Reflux & the Voice
SPPA 6400 Voice Disorders - Tasko
What is reflux?
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Reflux = “Backflow”
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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)
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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
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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
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Reflux laryngitis
(posterior)
Subglottic stenosis
Carcinoma of the larynx
Carcinoma of esophagus
Contact ulcers and
granulomas
Laryngospasm
Paradoxical Vocal Cord
Motion
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Globus pharyngeus
Vocal nodules
Reinke’s edema
Recurrent leukoplakia
Recurrent pneumonitis
Pharyngitis
Asthma
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Why is LPR not recognized?
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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)
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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 not pathognomonic
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
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%)
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Reflux Symptom Index
The Reflux Symptom Index
A score > 10 may indicate significant reflux
A score > 13 definitely abnormal
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Typical GI Patient vs. Typical ENT Patient
(Koufman, 1991)
GI
ENT
Symptoms
heartburn and/or regurgitation
Y
N
hoarseness, dysphagia, globus,
throat clearing, cough etc.
N
Y
Findings
endoscopic esophagitis
laryngeal inflammation
Y
N
N
Y
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Laryngoscopic Signs
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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
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- Tasko
or elsewhere
in the endolarynx.
Score of 7 or greater: likely to have LPR
LPR: Tissue Changes
Interarytenoid granuloma
Interarytenoid bar
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Vocal fold edema
Granulomas
LPR: Tissue Changes
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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
(J) aryepiglottic fold edema.
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Diagnostic value of laryngeal signs?
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Vavricka et al. (2007)
Diagnostic value of laryngeal signs?
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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
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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
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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
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From Ford (2005)
Treatment
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Common anti-reflux Meds
Antacids
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buffers pH
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e.g. Tums, Rolaids
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Not considered very effective
with LPR
H2 antagonists
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Blocks histamine action which
decreases acid production
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e.g. Tagamet, Ranitidine,
Zantac
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Not preferred for LPR
Proton Pump Inhibitor (PPI)
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Blocks action of proton pump
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Most potent acid suppression
medication
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e.g. Omeprazole (Prilosec),
Nexium, Prevacid
SPPA 6400 Voice Disorders - Tasko

Drug of choice for LPR
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From Ford (2005)
Conventional treatment for suspected LPR
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Dietary modification
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Lifestyle modification
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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
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Omeprazole (PPI) 20 mg b.i.d. (am and pm)
Treatment should continue for at least 3 months (up to 6 mos.)
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Typical GI Patient vs. Typical ENT Patient
(Koufman, 1991)
GI
Response to treatment
Dietary or lifestyle modification
Rate of success with H2 blockers
Rate of success with omeprazole
Y
sometimes
85%
65%
99%
99%
Assuming adequate dosage and duration of therapy
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ENT
Cochrane Database
From Cochrane Reviews (2005)
Also Williams et al. (2004)
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Fundoplication (Nissen)
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tightens LES by wrapping the upper part of the
stomach around the lower part of the esophagus.
Procedure may
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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
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Case Illustrations
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