Michelle Dotto April 3, 2003 Voice Disorders ASC 823C Gastroespohageal Reflux Disease (GERD) & Laryngopharyngeal Reflux Disease (LPRD) Michelle Dotto April 3, 2003 Voice Disorders ASC 823C

What are they? The term REFLUX comes from the Greek word meaning “backflow,” usually referring to the contents of the stomach. Just under the diaphragm, where the esophagus and stomach connect, is the lower esophageal sphincter (LES). This muscle normally prevents stomach juices and food from coming back up, relaxing only when you swallow. GERD: an abnormal amount of reflux up through the lower sphincters and into the esophagus. LPRD: when the reflux passes all the way through the upper sphincter and into the back of the throat, reaching the larynx and pharynx.

Symptoms for GERD The most common is a burning sensation in the chest, usually after eating (AKA heartburn). This sensation can also be associated with position, sleep, or exercise. Others include: belching, dysphagia, odynophagia (pain on swallowing), water brash, sore throat, cough, bronchospasms, atypical chest pain, hoarseness, and asthma exacerbation. Symptoms are more common over night Most common symptoms in the elderly include dysphagia, vomiting, and respiratory problems, among others which all lead to restrictive respiratory problems. AKA Heartburn Odynophagia = pain on swallowing Water Brash = sudden occurrence of fluid into mouth caused by increased saliva prod’n

Symptoms of LPRD Symptoms of the two may overlap, however, the pharynx, larynx, and lungs are more sensitive to stomach acid and digestive enzymes allowing less reflux to do more damage. Symptoms include: hoarseness, frequent throat clearing, sensation in the throat, bad/bitter taste in the mouth, referred ear pain, and post-nasal drip to name a few. Symptoms are commonly experienced during the day. Very few experience heartburn. Bitter taste = esp. in morning Little heartburn b/c caused from esophagus being irritated

Signs that may be seen by a professional Red, irritated arytenoids Red, irritated larynx Small laryngeal ulcers Swelling of the VF Granulomas in the larynx

Severe, long term affects Gastrointestinal bleeding Barrett’s esophagus There is columnar epithelium in the esophagus where stratified squamous epithelium should be Cancer

Causes Medications or food that relax the LES: Chocolate Caffeine Fatty/spicy foods Onions Mint Alcohol Acidic fruits and vegetables Hiatal hernia may also prevent closing of the LES – when the stomach protrudes above the diaphragm

Treatment Prevention/Lifestyle changes Medications Surgery Usually in this order

Prevention/Lifestyle changes The most important step is to minimize exposure to those factors that interfere with the normal function of the esophageal sphincter. Meals should be eaten at least 2 hours before bedtime to prevent stomach acids from moving up the esophagus. Do not exercise immediately after a meal Maintain a healthy body weight Reduce stress Elevate the head of the bed 4-6 inches. Simply sleeping on extra pillows does not help since it flexes the stomach and could actually worsen reflux. Tilting the entire bed upwards will allow gravity to do its job. Avoid tight clothing Do not smoke 10 degree slant

Medications reduce the acidity of the stomach contents increase the activity of the esophageal sphincters they will increase the motility of the stomach

Medications Continued “acid-blockers” They don’t reduce reflux but they do reduce acidity. "H-2 blockers” :block the histamine 2 receptor that is important in stomach acid production Tagamet Zantac Pepcid Proton pump inhibitor (PPI): reduce activity of a process that "pumps" protons across the cell membrane Prilosec Prevacid Reglan is also used to increase the activity of the sphincter and increase gastric motility

Surgery With severe cases when meds and other tx are not successful. Most common procedure: fundoplication, sewing a portion of the stomach around the esophagus to tighten its lower end. This operation can be done through small incisions in the abdomen using endoscopes. Last resort

Diagnosis Tests completed: pH monitoring (AKA pH-metry) Barium swallow Takes 24 hours (over night) Measure acid in esophagus and throat Small, soft, fexible tube (pH probe) through the nose and into the throat which is connected to a small computer worn around the waist Also allows doctors to determine the best treatment Barium swallow Easiest, most cost effective However, may be misleading Tube called a “pH probe” Misleading = show normal swallow yet have symptomatic GERD

How is the voice affected? Hoarseness Vocal fatigue Edema Ulceration Granulation Polypoid degeneration Vocal nodules Laryngospasm Arytenoid fixation Laryngeal stenosis Carcinoma of the larynx

Voice treatment Responsible for providing support for the reflux and appropriate voice therapy. Acute stages of voice change: decrease throat clearing and coughing, conserve voice use, initiating new functional voicing behaviors. Resonant Voice Therapy

References Center for Voice Disorders of Wake Forest University. (2003). Patient information sheet on reflux. http://www.bgsm.edu/voice/pt_info.html Columbia Presbyterian Medical Center. (2002). Laryngopharyngeal reflux disease and recommendations to prevent acid reflux. http://www.entcolumbia.org/lprd.htm Hensrud, D.D. (2002). Somethings burning [Electronic version]. Fortune, 146, issue I. Levy, R.A., Meiner, S.E., & Stamm, L. (2002). Conservative management of GERD: a case study. Medsurg Nursing, 11, No. 4. Stemple, J., Gerdeman, B.K., & Glaze, L. (2002). Clinical Voice Pathology: Theory and Management. 3rd ed. Singular Publishing Voice Center. (2003). Reflux disease and its effects on the larynx. http://www.voice-center.com/reflux.html