocal

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