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بسم الله الرحمن ارحيم. LARYNGOPHARYNGEAL REFLUX. Lega Natto , M.D. Nomenclature. GERD REFLUX LARYNGITIS GASTROLARYNGEAL REFLUX GASTROPHARYNGEAL REFLUX SUPRAESOPHAGEAL REFLUX LARYNGOPHARYNGEAL REFLUX. LPR.

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laryngopharyngeal reflux

LARYNGOPHARYNGEAL REFLUX

LegaNatto , M.D.

nomenclature
Nomenclature
  • GERD
  • REFLUX LARYNGITIS
  • GASTROLARYNGEAL REFLUX
  • GASTROPHARYNGEAL REFLUX
  • SUPRAESOPHAGEAL REFLUX
  • LARYNGOPHARYNGEAL REFLUX
slide4
LPR
  • Retrograde movement of gastric contents(acid and enzymes as pepsin) in to the laryngopharynx leading to symptoms referable to the larynx and hypopharynx.
slide5

dysphonia

Chronic cough

Mild dysphagia

Globuspharyngeus

Throat clearance

slide6

laryngospasm

Vfgranuloma

Laryngeal ca

Subglotticstenosis

lpr versus gerd
LPR versus GERD
  • Only 35% reporting heartburn
  • Esophagitis on biopsy only 25%
  • UES problem in upright position during physical exertion.
  • Lower incidence of esophageal dysmotility
  • Less acid required to create symptoms
slide11

Axford SE , sharp N, Ross PE, et al. Cell biology of laryngeal epithelial defenses in health and disease: preliminary study.

Ann OtolRhinolLaryngol 110: 1099-1108, 2001

pathophysiology
Pathophysiology
  • THEORY 1:

DIRECT INJURY FROM ACID OR PEPSIN

      • LOW UES PRESSURES, ESPECIALLY AT NIGHT
      • DYSMOTILITY WITH POOR ACID CLEARANCE
  • THEORY 2:

VAGALLY MEDIATED REFLEX -ACID IN LES EVOKES SYMPTOMS

symptoms
SYMPTOMS
  • HOARSENESS: 50-75%
  • THROAT-CLEARING
  • MUCUS, PHLEGM, PND
  • COUGH
  • SORE THROAT
  • VOCAL FATIGUE, BREAKS
  • DYSPHAGIA
  • GLOBUS: 25-50%
  • HALITOSIS
diagnosis
Diagnosis
  • BARIUM SWALLOW
  • MANOMETRY
  • ESOPHAGOSCOPY
diagnosis of lpr
Diagnosis of LPR
  • History and examination:
    • Reflux finding score (RFS)
    • Reflux severity index (RSI)
  • 24 hour dual sensor PH probe (gold standard)
  • Empiric trial of LPR
problems with the gold standard
PROBLEMS WITH THE GOLD STANDARD
  • EXPENSIVE
  • UNCOMFORTABLE
  • PROBE PLACEMENT
  • FALSE NEGATIVES
  • BILE REFLUX,

NON-ACID REFLUX

pulmonary symptoms asthma bronchiectasis
PULMONARY SYMPTOMS: ASTHMA, BRONCHIECTASIS
  • ~50% SEVERE ASTHMATICS HAVE DOCUMENTED GERD
  • ASPIRATION OF GASTRIC CONTENTS WITH ACID AND ENZYMATIC INJURY
  • NEURALLY MEDIATED REFLEX BRONCHOCONSTRICTION
  • ? LINK WITH OSA
lpr in dysplasia glottic ca of the larynx
LPR IN DYSPLASIA / GLOTTIC CA OF THE LARYNX
  • 40 pts, dysplasia, T1-2 ca
  • Dual probe pH monitoring
  • Incidence of LPR: 85%
  • LPR in ‘normals’: 52%
  • No relationship between histology, smoking, or heartburn and level LPR
  • More LPR upright

Lewin JS, Gillenwater AM, Garrett JD: Characterization of Laryngopharyngeal Reflux in Patients with Premalignant or Early Carcinomas of the Larynx: CANCER FEB 2003 p.1010-1014

gerd and laryngeal cancer meta analysis
GERD AND LARYNGEAL CANCER: META-ANALYSIS
  • All studies 1966-2004: 15 identified

Qadeer MA, Colabianchi N, Vaezi MF: Is GERD a Risk Factor for Laryngeal Cancer? LARYNGOSCOPE March 2005 p.486-491

gerd and laryngeal cancer meta analysis1
GERD AND LARYNGEAL CANCER: META-ANALYSIS
  • Reflux at least twice as common in laryngeal ca pts.
  • Suggests GERD may play role in carcinogenesis
  • Several case series: laryngeal ca in life non-smokers, non-drinkers with long hx GERD
slide31

GERD likely has an etiologic role in laryngeal ca as an independent factor or co-factor in carcinogenesis

  • There may be a dose and length of exposure relationship
treatment of lpr
Treatment of LPR
  • Diet modifications
  • Behavior modifications
  • Medicine:
    • PPI
      • WHAT DOSE?
      • FOR HOW LONG?
      • SUCCESS?
slide33

MORE RAPID AND EFFECTIVE RELIEF THAN H2 BLOCKERS

  • HANSON: N = 233
  • 96% RESPONSE TO ANTIREFLUX Rx
  • SHAW: N = 96
  • PPI TREATMENT 12 WEEKS
  • SIGNIFICANT RESPONSE
  • ACCOUSTIC MEASURES IMPROVE FIRST
  • KOUFMAN: N = 40 IMPROVEMENT IN RSI AND RFS
slide34
PPI
  • 4-6 months.
  • Bid, 30 min before meal.
  • Omeprazole (brand names: Losec®,
  • Lansoprazole (brand names: Prevacid
  • Esomeprazole (brand names: Nexium
  • Pantoprazole(brand names:Pantoloc
  • Rabeprazole(brand names: Pariet®)
ppi resistance in lpr
PPI RESISTANCE IN LPR
  • INABILITY TO KEEP GASTRIC pH >4 FOR >85% OF A 24 HR PERIOD
    • H2 BLOCKERS: RANITIDINE, CIMETIDINE, FAMOTIDINE
  • THEORY 1-INEFFECTIVE LES, ABSENT MOTILITY
    • PROKINETICS: METACLOPRAMIDE, BETHANECHOL, CISAPRIDE
  • THEORY 2-HIGHER BASAL OUTPUT OF ACID, ? FROM > ENZYMES