Reflux

 

Laryngopharyngeal Reflux

The term reflux, derived fromLatin, is composed of the incorporation of two words: Re, meaning backwards,and fleur, meaning flow. The integration of the words creates the term backwardflow or flow backward. When the contents of the stomach arrives through the esophagus to the throat, damage is done to the layingial and pharyngeal mucosa. The common complaints in this condition are: hoarsenessand voice disorders, throat clearing, the feeling of a foreign object in thethroat, trouble swallowing, pesky coughing, pain and a burning a sensation inthe throat. As opposed to Laryngopharyngeal reflux, GastroesophgealDisease-GERD refers to the flow of stomach content in to the esophagus whiledamaging the esophageal, mucosa with symptoms such as heartburn and chestpains. These complaints indicate an esophageal inflammation caused by theexposure of the esophagus to the stomach's acid and contents. The clinicalmanifestation usually appears at night (or while lying down).Patients with Laryngopharyngeal reflux, however, usually have nodisturbance in esophageal mobility or esophageal inflammation. The phenomenonusually appears during the day. Patients suffering fromLaryngopharyngeal reflux do not usually complain of  heartburn, sincethe active materials from the stomach do not remain in the esophagus for long,and the acid usually does not have sufficient time to cause irritation.However, even very small amounts of stomach content rising to the throat cancause damage to the mucosa. In the past it has been shown that three episodesof Laryngopharyngeal reflux a week are sufficient in tocause significant damage to the pharynx. The reflux symptom index (RSI) isa questionnaire composed of 9 questions regarding complaints common amongstpatients suffering from Laryngopharyngeal reflux. Its purpose is to easethe diagnosis and allow for follow-ups on patient treatment. The questionnairemay be filled in a short time (less than one minute). When the RSI is over, 10the patient is probably suffering from a throat reflux problems.


 
 
How has the problem affected the following ?
 
 
 
0=no problem 5=severe problem
 
 
 
 
Hoarsenessor voice problem
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Throatclearing
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
phlegm
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Difficultiesin swallowing food, fluids or pills
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Coughingafter drinking, eating or lying down
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Breathingdifficulties
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
PeskyCoughing
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Asensation of a "lump" in the throat
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 
 
Heartburn,chest pains/acid rising to the throat
 
 
 
 
0
 
 
 
1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
 
 

The diagnosis of Laryngopharyngeal reflux may be based on symptoms and findings in the pharynx or larynx. Monitoring acidity with asensor in the pharynx for 24 hours is the test of choice for final confirmation of the diagnosis. The excepted assumption is that half of the patients with pharynx problems suffer from Laryngopharyngeal reflux. When suspicion is raised about throat reflux disease, a flexible fiber optic examination is required. Criteria for the presence of reflux in the test are: presence of edema in the true/false vocal cords, edema in the rear intersection area,redness of the mucosa covering the arytenoids cartilages, presence of thick secretion or edema of the area beneath the vocal cords. As is accepted in literature, every sign receives a score (see table 2 presenting the reflux finding score) where a score of more than seven is considered positive for the presence of Laryngopharyngeal reflux.

 
 
0 = absent
 
 
 
Sub- glotticedema
 
 
 
 
2 = present
 
 
 
 
 
 
 
0 = absent
 
 
 
Falsevocal cord edema
 
 
 
 
2 = present
 
 
 

 
 
 
 
2 = arynoid area
 
 
 
redness/congestion

 
 
 
 
4 = general
 
 
 

 
 
 
 
1 = mild
 
 
 
Cord edema

 
 
 
 
2 = medium
 
 
 

 
 
 
 
3 = acute
 
 
 

 
 
 
 
4 = polypoid edema
 
 
 

 
 
 
 
1 = mild
 
 
 
General throat edema

 
 
 
 
2 = medium
 
 
 

 
 
 
 
3 = acute
 
 
 

 
 
 
 
4 = airway blockage
 
 
 

 
 
 
 
1 = mild
 
 
 
Rear edema

 
 
 
 
2 = medium
 
 
 

 
 
 
 
3 = acute
 
 
 

 
 
 
 
4 = airway blockage
 
 
 

 
 
 
 
0 = absent
 
 
 
Granuloma presence

 
 
 
 
2 = present
 
 
 
 
 
 
 
0 = absent
 
 
 
Thick secretion

 
 
 
 
2 = present
 
 
 
 
 
 
 

In general, treatment of Laryngopharyngeal reflux should be more aggressive and prolonged than treatment of stomach or esophagus reflux. Thepharynx is a sensitive area in comparison with the esophagus and has no defense mechanisms against acids secretions.The treatment for reflux according to the recommendations of the ear, nose and throat doctor's organization includes these of Proton pump inhibiting drugs at least twice a day. Medicinal treatments required twice a day, since none of the drugs in this family inhibits the production of the acid for more than 17 hours. In some cases there is also a need to add drugs from the H2-receptor blocker group to the treatment.There are also non medicinal actions in the treatment, such as voiding from large meals at night, fat, chocolate and coffee. These foods may cause a delay in the draining of the stomach and negatively affect the pressure in the lower stomach seal, thus allowing for a return of content from the stomach to the esophagus. 
 
 
 
בצקת מיתרים והשלבה האחורית
 
Cord and rear intersection edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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