Effect of proton pump inhibitor and voice therapy on reflux-related laryngeal disorders Ezzeldin H, Hasseba AA

Effect of proton pump inhibitor and voice therapy on reflux-related laryngeal disorders Ezzeldin H, Hasseba AA

The most commonly performed surgery is called the Nissen Fundoplication. It is done by wrapping the top part of the stomach around the junction between the stomach and esophagus and sewing it in place.

Antacids and medications called histamine antagonists – which also decrease stomach acid – can be used to treat laryngopharyngeal reflux, as well. Medications that increase the movements or contractions of the stomach and bowels, sometimes called pro-motility drugs, may be recommended for people with laryngopharyngeal reflux. The esophageal complications of GERD include esophagitis, esophageal webs and strictures, Barrett’s esophagus and carcinoma.18, 19 Barrett’s esophagus is defined as metaplasia of squamous epithelium to specialized columnar epithelium, occurring 2 to 3 cm above the gastroesophageal junction. However, short-segment (less than 2 cm) Barrett’s esophagus has also been described.6 Barrett’s esophagus is an endoscopic diagnosis and is associated with an increased incidence of adenocarcinoma. Heartburn, the classic symptom of GERD, is common in patients with gastrointestinal symptoms but uncommon in those with head and neck manifestations.

There are individuals with gastroesophageal reflux disease (GERD) who have throat discomfort. People with GERD have gastric reflux into the esophagus. This typically causes heartburn and regurgitation (a sense of fluid coming up). At either end of your esophagus is a ring of muscle (sphincter).

Conditions We Treat: Chronic Cough and LPR

assumed that the lower esophageal sphincter, surrounded by diaphragmatic muscle, prevents GERD, and, indirectly, the synergy of the function of the lower esophageal sphincter and its surrounding crura of the diaphragm, when superimposed, is of importance for competent closure. When these structures become incompetent, gastric contents may be traced back along the esophagus and cause LPR. Like any other striated muscle of the body, the diaphragm muscle should be amenable to improve performance with physical exercise. For these reasons, alternative therapies for the treatment of reflux disease has recently been studied, and, in particular, VT/relaxation techniques such as training of the diaphragm muscle with maneuvers and breathing exercises have been considered. In addition to potentially damaging the lower esophagus, frequent heartburn or GERD may also damage the upper throat.

Two pH sensors (one at the bottom of the esophagus and one at the top) allows the doctor see if acid moves back to the top of the esophagus. 4.

Pathophysiology of GERD

If only small amounts of stomach acid backflow into both the esophagus and voice box – swelling and irritation may occur only in the voice box without affecting the “tougher” more resistant lining cover (mucosa) of the esophagus. Physicians believe that the esophagus may be better able to resist the effects of stomach fluids (acid and enzymes) than the voice box. A history of symptoms and how the voice fluctuates in relation to eating patterns is key to diagnosing reflux laryngitis.

A raw score between 0 and 45 was generated by summing the responses for each of the nine variables. A score of 13 and above is considered to be abnormal. While the exposure of the mild and moderate pH levels in the upper airway may contribute to subtle tissue changes (e.g., posterior interarytenoid edema and erythema or accumulation of endolaryngeal mucous), the potential effects on voice quality, including hoarseness, loss of range, and vocal fatigue, are both highly variable and unpredictable. The performance demands placed on singers are considerable, requiring precise control of the larynx and upper respiratory structures, so even miniscule changes to vocal quality or endurance can be problematic [2-4, 8, 10, 27-33].

  • Its diagnosis is plagued by non-specific symptoms and signs, and by overlap with differential diagnoses such as upper respiratory infection, rhinitis, asthma, smoking, vocal abuse and allergy.
  • GERD has also been implicated in the development of leukoplakia and squamous cell carcinoma of the true vocal cords.3, 10, 11 Leukoplakia, defined as the presence of a whitish plaque on a mucosal surface, in itself does not carry any diagnostic implications.
  • Behavior changes and lifestyle modifications are considered the first-line treatment with the lowest possibility of side effects.

Heartburn / GERD Guide

In addition to dietary and behavioral adjustments, medications are often part of an anti-reflux program. Some are available without a prescription, while others require a prescription. Antacids are commonly used for this problem, and they work by neutralizing stomach acid. Other medications work to decrease stomach acid secretion before it happens and are more effective at controlling symptoms.

This is what I believe had happened to me. After years of singing on a full stomach, I had slightly weakened this muscle and consequently a tiny amount of stomach acid, on occasion, was allowed to pass from my stomach up through the oesophagus and onto my vocal cords. These findings suggest the existence of interindividual variability in terms of mucosal resistance to acid exposure, both in the esophagus and pharyngolarynx.

Perhaps of greatest global significance, there is persistent controversy regarding the accuracy of diagnosis of LPR, the efficacy of treatment, and the quality of research that has been performed. The lack of reliable data is apparent in a recent study from the Cochrane Database of Systemic Reviews. The investigators examined existing data to determine the efficacy of anti-reflux therapy for patients with hoarseness. Of the 302 studies identified, none met their inclusion criteria (Hopkins et al., 2008). Their conclusion that there is a “need for high quality randomized controlled trials to evaluate the efficacy of anti-reflux therapy” echoes the frustration of many current practitioners.

Therefore, the esophagus can tolerate a lower pH exposure than the larynx and upper airway. Antireflux medications are typically the first line of treatment for singers who report symptoms consistent with LPR [4, 10, 14]. Typical antireflux medications include over the counter (OTC) antacids, OTC and prescription strength H 2 -receptor antagonists, prokinetic agents, and OTC and prescription strength proton pump inhibitors (PPI). The decision to initiate antireflux medications is typically driven by patient report of symptoms, and, in some cases, evidence of LPR-related changes (edema and erythema) to the mucosal tissue lining the surface of the larynx and pharynx, typically observed during laryngoendoscopic examination. Recently more and more studies are finding potentially negative effects of long term PPI usage [15, 16].

For patients who show no response to reflux therapy, some otolaryngologists assume reflux has been ruled out and discontinue the PPI, substituting treatment for allergy or some other conditions. In the absence of studies, this approach is particularly problematic since many patients continue to produce at least some acid despite proton pump inhibitors twice daily, and it has been recognized for many years that some patients with reflux do not respond to proton pump inhibitors and continue to produce normal amounts of acid despite treatment (Bough et al., 1995). Other otolaryngologists assume that if the patient has failed a therapeutic trial, the LPR is severe and requires even higher doses of PPI therapy, and the addition of other reflux or promotility medications which often are prescribed empirically (without tests objective for reflux).

Moreover, reflux symptoms have been shown to be exacerbated or improved over time concomitant with weight gain or loss, respectively [Jacobson et al. 2006]. The HUNT study showed that, among individuals with GERD-related symptoms, a reduction higher than 3.5 units in BMI is related to a reduction or cessation in weekly antireflux medication use [Ness-Jensen et al. 2013]. On the other hand, whether weight reduction may improve the subjective or objective manifestations of reflux is still controversial [Kjellin et al. 1996]. Moreover, few data are available to determine whether weight loss is able to improve GERD-related symptoms such as LPR. Subsequently, the American Gastroenterological Association guidelines for GERD recommended against the use of acid-suppression therapy for acute treatment of patients with potential extraesophageal GERD syndromes (laryngitis, asthma) in the absence of typical GERD symptoms [Kahrilas et al. 2008].

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