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 under-
diagnosed/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 Globus pharyngeus
(posterior) Vocal nodules
Subglottic stenosis
Reinkes edema
Carcinoma of the larynx
Recurrent leukoplakia
Carcinoma of esophagus
Contact ulcers and Recurrent pneumonitis
granulomas Pharyngitis
Laryngospasm Asthma
Paradoxical Vocal Cord
Motion

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 not pathognomonic
SPPA 6400 Voice Disorders - Tasko
Symptoms of LPR
Koufman (1991) Book et al. (2002)
Chronic dysphonia (92 %) Throat clearing (98%)
Intermittent dysphonia
Persistent cough (97%)
Vocal fatigue
Globus pharyngeus (95%)
Nocturnal choking
Hoarseness (95%)
Chronic throat clearing
Excessive throat mucus
Chronic cough (44%)
Dysphagia (27%)
Globus pharyngeus (33 %)

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 N

hoarseness, dysphagia, globus,

throat clearing, cough etc. N Y

Findings
endoscopic esophagitis Y N
laryngeal inflammation 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
SPPA 6400 Voice Disorders in the endolarynx.
- Tasko

Score of 7 or greater: likely to have LPR

LPR: Tissue Changes

Interarytenoid bar Interarytenoid granuloma

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
(J) aryepiglottic fold edema.
SPPA 6400 Voice Disorders - Tasko
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 ENT
Diagnostic tests
Abnormal esophageal radiography Y sometimes
Esophageal pH monitoring Y Y
Pharyngeal pH monitoring N Y

Pattern of reflux
Supine (nocturnal) Y sometimes
Upright (awake) 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

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 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
SPPA 6400 Voice Disorders - Tasko
Drug of choice for LPR
SPPA 6400 Voice Disorders - Tasko

From Ford (2005)

Conventional treatment for suspected LPR
Dietary 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
Lifestyle modification
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 Y sometimes
Rate of success with H2 blockers 85% 65%
Rate of success with omeprazole 99% 99%

Assuming adequate dosage and duration of therapy

SPPA 6400 Voice Disorders - Tasko

 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