Treatment Strategies for Voice Disorders Associated with Larygopharyngeal Reflux (LPR)

A Literature ReviewKathleen Bell

December 5, 2012

Introduction• Research of the Literature reveals confusion and controversy

• “Interesting clinical paradox – Most underdiagnosed and overdiagnosed clinical entity in laryngology” (Bransky & Sulika)

REFLUX- BACKFLOW OF GASTRIC CONTENT

Two Esophageal Sphincters

LPR VS GERDLarynx & Pharynx Esophagus

Cough & hoarseness Heartburn

Normal motor dysfunction Abnormal motor dysfunction

Upper esophageal sphincter (UES) Lower esophageal sphincter (LES)

Symptoms when sitting or standing Symptoms when lying down

Not obese Obese

Acid activated pepsin Acid

Any exposure to acid damaging Up to 50 times a day is “normal”

Need aggressive & long term treatment 3 months of treatment

Reflux Finding Score (Belafsky et al, 2001

Subglottic edema

Ventricular

Erythema/hyperemia

Vocal fold edema

Diffuse laryngeal edema

Posterior commissure hypertrophy

Granuloma/granulation tissue

Thick endolaryngeal mucus

0 = absent2 = present2 = partial4 = complete2 = arytenoids only4 = diffuse1 = mild2 = moderate3 = severe4 = polypoid1= mild2 = moderate3 = severe4 = obstructing0 = mild2 = moderate3 = severe4 = obstructing0 = absent2 = present0 = absent2 = present

The Reflux Symptom Index (Belasky et al, 2002)

Within the past month, how did the following problems affect you?

0 = No Problem5 = Severe Problem

Hoarseness or a problem with your voice 0 1 2 3 4 5Clearing your throat 0 1 2 3 4 5Excess throat mucus or postnasal drip 0 1 2 3 4 5Difficulty swallowing food, liquids, or pills 0 1 2 3 4 5Coughing after you ate or after lying down 0 1 2 3 4 5Breathing difficulties or choking episodes 0 1 2 3 4 5Troublesome or annoying cough 0 1 2 3 4 5Sensations of something sticking in your throat or a lump in your throat 0 1 2 3 4 5Heartburn, chest pain, indigestion, or stomach and coming up 0 1 2 3 4 5

Laryngeal Findings(Lloyd, 2011)

STANDARD ANTIREFLUX THERAPY• Phase 1

A. Dietary modificationB. Life-style modificationC. Medications – antacids

• Phase 2A. H2 blockersB. Proton pump inhibitorsC. Prokinetic agents

• Phase 3A. Double dose PPIB. Surgery (fundoplication)

Jamie Koufman

pH water (8.8 & )

Dietary & Herbal Adjunctive Therapies

- Melatonin- D-Limonene- Iberogast- Gluten Free Diet

PPI’s & Pharmaceuticals

– Often double doses needed–Many patients unresponsive – Symptoms recurrent – Lifetime therapy– Prolonged use causes significant side-

effects

Body Modalities• Chiropractic Care

• Accupuncture

Voice Therapy & Psychological Therapy

• Preventative Strategy• Component of comprehensive Therapeutic

Strategy

Most Important Studies & Authors• Jamie Koufman (1991)– “The Otolaryngologic Manifestations of

Gastroesophageal Reflux Disease.” • Belafsky et al (2002) – “Symptoms and Findings of

Laryngopharyngeal Reflux.”• Johntson et al (2003) – “Cell Biology of Laryngeal Epithelial

Defenses in Health and Disease.”• Kahn et al (2006) – “Laryngopharyngeal Reflux – A Literature

Review.”• Sataloff et al (2006) – Reflux Laryngitis and Related Disorders• Bransky & Sulica (2009) – Classics in Voice and Laryngology• Patrick (2011) – “Gastroesophageal Reflux Disease (GERD): A

Review of Conventional and Alternative Treatments.”

References – 50+!!!• Alcantara & Anderson (2008)• Amin et al (2001)• Aronson & Bless (2009)• Behlau & Oliveira (2009)• Belafsky et al (2001, 2002)• Boone et al (2010) • Bransky & Sulica (2009)• Cammarota et al (2003) • Chen, Xu, & Chen (2009)• Cuomo et al (2002)• Davies & Jahn (2004)• Dickman et al (2007).• Gainor et al (2011)• Halum et al (2005) • Hein, Tina (1999)• Hershcovici & Fass (2011)• Hopkins et al (2009).• Johnston et al (2003, 2004 ) • Kahn et al (2006)• Karkos et al (2007)• Kelchner et al (2005)• Koufman (2011)• Koufman &Johnston (2012)

• Koufman et al (2002)• Koufman, Stern, & Bauer

(2010)• Lloyd, Adam Thomas (2011) • McGuirt, William F. (2003)• Miskovitz & Betancourt (2005) • Mjönes et al (2005) • Møller & West (2000) • Moniniet al (2006)• Moss & Kelly (2007)• Murry et al (2006) • Nowak et al (2010)• Patrick, Lyn (2011) • Pitman (2010) • Rees & Belafsky (2008)• Ross et al (1998) • Sana et al (2011) • Sandage & Emerich (2002)• Sataloff, Robert T. (1991,

1998,2005, 2006,2010)• Sataloff et al (2006, 2012) • Sereg-Baharet al (2005) • Smoak & Koufman (2001)

• Spencer (2006)• Syed & Bleach (2009) • Timmermans et al (2005) • Usai et al (2008)• Vashani et al (2010)• Watson et al (1997)• Wright et al (2005)

Images Used

• Slide 1 – funnyjokes.org• Slide 3 – babychoicbariatrics.com• Slide 4 – epgpatientdirect.org• Slide 10 – refluxcookbook.com• Slide 13 – http://en.wikipedia.org• Slide 13 – www.bennettclinic.com/chiropractic.jpg• http://www.w3.org/TR/xhtml1/DTD/xhtml1-

strict.dtd

Conclusions• Wealth of Research / Many Uncertainties

• What is normal ?• Subtle changes = significant effects• Multidisciplinary team• Need for more specific controlled studies• Literature review integral to discovering what has been done,

what needs to be done and whether or not you want to do it• Know the important publications: Journal of Singing, Journal of

Voice, Laryngoscope, Otolaryngology, Head & Neck Surgery,