What Is Laryngopharyngeal Reflux?

Reflux pharyngitis, also known as laryngeal reflux (LPR), is a disease that has been widely recognized by otolaryngologists in recent years. In fact, it is very common in clinical work. However, due to the lack of understanding in the past, The disease was misdiagnosed as common chronic pharyngitis for a long time. It was not treated for the cause, but was treated with antibiotics and other drugs, which caused no significant relief of symptoms, which plagued many patients for a long time and seriously reduced the quality of life of patients. In recent years, as otolaryngologists have gradually deepened their understanding of laryngo-pharyngeal reflux, it has been found that the incidence of laryngo-pharyngeal reflux is very high in the population, which can account for 10% of all patients in the ENT clinic. 50% of hoarseness patients. As the name suggests, laryngo-pharyngeal reflux is caused by reflux of gastric contents to the pharynx, irritating and injuring the pharynx mucosa and causing corresponding symptoms.

Basic Information

Also known as: Throat reflux
English name: laryngopharyngealreflux, LPR

Visiting department: Otorhinolaryngology
Common causes: Direct stimulation
Common symptoms: Throat foreign body sensation, ball sensation, hoarseness, difficulty in pronunciation, cough

Causes of reflux pharyngitis

Direct stimulation

Reflux acid directly irritates the throat mucosa causing injury and discomfort. Protective substances in normal laryngeal epithelium are missing in patients with laryngopharyngeal reflux, which together weakens the mucosal defense mechanism. At the same time, the pharyngeal mucosa lacks the ability to clear the movement of the esophagus and neutralize saliva, so it is significantly more sensitive to reflux stimulation than the latter.

2. Stray reflection

Reflux can stimulate the distal esophagus and cause vagal reflexes. Chronic cough and throat clearing can cause damage to the vocal fold mucosa, and at the same time, it can cause relaxation of the upper esophageal sphincter, causing the reflux to enter the throat and cause damage.

Clinical manifestations of reflux pharyngitis

Pharyngeal foreign body sensation or bulbar sensation; hoarseness and dysphonia; chronic cough: mostly irritating dry cough; throat clearing, sore throat, dyspnea, bad breath, increased vaginal mucus secretions, dry throat, etc. The first three are considered particularly common.

Reflux pharyngitis

Laryngoscope

Patients with laryngopharyngeal reflux have some specific manifestations under laryngoscopy, intersacral edema, false vocal sulcus, posterior annular edema, erythema, hypertrophy of vocal cord, polyps and ulcers, lightening or disappearing of laryngeal cavity, pebble-like changes in the throat, and diffuse Laryngitis, granulomas, subglottic stenosis, and stiff ring joints are thought to occur frequently in patients with laryngopharyngeal reflux. However, there is currently no recognized specific microscopic manifestation that can be used for clear diagnosis.

2.pH monitoring and impedance monitoring

At present, it is believed that the movable multi-channel intraluminal impedance and pH monitoring equipment is a better diagnostic method for laryngopharyngeal reflux because it can resist the different flowing substances (gas, liquid, clumps) between two metal electrodes. The combination of change and pH monitoring can provide a complete description of acid reflux, non-acid reflux, liquid, gas, etc., which can be recorded objectively and truthfully.

3. Behavioural change and experience treatment effective

Some scholars believe that the empirical treatment of proton pump inhibitors has a high sensitivity in the diagnosis of laryngo-pharyngeal reflux, but patients who do not respond to acid suppression therapy cannot consider that there is no laryngo-pharyngeal reflux disease.

4.Wireless Bravo Capsule pH Monitor

Placing the capsule detector under the pharyngeal muscle through the nasal cavity can avoid complications such as nosebleeds, throat discomfort, and difficulty swallowing caused by catheterization, and is particularly suitable for patients who cannot tolerate the catheterization. It has less impact on normal activities and provides a new way for diagnosis.

5. Vocal Analysis

It can provide important auxiliary information: professional voice function assessment mainly includes vocal cord vibration feature evaluation, subjective and objective assessment of pronunciation quality, aerodynamic laryngeal function assessment, and laryngeal neuromuscular electrical function assessment. Patients with laryngo-pharyngeal reflux often have hoarseness, intermittent dysphonia, or fatigue, because inflammation and vocal edema increase the quality of the vocal cords, reduce tension, increase stiffness, weaken their movement, and reduce the patient's voice quality and vocal function. Limited, the measurement of vocal parameters may be abnormal. Therefore, vocal analysis can provide effective auxiliary information for the diagnosis of laryngopharyngeal reflux.

Reflux pharyngitis diagnosis

According to the patient's symptoms and auxiliary examinations, patients with laryngeal reflux can be diagnosed. At present, the diagnosis of laryngo-pharyngeal reflux still needs to rely on a combination of the above methods to make it more convincing.

Differential diagnosis of reflux pharyngitis

Differentiation from gastroesophageal reflux: Although laryngopharyngeal reflux often coexists with gastroesophageal reflux, it still tends to think that laryngopharyngeal reflux and gastroesophageal reflux are two different wholes. For example, laryngopharyngeal reflux often occurs during the day, standing or sitting, often with difficulty in pronunciation, hoarseness, throat clearing, foreign body sensation, long-term cough, excessive throat secretions, and poor swallowing. The scope has specific features of the corresponding palate and vocal cords, which are related to poor sphincter function of the upper esophagus, and gastroesophageal reflux often occurs during supine at night. The main discomfort is acid reflux, heartburn, chest pain, and difficulty swallowing. Corresponding manifestations of esophagitis, gastroesophageal hernia, and Barrett's esophagus are mainly related to abnormal sphincter dysfunction.

Reflux pharyngitis complications

Laryngopharyngeal reflux may be related to laryngeal cancer, esophageal adenocarcinoma, secretory otitis media, throat stenosis, throat wheezing, chronic rhino-sinusitis, obstructive sleep hypoventilation syndrome, enamel damage, infant death syndrome, etc. ^{[1 ]} .

Reflux pharyngitis treatment

1. Acid suppression therapy combined with lifestyle changes

It is still the mainstream treatment method: the latter mainly includes avoiding eating before bedtime, raising the bedside, reducing dinner intake, avoiding overeating, smoking cessation, strong tea, coffee, high-fat foods, sweets, acid fruits (tangerines, bayberry, etc.) ), Weight loss, etc., the former two are considered to be particularly important, and even research has found that simple lifestyle improvements can significantly alleviate the symptoms of throat discomfort, and thus propose the improvement of lifestyle as the main treatment.

(1) Proton pump inhibitors (PPIs) Proton pump drives intracellular H ⁺ exchange with K ^{+ in} tubules. Proton pump inhibitors block this exchange pathway. Compared with the original histamine receptor antagonist that inhibits gastric acid, By comparison, the action sites are different, and the acid suppression at night is good and quick, the acid suppression is strong and the time is long, and it is convenient to take. Therefore, it plays a leading role in the acid suppression treatment of laryngeal reflux. Decrease. Long course of treatment can make the improvement of symptoms more obvious. In addition, the effectiveness of proton pump inhibitors is not only manifested in the improvement of laryngeal discomfort and laryngoscope performance, but its objective acoustic evaluation parameters have also improved with the course of treatment, which may be due to swollen vocal cords after treatment, Conditions such as inflammation improved, and local microscopic conditions such as capillary distribution, mucus volume, and stability of vocal cord mucosa movement improved. Relief of symptoms often precedes improvement in laryngoscopic performance.

Side effects of long-term application of proton pump inhibitors: inhibition of calcium absorption leading to osteoporosis and fractures (common in the hips and vertebrae), diarrhea caused by Clostridium difficile infection, tolerance, increased acid secretion rebound after withdrawal, and Combined use of piogrel increases the risk of cardiovascular disease recurrence and increases the risk of gastric cancer (especially in the presence of Hp infection). Whether VitB ₁₂ and iron deficiency can be caused remains to be determined.

(2) H ₂ receptor blockers are used to antagonize gastric acid secretion caused by histamine, mainly including cimetidine, ranitidine, famotidine and the like. Often applied before bedtime. There are mixed conclusions about its effectiveness. Can try to apply to patients with proton pump inhibitors and lifestyle improvement treatment still can not obtain significant relief.

2. Cases of relapse or poor efficacy

For cases with poor efficacy of PPIs, it is necessary to consider whether there is non-acid reflux, whether it is a more severe type of laryngo-pharyngeal reflux, and the possibility of increasing the treatment dose. It should also consider whether the diagnosis is wrong. There are other causes, such as Esophageal pharyngeal reflux, allergies, excessive alcohol and tobacco, lung disorders, sinus diseases, etc. Add histamine blockers, motility promoting agents, etc., and adjust lifestyle.

3. Esophageal pharyngeal reflux

In clinical practice, empirical acid suppression therapy has no obvious effect on a considerable number of patients, so some scholars have proposed that esophageal reflux (EPR) is a possible cause. It is mainly related to esophageal dyskinesia, decreased sphincter tone, and decreased volume clearance function. Common symptoms include chronic cough, dysphagia, dysphonia, throat clearing, bloating, and snoring. Diagnosis of esophageal hernia, delayed esophagus, and abnormal swallowing activity of the oropharynx can be seen through esophagus barium meal imaging in the lying position.

4. Voice therapy and related acoustic evaluations

Recent studies have found that for patients with laryngo-pharyngeal reflux, adding vocal therapy can enhance the treatment of laryngo-pharyngeal reflux, and symptoms such as hoarseness, shortness of breath, and some vocal parameters can be satisfactorily improved. Voice therapy is a personalized treatment method; the type of treatment method will vary depending on the patient's condition and will vary from doctor to doctor, but will have similar effects.

Voice therapy includes indirect voice therapy and direct voice therapy. The former refers to the purpose of vocal education to teach patients the knowledge of normal vocal cord anatomy and vocal pathology, as well as vocal hygiene related knowledge. The purpose of direct voice therapy is to improve the speaking skills of patients, in order to achieve the purpose of increasing vocal efficiency and improving voice quality. Includes vocal rest, resonance training, abdominal breathing, increased soft attack, reduced hard attack, airflow training, bite training, and local laryngeal massage (from the previous thyroid cartilage, placing the index finger and thumb on the thyroid cartilage Gap and circular massage, so as to reduce the laryngeal position and reduce the muscle tension in the larynx, used for hypervoice function, excessive glottal tension caused by insufficient glottal function) and other methods.

5. Surgical treatment

Symptomatic non-acid reflux (common among occupational voice users), poor combination of drugs and lifestyle, severe reflux, poor lower esophageal sphincter function, severe side effects, avoiding long-term medication for young patients or economic reasons, etc. As an indication for surgical treatment. Stomach fundus surgery is the most common operation, and it is now performed under laparoscopy. The mucosa at the bottom of the stomach is folded around the lower esophagus, thereby strengthening the esophageal sphincter to control the reflux.

6. New drugs

GABAB blocker AZD3355 and metabotropic glutamate receptor 5 antagonist ADX10059 can reduce temporary lower esophageal sphincter relaxation and increase its tension, which are currently emerging treatment options ^[2-3] .