Academic journal article Journal of Singing

Controversies and Confusions in Diagnosing Laryngopharyngeal Reflux

Academic journal article Journal of Singing

Controversies and Confusions in Diagnosing Laryngopharyngeal Reflux

Article excerpt

THE PROBLEM OF REFLUX has become well known among singing teachers. It is recognized as common for reasons that have been discussed extensively in previous literature.1 While being careful not to get too confused, it is worthwhile for singing teachers to recognize that diagnosis and treatment of reflux in singers and other otolaryngology patients remain more controversial than we would like.

Laryngopharyngeal reflux (LPR) is an extraesophageal variant of gastroesophageal reflux disease (GERD) that affects the larynx and pharynx. In recent years, many otolaryngologists have acknowledged the existence and potential importance of LPR in patients with otolaryngologic complaints,2 although the association between acid reflux and laryngeal abnormalities has been recognized for more than four decades.3 As otolaryngologists have been more diligent about looking for signs of LPR such as posterior laryngeal edema (swelling) and erythema (redness), obliteration of the laryngeal ventricles and interarytenoid hypertrophy, treatment for LPR based upon these findings has become increasingly common. Because of a paucity of convincing evidence regarding techniques for establishing definitive diagnosis and causation in individual patients, and because of a plethora of imperfect studies that have produced conflicting conclusions, LPR diagnosis and management remain controversial. Nevertheless, most recent evidence suggests that LPR represents a complex spectrum of abnormalities. It is essential for otolaryngologists and gastroenterologists (as well as other healthcare providers) to understand the latest concepts in basic science and clinical care of patients with LPR.

Symptoms and signs of LPR have been reported in 4% to 10% of all patients seen by otolaryngologists,4 but it is likely that these estimates are low. Among patients who present with voice disorders, the estimated prevalence is much higher. In 1989, Weiner et al. reported that 78% of 32 patients with voice complaints had LPR documented by pH probe.5 Koufman et al. found LPR in 78% of patients with hoarseness, and in roughly 50% of all patients who presented with voice complaints.6 Many other publications have addressed the pathogenesis of voice disorders and otolaryngologic manifestations of LPR, as well as its prevalence.7 Yet, definitive epidemiological studies to confirm the prevalence and otolaryngologic consequences of LPR are still lacking. Consequently, while many physicians believe the condition is still underdiagnosed, many also suspect overdiagnosis and misdiagnosis in many patients.

LPR is believed to damage the larynx either directly, or secondarily. Direct injury is due to the contact of acid and pepsin with laryngeal mucosa, resulting in mucosal injury.8 Alternatively, laryngeal irritation and injury may be produced without direct acid contact with the larynx when irritation of the distal esophagus by acid triggers a vagus nerve response that produces chronic cough and throat clearing capable of traumatizing laryngeal mucosa.9 Bile reflux also may be a cause of laryngeal mucosal inflammation.10

Other, more sophisticated, factors may be important, as well. For example, Eckley reported that decreased salivary epidermal growth factor appears to be associated with LPR;11 and Altman discovered a proton pump in laryngeal serous cells and ducts, raising additional intriguing questions about the pathophysiology of LPR.12 It has been long asserted that non-acid reflux also can trigger cough and throat clearing and cause mucosal irritation that is troublesome to some voice patients, and recent experience with impedance monitoring has confirmed the association between non-acid reflux and such symptoms.

LPR has been associated with numerous laryngeal conditions including muscle tension dysphonia, Reinke's edema, globus sensation, laryngeal hyperirritability, laryngospasm, delayed wound healing, posterior laryngitis, diffuse laryngitis, laryngeal pyogenic granuloma, glottic and subglottic stenosis, cricoarytenoid joint ankylosis, carcinoma and other conditions. …

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