1. Treatment Strategies for Voice Disorders Associated with Larygopharyngeal Reflux (LPR) A Literature Review Kathleen Bell December 5, 2012

2. Introduction Research of the Literature reveals confusion and controversy “Interesting clinical paradox – Most underdiagnosed and overdiagnosed clinical entity in laryngology” (Bransky & Sulika)

3. REFLUX- BACKFLOW OF GASTRIC CONTENT

4. Two Esophageal Sphincters

5. LPR VS GERD Larynx & PharynxEsophagus Cough & hoarsenessHeartburn Normal motor dysfunctionAbnormal motor dysfunction Upper esophageal sphincter (UES)Lower esophageal sphincter (LES) Symptoms when sitting or standingSymptoms when lying down Not obeseObese Acid activated pepsinAcid Any exposure to acid damagingUp to 50 times a day is “normal” Need aggressive & long term treatment3 months of treatment

6. Reflux Finding Score (Belafsky et al, 2001 Subglottic edema Ventricular Erythema/hyperemia Vocal fold edema Diffuse laryngeal edema Posterior commissure hypertrophy Granuloma/granulation tissue Thick endolaryngeal mucus 0 = absent 2 = present 2 = partial 4 = complete 2 = arytenoids only 4 = diffuse 1 = mild 2 = moderate 3 = severe 4 = polypoid 1= mild 2 = moderate 3 = severe 4 = obstructing 0 = mild 2 = moderate 3 = severe 4 = obstructing 0 = absent 2 = present 0 = absent 2 = present

7. The Reflux Symptom Index (Belasky et al, 2002) Within the past month, how did the following problems affect you? 0 = No Problem 5 = Severe Problem Hoarseness or a problem with your voice 012345 Clearing your throat 012345 Excess throat mucus or postnasal drip 012345 Difficulty swallowing food, liquids, or pills 012345 Coughing after you ate or after lying down 012345 Breathing difficulties or choking episodes 012345 Troublesome or annoying cough 012345 Sensations of something sticking in your throat or a lump in your throat 012345 Heartburn, chest pain, indigestion, or stomach and coming up 012345

8. Laryngeal Findings (Lloyd, 2011)

9. STANDARD ANTIREFLUX THERAPY Phase 1 A. Dietary modification B. Life-style modification C. Medications – antacids Phase 2 A. H 2 blockers B. Proton pump inhibitors C. Prokinetic agents Phase 3 A. Double dose PPI B. Surgery (fundoplication)

10. Jamie Koufman pH water (8.8 & )

11. Dietary & Herbal Adjunctive Therapies - Melatonin - D-Limonene - Iberogast - Gluten Free Diet

12. PPI’s & Pharmaceuticals – Often double doses needed – Many patients unresponsive – Symptoms recurrent – Lifetime therapy – Prolonged use causes significant side-effects

13. Body Modalities Chiropractic Care Accupuncture

14. Voice Therapy & Psychological Therapy Preventative Strategy Component of comprehensive Therapeutic Strategy

15. Most Important Studies & Authors Jamie Koufman (1991)– “The Otolaryngologic Manifestations of Gastroesophageal Reflux Disease.” Belafsky et al (2002) – “Symptoms and Findings of Laryngopharyngeal Reflux.” Johntson et al (2003) – “Cell Biology of Laryngeal Epithelial Defenses in Health and Disease.” Kahn et al (2006) – “Laryngopharyngeal Reflux – A Literature Review.” Sataloff et al (2006) – Reflux Laryngitis and Related Disorders Bransky & Sulica (2009) – Classics in Voice and Laryngology Patrick (2011) – “Gastroesophageal Reflux Disease (GERD): A Review of Conventional and Alternative Treatments.”

16. References – 50+!!! Alcantara & Anderson (2008) Amin et al (2001) Aronson & Bless (2009) Behlau & Oliveira (2009) Belafsky et al (2001, 2002) Boone et al (2010) Bransky & Sulica (2009) Cammarota et al (2003) Chen, Xu, & Chen (2009) Cuomo et al (2002) Davies & Jahn (2004) Dickman et al (2007). Gainor et al (2011) Halum et al (2005) Hein, Tina (1999) Hershcovici & Fass (2011) Hopkins et al (2009). Johnston et al (2003, 2004 ) Kahn et al (2006) Karkos et al (2007) Kelchner et al (2005) Koufman (2011) Koufman &Johnston (2012) Koufman et al (2002) Koufman, Stern, & Bauer (2010) Lloyd, Adam Thomas (2011) McGuirt, William F. (2003) Miskovitz & Betancourt (2005) Mjönes et al (2005) Møller & West (2000) Moniniet al (2006) Moss & Kelly (2007) Murry et al (2006) Nowak et al (2010) Patrick, Lyn (2011) Pitman (2010) Rees & Belafsky (2008) Ross et al (1998) Sana et al (2011) Sandage & Emerich (2002) Sataloff, Robert T. (1991, 1998,2005, 2006,2010) Sataloff et al (2006, 2012) Sereg-Baharet al (2005) Smoak & Koufman (2001) Spencer (2006) Syed & Bleach (2009) Timmermans et al (2005) Usai et al (2008) Vashani et al (2010) Watson et al (1997) Wright et al (2005)

17. Images Used Slide 1 – funnyjokes.org Slide 3 – babychoicbariatrics.com Slide 4 – epgpatientdirect.org Slide 10 – refluxcookbook.com Slide 13 – http://en.wikipedia.orghttp://en.wikipedia.org Slide 13 – www.bennettclinic.com/chiropractic.jpg http://www.w3.org/TR/xhtml1/DTD/xhtml1- strict.dtd

18. Conclusions