Reflux and the Voice

Question 1

Role of SLP in LPR dx and tx

Answer 1

Referral to ENT if this hasn’t already occurred
Education of patient
Encouragement and reinforcement of treatment
Need to understand the effects of LPR on voice and swallowing

Question 2

GERD Definition

Answer 2

Gastroesophageal Reflux may be a normal occurrence experienced occasionally in most people
Gastroesophageal Reflux Disease is when it becomes persistent, chronic, and includes symptoms such as heartburn
Abouth 20-30% prevalence of GERD in western population

Question 3

LPR Definition

Answer 3

laryngopharyngeal reflux: backflow of gastric contents into the larynx and pharynx
Extraesophageal, supraesophageal, and gastroesophagopharyngeal reflux; reflux or posterior laryngitis; silent reflux; atypical reflux disease

Question 4

GERD Profiles

Answer 4

Night-time, supine
<4 normal
Associated with obesity
Higher incidence of esophagitis
Longer reflux episodes
LES dysfuction

Question 5

LPR Profiles

Answer 5

Daytime, upright
1-2 episodes in pharynx abnormal
Not associated with obesity
Lower incidence of esophagitits
Brief reflux episodes
UES dysfunction

Question 6

Diagnosis of LPR

Answer 6

Symptoms reported by pt
Laryngeal examination
Empiric trial of acid suppression medication
pH probe testing is current gold standard: catheter through nose into esophagus, detect pH level in distal esophagus and hypopharynx
Esophageal manometry
Esophagoscopy

Question 7

Symptoms of LPR

Answer 7

Hoarseness/Dysphonia
Dysphagia
Throat pain
Globus pharyngeus
Post-nasal drip/Thick/extra mucous
Throat clearing/coughing
laryngospasm

Question 8

Reflux Symptom Index

Answer 8

9-item questionnaire completed by patient

Score greater than 13 is considered abnormal and is suggestive of LPR

Question 9

Reflux Finding Score

Answer 9

8-item clinical severity scale based on findings during fiberoptic laryngoscopy
95% chance that RFS greater than 7 is LPR

Question 10

Treatment of LPR

Answer 10

Pt education and behavioral change
Medical management
Surgical management

Question 11

Behavioral Changes & Education (LPR)

Answer 11

avoid reflux triggers
eat smaller meals, not late at night
avoid alcohol
lose weight
stop smoking
education re: effect of LPR on voice, optimal medication timing

Question 12

Medical Management

Answer 12

H2-receptor antagonists such as Zantac and Pepcid
Prokinetic agents that accelerate esophageal clearance and increase lower esophageal sphincter pressure are seldom used anymore due to adverse side effects
Over the counter antacids may help with GERD, but are not particularly useful for LPR

Question 13

Proton Pump Inhibitors

Answer 13

LPR may require a higher, more frequent dosage for longer periods of time when compared to GERD

Question 14

Surgical Management

Answer 14

tx of last resort for pts with chronic reflux that does not respond to medication and bx tx
fundoplication is most common procedure and attempts to improve LES fxn, reducing reflux; can now do laparoscopically or endoscopically
Less successful wit hLPR
New frontiers in surgery? Radiofrequency ablation; injections into LES

Question 15

Reflux Plus

Answer 15

pepsin and digestive enzyme responsible for laryngeal irritation
pepsin active in acidic env.