Laryngopharyngeal Reflux

Author Credentials 

Michele P. Morrison, DO
Chairman
Department of Otolaryngology-Head & Neck Surgery
Naval Medical Center Portsmouth
620 John Paul Jones Circle
Portsmouth, VA  23708
E-mail: michelepmorrison@yahoo.com

Module Summary

Laryngopharyngeal reflux results from laryngeal exposure to gastric contents leading to various symptoms including but not limited to globus, throat clearing, cough, and dysphonia. Patients should undergo a full head and neck examination including flexible laryngoscopy. Usually, a trial of empiric acid suppression is the mainstay of treatment giving patients time to undergo lifestyle modifications. It’s important to educate patients and understand the side effects of chronic proton pump inhibitor therapy and ensure patients are tapered off these medications once lifestyle changes are achieved.  In cases where symptoms do not resolve after several months of empiric therapy further work up is indicated.

Module Learning Objectives 
  1. Cite the signs and symptoms of laryngopharyngeal reflux (LPR). 
  2. Recognize the laryngoscopic findings of LPR.
  3. Summarize the consequences of LPR.
  4. Explain the principles of LPR treatment.

Anatomy

Learning Objectives 
  1. Review gastric reflux contents and physiology.
  2. Review the histology of the squamocolumnar junction.
  3. Review the transition of the musculature throughout the esophagus.
  4. Review the anatomy of the upper GI tract extending from the oropharynx to the stomach.  Include the anatomy of the diaphragm and the diaphragmatic hiatus where the esophagus transitions from the thoracic to the abdominal cavity.
    1. Identify the location of lower esophageal sphincter (LES).
    2. Describe how the LES functions as a sphincter.
    3. Identify location of upper esophageal sphincter (UES).
  5. Describe the association between the lower esophageal sphincter and squamocolumnar junction as well as diaphragmatic hiatus.
References 
  1. Blumin JH, Johnston, N. Laryngopharyngeal Reflux Chapter 66; Johnson, JT, Rosen, CA.  Bailey’s Head and Neck Surgery: Otolaryngology, 5th Edition.
  2. Ford CN. Evaluation and Management of Laryngopharyngeal Reflux. JAMA. 2005;294(12):1534–1540. 
  3. Woodson, GE.  Laryngeal and Pharyngeal Function. Cummings Otolaryngology, 54, 825-833.

Pathogenesis

Learning Objectives 
  1. Describe the major pathophysiologic mechanisms of esophageal reflux; understand the role of acid on laryngeal tissue and other structures.
  2. Understand difference between LPR and gastroesophageal reflux disease (GERD)
  3. Understand the role of non-acid reflux.
  4. Understand complicating anatomic factors and their potential impact on esophageal reflux
    1. Describe the pathophysiology of a hiatal hernia and it’s relationship to lower esophageal sphincter pressure
    2. Describe the mechanism of obesity in overcoming the lower esophageal sphincter pressure and refluxing gastric contents into the esophagus
  5. Describe transient lower esophageal sphincter relaxations and it’s role in reflux
  6. Describe the situation of a hypotensive lower esophageal sphincter 
    1. Describe diet and social factors that can contribute to transient lower esophageal sphincter relaxations
    2. Understand the role of alcohol, smoking, and caffeine the symptomatology of LPR
  7. Describe Barrett’s Esophagus
    1. Describe the suspected causative relationship between GERD and Barrett’s esophagus
    2. Describe the relationship between Barrett’s esophagus and esophageal adenocarcinoma
References 
  1. Dent, J, Dodds, WJ, Friedman, RH, et al. Mechanism of gastroesophageal reflux in recumbent asymptomatic human subjects. J Clin Invest. 1980 Feb;65(2):256–267.
  2. Sloan, S, Rademaker, AW, Kahrilas, PJ. Determinants of gastroesophageal junction incompetence: hiatus hernia, lower esophageal sphincter, or both? Ann Intern Med. 1992 Dec 15;117(12):977-82.
  3. Dodds, WJ, Dent, J, Hogan, WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med. 1982 Dec 16;307(25):1547-52.
  4. Wu JC, Cheung CM, Wong VW, Sung JJ. Distinct clinical characteristics between patients with nonerosive reflux disease and those with reflux esophagitis. Clin Gastroenterol Hepatol. 2007 Jun;5(6):690-5. Epub 2007 May 4.
  5. Spechler, SJ. Laser photoablation of Barrett's epithelium: Burning issues about burning tissues. Gastroenterology. 1993 Jun;104(6):1855-8.
  6. Cameron, AJ, Lomboy, CT, Pera, M, Carpenter, HA. Adenocarcinoma of the esophagogastric junction and Barrett's esophagus. Gastroenterology. 1995 Nov;109(5):1541-6.
  7. Mendes de Almeida, JC, Chaves, P, Pereira, AD, Altorki, NK. Is Barrett's esophagus the precursor of most adenocarcinomas of the esophagus and cardia? A biochemical study. Ann Surg. 1997 Dec;226(6):725-33; discussion 733-5.
  8. Kowalik K, Krzeski A. The role of pepsin in the laryngopharyngeal reflux. Otolaryngol Pol. 2017 Dec 30;71(6):7-13.

Incidence

Learning Objectives 
  1. Understand the impact of LPR on the population and know the incidence.
  2. Understand patients at risk to develop LPR.
References 
  1. BE, Kim GH. Globus pharyngeus. A review of its etiology, diagnosis and treatment. World J Gastroentrol. 2012;18(20):2462-2471. 
  2. Katz PO, Gerson LB, Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroentrol. 2013 Mar;108(3):308-28; quiz 329. 
  3. Cook, MB, Wild, CP, Forman, D. A systematic review and meta-analysis of the sex ratio for Barrett's esophagus, erosive reflux disease, and nonerosive reflux disease. Am J Epidemiol. 2005 Dec 1;162(11):1050-61.

Patient Evaluation

Learning Objectives 
  1. Describe signs and symptoms consistent with LPR.
  2. Understand objective findings consistent with LPR (i.e. on laryngoscopy).
  3. Know available scoring systems:
    1. Reflux finding score
    2. Reflux symptom index
  4. Understand when to perform further work up.
    1. Recognize the indications for an upper endoscopy.
    2. Recognize the indications for a pH study.
References 
  1. Gaynor EB. Otolaryngologic manifestations of gastroesophageal reflux. Am J Gastroenterol. 1991 Jul;86(7):801-8.
  2. Olson NR. Laryngopharyngeal manifestations of gastroesophageal reflux disease. Otolaryngol Clin North Am. 1991 Oct;24(5):1201-13.
  3. Belafsky PC, Postma GN, Koufman, JA. The association between laryngeal pseudosulcus and laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2002 Jun;126(6):649-52.
  4. Belafsky PC, Postma GN, Koufman, JA. The validity and reliability of the reflux finding score (RFS). Laryngoscope. 2001 Aug;111(8):1313-7.
  5. Belafsky PC, Postma GN, Koufman, JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002 Jun;16(2):274-7.
  6. Powitsky ES, Khaitan L, Garrett GC. Symptoms, quality of life, videolaryngoscopy and twenty-four hour triple-probe pH monitoring in patients with typical and extra-esophageal reflux.  Ann Otol Rhinol Laryngol. 2003 Oct;112(10):859-65.
  7. Klinkenberg-Knol Ec, Meuwissen SGM. Combined gastric and oesophageal 24-hour pH monitoring and oesophageal manometry in pateints with reflux disease, resistant to treatment with omeprazole. Aliment Pharmacol Ther. 1990 Oct;4(5):485-95.
  8. Jacob, P, Kahrilas, PJ, Herzon, G. Proximal esophageal pH-metry in patients with "reflux laryngitis". Gastroenterology. 1991 Feb;100(2):305-10.
  9. Koufman, JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.
  10. Koufman JA. Evaluation of laryngeal biomechanics by fiberoptic laryngoscopy. In Rubin JS, Sataloff RT, Korovin GS, editors:  Diagnosis and Treatment of Voice Disorders, Clifton Park, NY, 2003, Thomson/Delmar Learning.
  11. Postma GN, Tomek MS, Belafsky PC, et al. Esophageal motor function in laryngopharyngeal reflux is superior to that of classic gastroesophageal reflux disease. Ann Otol Rhinol Laryngol. 2001 Dec;110(12):1114-6.
  12. Johnson LF, Demeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974 Oct;62(4):325-32. 

Imaging

Learning Objectives 

Understand when to order barium esophagram.

References 
  1. Branstetter, BF. Diagnostic Imaging of the Pharynx and Esophagus. Cummings Otolaryngology, 101, 1507-1536.

Treatment

Learning Objectives 
  1. Explain the role behind gastric acid suppression in the treatment of LPR
    1. Review the pharmacology of proton pump inhibitors 
    2. Review the pharmacology of Histamine receptor blockers 
  2. Understand when to initiate acid suppression therapy 
  3. Understand when to revise therapy
    1. Understand the indications for increasing acid suppression therapy
  4. Review Non-medical therapies for LPR
    1. Understand the utility behind:
      1. Raising the head of the bed at night
      2. Avoiding late night meals
      3. Avoid smoking and alcohol 
      4. Dietary & lifestyle modifications
References 
  1. Johnson LF, Demeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974 Oct;62(4):325-32. 
  2. Willems-Bloemer LH, Vereeburg GCM, Brummer RJM. Treatment of reflux-related and non-reflux-related dysphonia with profound gastric acid inhibition. Folia Phonialr Logop. 2000 Nov-Dec;52(6):289-94.
  3. Koufman JA, Belafsky PC, Back KK, et al. Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Laryngoscope. 2002 Sep;112(9):1606-9.
  4. Ford CN. Evaluation and Management of Laryngopharyngeal Reflux. JAMA. 2005;294(12):1534–1540.

Medical Therapies

Learning Objectives 
  1. Review the indications for medical therapy. 
  2. Review the prescribing strategies for acid suppression therapy. 
  3. Understand when to prescribe bedtime doses of medications.
References 
  1. Mermelstein J, Chait Mermelstein A, Chait MM. Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions. Clin Exp Gastroenterol. 2018 Mar 21;11:119-134.
  2. Tseng WH, Tseng PH, Wu JF, et al.  Double-blind, placebo-controlled study with alginate suspension for laryngopharyngeal reflux disease.  Laryngoscope. 2018 Feb 5.
  3. Hanson DG, Kamel PL, Kahrilas PJ. Outcomes of antireflux therapy for the treatment of chronic laryngitis. Ann Oto Rhinol Layrngol. 1995 Jul;104(7):550-5.
  4. Amin MR, Postma GN, Johnson P, et al. Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2001 Oct;125(4):374-8.
  5. Leite LP, Just RJ, Castell DO, et al. Control of gastric acid with high dose H2-receptor antagonists after omeprazole failure: report of two cases.  Am J Gastroenterol. 1995 Oct;90(10):1874-7.

Pharmacology

Learning Objectives 
  1. Understand the pharmacology of proton pump inhibitors (and side effects).
  2. Understand the pharmacology of histamine receptor blockers.
References 
  1. Amin MR, Postma GN, Johnson P, et al. Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2001 Oct;125(4):374-8.
  2. Leite LP, Just RJ, Castell DO, et al. Control of gastric acid with high dose H2-receptor antagonists after omeprazole failure: report of two cases. Am J Gastroenterol. 1995 Oct;90(10):1874-7.
  3. Johnson DA, Oldfield EC 4th. Reported side effects and complications of long-term proton pump inhibitor use:  dissecting the evidence. Clin Gastroenterol Hepatol. 2013 May;11(5):458-64.

Surgical Therapies

Learning Objectives 
  1. Review the potential surgical options. 
  2. Describe a Nissen fundoplication.
    1. Review the rates of success of Nissen fundoplications and recognize the need for continued medical therapy as a function of time.
References 
  1. Sahin M, Vardar R, et al. The effect of antireflux surgery on laryngeal symtpoms, findings and voice parameters. Eur Arch Otorhinolaryngol. 2015 Nov;272(11):3375-83.

Case Studies

  1. A 33 y/o lawyer presents to your office complaining of sensation of something in his throat and frequent throat clearing causing issues at work.  What diagnosis to you suspect in this patient?  What would your work up include?  How would you treat this patient?
  2. A 24 y/o female college student presents to your office complaining of throat irritation that started recently as she’s been gearing up for final exams.  What is her likely diagnosis?  How would you treat this patient?

Review

Review Questions 
  1. What are the presenting symptoms of LPR?
  2. What is the mainstay of treatment for LPR?
  3. What are the side effects of prolonged proton pump inhibitor therapy?
Resources 

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