Reflux

What is Laryngopharyngeal Reflux or silent reflux?

Reflux

Laryngopharyngeal Reflux (LPR) otherwise known as ‘silent reflux’, the retrograde movement of gastric content into the upper aerodigestive tract (that is refluxate into the oesophagus, pharynx, larynx, oral cavity and the nasopharynx) is a common disease, which is often misdiagnosed or under-diagnosed. A continuum exists between Classic Reflux also commonly known as Gastroesophageal Reflux (GERD) and LPR. It is estimated that up to 80% of patients presenting with hoarseness have LPR.

Both conditions involve acid reflux. GERD involves repeated episodes of gastric refluxate entering the lower third, and/or the lower half of the oesophagus and is associated with the classic symptoms of heartburn, bloating, aerophagy and increased burping.

Most patients with LPR do not experience heartburn or have esophagitis. Interestingly, to have significant symptoms such as chronic cough or a sore throat you only need to have one episode of refluxate in the upper aerodigestive tract in a 24-hour period hence many of these patients are unaware of having reflux.


Clinical Manifestations of LPR

Mild: To diagnose the clinical manifestations flexible fibreoptic rhinolaryngoscopy needs to be performed.

There is a pattern of mucositis strongly suggestive of gastroesophageal reflux. Specifically, erythema and swelling of the arytenoid and inter arytenoid bar, redundancy of the post cricoid mucosa, vascular hyperaemia and inflammation of the false vocal cords and the petiole of the epiglottis.

Transnasal oesophagoscopy performed under local anaesthesia often shows elevated resting tone of the cricopharyngeus, free refluxate in the oesophagus to the level of the aortic arch, mucostits but no ulceration in the upper esophagus.

Moderate: As above, in addition there is erythema and swelling of the anterior subglottic wedge indicative of intermittent, spillover with microaspiration. These patients often have a history of laryngeal spasm due to spillover and occasionally paradoxical vocal fold movement can be seen. In rare instances specific laryngeal pathology such as polypoidal degeneration of the free edge of the vocal folds and or a discrete vocal fold polyp can be seen.

Severe: As above, but in addition there may be a vocal process ulcer/granuloma due to chronic throat clearing. There may be narrowing of the anterior of the subglottic wedge and upper trachea, there may be erythroplakia or leukoplakia of the vocal folds.


Laryngopharyngeal Reflux Symptoms

Laryngopharyngeal Reflux occurs across the full spectrum of age and body physiognomy. More than two thirds of laryngopharyngeal reflux is occult, that is to say it occurs while the patient is asleep and the patient is unaware of the reflux that is taking place. As a rule, people with laryngopharyngeal reflux do not get symptoms of heartburn. They do not get bloated. They do not get symptoms of aerophagie and pain. The most common signs and symptoms from most to least frequent include:

  • Throat clearing
  • Persistent non-productive cough
  • Sensation of a lump in the throat
  • Fluctuating intermittent change in voice (dysphonia)
  • Hoarseness
  • Choking episodes

A referral to an Otolaryngologist is warranted should the diagnosis remain unclear and the patient continues to be troubled by symptoms indicative of LPR. A referral is needed to rule out malignancy if the patient is older than 50 years and shows signs of 3 or more of the following: otalgia, weight loss, progressive hoarseness, neck mass, significant history of alcohol use or smoking.


What is Gastroesophageal Reflux (GERD)?

In Gastroesophageal Reflux, symptomatic patients can have numerous episodes of reflux into the lower oesophagus.

Conventionally laryngitis was considered an extra oesophageal component of GERD however in recent years, investigative studies have identified a new syndrome, LPR being responsible for mainly laryngeal symptoms. Failure to recognise and provide timely treatment for LPR may increase patients risk for a number of conditions including laryngeal ulcers, granulomas, subglottic stenosis, chronic sinusitis, laryngospasm, nasal congestion and or asthma. In order to minimize these risks, it is important for general practitioners to promptly identify the possibility of LPR and recognise that GERD and LPR represent different ends of a spectrum of a disorder and are appropriately referred to different specialists.

GERD, as defined by at least weekly heartburn and/or acid regurgitation is estimated to have a prevalence rate of between 10 to 20% in the Western world. In Australia, this prevalence is rising due to increasing obesity. GERD tends to occur in individuals with a body physiognomy characterised by obesity, age and tends to be more common in females than males.

LPR tends to occur with equal frequency in males and females irrespective of body physiognomy. The prevalence of LPR in the general population is uncertain. Reports suggest 10% of otolaryngology referrals are for patients with classic presentation of LPR and the 50 to 60% of cases of chronic laryngitis are related to LPR.


Occult Reflux

This refers to the presence of pH probe or manometry proven reflux in patients who are asymptomatic or deny having reflux symptoms.

Recent studies show two thirds of patients are refluxing in the upright position (day time) and one third are occult supine nocturnal refluxers.


Reflux Treatment

A common analogy is that the lining of your oesophagus is like industrial strength lino whereas the lining of your larynx is like a fine Persian rug.

Diet and Lifestyle modifications are both clinically effective and cost effective. Patients should also avoid eating too rapidly; drinking large quantities of fluid; late night meals and heavy lunches and dinners.

Other lifestyle changes include avoiding tight clothing, applying pressure to the abdomen, heavy lifting, singing, smoking, overuse or misuse of the voice, weight loss and elevating the head of the bed to 45-degree angle.

Drug therapy by way of acid suppression with proton pump inhibitors (PPIs) +/- prokinetic agents is the primary treatment for LPR as with GERD. LPR typically requires more aggressive and prolonged treatment because the larynx is extremely susceptible to damage from acid reflux.

PPIs should be taken twice daily for 4-6 months on an empty stomach, 30 minutes before a meal to increase bioavailability. Symptomatic relief may begin at 6-8 weeks of treatment however patients should gradually be weaned off the drug to prevent delayed rebound effects associated with abrupt cessation.

The complication profile of prokinetic agents in terms of cramping, abdominal pain, distension and diarrhea are unpleasant, but commonly occur.

Surgery has a role in the treatment of LPR for patients with a confirmed diagnosis, severe symptoms and little response to treatment. Laparoscopic fundoplication is a procedure in which the fundus of the stomach is passed posteriorly behind the oesophagus to encircle it and provide a mechanical obstruction to the retrograde movement of acid and reinforcing the natural lower oesophageal high pressure zone.