Reflux

Got mucus? Throat clearing? Could be Silent Reflux...

Reflux refers to the backflow of stomach contents into the esophagus and/or throat.

When stomach contents reflux into the esophagus in an excessive manner, causing tissue injury and symptoms like heartburn and regurgitation, it is called GastroEsophageal Reflux Disease (GERD).

When stomach contents reflux into the throat causing tissue injury and symptoms like hoarseness, throat clearing. increased phlegm and cough, it is called LaryngoPharyngeal Reflux (LPR).

Symptoms

GERD (GastroEsophageal Reflux Disease) symptoms are typically different than LPR (LaryngoPharyngeal Reflux) symptoms, but patients can have symptoms generally associated with either GERD or LPR.

Classic GERD symptoms are: Heartburn; regurgitation.

LPR Symptoms are: Hoarseness; frequent throat clearing; increased phlegm; post-nasal drip; chronic cough; difficulty swallowing (dysphagia); lump-like sensation in throat; choking sensation.

Laryngo-Pharyngeal Reflux (LPR) is DIFFERENT from Gastro-Esophageal Reflux Disease (GERD) . The "CLASSIC" Symptoms of GERD in a typical ESOPHAGITIS patient are HEARTBURN - 83%, COUGH - 47%, DYSPHAGIA - 40%, REGURGITATION - 23% (1). On the contrary, the typical symptoms of LPR in the typical ENT patient are HOARSENESS - 71%, CHRONIC COUGH - 51%, DYSPHAGIA - 51% GLOBUS - 47%, THROAT CLEARING - 42%, HEARTBURN and/or REGURGITATION - 10%-33% (2, 3, 4).

The reflux pattern in the typical GERD patient is a supine, nocturnal reflux (patient refluxing while lying flat at night) while the LPR patient generally refluxes while upright during the day (2, 3).

Esophageal function in the GERD patient generally demonstrates esophageal dysmotility with significantly prolonged esophageal acid clearance times and Lower Esophageal Sphincter dysfunction. In contrast, the LPR patient has good esophageal function with near normal esophageal acid clearance. Generally, LPR patients have Upper Esophageal Sphincter dysfunction (5, 6). In addition, the larynx is far more susceptible to acid injury than esophagus because in the larynx there are no acid clearing mechanisms (peristalsis; salivary bicarbonate) and the laryngeal tissues are thin, fragile and poorly adapted to protect against reflux. One normally refluxes about 50 times a day from the stomach into the esophagus. If as few as 2 of those normal reflux events contact the laryngeal tissues, it is abnormal, and changes in the laryngeal tissues can result (3, 7). Therefore, it is LARYNGEAL EDEMA, or swelling, not ERYTHEMA, or redness, that is the clinical hallmark of LPR (4).

DIAGNOSIS of LPR

• There are a variety of tests that can assist in making the diagnosis of LPR, including:
• Double probe pH monitoring - 24 hour or 48 hour testing; Sensory Testing; Flexible
• Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST); Barium
• esophagography - normal in 77%; Esophagoscopy - normal in 80%; Bernstein acid
• perfusion - normal in 70% and the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS).
• The Reflux symptom index is a questionnaire completed by the patient at each visit and attempts to quantify the patients symptoms. The Reflux Symptom Index is the following:
• Reflux Symptom Index (RSI) (8)
• Within the last MONTH, how did the following problems affect you?
• (0=no problem;5=severe problem)
• Hoarseness or problem with voice
• Clearing your throat
• Excess throat mucous or postnasal drip
• Difficulty swallowing food, liquids or pills
• Coughing after you ate or after lying down
• Breathing difficulties or choking episodes

Diagnosis

The common techniques to properly diagnose Reflux are as follows:

A) History and physical examination.

B) Transnasal Flexible Laryngoscopy (TFL)- A way of examining the larynx and throat with a thin, flexible endoscope that is passed via the nose which permits a magnified view of the laryngeal structures and functions. Patients with LPR have distinct physical examination findings such as swelling, or edema, of the laryngeal tissues  and often changes in the appearance of the vocal folds themselves.

C) Laryngeal Sensory Testing- Recent work is demonstrating that sensory testing can be added to TFL in order to make a diagnosis of acid reflux disease. Sensory testing involves administration of a discrete pulse of air via a port, or opening, in a transnasally placed, thin, flexible endoscope, in order to elicit an airway protective reflex. One can imagine that if acid injury has caused swelling of laryngeal tissues, the strength of the air pulse required to elicit the laryngeal adductor reflex (the airway protective reflex) would be greater in patients with acid-induced laryngeal swelling. Therefore, in patients without neurological disease (neurological disease alone (Parkinson's; ALS; Stroke) can cause sensory deficits) sensory deficits determined by laryngeal sensory testing can indicate acid reflux disease.

D) 24 hour pH testing- A probe is placed transnasally into the esophagus and pH changes that take place in various areas of the esophagus are recorded to a transmitter the patient wears or keeps nearby.

E) Barium Swallow (barium esophagography or esophagram)- An X-ray test of the esophagus where barium is swallowed an X-rays are then taken as the barium descends from the mouth to the throat to the esophagus inot the stomach. It is the esophageal portion of the well known X-ray test called an upper GI series.

F) Esophagoscopy (examining the esophagus endoscopically) - Examining the esophagus endoscopically. This can be performed with a rigid scope via the mouth under general anesthesia in the operating room, with a large flexible scope via the mouth under conscious (intravenous sedation) in an endoscopy suite, or with a thin, flexible scope via the nose under topical anesthesia in the office.

Treatment

Treatment for Reflux disease is divided into Behavioral, Dietary, Parmaco and Surgery.

Behavioral Treatment
Successful Behavioral Therapy includes elevating the head off the bed, which can be helpful in patients with GERD (GastroEsophageal Reflux Disease) and sometimes in patients with LPR (LaryngoPharyngeal Reflux), depending on the patient's symptoms.

In addition, avoiding eating meals late at night and avoiding tight fitting clothes also can be of help. Avoiding all tobacco is also an essential component of successful treatment of both GERD and LPR.

Dietary
Dietary considerations for the treatment of Reflux includes the limiting of judicious use of caffeine, chocolate, alcohol and mint. In addition, tomato-based foods can stimulate acid production by the stomach. In general, foods that cause symptoms should be used with caution.

Pharmacotherapy
While over the counter anti-acids and H2 receptor antagonists may give relief of symptoms, successful treatment of LPR generally requires a class of anti-acid medications known as proton pump inhibitors (PPI's). The majority of patients with LPR require twice-daily dosing of PPI's.

To see a video of anti-acid therapy before and after treatment of a left vocal fold granuloma, please click here.

(Kaufman J, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: Position statement of the Committee on Speech, Voice, and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002; 127:32-35).

Surgery
Surgery for Reflux disease involves either multiple endoscopic procedures, or a few diferent types of laparoscopic procedures.