A Powerpoint presentation on LPR

1. Gastroespohageal Reflux Disease
(GERD) & Laryngopharyngeal Reflux
Disease (LPRD)
Jerry Gathercole

2. What are they?
 The term REFLUX comes from
the Greek word meaning
“backflow,” usually referring to
the contents of the stomach.
 GERD: an abnormal amount of
reflux up through the lower
sphincters and into the
esophagus.
 LPRD: when the reflux passes all
the way through the upper
sphincter and into the back of the
throat, reaching the larynx and
pharynx.

3. Symptoms for GERD
 The most common is a burning sensation in the chest,
usually after eating (AKA heartburn). This sensation
can also be associated with position, sleep, or
exercise.
 Others include: belching, dysphagia, odynophagia
(pain on swallowing), water brash, sore throat, cough,
bronchospasms, atypical chest pain, hoarseness, and
asthma exacerbation.
 Symptoms are more common over night
 Most common symptoms in the elderly include
dysphagia, vomiting, and respiratory problems, among
others which all lead to restrictive respiratory problems.

4. Symptoms of LPRD
 Symptoms of the two may overlap, however, the
pharynx, larynx, and lungs are more sensitive to
stomach acid and digestive enzymes allowing less
reflux to do more damage.
 Symptoms include: hoarseness, frequent throat
clearing, sensation in the throat, bad/bitter taste in the
mouth, referred ear pain, and post-nasal drip to name
a few.
 Symptoms are commonly experienced during the day.
 Very few experience heartburn.

5. Common ENT Symptoms of
LPRD:
Hoarseness
Chronic (ongoing) cough
Frequent throat clearing
Pain or sensation in throat
Feeling of lump in throat
Problems while swallowing
Bad/bitter taste in mouth (Especially in morning)
Asthma-like symptoms
Referred ear pain
Post-nasal drip
Singing: Difficulty with high notes
Nighttime choking attacks

6. How is the voice affected?
 Hoarseness
 Vocal fatigue
 Oedema
 Ulceration
 Granulation
 Polypoid degeneration
 Vocal nodules
 Laryngospasm
 Arytenoid fixation
 Laryngeal stenosis
 Carcinoma of the larynx

7. GERD LPRD
Heartburn Common Infrequent
Oesophagitis Common Infrequent
Oesoph.
Abnormal Normal
Motility
Upright,
Pattern Supine, nocturnal
daytime
Treatment Regular dose PPI High dose PPI

8. Findings
 Red, irritated arytenoids
 Red, irritated larynx
 Small laryngeal ulcers
 Swelling of the VF
 Granulomas in the larynx

13. Definitive diagnostic for LPRD:
The 24-hour Pharyngo-Oesophageal pH monitoring is the gold
standard for monitoring reflux events associated with LPRD.
In LPRD patients, it is important that the upper channel is placed
at the level of the laryngeal inlet.

14. Diagnosis
 Tests completed:
– pH monitoring (AKA pH-metry)
 Takes 24 hours (over night)
 Measure acid in esophagus and throat
 Small, soft, fexible tube (pH probe) through the nose and
into the throat which is connected to a small computer
worn around the waist
– Barium swallow
 Easiest,
most cost effective
 However, may be misleading

15. Treatment
 Prevention/Lifestyle changes
 Medications
 Surgery

16. Treatment for LPRD:
1. Stress:
Take significant steps to reduce stress. Even
moderate stress can dramatically increase
the amount of reflux.

17. 2. Foods:
It may be necessary to avoid or minimize some of
the following foods:
- Spicy, acidic and tomato-based foods like Mexican
or Italian food.
- Acidic fruit juices such as orange juice, grapefruit
juice, cranberry juice, etc..
- Fast foods and other fatty foods.
- Caffeinated beverages (coffee, tea, soft drinks) and
chocolate.

18. 3. Mealtime:
- Do not gorge at mealtime
- Eat sensibly (moderate amount of food)
- Eat meals several hours before bedtime
- Avoid bedtime snacks
- Do not exercise immediately after eating

19. 4. Body Weight:
Try to maintain a healthy body
weight. Being overweight
can dramatically increase reflux.

20. 5. Night time Reflux:
If the 24-hour pH monitoring demonstrates nocturnal reflux,
elevate the head of your bed 4-6 inches with books, bricks
or a block of wood to achieve a 10 degree slant.
Do not prop the body up with extra pillows. This may
increase reflux by kinking the stomach. Recent studies have
shown that reflux occurs much more often during the day
when upright. Therefore, this suggestion may be much less
important than once believes.

21. 6. Smoking:
IF YOU SMOKE, STOP!!
This dramatically increases reflux.

22. Medications
 reduce the acidity of the
stomach contents
 increase the activity of
the esophageal
sphincters
 they will increase the
motility of the stomach

23. Medications for LPRD:
Over the counter antacid such as Quickeze ®, Gaviscon®
or Mylanta®. Tums has the added benefit of containing
calcium.
Medications such as H2Blockers (Axid®, Pepcid®,
Tagament®, Zantac®), Proton pump inhibitors (Losec®,
Somac®), or motility agents (Propulsid) .

24. Surgery
 Withsevere cases when meds and other tx are
not successful.
– Most common procedure: fundoplication, sewing a
portion of the stomach around the esophagus to
tighten its lower end. This operation can be done
endoscopically.

25. Severe, long term affects
 Gastrointestinal bleeding
 Barrett’s esophagus
– There is columnar
epithelium in the
esophagus where
stratified squamous
epithelium should be
 Laryngeal damage
 Cancer ??

26. Controversies
 Symptoms
 Post-nasal drip?

27. Controversies- Clinical Findings
 Is subglottic stenosis
caused by LPR and
intubation??
 Is reflux an inflammatory
catalyst for many airway
diseases?

28. Controversies- Diagnostic testing
 Does ph monitoring help
with diagnosis.
 Use proton pump
inhibitor as diagnostic
tool.

29. Controversies- Treatment
 Twice day proton pump
inhibitors

30. Controversies- Paediatric LPR
 Failure to thrive,
oesophagitis and airway
disturbance.
 Chronic cough
 Dysphonia
 Laryngomalacia
 Subglottic stenosis
 Apparent life-threatening
events

31. Controversies- Paediatric LPR
 Tasker et al recently
used pepsin assay to
demonstrate high levels
of pepsin in middle ears
of 45 of 54 children
requiring ventilation
tubes.

32. References
 Center for Voice Disorders of Wake Forest University. (2003). Patient
information sheet on reflux. http://www.bgsm.edu/voice/pt_info.html
 Columbia Presbyterian Medical Center. (2002). Laryngopharyngeal reflux
disease and recommendations to prevent acid reflux.
http://www.entcolumbia.org/lprd.htm
 Laryngopharyngeal reflux 2002: A new paradigm of airway disease..
James A Kaufman,MD. ENT Supplement.
 Levy, R.A., Meiner, S.E., & Stamm, L. (2002). Conservative management
of GERD: a case study. Medsurg Nursing, 11, No. 4.
 Stemple, J., Gerdeman, B.K., & Glaze, L. (2002). Clinical Voice
Pathology: Theory and Management. 3rd ed. Singular Publishing
 Voice Center. (2003). Reflux disease and its effects on the larynx.
http://www.voice-center.com/reflux.html