Amine Haddad, MD, FRCSC

Professor & Chair Dept of Otolaryngology

Associate Dean for Academic Affairs
St-Joseph University, School of Medicine
Beirut, Lebanon

LARYNGOPHARYNGEAL REFLUX
A DIFFERENT DISEASE
DEFINITION

Gastro-Esophageal Reflux Disease: GERD

Laryngopharyngeal Reflux : LPR, also called,

Pharyngeal Reflux, Gastropharyngeal Reflux,
Extradigestive Reflux, Atypical Reflux,
Respiratory Reflux
DEFINITION

GERD: upward movement of gastric content

into the esophagus

LPR: movement of gastric content beyond

the esophagus into the pharyngeal and
laryngeal area.
Normal pH values in distal
Esophagus:

pH < 4:
5.5% of the total time
8.2% of the time in the upright position
3% of the time in the supine position

C.F. Smit et al, clin. Otolaryngol 2000, 25:440-455

Normal pH values in proximal
Esophagus

pH < 4 is an abnormal event

0.2% of the time in proximal esophagus
0% of the time in the supine position

0% of the time in the pharynx in any position

C.F. Smit et al, clin. Otolaryngol 2000, 25:440-455

LPR

Only one episode of reflux into the pharynx

every few days is an abnormal event

The laryngeal mucosa has no defense

mechanism or protection against gastric
content

The cause is abnormal esophageal motility

involving the upper esophageal sphincter
 Two mechanisms describe these
symptoms and disorders:

They may be mediated by They may be a

a reaction originating from consequence of direct acid
an acid-sensitive distal injury by the acid gastric
oesophagus content in tissues beyond
the oesophagus, such as
larynx and pharynx

C.F.Smith et Al, Diagnosis and consequences of gastropharyngeal reflux; Clin.Otolaryngol.2000,25,440-445

 Prevalence of LPR

Reported in up to 10% of patients presenting to an

otolaryngologists office

And more than 50% of patients with Hoarseness

have been found to have reflux-related disease

Charles N. Ford, MD; Evaluation and Management of Laryngopharyngeal Reflux; JAMA. Sept28,2005-Vol 294. No. 12
 Koufman study on 113
patients with laryngeal and
voice disorders
90
80
70
60 All population
studied
50
Neoplastic vocal
40 cord
30 Muscle tension
20 Dysphonias
10
0
LPR prevalence
Koufman, Otolaryngology, head and neck surgery,2000
Symptoms and conditions reported to be related to LPR

Symptoms Conditions

Reflux Laryngitis
Subglottic Stenosis
Hoarseness
Carcinoma the larynx
Vocal Fatigue
Endotracheal intubation
Voice Breaks injury
Chronic Throat Clearing Contact ulcers and
Excessive Throat mucus granulomas
Postnasal drip Posterior glottic
Chronic cough stenosis
Dysphagia Arytenoid fixation
Globus Pharyngis Paroxymal
Intermittent Airway Laryngospasm
Obstruction Paradoxical vocal cord
Chronic Airway movement
Obstruction Globus Pharygis
Wheezing Vocal nodules
Polypoid degeneration
The overall definition of GERD
and its constituent syndromes

Vakil N et al. Am J Gastroenterol 2006; 101: 1900 - 1920

Extraoesophageal manifestations

J Poelmans and J Tack;

Extraoesophageal manifestations of
gastro-oesophageal reflux;
Gut 2005 54: 1492-1499
 Described extraoesophagal
manifestations of GERD
Hoarseness,
contact granulomas of the cords,
laryngospasm, regurgitation,
subglottic stenosis, vomiting
posterior laryngitis, cricopharyngeal dysfunction
chronic cough, bad breath,
pharyngeal tightness, sore throat,
globus hystericus, loss of dental/gingival structure,
choking sensation sandifer syndrome (unique neck position
aspiration, in infants/young children),
asthma, cervical pain,
apnoeic episodes, otitis media,
lung fibrosis, otalgia.
lung abscess,

K. K. Handa; LARYNGOPHARYNGEAL REFLUX: CURRENT OPINION; Indian Journal of Otolaryngology and Head and
Neck Surgery Vol. 57, No. 3, July-September 2005
Similarities and differences in Symptom Complex

Symptoms GERD LPR Chronic Sinusitis

Chronic Cough (%) 47 51 30
Throat Clearing(%) 40 42 30
Dysphagia(%) 40 42 -
Heartburn/Regurgitation(%) 83 40 -
Improvement after PPI(%) (High ) 75 -
Hoarseness (%) - 71 10
Globus (%) - 47 -
Nasal Obstruction(%) - - 80
Nasal/Sinus Congestion - - 70
Sinus Pressure/Pain - - 30
Thick nasal postnasal drip - - 75
Improvement After Antibiotic - - 90

Koufman, Laryngoscope, 91/ Aviv ; Close/ Laryngoscope 2000

 Clinical Manifestations of LPR

In a survey among members of the American Broncho-

Esophagological Association (ABEA), a large majority of the
responding otolaryngologists considered to be related to
LPR :

Throat clearing (98.3%),

persistent cough (96.6%),
globus sensation (94.9%),
and voice quality change (94.9%)

Diagnosis and management of laryngopharyngeal reflux disease Hans F. Mahieuaqba nd C. Frits Smita; Current
Opinion in otolaryngology&head and neck surgery 2006; 14:133-137
 Signs of LPR
1. Irritation in the posterior glottic area:
erythema, edema and/or hypertrophy (also known as
pachydermia of the posterior commissure

2. Irritation, ulceration or granuloma near the vocal

process;

3. Pseudo-sulcus of the vocal fold : a sign of diffuse infra-

glottic edema,

4. Edema and/or dilated vessels of the vocal folds.

Diagnosis and management of laryngopharyngeal reflux disease Hans F. Mahieuaqba nd C. Frits Smita; Current
Opinion in otolaryngology&head and neck surgery 2006; 14:133-137
Incidence of LPR in Head and
Neck cancer patients

Koufman and
cummins 95
66
Koufman 1995
LPR 71
incidence 62 copper
in 85
laryngeal 88 Lewin
cancer
Koufman 2000
0 50 100
 Differences between the typical
GI patient & LPR patient

GERD LPR
A. Symptoms
Heartburn/regurgitation Yes No

Hoerseness/dysphagia No Yes

B. Findings
Endoscopic esophagitis Yes No
Laryngeal inflamation No Yes
 Differences between GI patient & LPR
patient
GERD LPR
C. Abnormality

Esophageal motility Poor Good

LES Poor Good
UES Good Poor

D. Diagnostic yield

Esophageal bx Yes No
Abnormal esophageal XR Yes some times
Esoph. PH. Monitoring Yes Yes
Pharyngeal PH. Monitoring No Yes
 Differences between GI & LPR patient

GERD LPR
E. Pattern of reflux

Supine (Nocturnal) Yes some times

Upright ( Daytime) some times Yes

F. Response to RX

Dietary/life style
Modification Yes some times
Success with PP I 99% 99%
 When does one consider a
patient to have LPR?
The authors consider a patient to have LPRD, when he or she has at least
two of the seven symptoms listed:
globus pharyngeus;
dysphonia;
chronic throat clearing;
sore throat;
dysphagia;
chronic cough;
paroxysmal laryngospasm

In combination with at least one of the mentioned signs of LPR demonstrated at

laryngostroboscopy, with no other explanation

Diagnosis and management of laryngopharyngeal reflux disease Hans F. Mahieuaqba nd C. Frits Smita; Current
Opinion 14:133-137
 LPR classification
Minor LPR Major LPR Life-Threatening LPR
Annoying symptoms Symptoms have impact Airway obstruction
on work/social life including glottic or
subglottic stenosis
Symptoms do not impair their Mild intermittent Webs
ability to perform their job hoarseness

Symptoms do not impair their Laryngospasm

ability to interact socially

Severe paradoxical vocal

fold movement
Asthma

Dysplasia
Laryngeal carcinoma
Koufman, James A;Treatment of Laryngopharyngeal Reflux;Ear, nose and throat Journal,sept, 2002
LPR: Diagnostic Tools

pH monitoring -
Double probe pH monitoring ++
F.E.E.S.T. +
Therapeutic Test +++
Double Probe pH- monitoring = Gold Standard
Esophageal probe 5cm above LES.
Pharyngeal probe 2cm above UES.
% of time pH < 4.
-time recorded in supine position.
-time recorded in upright position.
Single pharyngeal reflux is +ve.
23% (28/122 had normal esophageal probe & abnormal
pharyngeal probe).
Pharyngeal pHmonitoring increases the yield for
diagnosis from 23% to 62%.
 Double Probe pHmonitoring:
Drawbacks
Frequent false positive results because of artifacts in the
upper probe requiring manual correction.
Common false-negative results because of the
intermittent character of the reflux episodes
Difficult probe placement

Ambulatory 24-hour multichannel intraluminal impedance

with pH monitoring?

Diagnosis and management of laryngopharyngeal reflux disease Hans F. Mahieuaqba nd C. Frits Smita; Current
Opinion 14:133-137
Video Endoscopic examination:
Flexible Endoscopic Evaluation of
Swallowing and Sensory Testing
(FEEST)
Overcome the limitations of Barium test to
assess not only the motor function but also the
sensory deficits
Dysphagia diagnosis is the major objective since
it is now 1 of the top 10 medical problems facing
society
Important tool for patients with dysphagia
 PPI Test to Diagnose Reflux
Disease
PPI test (symptom relief) vs. pH-metry in
non-erosive GERD

pH-metry gold standard PPI test gold standard

Pvpos: 68% Pvpos: 68%

Pvneg: 63% Pvneg: 63%

Schenk et al, Am J Gastroenterol 1997

LPR Diagnostic tools:
WARNING!

It is important to perform any other test to

rule out another underlying disease because
of the high prevalence of LPR
 Treatment of LPR: Patient
Education and Lifestyle Changes
Important behavioral changes include:
weight loss,
smoking cessation,
and alcohol avoidance.

Ideal dietary changes would restrict :

chocolate, fats, citrus fruits, carbonated beverages, spices, tomato
sauce, gas producing vegetables, redwines, caffeine, and late-night
meals.

Such behavioral changes appear to be an independently significant

variable in determining response to medical therapy.

Charles N. Ford, MD; Evaluation and Management of Laryngopharyngeal Reflux; JAMA. Sept28,2005-Vol 294. No. 12
 Treatment of LPR:
Medical Management

There are 4 categories of drugs used in treating

LPR:
PPIs,
H2-receptor antagonists,
prokinetic agents,
mucosal cytoprotectants
Treatment of LPR:
Medical Management

Proton pump inhibitors are considered the mainstay of medical

treatment, Responders can be weaned, while non responders
should undergo studies to confirm LPR.

Ranitidine has proven a more potent inhibitor of gastric

secretion than cimetidine and is the H2-receptor antagonist of
choice, although it has been found to be of limited value in
treating LPR. ( night escape)

Charles N. Ford, MD; Evaluation and Management of Laryngopharyngeal Reflux; JAMA. Sept28,2005-Vol 294. No. 12
 Treatment of LPR:
Medical Management
Duration = 6 months
Double dose PPI for at least 3 months
Importance of bid (average action 13 hours)
Importance of 30 to 60 min before meals
Symptoms improve significantly within 1-2
months
Signs may take up to 6 months to disappear

Koufman, Ear Nose & Throat Journal, 2002

Treatment of LPR: Surgery

When medical management fails,

patients with demonstrable high-volume
liquid reflux and lower sphincter
incompetence are often candidates for
surgical intervention.
In patients with major complications or
severe quality of life alteration
Fundoplication, either complete (Nissen
or Rossetti) or partial (Toupet or Bore), is
the most common procedure performed,
and the laparoscopic approach is
preferred.
Charles N. Ford, MD; Evaluation and Management of Laryngopharyngeal Reflux; JAMA. Sept28,2005-Vol
294. No. 12
 Algorithm for management of LPR

Charles N. Ford, MD; Evaluation and Management of Laryngopharyngeal Reflux; JAMA. Sept28,2005-Vol 294. No. 12
TAKE HOME MESSAGES: LPR

Know about it :
it is a different disease from GERD

Look for it:

ask the patient about symptoms he or she
attributes to other problems
You will find it:
high prevalence: 50% of patients with
hoarseness!