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

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

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

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

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

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

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

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

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

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

SPPA 6400 Voice Disorders - Tasko Laryngoscopic Signs SPPA 6400 Voice Disorders - Tasko

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

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

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

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

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

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

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

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

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

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

SPPA 6400 Voice Disorders - Tasko Treatment SPPA 6400 Voice Disorders - Tasko

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

SPPA 6400 Voice Disorders - Tasko From Ford (2005)

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

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

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

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

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