Laryngopharyngeal
Reflux
&
Granuloma
By Isabel C. Bula
Presented to Rebecca L. Gould, MSC, CCC-SLP
Overview
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Rationale
Definition
Etiology & Mechanisms of LPR
Symptoms
Diagnosis
Clinical Findings Associated with LPR
Associated Vocal Pathologies
Treatment
Conclusions
Why LPR?
 Common : 50% of ORL patients have
LPR (Koufman, 1994).
 Associated with a diversity of laryngeal
and voice disorders.
 Can have dangerous effects, especially if
left untreated.
 We (SLPs) are essential in management
of LPR!
Laryngopharyngeal
Reflux
Backflow of food and stomach acids
into the back of the throat and onto
the larynx.
Causes:
a. Physical
b. Lifestyles Factors
LPR: Etiology
PHYSICAL
 Improper functioning of
esophageal sphincters.
 Hiatal hernia.
 Abnormal esophageal
contractions.
 Slow emptying of the
stomach.
LIFESTYLE
 Diet
Irritants: chocolate,
caffeine, citrus, fatty
foods, spices.
 Unhealthy habits
Overeating
Smoking
Alcohol consumption
Mechanisms of LPR
LPR & Granuloma
 Granulomas: most often associated with
LPR as an etiological factor.
 LPR causes chronic irritation of the
posterior larynx, where granulomas
typically occur.
 Granulomas respond well to Anti-reflux
therapy.
Granulomas
 Non-cancerous growths that result from tissue
irritation.
 Occur in the posterior 2/3 of true vocal fold(s)
 vocal process of arytenoid.
 May occur unilaterally or bilaterally.
 Koufman (1994) suggests most likely cause is
a combination of LPR and long-term vocal
misuse.
 Tends to recur: Tx must address ALL
underlying causes.
SYMPTOMS OF LPR
 Hoarseness (reported by 100% of patients)
 Frequent throat clearing
 Globus pharyngeus (sensation of a lump in
the throat)
 Chronic Cough
 Dysphagia
 Bad/bitter taste in mouth
 Post-nasal drip
 Sore throat
 Heartburn*
LPR: Diagnosis
 Medical History
 Laryngoscopy/
Laryngoendoscopy/Videostroboscopy
 24 hour Double pH probe
 Barium Swallow Study
 Upper GI Endoscopy
 Manometry
Clinical Findings
Irritation from reflux of stomach fluids into the voice box causes: redness and
swelling (indicated with white arrows) in vocal folds (vf) and false vocal folds (f
vf); pachydermia (indicated with yellow arrow) or thickening of tissue in
between the focal folds.
LPR
Associated Vocal
Pathologies
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Laryngeal stenosis
Polypoid degeneration
Paroxysmal laryngospasm
Recurrent leukoplakia
Functional voice disorders
Laryngeal carcinoma
Arytenoid fixation
Vocal nodules
SIDS?
Treatment
 Levels I, II, III
 Medical
Antacids (Tums, Mylanta)
H2 Blockers (Tagament, Zantac,
Pepcid)
Proton Pump Inhibitors (Prevacid,
Nexium, Prilosec, Aciphex)
Recommended dose: 2x/day
If you are interested in understanding how PPIs work, visit this website:
http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/stomach/pariet
al.html
Treatment
1. Behavioral: anti-reflux therapy.
 Dietary Changes
 Lifestyle Modifications
-Low fat diet
-Avoid tight-fitting clothes.
-Avoid coffee, tea,
-If you are a smoker,
chocolate : (, tomatoQUIT!
based products,citrus
-Elevate the head of the
fruits, carbonated drinks,
bed (esp. if reflux at
cheese, eggs & onions.
night).
-Avoid overeating.
-Don’t exercise or sing too
-Avoid alcohol, especially
soon after eating
in the evening.
-Lose weight-if necessary
-Avoid eating/drinking
-Relax.
within 3 hour of bedtime.
Treatment
Voice Therapy
Vocal Hygiene
-reduce/eliminate throat clearing and
coughing.
-encourage conservative voice use
-initiate new functioning voicing
behaviors.
-production of voice with an extreme
forward focus.
Resonant voice therapy (RVT): most often
employed for LPR/granulomas (Stemple et
al, 2000)
Treatment: RVT
 Developed by Verdolini & Lessac.
 Resonant Voice: involves oral vibratory
sensations in the context of easy phonation.
 Goal: “…to achieve the strongest, cleanest
possible voice with the least effort and impact
between the vocal folds to minimize the
likelihood of injury and maximize the likelihood
of vocal health (Stemple et al., 2000)”.
 How? Pt. Is asked to monitor the “feel” and to
concentrate on auditory feedback.
Treatment
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Surgical: for
Severe LPR
Fundoplication
 Tightens LES
Treatment
Surgical:
 Considerations for patient with granuloma
Surgery is not the treatment of choice for granulomas,
due to their tendency to recur. However, surgery is
indicated in certain cases:
1.
2.
3.
4.
Granulomas compromise airway.
Carcinoma is suspected.
Granulomas mature (usually don’t respond to meds).
Patient relies on voice for professional use,.
Treatment
 **BOTOX A Injection is now being used
to treat granuloma. Preliminary studies
indicate it’s effective.
 Phonoscopic Therapy (2005) – provides
visual feedback using an endoscope.
Treatment
 Efficacious?
YES!
Granulomas respond well to ART + meds.
Voice therapy focused on reducing medial
compression of vocal folds, such as RVT are
effective.
PPIs are effective in reducing acid production in
the stomach.
Individualized treatment
Conclusions
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LPR
Can have very damaging effects
Associated with many vocal pathologies
Diagnostic procedures
Treatment options
Our role as SLPs
Educating clients
References
Belafsky, P. (2003). Abnormal endoscopic pharyngeal and laryngeal findings
attributable to reflux. American Journal of Medicine, 115 (3A): 90S-96S.
Garnett, J.D. (2005, May). Contact granulomas. Emedicine specialties. Retrieved on
July 5, 2005,
from http://www.emedicine.com/ent/topic603.htm
Koufman JA, Cummins MM. (1995) Reflux and early laryngeal carcinoma. Visible
Voice, 4:2-5, 19-23.
Koufman, J.A. (1994) Laryngopharyngeal Reflux and Voice Disorders. Visible Voice,
3:2-7.
Koufman, J.A., Aviv, J.E., Casiano, R.R. and Shaw, G.Y. (2002) Laryngopharyngeal
reflux: position statement of the committee on speech, voice, and swallowing
disorders of the American Academy of Otolaryngology-Head and Neck Surgery.
American Journal of Otolaryngology – Head and Neck Medicine and Surgery,
127, 32-35.
Leonard, R. & Kendall, K. (2005) Effects of voice therapy on vocal process
granuloma: a phonoscopic approach. American Journal of Otolaryngology –
Head and Neck Medicine and Surgery. 26. 101-107.
Stemple, J.C. & Glaze, L.E. (2000). Clinical Voice Pathology: Theory and
Management. San Diego: Singular Publishing Group, Inc.
Voice Disorders.org (n.d.). Voice Disorders: Reflux Laryngitis. Retrieved on July 5,
2005, from http://www.voiceproblem.org/pdfs/reflux_laryngitis.pdf