Laryngopharyngeal Reflux Disease – LPRD

Arranged by :
Andriyani Setiarini
30101507378

Mentor :
dr. Shelly Tjahyadewi, Sp. THT-KL, M.Kes

Faculty of Medicine
Sultan Agung Islamic University
Semarang
2019
 J O U R N A L
I D E N T I T Y

TITLE PUBLISHER
01 Laryngopharyngeal Reflux 03 Department of Emergency
Disease – LPRD Medicine, Faculty of Medicine,
University of Tuzla, Tuzla, Bosnia
and Herzegovina

AUTHORS YEAR
02 Nizama Salihefendic, Muharem 04 2017
Zildzic, Emir Cabric
A B S T R A C T
 Introduction
Laryngopharyngeal reflux disease (LPRD) referes to an inflammatory reaction of the mucous membrane of
pharynx, larynx and other associated respiratory organs, caused by a reflux of stomach contents into the
esophagus. LPRD is considered to be a relatively new clinical entity with a vast number of clinical
manifestations which are treated through different fields of medicine, often without a proper diagnosis. In
ABSTRACT gastroenterology it is still considered to be a manifestation of GERD, which stands for gastroesophageal reflux
disease. Patients suffering from LPRD communicate firstly with their primary physicians, and since further
treatment might ask for a multidisciplinary approach, it is important to have a unified approach among experts
when treating these patients.
Goal
This paper is written with the intention to assess the frequency of symptoms of LPR in family medicine,
possible diagnostics and adequate treatment in primary health care.
Materials and Methods
This is a prospective, descriptive cohort study. Authors used „The Reflux Symptom Index“ (RSI) questionnaire.
Examinees were all patients who reported to their family medicine office in Gracanica for the first time with
new symptoms during a period of one year. Patients with positive results for LPR (over 13 points) were treated
in accordance with the suggested algorithm and were monitored during the next year.
Result
Out of 2123 examinees who showed symptoms of LPR, 390 tested positive according to the questionnaire.
This group of examinees were treated in accordance with all suggested protocols and algorithms. 82% showed
signs of improvement as a response to basic treatment provided by their physicians.
Conclusion
Almost every fifth patient who reports to their family medicine physician shows LPR. On primary health care
levels it is possible to establish some form of prevention, diagnostics and therapy for LPR in accordance with
suggested algorithms. Only a small number of patients requires procedures which fall under other clinical
fields.
I N T R O D U C T I O N
 INTRODUCTION

Gastroesophageal Reflux Disease

(GERD) is stomach content reflux
Diagnostic and
into the esophagus with
therapeutic procedures
pathohistological changes of the
for GERD are precisely
mucous membranes of the
defined
esophageal and causes clinical
manifestations
 INTRODUCTION
most commonly manifested as
laryngeal symptoms such as
Laryngopharyngeal Reflux Disease
coughing, hoarseness,
(LPR) is stomach contents reflux
dysphagia, globus and sore
outside of the esophagus and into
throat, but there can be signs
respiratory organs
of nose, sinus, and lung
infections

LLPR is a multifactorial
syndrome with a vast clinical
representation, during the
disease and with
complications, so it requires a
multidisciplinary approach
INTRODUCTION
• Laryngeal and pharyngeal mucosa do not
ETIOLOGY possess these protective mechanisms
and acidopeptic activity of the stomach
content quickly leads to mucosal lesions
• Laryngeal and pharyngeal reflux occurs
most commonly during the day as a
result of the upper esophageal sphincter
dysfunction
• Other possible etiological factors are
GERD
PROBIOTIC pancreatic proteolytic enzymes, bile salts
and bacteria

• The lower esophageal sphincter dysfunction

• The dysfunction of the stomach emptying
LPRD
mechanism
• Esophageal mucosa has protective mechanisms
against aggressive factors of the stomach
content (mucosal barrier) and it remains intact
when a physiological reflux occurs, which
normally happens at night.
INTRODUCTION
INTRODUCTION

SYMPTOMS OF GERD
INTRODUCTION

SYMPTOMS OF LPRD
INTRODUCTION
INTRODUCTION Differences Between GERD
 INTRODUCTION
Laryngeal symptoms are most
common, so patients are treated
In clinical practice, by otolaryngologists.
LPR is mostly not
recognized because
it is a "silent reflux"
Otolaryngologists have developed a
diagnostic Reflux Symptom Index
diagnostic and (RSI) based on the importance of
therapeutic certain disease symptoms and
protocols are Reflux Finding Score (RFS) based on
inadequate frequency of pathological changes
determined by laryngoscopy

proper treatment is
usually delayed
 INTRODUCTION

LPR represents an
Knowledge of the
important medical
etiopathogenesis of the
problem and a
disease and its clinical Untreated LPR can
challenge in fast
manifestations can help
For family medicine diagnostics, proper be one of the
physicians in creating a
physicians treatment and proper etiological causes of
proper program for
selection of patients laryngeal cancer.
prevention, early
who require additional
diagnosis and adequate
multidisciplinary
therapy for LPRD.
diagnostic procedures.

INTRODUCTION
Diagnostic Tools
Evaluation of symptoms using the Reflux Symptom Index is
considered to be the basic diagnostic procedure.
1. Reflux Symptom Index
The reflux symptom index (RSI) can assist in
diagnosing LPR. The RSI is derived using a simple
nine-item questionnaire in which patients rate the
severity of their LPR symptoms on a Likert scale, with
0 representing no problem and 5 representing
extreme problems. The maximum score is 45, and a
score of more than 13 is diagnosed as abnormal acid
reflux.
 INTRODUCTION
Diagnostic Tools

2. Laryngoscopic Examination
Laryngoscopy is used to look for pathological changes
in the larynx. These changes are described as edema,
hyperemia or erythema of the vocal chords and
laryngeal edges, ventricular obliteration, granulation,
presence of dense endolaryngeal secretion and
hypertrophy of the posterior commissure.
INTRODUCTION 3. Reflux Finding Score
The RFS is an eight-item measure used by clinicians to rate the
severity of signs of inflammation revealed in laryngoscopic
Diagnostic Tools examinations. The clinicians rates the severity of each symptom by
assigning scores from 0 (normal) to 26 (worst possible score). LPR
can be diagnosed with 95% certainty in cases where the RFS
exceeds 7. It can also be used to track treatment responses in
patients. The RFS and RSI both help to improve the accuracy of LPR
diagnoses and evaluate the efficacy of treatments. The RFS is a
cost-efficient method, which can be included in otolaryngologic
examinations to facilitate the diagnosis of LPR.
INTRODUCTION
4. Upper Gastrointestinal Endoscopy
Diagnostic Tools UGE is also referred to as esophagogastroduodenoscopy
(EGD). UGE can detect signs associated with GERD, such as
mucosal injury, esophagitis, and Barrett esophagus as well as
other complications and malignancies. However, UGE has
proven to be less useful in detecting LPR than in identifying
GERD. In one study, UGE revealed esophageal lesions in 50%
of GERD patients and in less than 20% of LPR laryngitis
patients. For patients presenting warning signs of
complications (i.e., chronic cough, hoarseness, or dysphagia)
or malignancies, it is recommended that they be referred to
specialists, such as otolaryngologists, gastroenterologists,
and pulmonologists.
 INTRODUCTION 5. Dual-Sensor pH Probe
The 24-hour dual-sensor pH probe (simultaneous esophageal
and pharyngeal) is considered the gold standard in the
Diagnostic Tools diagnosis of GERD, with sensitivity of 93.3% and specificity of
90.4%, when using a cut-off value of 4.5% of total time with
pH < 4 during a 24-hour period. Ambulatory pH probe-
monitoring is often applied to evaluate the efficacy of drug
treatment in cases of LPR. However, it is considered a less
reliable test for confirming LPR. This is primarily due to the
difficulties involved in interpreting pH monitoring data and a
lack of consensus on normal pH limits, number of events,
and probe placement.

Monitoring esophageal pH, the distal pH probe is placed 5 cm above the lower esophangeal spincter (LES) and
the proximal pH probe is placed 20 cm above the LES, just below the upper esophageal spingter. a third pH test
is placed in the pharynx which simultaneously records changes associated with acids reaching the pharynx.

pH readings are recorded for 24 hours when the patient shows onset, last meal, sleep, and when recurrence is
reflux. information provided by this test includes the frequency, duration and location of the reflux event.
 6. Salivary Pepsin Test
INTRODUCTION A newer method of determining pepsins in spit - peptest,
can confirm LPR diagnosis because its sensitivity and
Diagnostic Tools specificity is 87%. The test which confirms the presence of
pepsins in spit (peptest) is important as it can be applied in
primary health care. Gastric pepsinogen is activated only in
acidic environment, so the presence of pepsin in spit
indicates that there is a reflux of acidic stomach content into
the respiratory tract. This test is simple, non-invasive and
could be the determining factor in the final diagnosis of LPR.
INTRODUCTION
Body weight reduction and physical activity,
quitting cigarettes and alcohol use are one of the
first steps in lowering the intensity of symptoms
in patients

Nutritional interventions with proper food choices

and bowel movement regulation lead to lowering
LPR therapy is complex dyspeptic difficulties, but also lower the number
of reflux episodes.
and requires modification
of patient's lifestyle and
habits. Emptying of the bowels causes lower intra-
abdominal pressure, which leads to lower
possibility of stomach content reflux into the
esophagus, larynx and pharynx.

Obesity, or more accurately high BMI, is an

independent factor in stomach reflux occurrence
because of its specific effect mechanism on the
gastroesophageal junction
 INTRODUCTION
High dosages of PPI (proton pump inhibitors)
have shown the best effects in reducing reflux in
the course of 24 hours.
LPR treatment and management is
supposed to reduce the acidity or
stomach contents and neutralize
acidopeptidic activity in larynx,
pharynx and esophagus.
Alkaline water and alginates show a positive
additional effect in lowering acidopeptidic activity
in the larynx and pharynx.

Patients are supposed to have long-term treatment during the course of 6 months because of high sensitivity of the
mucosal membrane in the stomach and pharynx.

Difficult cases with a proven hiatal hernia can be considered for surgical treatment as well
MATERIALS AND METHODS
MATERIALS AND METHODS

This research uses a prospective and descriptive cohort study.

This study was conducted during a period of one year (from October, 2015 to September, 2016) in the
Polyclinic "Medicus A", Gracanica, Bosnia and Herzegovina.

This study uses the questionnaire "The Reflux Symptom Index" (RSI).

Examinees were all patients who reported to their family medicine surgery in Gračanica for the first
time with new symptoms during a period of one year.

Patients with positive results for LPR (over 13 points) were treated in accordance with the suggested
algorithm and were monitored during the next year.
MATERIALS AND METHODS
Patients with symptoms of LPR were first educated about healthy lifestyles and habits and the
importance of regulating and monitoring the whole digestive system.

And then, they were put on an epmpirical treatment with high dosages of protein pump inhibitors,
alginates and alkaline water.

Nutritional interventions were implemented as needed.

Patients were monitored during the course of the next 6 months.

Those who showed alarming symptoms and incomplete response to procedures and druges were
reffered to additional searches and consultations (esophagoscopy, ORL consultations and
laryngoscopy, peptest and consultations with pulmonologists).
MATERIALS AND METHODS
R E S U L T
 RESULT

The Table 2 shows the frequency of symptoms of LPR in relation to others symptoms of different diseases.
390 patients showed symptoms of LPR, which is 18% of those who reported to their family medicine physicians.
Patients with dominant difficulties or esophageal refluxs constite 16% of all patients, or 332 patients.
 RESULT

During the 6 months course of this study which followed patients with symptoms of LPR those who
followed the program showed significant improvement (79% of patients). 58 patients were reffered to
further gastroenterological examinations and 8 to otorhinolaryngological examinations (Table 3.)
 RESULT

 Results of clinical monitoring of these patients

indicate that there is a possibility of early discovery,
adequate prevention and treatment of patients with
symptoms of LPR on primary health care levels.
 Applied algorithm of necesarry diagnostic and
therapeutical procedures for patients with
symptoms of LPR according to Reflux Symptom
Index (RSI) is shown in Figure 1. Use of this
algorithm enables optimal treatment for most
patients.
DISCUSSION
 DISCUSSION

esophageal syndroms
Clinical manifestations of
Gastroesophageal Reflux
Disease (GERD) are Symptoms of LPR are
classified extraesophageal unspecific and can be a
LPRD
syndroms characteristic of various
diseases

• Lifestyle
• Diet LPRD
• Obesity 18%
Etiology • Sports or physical activity
• Smoke
• Alcohol consumption GERD
16%
This study presented that out of 2123 examinees
18% showed symptoms of LPRD and 16% showed
symptoms of GERD.
 DISCUSSION

Only a small number

Primary of participants in
Health Care this study were
referred to

Evaluation of Reflux Finding

clinical Laryngoscopy Score (RFS)
symptoms Difficult to
perform on
Dual-Sensor pH Probe primary
Questionnaire
Reflux health care
Symptoms level
Index (RSI) Esophagogastroscopy

pepsins in spit -
peptest
 DISCUSSION
Proton pump inhibitors in
high doses and with long
Patients who showed term usage
symptoms of LPR were
Diagnostic-therapeutical
first treated with non
pharmacological ways Alginates and alkaline food and
water contributed to successful
treatment of these patients
• Dietary recommendations
for weight reduction
• Stool regulations
• Reducing alcohol usage
and quitting smoking
C O N C L U S I O N
 CONCLUSION

 LPR different from GERD. The methods to diagnostic about LPR ( RSI, Laryngoscopic, RFS, pH
Probe, EGD, Peptest).

 Education : changes in lifestyle (dietary recommendations for weight reduction, stool regulations,
exercising ,reducing alcohol usage and quitting smoking).

 Untreated LPR can be one of the etiological causes of laryngeal cancer.

 Critical Appraisal
Systematic Review
 P
Examinees were all patients who reported to I
their family medicine office in Gracanica for The Reflux Symptom Index“ (RSI)
the first time with new symptoms LPRD questionnaire
during a period of one year.

C O
Questionnaire Reflux Symptoms Index (RSI) is
Laryngoscopic Examination, Reflux Finding
important as it can be applied in primary
Score, . Upper Gastrointestinal Endoscopy,
health care to diagnostic LPRD.
Dual-Sensor pH Probe, Salivary Pepsin Test
JUDUL dan PENGARANG
No Kriteria Ya (+) atau Tidak (-)

1 Jumlah kata dalam judul < 12 kata (+)

2 Deskripsi judul Menggambarkan isi

utama penelitian,
menarik dan tanpa
singkatan
3 Daftar penulis sesuai aturan jurnal (+)

4 Korespondensi penulis (+)

5 Tempat & waktu penelitian dalam (+)
judul
 ABSTRAK

No Kriteria Ya (+) atau Tidak (-)

1 Abstrak 1 paragraf (+)

2 Mencakup IMRC Menggambarkan isi utama

penelitian dan tanpa singkatan
3 Secara keseluruhan informatif (+)

4 Tanpa singkatan selain yang (+)

baku
5 Kurang dari 250 kata (+)
 PENDAHULUAN

No Kriteria Ya (+) atau Tidak (-)

1 Terdiri dari 2 bagian atau 2 paragraf (+)
2 Paragraf pertama mengemukakan alasan (+)
dilakukan penelitian
3 Paragraf ke 2 menyatakan hipotesis atau (-)
tujuan penelitian
4 Didukung oleh pustaka yang relefan (+)
5 Kurang dari 1 halaman (-)
 BAHAN dan METODE
No Kriteria Ya (+) atau Tidak (-)
1 Jenis dan rancangan penelitian (+) (studi deskriptif prospektif,
kuesioner)
2 Waktu dan tempat penelitian waktu (+) Oktober 2015 - September
2016, tempat (+) Poliklinik “Medicus
A”, Gracanica, Bosnia dan Herzegovina
3 Populasi sumber -
4 Teknik sampling -
5 Kriteria inklusi +
6 Kriteria eksklusi +
7 Perkiraan dan perhitungan besar sempel -
8 Perincian cara penelitian +
9 Blind -
10 Uji Statistik -
11 Program komputer -
12 Persetujuan subjek -
 HASIL

No. Kriteria Ya (+) atau Tidak (-)

1 Jumlah Subjek (+)

2 Tabel Karakteristik (+)

3 Tabel Hasil Penelitian (+)

4 Komentar dan pendapat penulis tentang (+)

hasil penelitian
5 Tabel analisis data dengan uji (+)
 BAHASAN KESIMPULAN dan DAFTAR PUSTAKA

No. Kriteria Ya (+) atau Tidak (-)

1 Pembahasan dan kesimpulan terpisah (+)
2 Pembahasan dan kesimpulan di (+)
paparkan dengan jelas
3 Pembahasan mengacu dari penelitian (-)
sebelumnya
4 Pembahasan sesuai dengan landasan (+)
teori
5 Keterbatasan penelitian (-)
6 Simpulan berdasarkan penelitian (+)
7 Saran penelitian (-)
8 Penulisan daftar pustaka sesuai aturan (+)
 APLIKASI
Pertanyaan Jawaban
• Apakah terdapat perbedaan antara metode Ya
yang bisa di terapkan pada layanan
kesehatan primer dibandingkan dengan
metode yang lainnya?

• Apakah metode diagnosis dan algoritma Ya

tatalaksana tersebut mungkin dapat
diterapkan pada layanan kesehatan
primer?
• Apakah metode diagnosis dan algoritma Ya
tatalaksana tersebut memiliki potensi yang
menguntungkan dalam menangani pasien?
KESIMPULAN

Hasil penelitian valid

Hasil penelitian penting

Hasil penelitian dapat diterapkan

Thank You