Reflux Laryngitis Treatment & Management

Because of reservations regarding specificity of the laryngoscopic examination, many physicians have opted to begin a trial of empiric therapy.

Four categories of drugs are used in treating laryngopharyngeal reflux (LPR): proton pump inhibitors (PPIs), ^[7] H2-receptor agonists, prokinetic agents, and mucosal cryoprotectants.

PPIs are the mainstay of treatment. PPIs are the most effective drugs in treating GERD that involves the esophagus. Acid reflux events are decreased by greater than 80%, and healing of esophagitis is reported in 80-90% of patients. The response to medical therapy in patients with suspected supraesophageal complications of GERD is not as efficacious as that noted in esophageal complications of GERD. Although PPIs appear to be effective, higher doses for a longer duration are necessary as compared with esophageal GERD disease.

Based on these clinical experiences, a similar approach for the treatment of suspected supraesophageal complications of GERD was recommended by the Working Party at the First Multidisciplinary Symposium on Supraesophageal Complications of Reflux Disease. The recommendation calls for a double standard dose of PPI therapy initially for patients with suspected supraesophageal complications of GERD and a duration of therapy for at least 3, and possibly 6, months.

At the completion of this initial trial, assessment of the patient's symptoms and the response to therapy should be critically evaluated. Before medical therapy can be considered unsuccessful, adequate esophageal and gastric acid suppression should be documented. Recently, a noncontrolled study reported the results of PPI therapy in 16 patients with persistent posterior laryngitis for whom H2 receptor therapy was unsuccessful. Omeprazole treatment ranged from 6-24 weeks with a dosage of 40 mg of omeprazole at nighttime. (This dose was increased to 40 mg bid for 6 wk in 4 patients with continuing symptoms.) At the conclusion of the study, both the laryngoscopy scores and the esophageal symptom indices improved significantly. However, symptoms recurred after the discontinuation of acid suppressant therapy, suggesting that acid reflux was indeed the underling etiology.

In cases of unsuccessful medical therapy, consideration needs to be given to nonacidic refluxate. Multichannel intraluminal impedance testing may be indicated to look for nonacid, as well as gaseous, events as a possible cause.

The importance of long-term treatment for laryngeal complications of reflux disease is stressed because the injury to the epithelium is a chemical burn and takes weeks to months to resolve. For most patients, an 8-week course of antisecretory treatment, used for esophageal reflux injury, is inadequate. Recurrence of symptoms is common in patients who require PPI therapy for initial treatment.

Table 2. shows key features of the 7 studies that evaluated efficacy of antireflux medical treatment. These studies were published from 1991-1997 and reported on 346 adult patients with otherwise unexplained posterior laryngitis suspected to be caused by GERD who received antireflux medical treatment in an uncontrolled nonblinded clinical trial. Outcomes Reported by Trials of Antireflux Medical Treatment of Reflux Laryngitis (Open Table in a new window)

Intervention generally consists of standard antireflux nonpharmacologic measures and acid suppression with a variable dose of omeprazole and in one trial with H2 receptor antagonists (H2RA). The duration of intervention varied from 6-24 weeks, and postintervention follow-up varied considerably.

Outcome was generally assessed by change in symptom score and laryngoscopic severity score. One study reported only acoustic parameters as the outcome, and another study evaluated only patient-reported overall improvement. Except for one study, others performed ambulatory pH monitoring in only selected patients with refractory symptoms. Most studies reported recurrent symptoms off treatment after an initial favorable response maintained while on treatment.

However, at present, difficulties exist with the interpretation of trials using PPIs for treatment of patients with suspected supraesophageal complications of GERD. This is because studies contain small groups of patients, treatment duration is very short, and no control groups have been included.

Future studies using PPIs in patients with suspected supraesophageal complications of GERD require properly designed controlled protocols to fully evaluate treatment efficacy. H2RA and prokinetic medications have not, for the most part, found an effective role in treating patients with suspected supraesophageal GERD complications. Because the efficacy of diagnostic testing is not 100% in substantiating the role of acid reflux in supraesophageal disorders, at times a therapeutic trial may be the only recourse. In this situation, attempts at maximal acid suppression are critical and require potent PPI therapy.

A study by Zalvan et al reported that a diet-based approach to the treatment of laryngopharyngeal reflux (LPR) compared favorably with the use of PPIs. The study found that in patients who followed a treatment regimen consisting of alkaline water (pH >8.0) and a 90% plant-based, Mediterranean-style diet, along with standard reflux precautions, the percentage who experienced a clinically meaningful reduction in the Reflux Symptom Index (RSI) was greater than it was for those who underwent PPI therapy in combination with standard reflux precautions (62.6% vs 54.1%, respectively). There was also a greater mean RSI reduction in the Mediterranean-diet group than in the PPI patients (39.8% vs 27.2%, respectively). The investigators cautioned, however, that the clinical significance of these results needs further research. ^[19]

A study by Lechien et al indicated that gender-related variation exists with regard to voice quality changes following PPI and dietary therapy for laryngopharyngeal reflux (LPR). While both males and females who underwent treatment showed significant improvement in the reflux finding score and reflux symptom index, a number of acoustic measurements (such as percent jitter, percent shimmer, phonatory fundamental frequency range, fundamental frequency variation, peak-to-peak amplitude variation) improved significantly in males but not in females. ^[20]

In a study of patients with acid, weakly acid, and alkaline laryngopharyngeal reflux (LPR), Lechien and colleagues found that all three groups experienced significant posttreatment improvement in their reflux symptoms scores and reflux sign assessments, but that the best voice quality improvement was reported by those with alkaline LPR. Patients in the study underwent 3 months of treatment with a combination of diet, PPIs, magaldrate, and alginate. ^[21]

The apparent advantage of operative therapy is that it corrects the antireflux barrier at the gastroesophageal junction and prevents the reflux of most stomach contents, thus preventing acid and nonacidic material from coming in contact with the pharyngolaryngeal mucosa. The candidates for antireflux surgery are often patients who require continuous or increasing doses of medication to maintain their response to acid suppressive therapy. The case has been made for young patients, noncompliant patients, and those who choose to have this type of therapy. Often, financial concerns of the patient have been a reason for a fundoplication operation.

Except for 2 studies reporting the result of Nissen fundoplication in patients with pharyngolaryngeal complications of reflux disease, the published reports generally deal with efficacy and long-term outcomes of the operation in patients with esophageal complications of reflux disease. Although the long-term efficacy of laparoscopic fundoplication is not available, 80-90% of patients are reported to be asymptomatic or have minimal symptoms following a conventional open fundoplication operation. In a 10-year follow-up after open fundoplication surgery, 91% of patients continued to have control of their symptoms. Short-term outcome results following laparoscopic fundoplication indicate symptom control in 85-90% of patients with acceptable low morbidity rates.

Two prospective uncontrolled clinical trials evaluated the efficacy of Nissen fundoplication for patients with GERD–related laryngeal disorders. In 1993, Deveney et al studied 13 consecutive patients with symptomatic laryngitis and objective evidence of GERD who were refractory to treatment with H2RA and included those with previous laryngeal carcinoma (38%) and leucoplakia (46%). Symptoms resolved and laryngoscopic abnormalities disappeared in 73% of patients who were monitored for 11 months.

In 1998, So et al evaluated improvement in symptom score over an average of 22 months in 35 patients with cervical or thoracic symptoms, most of whom had pharyngeal acid reflux by a 24-hour pH study. ^[22] Heartburn requiring antacids was reported by 86% of patients, and 37% had evidence of esophagitis. Although 93% of patients were relieved of heartburn, only 58% of them showed an improved supraesophageal symptom score. Symptom response to preoperative acid suppression was a significant predictor of postoperative improvement.

The recent introduction of minimally invasive laparoscopic fundoplication for the most part has replaced conventional open fundoplication operation. Subsequently, an increasing number of patients are undergoing laparoscopic fundoplication encouraged by this new technology and a greater acceptance on the part of the treating physician. Because many surgeons with little experience in esophageal physiology or traditional fundoplication operation have begun to perform this procedure, not unexpectedly, the number and severity of complications resulting from laparoscopic fundoplication have increased. For that reason, this operation should not be first-line therapy for patients with suspected supraesophageal complications of GERD. Exceptions to this approach would be dramatic situations such as obvious regurgitation and aspiration or laryngospasm.

In fact, demonstration of the effectiveness of acid suppression therapy should be the major criteria for predicting successful outcome of fundoplication operation. The morbidity associated with fundoplication operations varies but may be significant. The frequency of postoperative dysphagia ranges from 0-17% in large reported series.

Fundoplication surgery is championed as the treatment of choice, particularly for the young patient with significant GERD who faces a lifetime of medical treatment with a potentially negative impact on lifestyle.

In a recent long-term Finnish study, ^[23] evidence showed that laparoscopic Nissen fundoplication did provide long-term satisfactory results in patients suffering from reflux-induced laryngitis.

A multidisciplinary approach involving an otolaryngologist, gastroenterologist, speech therapist, and pulmonologist optimizes the diagnostic evaluation and management.

ENT physicians consider symptoms such as throat clearing and chronic cough most useful in the diagnosis of laryngopharyngeal reflux (LPR), along with findings on laryngoscopic examination. Many gastroenterologists perform pretherapy testing, which has low sensitivity in laryngopharyngeal reflux (LPR). Furthermore, a dichotomy can be found in treatment dose, duration, and perceived patient response to therapy between the 2 specialties. Cross-communication education between gastroenterology and otolaryngology is needed in understanding and treating LPR- and GERD-related laryngitis better. ^[16]

See the list below:

• Decrease the size of portions at mealtimes.

• Meals should be eaten 2-3 hours before lying down.

• Avoid food and beverages that affect the LES muscle action (eg, fried or fatty foods, chocolate, peppermint, alcohol, coffee, carbonated beverages, citrus fruits or juices, tomato sauce, ketchup, mustard, vinegar).

• Eat at a slower pace to reduce aerophagy.

• Patients with concurrent deglutitive abnormalities benefit from specifically targeted interventions (eg, swallowing therapy by a speech-language pathologist).

See the list below:

• Lose weight if overweight.

• Elevate the head of the bed 4-6 inches.

• Avoid tight clothing.

• Stop smoking.