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

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

3. SPPA 6400 Voice Disorders - Tasko
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. SPPA 6400 Voice Disorders - Tasko
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. Conditions reported to be associated with reflux
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
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. SPPA 6400 Voice Disorders - Tasko
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. SPPA 6400 Voice Disorders - Tasko
Symptoms of LPR
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%)
SPPA 6400 Voice Disorders - Tasko

9. SPPA 6400 Voice Disorders - Tasko
Reflux Symptom 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. SPPA 6400 Voice Disorders - Tasko
Laryngoscopic Signs
SPPA 6400 Voice Disorders - Tasko

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

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

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

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

23. SPPA 6400 Voice Disorders - Tasko
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. SPPA 6400 Voice Disorders - Tasko
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. SPPA 6400 Voice Disorders - Tasko
Case Illustrations
SPPA 6400 Voice Disorders - Tasko