LPRD IN CHILDREN

Naren N. Venkatesan, et. All. Dept of Otolaryngology-Head and Neck Surgery,

University of Texas Medical Branch, USA.
Pediatr Clin North Am. 2013 August ; 60(4): 865–878. doi:10.1016/j.pcl.2013.04.011.

Journal Reading
Tita Puspitasari

Supervisor : dr. Ongka M. Saifuddin, SpTHT-KL (K)

DEPT OF OTORHINOLARYNGOLOGY – HNS

SCHOOL OF MEDICINE PADJADJARAN UNIVERSITY
BANDUNG
2019
 INTRODUCTION
• Extraesophageal reflux disease = Laryngopharyngeal reflux disease
(LPRD).
• Gastroesophageal reflux disease (GERD)
• LPRD : Reflux of either gastric acid or refluxate (containing pepsin)
into the larynx, oropharynx, and/or nasopharynx
• Corelate with failure to thrive, laryngomalacia, recurrent
respiratory papillomatosis (RRP), chronic cough, hoarseness,
esophagitis, aspiration, obesity.
• 1 in 5 children
Various Extraesophageal Manifestations of GERD

Infants
Failure to thrive Children
Wheezing Cough
Stridor Hoarseness
Persistent cough Stridor
Sore throat
Apnea
Asthma
Feeding difficulties
Vomiting
Aspiration Globus sensation
Regurgitation Wheezing
Recurrent croup Aspiration
Recurrent
 DISEASES AFFECTED BY REFLUX

• Subglottic stenosis
• Laryngomalacia
• Asthma
• Recurrent otitis media
• Vocal cord nodules
• Vocal cord granuloma
• Eosinophilic esophagitis
• Allergic rhinitis
• Recurrent respiratory papillomatosis
IMPAIRED SWALLOWING AND ASPIRATION

• Swallow : Coordinate the actions of suck-swallow-breathe.

• All ages : Supraglottic mucosa must sense bolus →

Appropriate vocal fold closure, stimulating opening
hypopharynx and UES.

• Edema from chronic irritation by gastric aspirate ↓sensation,

↑ risk aspiration
IMPAIRED SWALLOWING AND ASPIRATION

• Suskind : Significant improvement in videofluoroscopic swallow

evaluations and pharyngeal impairment scores when infants with
swallowing issues were treated for GERD.

• Aviv : 3 months of GERD treatment → normal laryngopharyngeal

sensation.

• ↑ Swallowing function and decreased posterior laryngeal edema.

• Antireflux medication, thickening of feeds → ↑

laryngopharyngeal sensing of the bolus and ↑ coordination of
swallowing → preventing microaspiration.
TESTING OF THE LARYNGEAL ADDUCTOR REFLEX

• Testing LAR can be checked by endoscopy with a pulse of air

to the aryepiglottic folds

• Pressure of 2.5 mm Hg, gradually increases in increments of

0.5 mm Hg to 10 mm Hg.

• Positive response being a cough or break in respiration.

• >4.5 mm Hg →suggestive of microaspiration and poor LAR.

 LARYNGOMALACIA
• Congenital softening laryngeal tissues → floppy above vocal cord
(supraglottic larynx) fall into airway→pediatric airway distress.

• Laryngomalacia severity category:

Mild (inconsequential stridor during feeding)

Moderate (inspiratory stridor, no failure to thrive, inconsequential

dyspnea, cyanosis, or brief apneas)

Severe (inspiratory stridor and life-threatening complications).

• 65% severe laryngomalacia had reflux.

• Moderate - severe laryngomalacia 10 x suffer from reflux > mild

laryngomalacia.
Olney’s classification: Type I LM: prolapsing supra arytenoid floppy
tissues, Type II LM: shortened aryepiglottic folds associated with a long,
omega-shape epiglottis that curls on itself, Type III LM: overhanging
retroflexed epiglottis collapsing posteriorly during inspiration
 LARYNGOMALACIA
• Aerophagia during feedings → gastric distention →vagal reflexes →
postprandial vomiting + regurgitation.

• ↑ association laryngomalacia + reflux ???, reflux → laryngomalacia

or simply present concurrently.

• Supraglottic biopsies : Mild intraepithelial infiltrate,

pathognomonic for reflux,

• 2 studies using 24-hour dual-probe pH manometry : 100%

correlation between laryngomalacia and reflux

• Reflux : at least 1 episode of pH less than 4 for at least 4 seconds.

 LARYNGOMALACIA

• Studies : Improvement in laryngomalacia symptoms (cough,

stridor, choking) with antireflux treatment.

• Nearly 89% of patients moderate and severe → improvement

in coughing and choking after 7.3 months of GERD therapy.

• Improvements in regurgitation were reported in nearly 70% of

patients.
 SUBGLOTTIC STENOSIS
• Neonate/infant with recurrent crouplike episodes and chronic
cough.
• Major causes : Trauma, infection, and LPRD.
• 2/3children subglottic stenosis have reflux disease.
• 1/3 subglottic stenosis treated for reflux → avoid surgical
intervention
• Reflux effect : Downregulation of epidermal growth factor
receptor→↓mucosal turnover, ↑transforming growth factor
β1→fibroblast differentiation+excessive connective tissue
deposition.
• Vocal cord granulomas → sequela of reflux, = histologic changes in
early subglottic stenosis lesions.
 RRP/RECURRENT RESPIRATORY PAPILLOMATOSIS
• Often prolonged, infection of
the upper airway by the HPV.
• ↑ Sensitivity the ciliated
respiratory epithelium larynx
→ more advanced
presentations of the disease
or a more frequent need for
surgical debridement
• ↓ Disease progression of RRP,
such as laryngeal webs, with
antireflux therapy.
 ASTHMA

• Gastroesophageal reflux may be present in 40% to 80% of children with

asthma.

• Asthma + Rhinitis → laryngeal changes may mimic LPRD changes.

• LPRD changes in the larynx 70% of cases.

• β-agonists reducing the tone of the lower esophageal sphincter →

trigger reflux.

• Controlled or uncontrolled asthma have similar rates of LPRD.

• LPRD and asthma, are often present together, the effect of treatment of
one on the status of the other requires further research.
 HOARSENESS

• Vocal cord nodules : Most common cause of pediatric hoarseness.

• Gumpert : Interarytenoid edema as a sign of LPRD, found 90% of

children with hoarseness.

• LPRD may mimic vocal cord nodules.

• Nodules : Junction anterior 1/3 - posterior 2/3 vocal folds.

• Pseudonodules of LPRD : Edema in the anterior 1/3 vocal folds.

• Children : Antireflux medication (PPI), speech th/

 COUGH

• Rapidly adapting receptors, example : nocireceptors → primary

sensory receptors involved in chronic cough > 4 weeks → LPRD,
allergy, and asthma should be strongly suspected

• Rapidly adapting receptors : Stimuli smoke, ingested solutions,

chemical stimuli (histamines, bradykinins, prostaglandins, and
substance P.

• Several specialists 40 children with cough > 8 weeks→ reflux and

asthma ½ and another ¼ multiple causes
 DIAGNOSIS LPR IN CHILDREN

• History :
 Feeding : Regurgitation, emesis (timing), adequate weight gain .
 Previous airway issues : Subglottic stenosis, laryngomalacia, and
RRP .
 Choking incidents, chronic cough, and recurrent crouplike
episodes may suggest an underlying anatomic airway issue or
even microaspiration.
• Test : Esophageal biopsies, barium esophograms, 24-hour pH
probe.
 TREATMENT : Lifestyle modifications

• Altering food composition

• Adjusting the diet to eliminate known triggers of reflux (juices

and spicy foods, chocolates, and mints)

• Fasting before bedtime

• Milk thickening

• Sleep in the lateral position

• Elevating the head of the bed

 TREATMENT : Medical Therapy

• PPI : Lansoprazole, Omeprazole, Esomeprazole, 30’ before meals .

• Histamine-2 receptor antagonists (H2RAs) as second-line therapy.

 Help wean off PPIs or to supplement PPI therapy.

 Taken at night.

 Ranitidine as a syrup

 Failure to respond : Lack of significant reflux,

insufficient dosage, consider surgical intervention.

TREATMENT : Surgical

I : reflux symptoms life

threatening , affecting QOL
despite maximum medical
therapy.
Fundoplication :
Gold standard procedure
surgical treatment of GERD
Restore the integrity of the
lower esophageal
sphincter.
 SUMMARY
• Extraesophageal symptoms of GERD have long been recognized
and referred to as LPRD.

• LPRD more difficult to diagnose accurately and consistently.

• Role of LPRD conjunction with laryngomalacia, subglottic stenosis,

vocal cord nodules.

• Treatment of LPRD : Symptomatic benefits = Improvements in

these concomitant diseases.

• Future studies : Illuminate the role of gastric acid and refluxate on

the upper aerodigestive tract.