Reflux & the Voice

SPPA 6400 Voice Disorders - Tasko

What is reflux?

SPPA 6400 Voice Disorders - Tasko

Reflux = Backflow

7% of US population have daily complaints of

heartburn (Talley 1992).
18 million self-medicate with antacids at least
twice weekly

SPPA 6400 Voice Disorders - Tasko

Gastroesophageal Reflux Disease (GERD) vs.

Laryngopharyngeal Reflux (LPR)

GERD involves lower esophageal sphincter dysfunction

LPR involves both upper and lower esophageal sphincter
dysfunction
Until recently, LPR often considered to be underdiagnosed/under-treated
Koufman (1991, 2000) reports

LPR present in 4-10% of attendees of otolaryngology clinic

(Koufman, 1991)
LPR present in 55% of patients with hoarseness (Koufman,
2000)
SPPA 6400 Voice Disorders - Tasko

Conditions reported to be associated with

reflux

Reflux laryngitis
(posterior)
Subglottic stenosis
Carcinoma of the larynx
Carcinoma of esophagus
Contact ulcers and
granulomas
Laryngospasm
Paradoxical Vocal Cord
Motion

Globus pharyngeus
Vocal nodules
Reinkes edema
Recurrent leukoplakia
Recurrent pneumonitis
Pharyngitis
Asthma

SPPA 6400 Voice Disorders - Tasko

Why is LPR not recognized?

Patients with LPR usually deny symptoms of

heartburn or regurgitation (silent reflux)
Findings of LPR on laryngeal exam vary
considerably
Traditional tests for GERD lack both sensitivity and
specificity for LPR
Therapeutic trials using traditional antireflux therapy
often fail (false negatives)
SPPA 6400 Voice Disorders - Tasko

How is LPR Identified?

Patient symptoms
Vocal and Laryngoscopic signs
Ambulatory 24 hour double/triple probe pH monitoring
Considered by some to be diagnostic Gold Standard
Multichannel intraluminal impedance (MII)
measures presence of liquid and gaseous events in upper
aerodigestive tract
Barium esophagram
Esophagoscopy
Esophageal manometry
Trial period of acid suppression treatment (PPI for at least
three months)
NOTE: Signs and symptoms
are
pathognomonic
SPPA 6400
Voicenot
Disorders
- Tasko

Symptoms of LPR
Koufman (1991)
Chronic dysphonia (92 %)
Intermittent dysphonia
Vocal fatigue
Nocturnal choking
Chronic throat clearing
Excessive throat mucus
Chronic cough (44%)
Dysphagia (27%)
Globus pharyngeus (33 %)

Book et al. (2002)

Throat clearing (98%)
Persistent cough (97%)
Globus pharyngeus (95%)
Hoarseness (95%)

SPPA 6400 Voice Disorders - Tasko

Reflux Symptom Index

The Reflux Symptom Index

A score > 10 may indicate significant reflux
A score > 13 definitely abnormal
SPPA 6400 Voice Disorders - Tasko

Typical GI Patient vs. Typical ENT Patient

(Koufman, 1991)
GI
ENT
Symptoms
heartburn and/or regurgitation Y

hoarseness, dysphagia, globus,

throat clearing, cough etc.

Findings
endoscopic esophagitis Y
laryngeal inflammation N

N
Y

SPPA 6400 Voice Disorders - Tasko

Laryngoscopic Signs

SPPA 6400 Voice Disorders - Tasko

The Reflux Finding Score (Belafsky et al. 2002)

Groove along the full margin of the vocal
fold
Diminished size of the ventricle revealed by a
swelling of the ventricular bands
Erythema (redness)
Hyperemia (increased blood flow to tissue)

Edema localized in the vocal folds

Edema throughout the larynx

Granuloma or granulation tissue anywhere in

the larynx
Thick, white endolaryngeal mucus on the vocal folds
or elsewhere in the endolarynx.

SPPA 6400 Voice Disorders - Tasko

Score of 7 or greater: likely to have LPR

LPR: Tissue Changes

Interarytenoid granuloma

Interarytenoid bar

SPPA 6400 Voice Disorders - Tasko

Vocal fold edema

Granulomas

LPR: Tissue Changes

SPPA 6400 Voice Disorders - Tasko

From Vavricka et al. (2007)

(A) posterior pharyngeal wall
cobblestoning
(B) interarytenoid bar with
erythema
(C) posterior commissure with
erythema and surface
irregularity
(D) posterior cricoid wall edema
(E) arytenoid complex with apex
edema, erythema, and medial
wall erythema
(F) true vocal folds with edema
(G) false vocal folds erythema,
(H) anterior commissure erythema
(I) epiglottis erythema
SPPA 6400 Voice Disorders - Tasko
(J) aryepiglottic fold edema.

Diagnostic value of laryngeal signs?

SPPA 6400 Voice Disorders - Tasko

Vavricka et al. (2007)

Diagnostic value of laryngeal signs?

SPPA 6400 Voice Disorders - Tasko

Hicks et al. (2002)

Typical GI Patient vs. Typical ENT Patient

(Koufman, 1991)
GI
Diagnostic tests
Abnormal esophageal radiography
Esophageal pH monitoring
Pharyngeal pH monitoring
Pattern of reflux
Supine (nocturnal)
Upright (awake)

Y
Y
N

ENT
sometimes
Y
Y

Y
sometimes
sometimes
Y
SPPA 6400 Voice Disorders - Tasko

pH monitoring +/- MII

Gold standard for GERD
Some problems for diagnosing LPR
Problems
Double/triple probe is required
Probe placements effects measures
Disagreement about threshold values
There can be both liquid and gaseous refluxate gas
can be more problematic for LPR but not well
monitored
Non-acid (alkaline) refluxate

SPPA 6400 Voice Disorders - Tasko

Are we good at diagnosing LPR?

Issues
Which signs, which symptoms?
Specificity and sensitivity
Examination procedures
Differential diagnosis

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Clinical Decision Making

SPPA 6400 Voice Disorders - Tasko

From Ford (2005)

Treatment

SPPA 6400 Voice Disorders - Tasko

Common anti-reflux Meds

Antacids

buffers pH

e.g. Tums, Rolaids

Not considered very effective

with LPR
H2 antagonists

Blocks histamine action which

decreases acid production

e.g. Tagamet, Ranitidine,

Zantac

Not preferred for LPR

Proton Pump Inhibitor (PPI)

Blocks action of proton pump

Most potent acid suppression

medication

e.g. Omeprazole (Prilosec),

Nexium, Prevacid

Drug of choice for LPR

SPPA 6400 Voice Disorders - Tasko

SPPA 6400 Voice Disorders - Tasko

From Ford (2005)

Conventional treatment for suspected LPR

Dietary modification

Lifestyle modification

No eating/drinking within 3 hrs of bedtime

Avoid overeating or reclining after meals
Avoid fried foods and adhere to low fat diet
Avoid coffee, tea, chocolate, mints and soda (refluxogenic)
Avoid caffeine of all kinds
Avoid alcohol especially in the evening
Avoid spicy, tomato based products, fruit juices
Elevate head of bed 4-6 inches
Avoid wearing tight fitting clothing or belts
Cease tobacco use

Medication

Omeprazole (PPI) 20 mg b.i.d. (am and pm)

Treatment should continue for at least 3 months (up to 6 mos.)

SPPA 6400 Voice Disorders - Tasko

Typical GI Patient vs. Typical ENT Patient

(Koufman, 1991)
GI

ENT

Response to treatment
Dietary or lifestyle modification
Rate of success with H2 blockers

Y
sometimes
85%
65%

Rate of success with omeprazole

99%

Assuming adequate dosage and duration of therapy

SPPA 6400 Voice Disorders - Tasko

99%

Cochrane Database

From Cochrane Reviews (2005)

Also Williams et al. (2004)
SPPA 6400 Voice Disorders - Tasko

Fundoplication (Nissen)

tightens LES by wrapping the upper part of the

stomach around the lower part of the esophagus.
Procedure may

Be open (external incisions)

Use endoscopy (small external incisions)

reports of 90 % of patients undergoing the

endoscopic Nissen fundoplication are symptom
free after surgery.
Suggestions that Tx is more effective for GERD
vs. LPR
SPPA 6400 Voice Disorders - Tasko

Case Illustrations

SPPA 6400 Voice Disorders - Tasko