LARYNGOLOLGY SEMINAR
Laryngopharyngeal Reflux (Extraesophageal reflux)
R3 黃同村/P 蕭自佑
2002/12/25 17:00~18:00
Introduction
 Acid reflux related diseases — 10%~50% Americans
Classical GERD
Atypical GERD ? → LPR or EER: pharynx, larynx, lung

LPR is not GERD
Heart Finding
Reflux pattern
burn
LPR
Esophageal Sphincter
function
<35% Laryngeal
Upright, daytime Good
inflammation
GERD +
Esophagitis
dysfunction
Upper
Supine, nocturnal Dysfunction Lower
Pathophysiology
 Two mechanisms of EER
1. Distal esophageal acid exposure stimulates vagally mediated reflexes,
causing bronchospasm and, perhaps, the cough and throat-clearing

2. Refluxed stomach acid and pepsin above UES (figure 1)
Host barriers to reflux
1. UES, LES, tone and coordinated function
2. Esophageal acid clearance: peristalsis, salivary bicarbonate
Larynx: hypersensitivity to reflux damage (100 times than esophagus)

1. Extrinsic: no bicarbonate-rich saliva coating, no peristalsis
2. Intrinsic: mucosal resistance-- isoenzymes of carbonic anhydrase
3. Other: damage to the larynx from coughing, voice abuse, intubation, URI
Vagally mediated protective reflexes: pharyngo-UES contractile reflex

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Clinical Manifestations
Table 1. Common symptoms of LPR
in order of incidence (Reference 2)
Table2. Clinical manifestations related
to LPR (Reference 2)
Chronic dysphonia
Laryngeal
Reflux laryngitis
Subglottic and tracheal stenosis
Carcinoma of the larynx
Endotracheal intubation injury
Contact ulcers and granulomas
Posterior glottic stenosis
Intermittent dysphonia
Vocal fatigue
Voice breaks
Chronic throat clearing
Excessive throat mucus
Postnasal drip
Arytenoid fixation
Paroxysmal laryngospasm
Paradoxical vocal fold movement
Vocal fold nodules
Polypoid degeneration
Laryngomalacia
Recurrent respiratory papillomas
Pachydermia laryngis
Recurrent leukoplakia
Chronic cough
Dysphagia
Globus pharyngeus
Heartburn
Regurgitation
Airway obstruction
Paroxysmal laryngospasm
Wheezing
Figure 1. (Reference 2)
Pharyngeal
Globus pharyngeus
Chronic sore throat
Dysphagia
Zenker's diverticulum
Pulmonary
Chronic cough
Exacerbation of asthma/COPD
Bronchiectasis
Aspiration pneumonia
Miscellaneous
Sudden infant death syndrome
Sinusitis
Otitis media
Obstructive sleep apnea syndrome
Dental erosions
2
Diagnosis
 History-- symptoms
Laryngeal and hypopharyngeal examination
Confirmed with 24-hour pH monitoring
Empiric trial

Symptoms
1. Less than 35% have the typical GERD symptoms
2. Symptom scores predict pathologic GERD on pH monitoring
3. Symptoms associated with LPR: nonspecific, associated also with other
laryngeal disorders, correlated poorly with pH monitoring
4. Change in symptoms is a good guide to the efficacy of therapy

Laryngeal finding
1. Characteristic : posterior laryngitis
2. Reflux finding score (Koufman, et al)
Figure 2 (Reference 2, 8)
Pseudosulcus (infraglottic edema)
Ventricular obliteration
Erythema/hyperemia
Vocal fold edema
Diffuse laryngeal edema
Posterior commissure hypertrophy
Granuloma/granulation
3.

Thick endolaryngeal mucus
No single finding predictive of a
positive pH study result
Ambulatory 24h double-probe pH monitoring (Figure 2)
1. Pathologic LPR: pH drop to <4 (or 5), >4-6 episodes in 24 hours
2. Indications: in all suspected patients?
--failure of improve after adequate therapeutic trial
--assessing the efficacy of the current dosing regimen in patients presenting
with severe complications of reflux, especially if surgery is warranted
--guiding therapy in those patients on medications predisposing to reflux, or
in those in whom therapy with proton pump inhibitors is contraindicated
--patients considering a surgical antireflux procedure
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Treatment
 Dietary and lifestyle modifications
1. Quit tobacco, alcohol
2. Avoidance of high-fat, refluxogenic foods, citrus, caffeine, starches,
concentrated sweets
3. Elevate the head of the bed (?) and avoid eating 3 hours prior to bedtime
 Medical treatment
1. Proton pump inhibitors: H+-K+ ATPase
2. Twice daily dose PPI for 3-6 months
3. Addition of an H2-blocker at night
4. Fail→ change dose or type of PPI, or refer for op in severe cases

Surgical treatment
1. Laparoscopic Nissen fundoplication
2. Radiofrequency energy to treat the lower esophageal sphincter
References
1. Powitzky ES: Extraesophageal reflux: the role in laryngeal disease. Current
opinion in Otolaryngol & HNS 2002, 10:485-491.
2. ENT: Ear, Nose & Throat Journal 2002, 81 suppl: 1-31 (PS. including 7 separate
articles about LPR by Koufman JA et al.)
3. Am J Gastroenterol 2000, 95:S1-S44 (PS. including 7 separate chapters about
4.
5.
6.
7.
8.
extraesophageal presentations of GERD by Richter JE et al.)
Postma GN, Tomek MS, Belafsky PC, et al: Esophageal motor function in
laryngopharyngeal reflux is superior to that in classic gastroesophageal reflux
disease. Ann Otol Rhino Laryngol 2001, 110:1114-1116.
Axford SE, Sharp N, Ross PE, et al: Cell biology of laryngeal epithelial defenses
in health and disease: preliminary studies. Ann Otol Rhinol Laryngol 2001,
110:1099-1108.
Offman JJ: The relation between gastroesophageal reflux disease and esophageal
and head and neck cancers: a critical appraisal of the epidemiologic literature.
Am J Med 2001, 111:124S-129S.
Heavner SB, Hardy SM, White DR, et al: Transient inflammation and
dysfunction of the eustachian tube secondary to multiple exposures of simulated
gastroesophageal refluxant. Ann Otol Rhinol Laryngol 2001, 110:928-934.
Johnson PE, Koufman JA, Nowak LJ, et al: Ambulatory 24-hour double probe
pH monitoring: the importance of manometry. Laryngoscope 2001,
111:1970-1975.
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