Reflux & the Voice

1. Reflux & the Voice SPPA 6400 Voice Disorders - Tasko

2. What is reflux? SPPA 6400 Voice Disorders - Tasko

3. 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

4. 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

5. Reflux laryngitis (posterior) Subglottic stenosis Carcinoma of the larynx Carcinoma of esophagus Contact ulcers and granulomas Laryngospasm Paradoxical Vocal Cord Motion Globus pharyngeus Vocal nodules Reinke’s edema Recurrent leukoplakia Recurrent pneumonitis Pharyngitis Asthma Conditions reported to be associated with reflux SPPA 6400 Voice Disorders - Tasko

6. 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

7. 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

8. Koufman (1991) Chronic dysphonia (92 %) Intermittent dysphonia Vocal fatigue Nocturnal choking Chronic throat clearing Excessive throat mucus Chronic cough (44%) Dysphagia (27%) Globus pharyngeus (33 %) Book et al. (2002) Throat clearing (98%) Persistent cough (97%) Globus pharyngeus (95%) Hoarseness (95%) Symptoms of LPR SPPA 6400 Voice Disorders - Tasko

9. Reflux Severity Index The Reflux Symptom Index A score > 10 may indicate significant reflux A score > 13 definitely abnormal SPPA 6400 Voice Disorders - Tasko

10. 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

11. Laryngoscopic Signs SPPA 6400 Voice Disorders - Tasko

12. ‘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 in the endolarynx. The Reflux Finding Score (Belafsky et al. 2002) SPPA 6400 Voice Disorders - Tasko Score of 7 or greater: likely to have LPR

13. LPR: Tissue Changes Interarytenoid granuloma Interarytenoid bar SPPA 6400 Voice Disorders - Tasko Vocal fold edema Granulomas

14. LPR: Tissue Changes SPPA 6400 Voice Disorders - Tasko

15. (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. From Vavricka et al. (2007) SPPA 6400 Voice Disorders - Tasko

16. Diagnostic value of laryngeal signs? SPPA 6400 Voice Disorders - Tasko Vavricka et al. (2007)

17. Diagnostic value of laryngeal signs? SPPA 6400 Voice Disorders - Tasko Hicks et al. (2002)

18. 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

19. 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

20. Are we good at diagnosing LPR? Issues • Which signs, which symptoms? • Specificity and sensitivity • Examination procedures • Differential diagnosis SPPA 6400 Voice Disorders - Tasko

21. Clinical Decision Making From Ford (2005) SPPA 6400 Voice Disorders - Tasko

22. Treatment SPPA 6400 Voice Disorders - Tasko

23. 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 • Drug of choice for LPR SPPA 6400 Voice Disorders - Tasko

24. SPPA 6400 Voice Disorders - Tasko From Ford (2005)

25. 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

26. 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

27. Cochrane Database From Cochrane Reviews (2005) Also Williams et al. (2004) SPPA 6400 Voice Disorders - Tasko

28. 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

29. Case Illustrations SPPA 6400 Voice Disorders - Tasko