In the last two decades, the medical community has developed keen awareness of
extraesophageal manifestations of acid reflux disease. This “atypical reflux” is now
recognized as distinctly different from typical GERD. In 1968, there was a description of
a relationship between contact ulcers and granulomas of the larynx with reflux. Then, in
1989, Weinert documented PH findings of reflux in the laryngopharynx. In 1991, Kaufman
pioneered research into reflux laryngitis.
Symptomatically LPR (laryngopharyngeal reflux) is very
different from GERD (the symptoms of which are primarily
linked to esophagitis). The LPR patient is likely to have
only 25% incidence of esophagitis which evokes symptoms
such as heartburn. Common presenting symptoms of LPR
are: hoarseness, globus pharyngeus, cough, sore throat,
and chronic throat clearing. LPR patients are upright
(daytime) refluxers, unlike their GERD counterparts that are
predominantly supine (nocturnal) refluxers.
Diagnosis of LPR is made by relevant history and laryngeal
exam. The classic findings on laryngeal office endoscopy are:
posterior commisure hypertrophy (pachyderma), persistent
secretions, vocal process and aretynoid erythema, obliteration
of laryngeal ventricle, and contact ulcers and granuloma of
vocal cords. (See figure 1). Of course, ambulatory 24-hour
double probe (esophageal and pharyngeal) PH monitoring
remains the gold standard for the diagnosis of LPR.
Proton pump inhibitors (PPI’s) have become the cornerstone
of LPR treatment. The therapy needs to be more aggressive
and prolonged than GERD treatment. Twice daily therapy is
recommended for a minimum period of six months.
Some studies show that fewer than one-half of patients on
PPI’s were completely asymptomatic four months into their therapy.
Behavioral modifications that include elevation of the torso in bed, maintenance of an
ideal body weight, avoidance of late night meals, tobacco, fatty foods, spices, alcohol, and
caffeine are an important part of chronic treatment of all forms of acid reflux disease.
Finally, those patients that fail aggressive pharmaco therapy for LPR may benefit from
surgical treatment of fundoplication.
Call us at 612-339-2836 or toll-free at 866-316-0769 to refer your patient for an appointment, or submit an online referral.
A granuloma caused by reflux
is noted on the left vocal cord
of a patient with LPR. The
image was obtained using
Tiger striping of the
postcricoid area is seen in this
Images used with permission from the Journal of the American Academy of
Physician Assistants. Vol. 18, No. 8 August 2005: 50-53. www.jaapa.com