Laryngopharyngeal Laryngopharyngeal RefluxReflux

& & GranulomaGranuloma

By Isabel C. BulaBy Isabel C. BulaPresented to Rebecca L. Gould, MSC, CCC-SLPPresented to Rebecca L. Gould, MSC, CCC-SLP

OverviewOverview

RationaleRationale DefinitionDefinition Etiology & Mechanisms of LPREtiology & Mechanisms of LPR SymptomsSymptoms DiagnosisDiagnosis Clinical Findings Associated with LPRClinical Findings Associated with LPR Associated Vocal PathologiesAssociated Vocal Pathologies Treatment Treatment ConclusionsConclusions

Why LPR?Why LPR?

Common : 50% of ORL patients have Common : 50% of ORL patients have LPR (Koufman, 1994).LPR (Koufman, 1994).

Associated with a diversity of laryngeal Associated with a diversity of laryngeal and voice disorders.and voice disorders.

Can have dangerous effects, especially if Can have dangerous effects, especially if left untreated.left untreated.

We (SLPs) are essential in management We (SLPs) are essential in management of LPR!of LPR!

Laryngopharyngeal Laryngopharyngeal RefluxRefluxBackflow of food and stomach acids Backflow of food and stomach acids into the back of the throat and onto into the back of the throat and onto the larynx.the larynx.

Causes: Causes:

a. Physicala. Physical

b. Lifestyles Factorsb. Lifestyles Factors

LPR: EtiologyLPR: Etiology

PHYSICALPHYSICAL Improper functioning of Improper functioning of

esophageal sphincters.esophageal sphincters. Hiatal hernia.Hiatal hernia. Abnormal esophageal Abnormal esophageal

contractions.contractions. Slow emptying of the Slow emptying of the

stomach.stomach.

LIFESTYLELIFESTYLE DietDiet

Irritants: chocolate, Irritants: chocolate, caffeine, citrus, fatty caffeine, citrus, fatty foods, spices.foods, spices.

Unhealthy habitsUnhealthy habits

OvereatingOvereating

SmokingSmoking

Alcohol consumptionAlcohol consumption

Mechanisms of LPRMechanisms of LPR

LPR & GranulomaLPR & Granuloma

Granulomas: most often associated with Granulomas: most often associated with LPR as an etiological factor.LPR as an etiological factor.

LPR causes chronic irritation of the LPR causes chronic irritation of the posterior larynx, where granulomas posterior larynx, where granulomas typically occur.typically occur.

Granulomas respond well to Anti-reflux Granulomas respond well to Anti-reflux therapy.therapy.

GranulomasGranulomas Non-cancerous growths that result from tissue Non-cancerous growths that result from tissue

irritation.irritation. Occur in the posterior 2/3 of true vocal fold(s) Occur in the posterior 2/3 of true vocal fold(s)

vocal process of arytenoid. vocal process of arytenoid. May occur unilaterally or bilaterally.May occur unilaterally or bilaterally. Koufman (1994) suggests most likely cause is Koufman (1994) suggests most likely cause is

a combination of LPR and long-term vocal a combination of LPR and long-term vocal misuse.misuse.

Tends to recur: Tx must address ALL Tends to recur: Tx must address ALL underlying causes.underlying causes.

SYMPTOMS OF LPRSYMPTOMS OF LPR Hoarseness (reported by 100% of patients)Hoarseness (reported by 100% of patients) Frequent throat clearingFrequent throat clearing Globus pharyngeus (sensation of a lump in Globus pharyngeus (sensation of a lump in

the throat)the throat) Chronic CoughChronic Cough Dysphagia Dysphagia Bad/bitter taste in mouthBad/bitter taste in mouth Post-nasal dripPost-nasal drip Sore throatSore throat Heartburn*Heartburn*

LPR: DiagnosisLPR: Diagnosis

Medical HistoryMedical History Laryngoscopy/ Laryngoscopy/

Laryngoendoscopy/VideostroboscopyLaryngoendoscopy/Videostroboscopy

24 hour Double pH probe24 hour Double pH probe Barium Swallow StudyBarium Swallow Study Upper GI EndoscopyUpper GI Endoscopy ManometryManometry

Clinical FindingsClinical Findings

Irritation from reflux of stomach fluids into the voice box causes: redness and Irritation from reflux of stomach fluids into the voice box causes: redness and swelling (indicated with white arrows) in vocal folds (vf) and false vocal folds (f swelling (indicated with white arrows) in vocal folds (vf) and false vocal folds (f vf); pachydermia (indicated with yellow arrow) or thickening of tissue in vf); pachydermia (indicated with yellow arrow) or thickening of tissue in between the focal folds.between the focal folds.

LPRLPR

Associated Vocal Associated Vocal PathologiesPathologies

Laryngeal stenosisLaryngeal stenosis Polypoid degenerationPolypoid degeneration Paroxysmal laryngospasmParoxysmal laryngospasm Recurrent leukoplakiaRecurrent leukoplakia Functional voice disordersFunctional voice disorders Laryngeal carcinomaLaryngeal carcinoma Arytenoid fixationArytenoid fixation Vocal nodulesVocal nodules SIDS?SIDS?

TreatmentTreatment

Levels I, II, IIILevels I, II, III MedicalMedical

Antacids Antacids (Tums, Mylanta)(Tums, Mylanta)

H2 BlockersH2 Blockers (Tagament, Zantac, (Tagament, Zantac,

Pepcid)Pepcid)

Proton Pump InhibitorsProton Pump Inhibitors (Prevacid, (Prevacid,

Nexium, Prilosec, Aciphex)Nexium, Prilosec, Aciphex)

Recommended dose: 2x/dayRecommended dose: 2x/day

If you are interested in understanding how PPIs work, visit this website: http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/stomach/parietal.html

TreatmentTreatment

Dietary ChangesDietary Changes-Low fat diet-Low fat diet-Avoid coffee, tea, chocolate : (, -Avoid coffee, tea, chocolate : (, tomato-based products,citrus tomato-based products,citrus fruits, carbonated drinks, fruits, carbonated drinks, cheese, eggs & onions.cheese, eggs & onions.-Avoid overeating.-Avoid overeating.-Avoid alcohol, especially in the -Avoid alcohol, especially in the evening.evening.-Avoid eating/drinking within 3 -Avoid eating/drinking within 3 hour of bedtime.hour of bedtime.

Lifestyle ModificationsLifestyle Modifications-Avoid tight-fitting clothes.-Avoid tight-fitting clothes.-If you are a smoker, -If you are a smoker,

QUIT!QUIT!-Elevate the head of the -Elevate the head of the

bed (esp. if reflux at bed (esp. if reflux at night).night).

-Don’t exercise or sing too -Don’t exercise or sing too soon after eatingsoon after eating

-Lose weight-if necessary-Lose weight-if necessary-Relax.-Relax.

1. Behavioral: anti-reflux therapy.

TreatmentTreatmentVoice TherapyVoice Therapy

Vocal Hygiene Vocal Hygiene ---reduce/eliminate throat clearing and -reduce/eliminate throat clearing and coughing.coughing.

-encourage conservative voice use-encourage conservative voice use-initiate new functioning voicing -initiate new functioning voicing

behaviors.behaviors.-production of voice with an extreme -production of voice with an extreme forward focus.forward focus.

Resonant voice therapy (RVT): most often Resonant voice therapy (RVT): most often

employed for LPR/granulomas (Stemple et employed for LPR/granulomas (Stemple et al, 2000)al, 2000)

Treatment: RVTTreatment: RVT Developed byDeveloped by Verdolini & Lessac. Verdolini & Lessac. Resonant VoiceResonant Voice: involves oral vibratory : involves oral vibratory

sensations in the context of easy phonation.sensations in the context of easy phonation. GoalGoal: “…to achieve the strongest, cleanest : “…to achieve the strongest, cleanest

possible voice with the least effort and impact possible voice with the least effort and impact between the vocal folds to minimize the between the vocal folds to minimize the likelihood of injury and maximize the likelihood likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2000)”.of vocal health (Stemple et al., 2000)”.

How?How? Pt. Is asked to monitor the “feel” and to Pt. Is asked to monitor the “feel” and to concentrate on auditory feedback.concentrate on auditory feedback.

TreatmentTreatment

SurgicalSurgical: : forfor Severe LPRSevere LPRFundoplication Tightens LESTightens LES

TreatmentTreatment

Surgical:Surgical: Considerations for patient with granulomaConsiderations for patient with granuloma

Surgery is not the treatment of choice for granulomas,Surgery is not the treatment of choice for granulomas,due to their tendency to recur. However, surgery isdue to their tendency to recur. However, surgery isindicated in certain cases:indicated in certain cases:

1.1. Granulomas compromise airway.Granulomas compromise airway.2.2. Carcinoma is suspected.Carcinoma is suspected.3.3. Granulomas mature (usually don’t respond to meds).Granulomas mature (usually don’t respond to meds).4.4. Patient relies on voice for professional use,.Patient relies on voice for professional use,.

TreatmentTreatment

**BOTOX A Injection is now being used **BOTOX A Injection is now being used to treat granuloma. Preliminary studies to treat granuloma. Preliminary studies indicate it’s effective.indicate it’s effective.

Phonoscopic Therapy (2005) – provides Phonoscopic Therapy (2005) – provides visual feedback using an visual feedback using an endoscope.endoscope.

TreatmentTreatment

Efficacious?Efficacious? YES! YES! Granulomas respond well to ART + meds.Granulomas respond well to ART + meds.Voice therapy focused on reducing medial Voice therapy focused on reducing medial

compression of vocal folds, such as RVT are compression of vocal folds, such as RVT are effective. effective.

PPIs are effective in reducing acid production in PPIs are effective in reducing acid production in the stomach.the stomach.

Individualized treatment Individualized treatment

ConclusionsConclusions

LPR LPR Can have very damaging effectsCan have very damaging effects Associated with many vocal pathologiesAssociated with many vocal pathologies Diagnostic proceduresDiagnostic procedures Treatment optionsTreatment options Our role as SLPsOur role as SLPs Educating clientsEducating clients

ReferencesReferences

Belafsky, P. (2003). Abnormal endoscopic pharyngeal and laryngeal findings Belafsky, P. (2003). Abnormal endoscopic pharyngeal and laryngeal findings attributable to reflux. attributable to reflux. American Journal of MedicineAmerican Journal of Medicine, 115 (3A): 90S-96S., 115 (3A): 90S-96S.

Garnett, J.D. (2005, May). Contact granulomas. Emedicine specialties. Retrieved on Garnett, J.D. (2005, May). Contact granulomas. Emedicine specialties. Retrieved on July 5, 2005, July 5, 2005, from from http://www.emedicine.com/ent/topic603.htmhttp://www.emedicine.com/ent/topic603.htm

Koufman JA, Cummins MM. (1995) Reflux and early laryngeal carcinoma. Koufman JA, Cummins MM. (1995) Reflux and early laryngeal carcinoma. Visible Visible Voice,Voice, 4:2-5, 19-23. 4:2-5, 19-23.

Koufman, J.A. (1994) Laryngopharyngeal Reflux and Voice Disorders. Koufman, J.A. (1994) Laryngopharyngeal Reflux and Voice Disorders. Visible Voice,Visible Voice, 3:2-7.3:2-7.

Koufman, J.A., Aviv, J.E., Casiano, R.R. and Shaw, G.Y. (2002) Laryngopharyngeal Koufman, J.A., Aviv, J.E., Casiano, R.R. and Shaw, G.Y. (2002) Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. disorders of the American Academy of Otolaryngology-Head and Neck Surgery. American Journal of Otolaryngology – Head and Neck Medicine and SurgeryAmerican Journal of Otolaryngology – Head and Neck Medicine and Surgery, , 127, 32-35.127, 32-35.

Leonard, R. & Kendall, K. (2005) Effects of voice therapy on vocal process Leonard, R. & Kendall, K. (2005) Effects of voice therapy on vocal process granuloma: a phonoscopic approach. granuloma: a phonoscopic approach. American Journal of Otolaryngology – Head American Journal of Otolaryngology – Head and Neck Medicine and Surgeryand Neck Medicine and Surgery. 26. 101-107.. 26. 101-107.

Stemple, J.C. & Glaze, L.E. (2000). Clinical Voice Pathology: Theory and Stemple, J.C. & Glaze, L.E. (2000). Clinical Voice Pathology: Theory and Management. San Diego: Singular Publishing Group, Inc.Management. San Diego: Singular Publishing Group, Inc.

Voice Disorders.org (n.d.). Voice Disorders: Reflux Laryngitis. Retrieved on July 5, Voice Disorders.org (n.d.). Voice Disorders: Reflux Laryngitis. Retrieved on July 5, 2005, from http://www.voiceproblem.org/pdfs/reflux_laryngitis.pdf2005, from http://www.voiceproblem.org/pdfs/reflux_laryngitis.pdf