Laryngopharyngeal Reflux & Granuloma By Isabel C. Bula Presented to Rebecca L. Gould, MSC, CCC-SLP

Overview Rationale Definition Etiology & Mechanisms of LPR Symptoms Diagnosis Clinical Findings Associated with LPR Associated Vocal Pathologies Treatment Conclusions

Why LPR? Common : 50% of ORL patients have LPR (Koufman, 1994). Associated with a diversity of laryngeal and voice disorders. Can have dangerous effects, especially if left untreated. We (SLPs) are essential in management of LPR!

Laryngopharyngeal Reflux Backflow of food and stomach acids into the back of the throat and onto the larynx. Causes: a. Physical b. Lifestyles Factors

LPR: Etiology PHYSICAL LIFESTYLE Improper functioning of esophageal sphincters. Hiatal hernia. Abnormal esophageal contractions. Slow emptying of the stomach. LIFESTYLE Diet Irritants: chocolate, caffeine, citrus, fatty foods, spices. Unhealthy habits Overeating Smoking Alcohol consumption

Mechanisms of LPR

LPR & Granuloma Granulomas: most often associated with LPR as an etiological factor. LPR causes chronic irritation of the posterior larynx, where granulomas typically occur. Granulomas respond well to Anti-reflux therapy.

Granulomas Non-cancerous growths that result from tissue irritation. Occur in the posterior 2/3 of true vocal fold(s)  vocal process of arytenoid. May occur unilaterally or bilaterally. Koufman (1994) suggests most likely cause is a combination of LPR and long-term vocal misuse. Tends to recur: Tx must address ALL underlying causes.

SYMPTOMS OF LPR Hoarseness (reported by 100% of patients) Frequent throat clearing Globus pharyngeus (sensation of a lump in the throat) Chronic Cough Dysphagia Bad/bitter taste in mouth Post-nasal drip Sore throat Heartburn*

LPR: Diagnosis 24 hour Double pH probe Medical History Laryngoscopy/ Laryngoendoscopy/Videostroboscopy 24 hour Double pH probe Barium Swallow Study Upper GI Endoscopy Manometry

Clinical Findings Irritation from reflux of stomach fluids into the voice box causes: redness and swelling (indicated with white arrows) in vocal folds (vf) and false vocal folds (f vf); pachydermia (indicated with yellow arrow) or thickening of tissue in between the focal folds.

LPR

Associated Vocal Pathologies Laryngeal stenosis Polypoid degeneration Paroxysmal laryngospasm Recurrent leukoplakia Functional voice disorders Laryngeal carcinoma Arytenoid fixation Vocal nodules SIDS?

Treatment Levels I, II, III Medical Antacids (Tums, Mylanta) H2 Blockers (Tagament, Zantac, Pepcid) Proton Pump Inhibitors (Prevacid, Nexium, Prilosec, Aciphex) Recommended dose: 2x/day If you are interested in understanding how PPIs work, visit this website: http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/stomach/parietal.html

Treatment 1. Behavioral: anti-reflux therapy. Dietary Changes -Low fat diet -Avoid coffee, tea, chocolate : (, tomato-based products,citrus fruits, carbonated drinks, cheese, eggs & onions. -Avoid overeating. -Avoid alcohol, especially in the evening. -Avoid eating/drinking within 3 hour of bedtime. Lifestyle Modifications -Avoid tight-fitting clothes. -If you are a smoker, QUIT! -Elevate the head of the bed (esp. if reflux at night). -Don’t exercise or sing too soon after eating -Lose weight-if necessary -Relax.

Treatment Voice Therapy Vocal Hygiene - -reduce/eliminate throat clearing and coughing. -encourage conservative voice use -initiate new functioning voicing behaviors. -production of voice with an extreme forward focus. Resonant voice therapy (RVT): most often employed for LPR/granulomas (Stemple et al, 2000)

Treatment: RVT Developed by Verdolini & Lessac. Resonant Voice: involves oral vibratory sensations in the context of easy phonation. Goal: “…to achieve the strongest, cleanest possible voice with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2000)”. How? Pt. Is asked to monitor the “feel” and to concentrate on auditory feedback.

Treatment Surgical: for Severe LPR Fundoplication  Tightens LES

Treatment Surgical: Considerations for patient with granuloma Surgery is not the treatment of choice for granulomas, due to their tendency to recur. However, surgery is indicated in certain cases: Granulomas compromise airway. Carcinoma is suspected. Granulomas mature (usually don’t respond to meds). Patient relies on voice for professional use,.

Treatment **BOTOX A Injection is now being used to treat granuloma. Preliminary studies indicate it’s effective. Phonoscopic Therapy (2005) – provides visual feedback using an endoscope.

Treatment Efficacious? YES! Granulomas respond well to ART + meds. Voice therapy focused on reducing medial compression of vocal folds, such as RVT are effective. PPIs are effective in reducing acid production in the stomach. Individualized treatment

Conclusions LPR Can have very damaging effects Associated with many vocal pathologies Diagnostic procedures Treatment options Our role as SLPs Educating clients

References Belafsky, P. (2003). Abnormal endoscopic pharyngeal and laryngeal findings attributable to reflux. American Journal of Medicine, 115 (3A): 90S-96S. Garnett, J.D. (2005, May). Contact granulomas. Emedicine specialties. Retrieved on July 5, 2005, from http://www.emedicine.com/ent/topic603.htm Koufman JA, Cummins MM. (1995) Reflux and early laryngeal carcinoma. Visible Voice, 4:2-5, 19-23. Koufman, J.A. (1994) Laryngopharyngeal Reflux and Voice Disorders. Visible Voice, 3:2-7. Koufman, J.A., Aviv, J.E., Casiano, R.R. and Shaw, G.Y. (2002) Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. American Journal of Otolaryngology – Head and Neck Medicine and Surgery, 127, 32-35. Leonard, R. & Kendall, K. (2005) Effects of voice therapy on vocal process granuloma: a phonoscopic approach. American Journal of Otolaryngology – Head and Neck Medicine and Surgery. 26. 101-107. Stemple, J.C. & Glaze, L.E. (2000). Clinical Voice Pathology: Theory and Management. San Diego: Singular Publishing Group, Inc. Voice Disorders.org (n.d.). Voice Disorders: Reflux Laryngitis. Retrieved on July 5, 2005, from http://www.voiceproblem.org/pdfs/reflux_laryngitis.pdf